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Thomas M, Hayes K, White P, Ramesh A, Culliford L, Ackland G, Pickering A. Early Intravenous Beta-Blockade with Esmolol in Adults with Severe Traumatic Brain Injury (EBB-TBI): Protocol for a Phase 2a Intervention Design Study. Neurocrit Care 2024; 40:795-806. [PMID: 37308729 PMCID: PMC10959800 DOI: 10.1007/s12028-023-01755-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/10/2023] [Indexed: 06/14/2023]
Abstract
Traumatic brain injury is a leading cause of death and disability worldwide. Interventions that mitigate secondary brain injury have the potential to improve outcomes for patients and reduce the impact on communities and society. Increased circulating catecholamines are associated with worse outcomes and there are supportive animal data and indications in human studies of benefit from beta-blockade after severe traumatic brain injury. Here, we present the protocol for a dose-finding study using esmolol in adults commenced within 24 h of severe traumatic brain injury. Esmolol has practical advantages and theoretical benefits as a neuroprotective agent in this setting, but these must be balanced against the known risk of secondary injury from hypotension. The aim of this study is to determine a dose schedule for esmolol, using the continual reassessment method, that combines a clinically significant reduction in heart rate as a surrogate for catecholamine drive with maintenance of cerebral perfusion pressure. The maximum tolerated dosing schedule for esmolol can then be tested for patient benefit in subsequent randomized controlled trials.Trial registration ISRCTN, ISRCTN11038397, registered retrospectively 07/01/2021 https://www.isrctn.com/ISRCTN11038397.
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Affiliation(s)
- Matt Thomas
- Intensive Care Unit, North Bristol NHS Trust, Bristol, UK.
| | - Kati Hayes
- Intensive Care Unit, North Bristol NHS Trust, Bristol, UK
| | - Paul White
- School of Data Science and Mathematics, University of the West of England, Bristol, UK
| | - Aravind Ramesh
- GW4 Clinical Academic Training Programme for Health Professionals, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Lucy Culliford
- Bristol Trials Centre, Bristol Medical School (PHS), University of Bristol, Bristol, UK
| | - Gareth Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anthony Pickering
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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Kelly-Hedrick M, Liu SY, Komisarow J, Hatfield J, Ohnuma T, Treggiari MM, Colton K, Arulraja E, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Krishnamoorthy V. Early Beta-Blocker Utilization in Critically Ill Patients With Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study. J Intensive Care Med 2024:8850666241236724. [PMID: 38449336 DOI: 10.1177/08850666241236724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND There is limited evidence that beta-blockers may provide benefit for patients with moderate-severe traumatic brain injury (TBI) during the acute injury period. Larger studies on utilization patterns and impact on outcomes in clinical practice are lacking. OBJECTIVE The present study uses a large, national hospital claims-based dataset to examine early beta-blocker utilization patterns and its association with clinical outcomes among critically ill patients with moderate-severe TBI. METHODS We conducted a retrospective cohort study of the administrative claims Premier Healthcare Database of adults (≥17 years) with moderate-severe TBI admitted to the intensive care unit (ICU) from 2016 to 2020. The exposure was receipt of a beta-blocker during day 1 or 2 of ICU stay (BB+). The primary outcome was hospital mortality, and secondary outcomes were: hospital length of stay (LOS), ICU LOS, discharge to home, and vasopressor utilization. In a sensitivity analysis, we explored the association of beta-blocker class (cardioselective and noncardioselective) with hospital mortality. We used propensity weighting methods to address possible confounding by treatment indication. RESULTS A total of 109 665 participants met inclusion criteria and 39% (n = 42 489) were exposed to beta-blockers during the first 2 days of hospitalization. Of those, 42% received cardioselective only, 43% received noncardioselective only, and 14% received both. After adjustment, there was no association with hospital mortality in the BB+ group compared to the BB- group (adjusted odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.94, 1.04). The BB+ group had longer hospital stays, lower chance of discharged home, and lower risk of vasopressor utilization, although these difference were clinically small. Beta-blocker class was not associated with hospital mortality. CONCLUSION In this retrospective cohort study, we found variation in use of beta-blockers and early exposure was not associated with hospital mortality. Further research is necessary to understand the optimal type, dose, and timing of beta-blockers for this population.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Evangeline Arulraja
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Michael L James
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Smith JA, Nguyen T, Davis BC, Lahiri DK, Hato T, Obukhov AG, White FA. Propranolol treatment during repetitive mild traumatic brain injuries induces transcriptomic changes in the bone marrow of mice. Front Neurosci 2023; 17:1219941. [PMID: 37817806 PMCID: PMC10561692 DOI: 10.3389/fnins.2023.1219941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction There are 1.5 million new mild traumatic brain injuries (mTBI) annually in the US, with many of the injured experiencing long-term consequences lasting months after the injury. Although the post injury mechanisms are not well understood, current knowledge indicates peripheral immune system activation as a causal link between mTBI and long-term side effects. Through a variety of mechanisms, peripheral innate immune cells are recruited to the CNS after TBI to repair and heal the injured tissue; however, the recruitment and activation of these cells leads to further inflammation. Emerging evidence suggests sympathetic nervous system (SNS) activity plays a substantial role in the recruitment of immune cells post injury. Methods We sought to identify the peripheral innate immune response after repeated TBIs in addition to repurposing the nonselective beta blocker propranolol as a novel mTBI therapy to limit SNS activity and mTBI pathophysiology in the mouse. Mice underwent repetitive mTBI or sham injury followed by i.p. saline or propranolol. Isolated mRNA derived from femur bone marrow of mice was assayed for changes in gene expression at one day, one week, and four weeks using Nanostring nCounter® stem cell characterization panel. Results Differential gene expression analysis for bone marrow uncovered significant changes in many genes following drug alone, mTBI alone and drug combined with mTBI. Discussion Our data displays changes in mRNA at various timepoints, most pronounced in the mTBI propranolol group, suggesting a single dose propranolol injection as a viable future mTBI therapy in the acute setting.
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Affiliation(s)
- Jared A. Smith
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Tyler Nguyen
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brittany C. Davis
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Debomoy K. Lahiri
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Takashi Hato
- Department of Medicine, Indiana University, Indianapolis, IN, United States
| | - Alexander G. Obukhov
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Fletcher A. White
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
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Wang J, Venugopal J, Silaghi P, Su EJ, Guo C, Lawrence DA, Eitzman DT. Beta1-receptor blockade attenuates atherosclerosis progression following traumatic brain injury in apolipoprotein E deficient mice. PLoS One 2023; 18:e0285499. [PMID: 37235594 DOI: 10.1371/journal.pone.0285499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
Traumatic brain injury (TBI) is associated with cardiovascular mortality in humans. Enhanced sympathetic activity following TBI may contribute to accelerated atherosclerosis. The effect of beta1-adrenergic receptor blockade on atherosclerosis progression induced by TBI was studied in apolipoprotein E deficient mice. Mice were treated with metoprolol or vehicle following TBI or sham operation. Mice treated with metoprolol experienced a reduced heart rate with no difference in blood pressure. Six weeks following TBI, mice were sacrificed for analysis of atherosclerosis. Total surface area and lesion thickness, analyzed at the level of the aortic valve, was found to be increased in mice receiving TBI with vehicle treatment but this effect was ameliorated in TBI mice receiving metoprolol. No effect of metoprolol on atherosclerosis was observed in mice receiving only sham operation. In conclusion, accelerated atherosclerosis following TBI is reduced with beta-adrenergic receptor antagonism. Beta blockers may be useful to reduce vascular risk associated with TBI.
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Affiliation(s)
- Jintao Wang
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jessica Venugopal
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Paul Silaghi
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Enming J Su
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Chiao Guo
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Daniel A Lawrence
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Daniel T Eitzman
- Department of Internal Medicine, Cardiovascular Research Center, University of Michigan, Ann Arbor, Michigan, United States of America
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Wang X, Li X, Ma L, Chen H, You C. Pharmacological components with neuroprotective effects in the management of traumatic brain injury: evidence from network meta-analysis. Neurol Sci 2023; 44:1665-1678. [PMID: 36642741 DOI: 10.1007/s10072-023-06600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/31/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Neuroprotective drugs have been used to prevent secondary brain injury in patients with traumatic brain injury; however, the optimal medication remains questionable. We performed a Bayesian network meta-analysis to evaluate the safety and efficacy of different medications with known neuroprotective properties in this group of patients. METHODS Several databases were searched to identify any eligible trials comparing pharmacological components with confirmed neuroprotective mechanisms. Bayesian network meta-analysis was performed to combine direct and indirect evidence. The surface under the cumulative ranking curve was obtained to determine the ranking probability of the treatment agents for each outcome. The primary outcome was all-cause mortality. RESULTS A total of 23 trials comprising 4,325 participants were identified. The pooled relative risk (RR) showed administration of erythropoietin (RR: 0.68; 95% CrI: 0.50-0.93) and propranolol (RR: 0.43; 95% CrI: 0.20-0.85) decreased all-cause mortality compared with placebo. We also found erythropoietin (RR: 1.55; 95% CrI: 1.03-2.35), propranolol (RR: 1.52; 95% CrI: 1.05-2.20), and progesterone (RR: 1.47; 95% CrI: 1.03-2.10) showed better efficacy in functional recovery. CONCLUSION Overall, erythropoietin and propranolol were associated with reduced mortality in adults with traumatic brain injury. These treatment agents were also associated with improved functional outcomes.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xiaolong Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Hui Chen
- Department of Neurosurgery, Sichuan Friendship Hospital, Chengdu, Sichuan, People's Republic of China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
- West China Brain Research Centre, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Zagales I, Selvakumar S, Ngatuvai M, Fanfan D, Kornblith L, Santos RG, Ibrahim J, Elkbuli A. Beta-Blocker Therapy in Patients With Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Am Surg 2022:31348221101583. [PMID: 35575287 DOI: 10.1177/00031348221101583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI), a leading cause of morbidity and mortality among trauma patients worldwide, poses the risk of secondary neurological insult due to significant catecholamine surge. We aim to investigate the effectiveness and outcomes of beta-blocker administration in patients with severe TBI. METHODS A search through PubMed, EMBASE, JAMA network, and Google Scholar databases was conducted for relevant peer-reviewed original studies published before February 15, 2022. A standard random-effects model was used, as justified by a high Cohen's Q test. RESULTS Twelve studies met inclusion criteria and were included in the meta-analysis. Severe TBI patients who were administered beta-blockers had a significantly reduced incidence of in-hospital mortality compared to the non-beta-blocker group (14.5% vs 19.2%). However, the beta-blocker group was reported to have a significantly greater number of ventilator days (5.58 vs 2.60 days). Similarly, intensive care unit (9.00 vs 6.84 days) and hospital (17.30 vs 11.02 days) lengths of stay (LOS) were increased in the beta-blocker group compared to those who were not administered beta-blocker therapy, but only the difference in hospital-LOS was significant. CONCLUSIONS Beta-blockers have significantly decreased in-hospital mortality in patients with severe TBI despite being associated with an increase in ventilator days and hospital-LOS. The administration of beta-blocker therapy in the management of severe TBI may be warranted and should be discussed in future guidelines.
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Affiliation(s)
- Israel Zagales
- Universidad Iberoamericana (UNIBE) Escuela de Medicina, Santo Domingo, Dominican Republic
| | - Sruthi Selvakumar
- Dr. Kiran.C. Patel College of Allopathic Medicine, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Micah Ngatuvai
- Dr. Kiran.C. Patel College of Allopathic Medicine, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Dino Fanfan
- Herbert Wertheim College of Medicine,5450Florida International University, Miami, FL, USA
| | - Lucy Kornblith
- Division of Trauma and Surgical Critical Care, Department of Surgery, 36558Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA.,Department of Surgery, University of San Francisco, San Francisco, CA, USA
| | - Radleigh G Santos
- Department of Mathematics, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Joseph Ibrahim
- Division of Trauma and Surgical Critical Care, Department of Surgery, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
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Baron DH, Skrobot OA, Palmer JC, Sharma K, Kehoe P. The Renin Angiotensin System as a potential treatment target for Traumatic Brain Injury. J Neurotrauma 2022; 39:473-486. [PMID: 35029131 DOI: 10.1089/neu.2021.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Traumatic brain injury (TBI) is a major health concern and leading cause of death and disability in young adults in the UK and worldwide, however, there is a paucity of disease modifying therapies for the treatment of TBI. This review investigates the potential of the renin-angiotensin system (RAS) as a treatment pathway for traumatic brain injury (TBI) in adults. Relevant electronic databases were searched on 18 December 2019, updated 16 May 2021. All English language articles with adult human or animal populations investigating RAS drugs as an intervention for TBI or reporting genetic evidence relevant to the RAS and TBI were screened. Eighteen preclinical RCTs (n=2269) and 2 clinical cohort studies (n=771) were included. Meta-analyses of 6 preclinical randomised-controlled trials (n=99) indicated candesartan improved neurological function short-term (<7 days: standardised mean difference (SMD) 0.61, 95% confidence interval (CI) 0.19 - 1.03, I2=0%) and long-term (≥7 days: SMD 1.06, 95% CI 0.38; 1.73, I2=0%) post-TBI. Findings were similar for most secondary outcomes. There was a suggestion of benefit from other RAS-targeting drugs, although evidence was limited due to few small studies. There was insufficient evidence to enable strong assessment of these drugs on mortality post-TBI. We conclude that angiotensin-receptor blockers, especially candesartan, show positive outcomes post-TBI in preclinical studies with moderate quality of evidence (GRADE). More research into the effect of regulatory-RAS targeting drugs is needed. Clinical trials of candesartan following TBI are recommended, due to strong and consistent evidence of neuroprotection shown by these preclinical studies.
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Affiliation(s)
- Daniel Hendrik Baron
- University of Bristol, 1980, Dementia Research Group, Clinical Neurosciences, School of Clinical Sciences, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Olivia A Skrobot
- University of Bristol, 1980, Translational Health Sciences, Dementia Research Group, Clinical Neurosciences, School of Clinical Sciences, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Jennifer C Palmer
- University of Bristol, 1980, Population Health Sciences, Bristol Medical School, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland.,University of Bristol, 1980, MRC Integrative Epidemiology Unit, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Kanchan Sharma
- University of Bristol, 1980, Translational Health Sciences, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland.,North Bristol NHS Trust, 1982, Neurology, Westbury on Trym, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Patrick Kehoe
- University of Bristol, 1980, Translational Health Sciences, Dementia Research Group,, Clinical Neurosciences, School of Clinical Sciences, Bristol, - None -, United Kingdom of Great Britain and Northern Ireland, BS10 5NB.,University of Bristol;
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Scharenbrock AR, Katzenberger RJ, Fischer MC, Ganetzky B, Wassarman DA. Beta-blockers reduce intestinal permeability and early mortality following traumatic brain injury in Drosophila. MICROPUBLICATION BIOLOGY 2021; 2021:10.17912/micropub.biology.000461. [PMID: 34723144 PMCID: PMC8553408 DOI: 10.17912/micropub.biology.000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022]
Abstract
Traumatic brain injury (TBI) frequently leads to non-neurological consequences such as intestinal permeability. The beta-blocker drug labetalol, which inhibits binding of catecholamine neurotransmitters to adrenergic receptors, reduces intestinal permeability in a rat TBI model. Using a Drosophila melanogaster TBI model, we previously found a strong positive correlation between intestinal permeability and mortality within 24 hours of TBI in a standard laboratory line (w1118 ) and across genetically diverse inbred lines from the Drosophila Genetic Reference Panel (DGRP). Here, we report that feeding injured w1118 flies the beta-blockers labetalol and metoprolol reduced intestinal permeability and mortality. Additionally, metoprolol reduced intestinal permeability when 18 DGRP fly lines were analyzed in aggregate, but neither beta-blocker affected mortality. These data indicate that the mechanism underlying disruption of the intestinal barrier by adrenergic signaling following TBI is conserved between humans and flies and that mortality following TBI in flies is not strictly dependent on disruption of the intestinal barrier. Thus, the fly TBI model is useful for shedding light on the mechanism and consequences of adrenergic signaling between the brain and intestine following TBI in humans.
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Affiliation(s)
- Amanda R Scharenbrock
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706
| | - Rebeccah J Katzenberger
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706
| | - Megan C Fischer
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706
| | - Barry Ganetzky
- Department of Genetics, College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison, WI 53706
| | - David A Wassarman
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706,
Correspondence to: David A Wassarman ()
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