Epilepsy in autism is associated with intellectual disability and gender: evidence from a meta-analysis

BACKGROUND

The association between epilepsy and autism is consistently reported, with a wide range of prevalence rates. This may be attributed to the heterogeneity of the samples with respect to age, comorbidity, sex, and intellectual disability (ID). We aimed to compare the prevalence of epilepsy 1) among autistic patients with ID versus autistic patients without ID and 2) among male versus female autistic patients.

METHODS

We reviewed all data available from published reports (1963-2006) on autism and epilepsy and conducted a meta-analysis of 10 and 14 studies, respectively, to assess the relative risk (RR) of epilepsy in autism according to ID and gender. The pooled groups included 2112 (627 with IQ > or = 70, 1485 with IQ < 70) and 1530 (1191 male, 339 female) patients, respectively.

RESULTS

There was a strong discrepancy in relative risk (RR) according to IQ, with more autistic patients with ID having epilepsy (RR = .555; 95% confidence interval [CI]: .42-.73; p < .001). The pooled prevalence of epilepsy was 21.5% in autistic subjects with ID versus 8% in autistic subjects without ID. There was a strong discrepancy in RR according to sex, favoring comorbidity of epilepsy in autistic girls (RR = .549; 95% CI: .45-.66; p < .001). The male:female ratio of autism comorbid with epilepsy was close to 2:1 whereas the male:female ratio of autism without epilepsy was 3.5:1.

CONCLUSIONS

The results of this meta-analysis indicate that risk for epilepsy in autism is a function of ID severity and distinguishes autism associated with epilepsy as a subgroup of autism by its male-female ratio.

Multidrug resistance-associated protein 4 regulates cAMP-dependent signaling pathways and controls human and rat SMC proliferation

The second messengers cAMP and cGMP can be degraded by specific members of the phosphodiesterase superfamily or by active efflux transporters, namely the multidrug resistance-associated proteins (MRPs) MRP4 and MRP5. To determine the role of MRP4 and MRP5 in cell signaling, we studied arterial SMCs, in which the effects of cyclic nucleotide levels on SMC proliferation have been well established. We found that MRP4, but not MRP5, was upregulated during proliferation of isolated human coronary artery SMCs and following injury of rat carotid arteries in vivo. MRP4 inhibition significantly increased intracellular cAMP and cGMP levels and was sufficient to block proliferation and to prevent neointimal growth in injured rat carotid arteries. The antiproliferative effect of MRP4 inhibition was related to PKA/CREB pathway activation. Here we provide what we believe to be the first evidence that MRP4 acts as an independent endogenous regulator of intracellular cyclic nucleotide levels and as a mediator of cAMP-dependent signal transduction to the nucleus. We also identify MRP4 inhibition as a potentially new way of preventing abnormal VSMC proliferation.

Pharmacokinetic study of mycophenolate mofetil in patients with systemic lupus erythematosus and design of Bayesian estimator using limited sampling strategies

BACKGROUND

Monitoring of the area under the plasma concentration-time curve (AUC) of mycophenolic acid (MPA) has been developed for individual dose adjustment of mycophenolate mofetil (MMF) in renal allograft recipients. MMF is currently used as an off-label drug in the treatment of systemic lupus erythematosus (SLE), but factors of its exposition may be different in these patients and need to be determined for therapeutic drug monitoring (TDM) purposes.

OBJECTIVE

The aim of the study was to develop a maximum a posteriori probability (MAP) Bayesian estimator of MPA exposition in patients with SLE, with the objective of TDM based on a limited sample strategy.

METHODS

Twenty adult patients with SLE given a stable 1 g/day, 2 g/day or 3 g/day dose of MMF orally for at least 10 weeks were included in the study. MPA was measured by high-performance liquid chromatography (HPLC) coupled to a photodiode array detector (11 plasma measurements over 12 hours post-dose per patient). Free MPA concentrations were measured by HPLC with fluorescence detection. Two different one-compartment models with first-order elimination were tested to fit the data: one convoluted with a double gamma distribution to describe secondary concentrations peaks, and one convoluted with a triple gamma distribution to model a third, later peak.

RESULTS

A large interindividual variability in MPA concentration-time profiles was observed. The mean maximum plasma concentration, trough plasma concentration, time to reach the maximum plasma concentration and AUC from 0 to 12 hours (AUC(12)) were 13.6 +/- 8.4 microg/mL, 1.4 +/- 1.2 microg/mL, 1.1 +/- 1.2 hours and 32.2 +/- 17.1microg . h/mL, respectively. The mean free fraction of MPA was 1.7%. The one-compartment model with first-order elimination convoluted with a triple gamma distribution best fitted the data. Accurate Bayesian estimates of the AUC(12) were obtained using three blood samples collected at 40 minutes, 2 hours and 3 hours, with a coefficient of correlation (R) = 0.95 between the observed and predicted AUC(12) and with a difference of <20% in 16 of the 20 patients.

CONCLUSION

A specific pharmacokinetic model was built to accurately fit MPA blood concentration-time profiles after MMF oral dosing in SLE patients, which allowed development of an accurate Bayesian estimator of MPA exposure that should allow MMF monitoring based on the AUC(12) in these patients. The predictive value of targeting one specific or different AUC values on patients' outcome using this estimator in SLE will need to be evaluated.

Potentiation of fluindione or warfarin by dexamethasone in multiple myeloma and AL amyloidosis

OBJECTIVES

Patients with primary systemic (AL) amyloidosis or multiple myeloma are frequently treated with cyclic dexamethasone (DXM) courses and often require oral anticoagulants. We previously reported a strong potentiation of oral anticoagulants with intravenous methylprednisolone and observed a similar potentiation with DXM in 3 patients, which led us to prospectively investigate the interaction between DXM and oral anticoagulants.

METHODS

Nine patients with multiple myeloma (n=6) or AL amyloidosis (n=3), including 6 prospective patients, taking fluindione (n=8) or warfarin (n=1), were studied for a total of 10 cycles. DXM (40 mg/day for 4 days every 28 days) was administered alone (n=4) or with melphalan (n=5). One patient was studied for 2 consecutive cycles after a moderate increase in the international normalized ratio (INR) during the first course of DXM. International normalized ratio (INR) was measured serially during DXM administration. Plasma oral anticoagulant concentrations were measured for 5 cycles.

RESULTS

The mean INR increased from 2.75 (range: 1.80-3.6) at baseline to 5.22 (3.09-7.07) after DXM. Oral anticoagulants were transiently stopped during 8 cycles and 1 mg oral vitamin K was given during 2. No serious bleeding was observed. Plasma oral anticoagulant concentrations increased after DXM administration. In controls receiving DXM without oral anticoagulants, DXM alone did not increase prothrombin time.

CONCLUSION

High dose DXM can potentiate oral anticoagulants and elevate INR substantially. INR should therefore be monitored repeatedly during concomitant administration of these 2 drugs to allow individual adaptation of oral anticoagulant doses.

Predictors of cardiovascular events in patients with end-stage renal disease: an analysis from the Fosinopril in Dialysis study

BACKGROUND

Cardiovascular events (CVE) are a major cause of morbidity and mortality in end-stage renal disease (ESRD) patients. These patients are often excluded from CV clinical trials, and the prognostic factors associated with CVE in patients with ESRD have not been fully explored. A risk prediction model was created from the FOSIDIAL trial to identify factors predictive of CVE and to evaluate the relative strength of known predictors when considered together in a multivariate model.

METHODS

FOSIDIAL was a prospective, randomized, double-blind study with 2-year follow-up and CVE adjudication. The study enrolled 397 patients with ESRD and left ventricular hypertrophy (LVH). CVE included cardiovascular death, non-fatal myocardial infarction, unstable angina, stroke, revascularization, heart failure hospitalization, resuscitated cardiac arrest and confirmed stroke. The model was built using a forward selection of all baseline variables. A structural equation model (SEM) was used to identify factors with an indirect association with CVE.

RESULTS

CV history was the most important prognostic factor, followed by C-reactive protein (CRP), left ventricular mass index, diabetes and age. Smoking, low HDL, female gender and Kt/V were indirectly associated with CVE.

CONCLUSION

Prior CV disease, elevated CRP, LVH, diabetes or advanced age identifies patients at the highest risk for CVE. These data may be useful to detect high risk patients, to define potential targets for pharmacologic intervention, and to plan future studies in ESRD. Further research is needed to identify effective approaches that reduce the rate of CVE in these patients.

A meta-analysis to assess the efficacy of oral antiviral treatment to prevent genital herpes outbreaks

BACKGROUND

Efficacy of oral antiviral therapies, ie, acyclovir, valacyclovir (VACV), and famciclovir, for suppression of recurrent genital herpes was studied at different doses and regimens.

OBJECTIVE

We sought to compare the clinical efficacies of the different oral antiviral drugs prescribed prophylactically to suppress recurrent genital herpes.

METHODS

MEDLINE and EMBASE databases were searched for articles on genital herpes and selected antiviral drugs. The selected trials were: parallel randomized clinical trials testing prophylactic oral antiviral treatment of genital herpes versus placebo in immunocompetent and nonpregnant patients.

RESULTS

Fourteen randomized clinical trials were selected, including a total of 6158 patients. The global relative risk of developing at least one recurrence during the study was reduced by 47% (95% confidence interval 45%-49%) in antiviral drug groups compared with the placebo. The best evaluated regimens, with comparable efficacies, were given twice daily, ie, acyclovir (400 mg twice daily), VACV (250 mg twice daily), and famciclovir (250 mg twice daily), or once daily (VACV 500 mg).

LIMITATIONS

The only end point available for all the studies was the number of patients presenting at least one recurrence of genital herpes during the observation period.

CONCLUSION

The results of this first meta-analysis confirmed the high clinical efficacy of oral acyclovir, VACV, or famciclovir for prophylaxis against recurrent genital herpes.

Comorbidity with ADHD decreases response to pharmacotherapy in children and adolescents with acute mania: evidence from a metaanalysis

OBJECTIVE

To assess whether comorbid attention-deficit hyperactivity disorder (ADHD) influences response to treatment in young patients with acute mania.

METHODS

We conducted a metaanalysis of 5 open trials of 100, 35, 41, 60, and 37 children and adolescents. The pooled group included 273 children and adolescents with bipolar disorder (BD), divided into 2 subgroups: those with (n = 132), and those without (n = 141), ADHD comorbidity.

RESULTS

There was a moderate and significant reduction in relative risk (RR) favouring treatment response in children and adolescents with BD but without ADHD comorbidity (RR 0.822; 95% CI, 0.69 to 0.97; P = 0.021). The negative effect of ADHD comorbidity on treatment response was more significant in studies including adolescents only or subjects with BD I only.

CONCLUSION

These findings suggest that children and adolescents with BD and ADHD tend to be less responsive to drugs used in treatment of acute mania.