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Needham E, Webb G. Hepatic encephalopathy: a neurologist's perspective. Pract Neurol 2024:pn-2023-003802. [PMID: 38453473 DOI: 10.1136/pn-2023-003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
Liver disease is increasingly common, estimated to affect over 25% of the world's population. Failure of the liver to maintain a normal metabolic milieu leads to impaired brain function (hepatic encephalopathy), and conditions that cause liver disease can themselves predispose to neurological disease. As neurologists' involvement with the acute take increases, it is important that we are familiar with the neurological complications of liver disease, their investigation and management, and to know which other neurological diseases occur in this patient population. In this article, we review the causes, presentation and treatment of hepatic encephalopathy, and discuss important differential diagnoses in patients with liver disease who present with neurological disturbance.
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Affiliation(s)
- Edward Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gwilym Webb
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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2
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Alexander SK, Needham E. Diagnosis of delirium: a practical approach. Pract Neurol 2022; 23:192-199. [PMID: 36581459 DOI: 10.1136/pn-2022-003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/31/2022]
Abstract
Delirium is an acute disorder of fluctuating attention and awareness with cardinal features that allow it to be positively distinguished from other causes of an acute confusional state. These features include fluctuations, prominent inattentiveness with other cognitive deficits, a change in awareness and visual hallucinations. We describe a framework for diagnosing delirium, noting the need to consider certain caveats and differential diagnoses. Delirium is a clinical diagnosis where a thorough history and clinical examination are much more helpful diagnostically than any single test or combination of tests.
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Affiliation(s)
- Sian K Alexander
- Department of Neurology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Edward Needham
- Department of Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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3
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Mukherjee T, Needham E, Crisp S. An astra-nomical headache. J Neurol Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn2.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
IntroductionWe present a case of myelin-oligodendrocyte glycoprotein antibody disease (MOGAD) requiring long-term immunosuppression triggered by a dose of the AstraZeneca COVID-19 vaccination. Relapsing MOGAD is thus far an unknown complication of COVID-19 vaccination.Case Description: A 58-year-old lady developed headache, nausea, dizziness, facial numbness, ataxia and slurred speech 8 days after the COVID-19 AstraZeneca vaccination. Her imaging showed acute disseminated encephalomyelitis (ADEM) with a white matter lesion in the left cerebellum and bilateral smaller lesions. Her cerebrospinal fluid showed 38 white cells and elevated protein. She initially responded well to steroids, however relapsed with optic neuritis 7 months later, requiring long-term immunosuppres- sion with mycophenolate mofetil.DiscussionAlthough there have been some case reports of MOGAD following COVID-19 infection, to our knowledge this is only the second reported case of MOGAD following vaccination against COVID-19, and the first such case to require long-term immunosuppression. The other reported case also occurred following the COVID-19 AstraZeneca vaccine, and also presented with ADEM. This is in contrast to reported cases of MOGAD following COVID-19 infection, where adults mostly presented with optic neuritis. We wanted to highlight the possibility of this vaccine-related neurological complication occurring, particularly in the context of potentially frequent ongoing COVID-19 booster vaccinations.
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Newcombe VFJ, Ashton NJ, Posti JP, Glocker B, Manktelow A, Chatfield DA, Winzeck S, Needham E, Correia MM, Williams GB, Simrén J, Takala RSK, Katila AJ, Maanpää HR, Tallus J, Frantzén J, Blennow K, Tenovuo O, Zetterberg H, Menon DK. Post-acute blood biomarkers and disease progression in traumatic brain injury. Brain 2022; 145:2064-2076. [PMID: 35377407 PMCID: PMC9326940 DOI: 10.1093/brain/awac126] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/09/2022] [Accepted: 02/13/2022] [Indexed: 11/23/2022] Open
Abstract
There is substantial interest in the potential for traumatic brain injury to result in progressive neurological deterioration. While blood biomarkers such as glial fibrillary acid protein (GFAP) and neurofilament light have been widely explored in characterizing acute traumatic brain injury (TBI), their use in the chronic phase is limited. Given increasing evidence that these proteins may be markers of ongoing neurodegeneration in a range of diseases, we examined their relationship to imaging changes and functional outcome in the months to years following TBI. Two-hundred and three patients were recruited in two separate cohorts; 6 months post-injury (n = 165); and >5 years post-injury (n = 38; 12 of whom also provided data ∼8 months post-TBI). Subjects underwent blood biomarker sampling (n = 199) and MRI (n = 172; including diffusion tensor imaging). Data from patient cohorts were compared to 59 healthy volunteers and 21 non-brain injury trauma controls. Mean diffusivity and fractional anisotropy were calculated in cortical grey matter, deep grey matter and whole brain white matter. Accelerated brain ageing was calculated at a whole brain level as the predicted age difference defined using T1-weighted images, and at a voxel-based level as the annualized Jacobian determinants in white matter and grey matter, referenced to a population of 652 healthy control subjects. Serum neurofilament light concentrations were elevated in the early chronic phase. While GFAP values were within the normal range at ∼8 months, many patients showed a secondary and temporally distinct elevations up to >5 years after injury. Biomarker elevation at 6 months was significantly related to metrics of microstructural injury on diffusion tensor imaging. Biomarker levels at ∼8 months predicted white matter volume loss at >5 years, and annualized brain volume loss between ∼8 months and 5 years. Patients who worsened functionally between ∼8 months and >5 years showed higher than predicted brain age and elevated neurofilament light levels. GFAP and neurofilament light levels can remain elevated months to years after TBI, and show distinct temporal profiles. These elevations correlate closely with microstructural injury in both grey and white matter on contemporaneous quantitative diffusion tensor imaging. Neurofilament light elevations at ∼8 months may predict ongoing white matter and brain volume loss over >5 years of follow-up. If confirmed, these findings suggest that blood biomarker levels at late time points could be used to identify TBI survivors who are at high risk of progressive neurological damage.
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Affiliation(s)
| | - Nicholas J Ashton
- Wallenberg Centre for Molecular and Translational Medicine, University of
Gothenburg, Gothenburg, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and
Physiology, The Sahlgrenska Academy at the University of Gothenburg,
Mölndal, Sweden
- King’s College London, Institute of Psychiatry, Psychology and
Neuroscience, Maurice Wohl Institute Clinical Neuroscience Institute,
London, UK
- Mental Health and Biomedical Research Unit for Dementia, Maudsley NIHR
Biomedical Research Centre, London, UK
| | - Jussi P Posti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and
University of Turku, Turku, Finland
- Turku Brain Injury Center, Turku University Hospital and University of
Turku, Turku, Finland
| | - Ben Glocker
- Biomedical Image Analysis Group, Department of Computing, Imperial College
London, London, UK
| | - Anne Manktelow
- University Division of Anaesthesia, Department of Medicine, University of
Cambridge, Cambridge, UK
| | - Doris A Chatfield
- University Division of Anaesthesia, Department of Medicine, University of
Cambridge, Cambridge, UK
| | - Stefan Winzeck
- University Division of Anaesthesia, Department of Medicine, University of
Cambridge, Cambridge, UK
- Biomedical Image Analysis Group, Department of Computing, Imperial College
London, London, UK
| | - Edward Needham
- University Division of Anaesthesia, Department of Medicine, University of
Cambridge, Cambridge, UK
| | - Marta M Correia
- MRC (Medical Research Council) Cognition and Brain Sciences Unit,
University of Cambridge, Cambridge, UK
| | - Guy B Williams
- Wolfson Brain Imaging Centre, Department of Clinical
Neurosciences, Cambridge, UK
| | - Joel Simrén
- Institute of Neuroscience and Physiology, Department of Psychiatry and
Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg,
Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University
Hospital, Mölndal, Sweden
| | - Riikka S K Takala
- Perioperative Services, Intensive Care Medicine and Pain Management,
Department of Anesthesiology and Intensive Care, Turku University Hospital, University
of Turku, Turku, Finland
| | - Ari J Katila
- Perioperative Services, Intensive Care Medicine and Pain Management,
Department of Anesthesiology and Intensive Care, Turku University Hospital, University
of Turku, Turku, Finland
| | - Henna Riikka Maanpää
- Neurocenter, Department of Neurosurgery, Turku University Hospital and
University of Turku, Turku, Finland
- Turku Brain Injury Center, Turku University Hospital and University of
Turku, Turku, Finland
| | - Jussi Tallus
- Turku Brain Injury Center, Turku University Hospital and University of
Turku, Turku, Finland
| | - Janek Frantzén
- Neurocenter, Department of Neurosurgery, Turku University Hospital and
University of Turku, Turku, Finland
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and
Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg,
Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University
Hospital, Mölndal, Sweden
| | - Olli Tenovuo
- Turku Brain Injury Center, Turku University Hospital and University of
Turku, Turku, Finland
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and
Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg,
Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University
Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of
Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, University College
London, London, UK
- Hong Kong Center for Neurodegenerative Disease,
Hong Kong, China
| | - David K Menon
- Correspondence to: David Menon University Division of Anaesthesia
University of Cambridge Box 93, Addenbrooke’s Hospital Hills Road, Cambridge CB2 0QQ, UK
E-mail:
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Brown JWL, Cunniffe NG, Prados F, Kanber B, Jones JL, Needham E, Georgieva Z, Rog D, Pearson OR, Overell J, MacManus D, Samson RS, Stutters J, Ffrench-Constant C, Gandini Wheeler-Kingshott CAM, Moran C, Flynn PD, Michell AW, Franklin RJM, Chandran S, Altmann DR, Chard DT, Connick P, Coles AJ. Safety and efficacy of bexarotene in patients with relapsing-remitting multiple sclerosis (CCMR One): a randomised, double-blind, placebo-controlled, parallel-group, phase 2a study. Lancet Neurol 2021; 20:709-720. [PMID: 34418398 DOI: 10.1016/s1474-4422(21)00179-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/17/2021] [Accepted: 05/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Progressive disability in multiple sclerosis occurs because CNS axons degenerate as a late consequence of demyelination. In animals, retinoic acid receptor RXR-gamma agonists promote remyelination. We aimed to assess the safety and efficacy of a non-selective retinoid X receptor agonist in promoting remyelination in people with multiple sclerosis. METHODS This randomised, double-blind, placebo-controlled, parallel-group, phase 2a trial (CCMR One) recruited patients with relapsing-remitting multiple sclerosis from two centres in the UK. Eligible participants were aged 18-50 years and had been receiving dimethyl fumarate for at least 6 months. Via a web-based system run by an independent statistician, participants were randomly assigned (1:1), by probability-weighted minimisation using four binary factors, to receive 300 mg/m2 of body surface area per day of oral bexarotene or oral placebo for 6 months. Participants, investigators, and outcome assessors were masked to treatment allocation. MRI scans were done at baseline and at 6 months. The primary safety outcome was the number of adverse events and withdrawals attributable to bexarotene. The primary efficacy outcome was the patient-level change in mean lesional magnetisation transfer ratio between baseline and month 6 for lesions that had a baseline magnetisation transfer ratio less than the within-patient median. We analysed the primary safety outcome in the safety population, which comprised participants who received at least one dose of their allocated treatment. We analysed the primary efficacy outcome in the intention-to-treat population, which comprised all patients who completed the study. This study is registered in the ISRCTN Registry, 14265371, and has been completed. FINDINGS Between Jan 17, 2017, and May 17, 2019, 52 participants were randomly assigned to receive either bexarotene (n=26) or placebo (n=26). Participants who received bexarotene had a higher mean number of adverse events (6·12 [SD 3·09]; 159 events in total) than did participants who received placebo (1·63 [SD 1·50]; 39 events in total). All bexarotene-treated participants had at least one adverse event, which included central hypothyroidism (n=26 vs none on placebo), hypertriglyceridaemia (n=24 vs none on placebo), rash (n=13 vs one on placebo), and neutropenia (n=10 vs none on placebo). Five (19%) participants on bexarotene and two (8%) on placebo discontinued the study drug due to adverse events. One episode of cholecystitis in a placebo-treated participant was the only serious adverse event. The change in mean lesional magnetisation transfer ratio was not different between the bexarotene group (0·25 percentage units [pu; SD 0·98]) and the placebo group (0·09 pu [0·84]; adjusted bexarotene-placebo difference 0·16 pu, 95% CI -0·39 to 0·71; p=0·55). INTERPRETATION We do not recommend the use of bexarotene to treat patients with multiple sclerosis because of its poor tolerability and negative primary efficacy outcome. However, statistically significant effects were seen in some exploratory MRI and electrophysiological analyses, suggesting that other retinoid X receptor agonists might have small biological effects that could be investigated in further studies. FUNDING Multiple Sclerosis Society of the United Kingdom.
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Affiliation(s)
- J William L Brown
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK; Clinical Outcomes Research Unit, University of Melbourne, Melbourne, VIC, Australia
| | - Nick G Cunniffe
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Ferran Prados
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK; Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK; e-Health Center, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Baris Kanber
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK; Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK; National Institute for Health Research Biomedical Research Centre, University College London Hospitals NHS Foundation Trust and University College London, London, UK
| | - Joanne L Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Edward Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Zoya Georgieva
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Owen R Pearson
- Department of Neurology, Swansea Bay University Health Board, Swansea, UK
| | - James Overell
- Product Development Neuroscience, F Hoffmann-La Roche, Basel, Switzerland; Institute of Neurological Sciences, University of Glasgow, Glasgow, UK
| | - David MacManus
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Rebecca S Samson
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Jonathan Stutters
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | - Claudia A M Gandini Wheeler-Kingshott
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK; Brain Connectivity Centre, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Carla Moran
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Paul D Flynn
- Division of Cardiovascular Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Andrew W Michell
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Robin J M Franklin
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel R Altmann
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Declan T Chard
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, University College London, London, UK; National Institute for Health Research Biomedical Research Centre, University College London Hospitals NHS Foundation Trust and University College London, London, UK
| | - Peter Connick
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Needham E, Newcombe V, Michell A, Thornton R, Grainger A, Anwar F, Warburton E, Menon D, Trivedi M, Sawcer S. Mononeuritis multiplex: an unexpectedly frequent feature of severe COVID-19. J Neurol 2020; 268:2685-2689. [PMID: 33244712 PMCID: PMC7690651 DOI: 10.1007/s00415-020-10321-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/02/2020] [Accepted: 11/15/2020] [Indexed: 12/23/2022]
Abstract
The prolonged mechanical ventilation that is often required by patients with severe COVID-19 is expected to result in significant intensive care unit-acquired weakness (ICUAW) in many of the survivors. However, in our post-COVID-19 follow-up clinic we have found that, as well as the anticipated global weakness related to loss of muscle mass, a significant proportion of these patients also have disabling focal neurological deficits relating to multiple axonal mononeuropathies. Amongst the 69 patients with severe COVID-19 that have been discharged from the intensive care units in our hospital, we have seen 11 individuals (16%) with such a mononeuritis multiplex. In many instances, the multi-focal nature of the weakness in these patients was initially unrecognised as symptoms were wrongly assumed to relate simply to “critical illness neuromyopathy”. While mononeuropathy is well recognised as an occasional complication of intensive care, our experience suggests that such deficits are surprisingly frequent and often disabling in patients recovering from severe COVID-19.
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Affiliation(s)
- Edward Needham
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Virginia Newcombe
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Andrew Michell
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Rachel Thornton
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Andrew Grainger
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Fahim Anwar
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Elizabeth Warburton
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - David Menon
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Monica Trivedi
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Stephen Sawcer
- Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
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Coles AJ, Azzopardi L, Kousin-Ezewu O, Mullay HK, Thompson SA, Jarvis L, Davies J, Howlett S, Rainbow D, Babar J, Sadler TJ, Brown JWL, Needham E, May K, Georgieva ZG, Handel AE, Maio S, Deadman M, Rota I, Holländer G, Dawson S, Jayne D, Seggewiss-Bernhardt R, Douek DC, Isaacs JD, Jones JL. Keratinocyte growth factor impairs human thymic recovery from lymphopenia. JCI Insight 2019; 5:125377. [PMID: 31063156 PMCID: PMC6629095 DOI: 10.1172/jci.insight.125377] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The lymphocyte-depleting antibody alemtuzumab is a highly effective treatment of relapsing-remitting multiple sclerosis (RRMS); however 50% of patients develop novel autoimmunity post-treatment. Most at risk are individuals who reconstitute their T-cell pool by proliferating residual cells, rather than producing new T-cells in the thymus; raising the possibility that autoimmunity might be prevented by increasing thymopoiesis. Keratinocyte growth factor (palifermin) promotes thymopoiesis in non-human primates. METHODS Following a dose-tolerability sub-study, individuals with RRMS (duration ≤10 years; expanded disability status scale ≤5·0; with ≥2 relapses in the previous 2 years) were randomised to placebo or 180mcg/kg/day palifermin, given for 3 days immediately prior to and after each cycle of alemtuzumab, with repeat doses at M1 and M3. The interim primary endpoint was naïve CD4+ T-cell count at M6. Exploratory endpoints included: number of recent thymic-emigrants (RTEs) and signal-joint T-cell receptor excision circles (sjTRECs)/mL of blood. The trial primary endpoint was incidence of autoimmunity at M30. FINDINGS At M6, individuals receiving palifermin had fewer naïve CD4+T-cells (2.229x107/L vs. 7.733x107/L; p=0.007), RTEs (16% vs. 34%) and sjTRECs/mL (1100 vs. 3396), leading to protocol-defined termination of recruitment. No difference was observed in the rate of autoimmunity between the two groupsConclusion: In contrast to animal studies, palifermin reduced thymopoiesis in our patients. These results offer a note of caution to those using palifermin to promote thymopoiesis in other settings, particularly in the oncology/haematology setting where alemtuzumab is often used as part of the conditioning regime. TRIAL REGISTRATION ClinicalTrials.gov NCT01712945Funding: MRC and Moulton Charitable Foundation.
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Affiliation(s)
- Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Laura Azzopardi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Onajite Kousin-Ezewu
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Harpreet Kaur Mullay
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sara Aj Thompson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Lorna Jarvis
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jessica Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Howlett
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel Rainbow
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Judith Babar
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Timothy J Sadler
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - J William L Brown
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Edward Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Karen May
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Zoya G Georgieva
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | | | - Stefano Maio
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Mary Deadman
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ioanna Rota
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Georg Holländer
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Sarah Dawson
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Medical Research Council (MRC) Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - David Jayne
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ruth Seggewiss-Bernhardt
- University Hospital of Würzburg, Würzburg, Germany.,Department of Hematology/Oncology, Soziastiftung Bamberg, Bamberg, Germany
| | - Daniel C Douek
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - John D Isaacs
- Institute of Cellular Medicine, Newcastle University, and Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Joanne L Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Bacchi S, Franke K, Wewegama D, Needham E, Patel S, Menon D. Magnetic resonance imaging and positron emission tomography in anti-NMDA receptor encephalitis: A systematic review. J Clin Neurosci 2018; 52:54-59. [DOI: 10.1016/j.jocn.2018.03.026] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/20/2018] [Accepted: 03/05/2018] [Indexed: 02/06/2023]
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Needham E, McFadyen C, Newcombe V, Synnot AJ, Czosnyka M, Menon D. Cerebral Perfusion Pressure Targets Individualized to Pressure-Reactivity Index in Moderate to Severe Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2016; 34:963-970. [PMID: 27246184 DOI: 10.1089/neu.2016.4450] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Traumatic brain injury (TBI) frequently triggers a disruption of cerebral autoregulation. The cerebral perfusion pressure (CPP) at which autoregulation is optimal ("CPPopt") varies between individuals, and can be calculated based on fluctuations between arterial blood pressure and intracranial pressure. This review assesses the effect of individualizing CPP targets to pressure reactivity index (a measure of autoregulation) in patients with TBI. Cochrane Central Register of Controlled Trials, MEDLINE®, Embase, and Cumulative Index of Nursing and Allied Health Literature were searched in March 2015 for studies assessing the effect of targeting CPPopt in TBI. We included all studies that assessed the impact of targeting CPPopt on outcomes including mortality, neurological outcome, and physiological changes. Risk of bias was assessed using the RTI Item Bank and evidence quality was considered using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Eight cohort studies (based on six distinct data sets) assessing the association between CPPopt and mortality, Glasgow Outcome Scale and physiological measures in TBI were included. The quality of evidence was deemed very low based on the GRADE criteria. Although the data suggest an association between variation from CPPopt and poor clinical outcome at 6 months, the quality of evidence prevents firm conclusions, particularly regarding causality, from being drawn. Available data suggest that targeting CPPopt might represent a technique to improve outcomes following TBI, but currently there is insufficient high-quality data to support a recommendation for use in clinical practice. Further prospective, randomized controlled studies should be undertaken to clarify its role in the acute management of TBI.
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Affiliation(s)
- Edward Needham
- 1 Department of Neurology, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Charles McFadyen
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Virginia Newcombe
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Anneliese J Synnot
- 3 Australian & New Zealand Intensive Care Research Centre (ANZIC-RC) , School of Public Health and Preventive Medicine, Monash University, Melbourne Victoria, Australia; Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; National Trauma Research Institute, Melborne, Australia
| | - Marek Czosnyka
- 4 Brain Physics Lab, Division of Neurosurgery, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - David Menon
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
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Sekhon MS, Griesdale DE, Robba C, McGlashan N, Needham E, Walland K, Shook AC, Smielewski P, Czosnyka M, Gupta AK, Menon DK. Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury. Intensive Care Med 2014; 40:1267-74. [DOI: 10.1007/s00134-014-3392-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/01/2014] [Indexed: 10/25/2022]
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Abstract
The psychoses of epilepsy are well recognized complications of seizure disorders, diagnosed easily from the history. However, in the absence of recognized seizures, the diagnosis can be challenging. We present a 27-year-old female, who suffered a treatment refractory psychosis for 6 years. She did not report, or display, any seizure activity, and extensive investigation was unremarkable. The onset of new symptoms prompted a repeat work-up which clinched the diagnosis of psychosis of epilepsy. Treatment with Lamotrigine and Amisulpiride achieved an excellent response, and she has remained symptom free for 7 months. We conclude with a brief literature review.
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Galton DJ, Thorn J, Mattu R, Needham E, Stocks J. Common genetic variants relating to familial hypertriglyceridaemia. Anal Bioanal Chem 1992. [DOI: 10.1007/bf00331975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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