Description of the Method for Evaluating Digital Endpoints in Alzheimer Disease Study: Protocol for an Exploratory, Cross-sectional Study

Background

More sensitive and less burdensome efficacy end points are urgently needed to improve the effectiveness of clinical drug development for Alzheimer disease (AD). Although conventional end points lack sensitivity, digital technologies hold promise for amplifying the detection of treatment signals and capturing cognitive anomalies at earlier disease stages. Using digital technologies and combining several test modalities allow for the collection of richer information about cognitive and functional status, which is not ascertainable via conventional paper-and-pencil tests.

Objective

This study aimed to assess the psychometric properties, operational feasibility, and patient acceptance of 10 promising technologies that are to be used as efficacy end points to measure cognition in future clinical drug trials.

Methods

The Method for Evaluating Digital Endpoints in Alzheimer Disease study is an exploratory, cross-sectional, noninterventional study that will evaluate 10 digital technologies’ ability to accurately classify participants into 4 cohorts according to the severity of cognitive impairment and dementia. Moreover, this study will assess the psychometric properties of each of the tested digital technologies, including the acceptable range to assess ceiling and floor effects, concurrent validity to correlate digital outcome measures to traditional paper-and-pencil tests in AD, reliability to compare test and retest, and responsiveness to evaluate the sensitivity to change in a mild cognitive challenge model. This study included 50 eligible male and female participants (aged between 60 and 80 years), of whom 13 (26%) were amyloid-negative, cognitively healthy participants (controls); 12 (24%) were amyloid-positive, cognitively healthy participants (presymptomatic); 13 (26%) had mild cognitive impairment (predementia); and 12 (24%) had mild AD (mild dementia). This study involved 4 in-clinic visits. During the initial visit, all participants completed all conventional paper-and-pencil assessments. During the following 3 visits, the participants underwent a series of novel digital assessments.

Results

Participant recruitment and data collection began in June 2020 and continued until June 2021. Hence, the data collection occurred during the COVID-19 pandemic (SARS-CoV-2 virus pandemic). Data were successfully collected from all digital technologies to evaluate statistical and operational performance and patient acceptance. This paper reports the baseline demographics and characteristics of the population studied as well as the study's progress during the pandemic.

Conclusions

This study was designed to generate feasibility insights and validation data to help advance novel digital technologies in clinical drug development. The learnings from this study will help guide future methods for assessing novel digital technologies and inform clinical drug trials in early AD, aiming to enhance clinical end point strategies with digital technologies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35442

An orally available, brain penetrant, small molecule lowers huntingtin levels by enhancing pseudoexon inclusion

Huntington's Disease (HD) is a progressive neurodegenerative disorder caused by CAG trinucleotide repeat expansions in exon 1 of the huntingtin (HTT) gene. The mutant HTT (mHTT) protein causes neuronal dysfunction, causing progressive motor, cognitive and behavioral abnormalities. Current treatments for HD only alleviate symptoms, but cerebral spinal fluid (CSF) or central nervous system (CNS) delivery of antisense oligonucleotides (ASOs) or virus vectors expressing RNA-induced silencing (RNAi) moieties designed to induce mHTT mRNA lowering have progressed to clinical trials. Here, we present an alternative disease modifying therapy the orally available, brain penetrant small molecule branaplam. By promoting inclusion of a pseudoexon in the primary transcript, branaplam lowers mHTT protein levels in HD patient cells, in an HD mouse model and in blood samples from Spinal Muscular Atrophy (SMA) Type I patients dosed orally for SMA (NCT02268552). Our work paves the way for evaluating branaplam's utility as an  HD therapy, leveraging small molecule splicing modulators to reduce expression of dominant disease genes by driving pseudoexon inclusion.

A Study of Novel Exploratory Tools, Digital Technologies, and Central Nervous System Biomarkers to Characterize Unipolar Depression

Background: Digital technologies have the potential to provide objective and precise tools to detect depression-related symptoms. Deployment of digital technologies in clinical research can enable collection of large volumes of clinically relevant data that may not be captured using conventional psychometric questionnaires and patient-reported outcomes. Rigorous methodology studies to develop novel digital endpoints in depression are warranted. Objective: We conducted an exploratory, cross-sectional study to evaluate several digital technologies in subjects with major depressive disorder (MDD) and persistent depressive disorder (PDD), and healthy controls. The study aimed at assessing utility and accuracy of the digital technologies as potential diagnostic tools for unipolar depression, as well as correlating digital biomarkers to clinically validated psychometric questionnaires in depression. Methods: A cross-sectional, non-interventional study of 20 participants with unipolar depression (MDD and PDD/dysthymia) and 20 healthy controls was conducted at the Centre for Human Drug Research (CHDR), the Netherlands. Eligible participants attended three in-clinic visits (days 1, 7, and 14), at which they underwent a series of assessments, including conventional clinical psychometric questionnaires and digital technologies. Between the visits, there was at-home collection of data through mobile applications. In all, seven digital technologies were evaluated in this study. Three technologies were administered via mobile applications: an interactive tool for the self-assessment of mood, and a cognitive test; a passive behavioral monitor to assess social interactions and global mobility; and a platform to perform voice recordings and obtain vocal biomarkers. Four technologies were evaluated in the clinic: a neuropsychological test battery; an eye motor tracking system; a standard high-density electroencephalogram (EEG)-based technology to analyze the brain network activity during cognitive testing; and a task quantifying bias in emotion perception. Results: Our data analysis was organized by technology - to better understand individual features of various technologies. In many cases, we obtained simple, parsimonious models that have reasonably high diagnostic accuracy and potential to predict standard clinical outcome in depression. Conclusion: This study generated many useful insights for future methodology studies of digital technologies and proof-of-concept clinical trials in depression and possibly other indications.

Effect of the sexual abstinence period recommended by the World Health Organization on clinical outcomes of fresh embryo transfer cycles with normal ovarian response after intracytoplasmic sperm injection

This study was to investigate whether the sexual abstinence period (SAP) recommended by the World Health Organization (WHO) affects clinical outcomes. We compared the rate of clinical outcomes between 2-7 and ≥8 days of SAP in first fresh embryo transfer after intracytoplasmic sperm injection (ICSI) in groups of young maternal age (YMA: <38 years) and old maternal age (OMA: ≥38 years). We conducted a retrospective study of 449 first ICSI cycles with a normal ovarian response. SAP was identified before collecting the semen samples. Semen analysis was performed based on the guidelines recommended by WHO (2010). Sperm preparation was made using the swim-up method. Patients' baseline characteristics in the YMA and OMA groups did not differ. The rates of fertilisation, top-quality embryos on day 3, biochemical pregnancy, clinical pregnancy, ongoing pregnancy, abortion and implantation per cycle were not significantly different between 2-7 and ≥8 days of SAP in the YMA or OMA group. In conclusion, SAP beyond the recommended period by WHO was not associated with the rates of a lower fertilisation and pregnancy in human in vitro fertilisation (IVF). We think that a new criterion of SAP for clinical application in human IVF needs to be considered by WHO.

Mavoglurant Augmentation in OCD Patients Resistant to Selective Serotonin Reuptake Inhibitors: A Proof-of-Concept, Randomized, Placebo-Controlled, Phase 2 Study

INTRODUCTION

To determine if mavoglurant (modified release) as an augmentation therapy to selective serotonin reuptake inhibitors (SSRIs) could have beneficial effects reducing Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score in patients with obsessive-compulsive disorder (OCD) resistant to SSRI treatment.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase 2 study. Patients remained on their SSRI treatment and mavoglurant or placebo was added on. Non-smoking men and women aged 18-65 years primarily diagnosed with OCD according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria were randomized (1:1) to mavoglurant or placebo groups. After 50 patients were randomized, an interim analysis was conducted to determine whether the study should be continued. The primary outcome measure was absolute change in Y-BOCS from baseline at week 17. Safety was assessed by recording adverse events (AEs) and serious adverse events (SAEs).

RESULTS

Interim analysis led to a decision to terminate the study. In total 38 (76.0%) participants completed 17 weeks of treatment and 37 (74.0%) completed the study. There was no significant difference in least squares (LS) mean change from baseline at week 17 in Y-BOCS total score for mavoglurant compared with placebo groups [-6.9 (1.75) vs. -8.0 (1.78), respectively; LS mean difference 1.1; 95% CI -3.9, 6.2; p = 0.671]. The incidence of AEs was higher in the mavoglurant compared with the placebo group (80.8% vs. 70.8%, respectively).

CONCLUSION

This study of mavoglurant in OCD was terminated because of the lack of efficacy at interim analysis. The study did not support the use of an antagonist of mGluR5 receptors for OCD treatment.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov: NCT01813019.

FUNDING

This study was sponsored by Novartis Pharma AG, Basel, Switzerland.

A randomized, crossover, placebo-controlled clinical trial to assess the sensitivity of the CRCDS Mini-Sim to the next-day residual effects of zopiclone

OBJECTIVES

We sought to validate Cognitive Research Corporation's Driving Simulator (CRCDS Mini-Sim) for studies of drug safety with respect to driving ability.

METHODS

A total of 30 healthy subjects were randomized to receive placebo or 7.5 mg zopiclone, a hypnotic known to impair driving, in random order during the 2 treatment periods of a 2 period crossover design.

RESULTS

Evening administration of 7.5 mg zopiclone increased next-day standard deviation of lateral lane position (SDLP) by 2.62 cm on average compared with evening administration of placebo, and caused significant effects on symmetry analysis. The magnitude of the change in SDLP is highly similar to changes previously observed using on-the-road driving methods.

CONCLUSIONS

Further validation of the CRCDS Mini-Sim is warranted to develop this platform for drug safety studies.

Prediction of pathological complete response of breast cancer patients undergoing neoadjuvant chemotherapy: usefulness of breast MRI computer-aided detection

OBJECTIVE

To evaluate the usefulness of MR computer-aided detection (CAD) in patients undergoing neoadjuvant chemotherapy for prediction of the pathological complete response of tumours.

METHODS

148 patients with breast cancer (mean age, 47.3 years; range, 29-72 years) who underwent neoadjuvant chemotherapy were included in our study. They underwent MRI before and after neoadjuvant chemotherapy, and we reviewed the pathological result as the gold standard. The computer-generated kinetic features for each lesion were recorded, and the features analysed included "threshold enhancement" at 50% and 100% minimum thresholds; degree of initial peak enhancement; and enhancement profiles comprising lesion percentages of washout, plateau and persistent enhancement. The final pathological size and character of tumours were correlated with post-chemotherapy mammography, ultrasonography and MR CAD findings. Kruskal-Wallis test and intraclass correlation coefficient were used to analyse the findings.

RESULTS

We divided the 148 patients into complete pathological response and non-complete pathological response groups. A complete pathological response was defined as no histopathological evidence of any residual invasive cancer cells in the breast or axillary lymph nodes. 39 patients showed complete pathological response, and 109 patients showed non-complete pathological response. Between enhancement profiles of MR CAD, plateau proportion of tumours was significantly correlated with the pathological response of tumours (mean proportion of plateau on complete pathological response group was 27%, p = 0.007).

CONCLUSION

When plateau proportion of tumours is high, we can predict non-complete pathological response of neoadjuvant chemotherapy.

ADVANCES IN KNOWLEDGE

MR CAD can be a useful tool for the assessment of response to neoadjuvant chemotherapy and prediction of pathological results.

Assessment of extent of breast cancer: comparison between digital breast tomosynthesis and full-field digital mammography

AIM

To compare the accuracy of digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM) in preoperative assessment of local extent of breast cancer.

MATERIALS AND METHODS

Lesion sizes of breast cancers on DBT and FFDM images were independently evaluated by breast radiologists. Each lesion was flagged as either mis-sized or not depending on whether the assessment of size at imaging was within 1 cm of the lesion size at surgery. Additional analyses were made by mammographic parenchymal density and by lesion size, using 2 cm as the boundary to separate the two subgroups. Statistical comparisons were performed using a repeated measures linear model on the percent mis-sized. P-values < 0.05 were considered statistically significant.

RESULTS

The dataset included 173 malignant breast lesions (mean size 23.8 mm, 43% of lesions were ≤2 cm in size) in 169 patients, two-thirds of which had heterogeneously or extremely dense breasts. Overall, the percentage of lesions mis-sized at DBT was significantly lower than at FFDM (19% versus 29%, p = 0.003). There was significantly less mis-sizing at DBT in both heterogeneously dense breasts (11.1% difference between DBT and FFDM, p = 0.016) and extremely dense breasts (15.8% difference, p = 0.024). DBT also had significantly less mis-sizing than FFDM in the subgroup of lesions that were ≤2 cm in size (14.7% difference, p = 0.005).

CONCLUSION

DBT was significantly superior to FFDM for the evaluation of lesion size overall, and specifically for small lesions and for lesions in dense breasts. The superiority of DBT versus FFDM increased with parenchymal density.

Longitudinal split of the posterior cruciate ligament: description of a new MR finding and evaluation of its potential clinical significance

AIM

To evaluate the clinical significance of the intra-substance longitudinal split of the posterior cruciate ligament (LS-PCL) and to evaluate its potential clinical significance on MRI.

MATERIALS AND METHODS

The databases of two centres were searched for LS-PCL, 6917 knee magnetic resonance imaging (MRI) examinations undertaken were retrospectively reviewed. LS-PCL was defined as increased signal intensity in a PCL in the longitudinal direction, but with an intact ligament outer surface on MRI. Twelve patients were enrolled in this study. Available arthroscopic results, degree of posterior knee instability, and changes in MRI findings, or the degree of instability during follow-up (FU), were reviewed from the patients medical records and via their MRI images. MRI images were reviewed by two musculoskeletal radiologists in consensus for presence and location of LS-PCL and any combined injuries: menisci lesions, ligament injuries, and bone marrow changes.

RESULTS

Seven of 12 patients (58.3%) had morphological or functional evidence of PCL injury or insufficiency according to the change of posterior instability on FU stress testing (n=3), insufficiency during arthroscopy (n=2), or decreased extent and altered shape of the PCL split on the FU MRI (n=3). One patient revealed both change of posterior instability on FU stress testing and insufficiency during arthroscopy. Combined injuries were revealed in seven patients. Five patients had isolated LS-PCL: two patients underwent arthroscopic PCL reconstructions; and another three patients revealed knee instability on stress testing.

CONCLUSION

Although LS-PCL has not been described before, it can be a type of partial tear of the PCL, which causes PCL insufficiency.

Altered white matter microstructure in the corpus callosum in Huntington's disease: implications for cortical "disconnection"

The corpus callosum (CC) is the major conduit for information transfer between the cerebral hemispheres and plays an integral role in relaying sensory, motor and cognitive information between homologous cortical regions. The majority of fibers that make up the CC arise from large pyramidal neurons in layers III and V, which project contra-laterally. These neurons degenerate in Huntington's disease (HD) in a topographically and temporally selective way. Since any focus of cortical degeneration could be expected to secondarily de-afferent homologous regions of cortex, we hypothesized that regionally selective cortical degeneration would be reflected in regionally selective degeneration of the CC. We used conventional T1-weighted, diffusion tensor imaging (DTI), and a modified corpus callosum segmentation scheme to examine the CC in healthy controls, huntingtin gene-carriers and symptomatic HD subjects. We measured mid-sagittal callosal cross-sectional thickness and several DTI parameters, including fractional anisotropy (FA), which reflects the degree of white matter organization, radial diffusivity, a suggested index of myelin integrity, and axial diffusivity, a suggested index of axonal damage of the CC. We found a topologically selective pattern of alterations in these measures in pre-manifest subjects that were more extensive in early symptomatic HD subjects and that correlated with performance on distinct cognitive measures, suggesting an important role for disrupted inter-hemispheric transfer in the clinical symptoms of HD. Our findings provide evidence for early degeneration of commissural pyramidal neurons in the neocortex, loss of cortico-cortical connectivity, and functional compromise of associative cortical processing.

Identification of process operating state with operational map in municipal wastewater treatment plant

This work was performed to develop an operational map for the objective diagnosis of the process operating states of a municipal wastewater treatment plant, for which multivariate statistical analysis techniques were applied. PCA (principal component analysis) was used to reduce the dimension of the data sets obtained from the field municipal wastewater treatment plant. A K-means clustering analysis was used to classify the group according to the property of the process operating state. A Fisher's linear discriminant analysis was used to derive the discriminant function of each classified group. An operational map was developed by scatter-plotting the derived principal components (PCs) on a two-dimensional coordinate according to the classified groups. Using the new data sets not used for developing the operational map, the practical usefulness of the operational map and discriminant function in diagnosing the process operating state were evaluated. Hence, the process operating state could be easily and quickly diagnosed and the dynamic trend of the process operating state was also able to be estimated using the operational map.

Dopamine release is impaired in a mouse model of DYT1 dystonia

Early onset torsion dystonia, the most common form of hereditary primary dystonia, is caused by a mutation in the TOR1A gene, which codes for the protein torsinA. This form of dystonia is referred to as DYT1. We have used a transgenic mouse model of DYT1 dystonia [human mutant-type (hMT)1 mice] to examine the effect of the mutant human torsinA protein on striatal dopaminergic function. Analysis of striatal tissue dopamine (DA) and metabolites using HPLC revealed no difference between hMT1 mice and their non-transgenic littermates. Pre-synaptic DA transporters were studied using in vitro autoradiography with [(3)H]mazindol, a ligand for the membrane DA transporter, and [(3)H]dihydrotetrabenazine, a ligand for the vesicular monoamine transporter. No difference in the density of striatal DA transporter or vesicular monoamine transporter binding sites was observed. Post-synaptic receptors were studied using [(3)H]SCH-23390, a ligand for D(1) class receptors, [(3)H]YM-09151-2 and a ligand for D(2) class receptors. There were again no differences in the density of striatal binding sites for these ligands. Using in vivo microdialysis in awake animals, we studied basal as well as amphetamine-stimulated striatal extracellular DA levels. Basal extracellular DA levels were similar, but the response to amphetamine was markedly attenuated in the hMT1 mice compared with their non-transgenic littermates (253 +/- 71% vs. 561 +/- 132%, p < 0.05, two-way anova). These observations suggest that the mutation in the torsinA protein responsible for DYT1 dystonia may interfere with transport or release of DA, but does not alter pre-synaptic transporters or post-synaptic DA receptors. The defect in DA release as observed may contribute to the abnormalities in motor learning as previously documented in this transgenic mouse model, and may contribute to the clinical symptoms of the human disorder.

Vertebroplasty: magnetic resonance findings related to cement leakage risk

PURPOSE

To find magnetic resonance (MR) findings predicting cement leakage in patients receiving percutaneous vertebroplasty (PVP) due to osteoporotic compression fractures.

MATERIAL AND METHODS

MR was done in 43 patients (age 52-89 years) before PVP (56 vertebrae), which was done via a bipedicular approach with fluoroscopic monitoring. Shortly after the procedure, a non-contrast-enhanced computed tomography (CT) scan was done at the vertebroplasty sites for evaluation of bone cement leakage. The following MR findings of fractured vertebral bodies were retrospectively reviewed for correlation with leakage risk: severity of bone-marrow edema, presence of a T2-weighted low-signal-intensity line, percentage residual vertebral body height, presence of either a vacuum or cystic change within the vertebral body, and presence of a cortical disruption.

RESULTS

After PVP, cement leakage was detected in 35 vertebrae (62.5%). Leakage was most frequently observed in the anterior external vertebral venous plexus (46%). Cement leakage rate increased when there was a cortical disruption (P = 0.037), especially at the endplates, while it decreased when there was a vacuum or a cystic change within the fractured vertebra (P = 0.019). Other MR findings were not related to the risk of cement leakage.

CONCLUSION

The risk of cement leakage in PVP increases when MR shows cortical disruption in a fractured vertebral body, especially at the endplates. It decreases when MR shows a vacuum or cystic change within the body.

High frequency broadband PZT thick film ultrasonic transducers for medical imaging applications

A modified sol-gel method is used to prepare PZT thick film on Pt-coated silicon substrate. A new method of vacuum filling sol-gel precursor solution is introduced to improve film quality. The effects of the filling on PZT thick film structure and ferroelectric properties are discussed. The fabrication of a high frequency transducer with the PZT film as the actuating layer is described. The performance of the transducer is measured and results show that the transducer backed by E-Solder without a matching layer has a center frequency of 103 MHz and a bandwidth of 70%. Beam profile measurements show that the transducer has an axial resolution of 9.2 microm and a lateral resolution of 33 microm.

Venezuelan kindreds reveal that genetic and environmental factors modulate Huntington's disease age of onset

Huntington's disease (HD) is an autosomal dominant neurodegenerative disease caused by a triplet (CAG) expansion mutation. The length of the triplet repeat is the most important factor in determining age of onset of HD, although substantial variability remains after controlling for repeat length. The Venezuelan HD kindreds encompass 18,149 individuals spanning 10 generations, 15,409 of whom are living. Of the 4,384 immortalized lymphocyte lines collected, 3,989 DNAs were genotyped for their HD alleles, representing a subset of the population at greatest genetic risk. There are 938 heterozygotes, 80 people with variably penetrant alleles, and 18 homozygotes. Analysis of the 83 kindreds that comprise the Venezuelan HD kindreds demonstrates that residual variability in age of onset has both genetic and environmental components. We created a residual age of onset phenotype from a regression analysis of the log of age of onset on repeat length. Familial correlations (correlation +/- SE) were estimated for sibling (0.40 +/- 0.09), parent-offspring (0.10 +/- 0.11), avuncular (0.07 +/- 0.11), and cousin (0.15 +/- 0.10) pairs, suggesting a familial origin for the residual variance in onset. By using a variance-components approach with all available familial relationships, the additive genetic heritability of this residual age of onset trait is 38%. A model, including shared sibling environmental effects, estimated the components of additive genetic (0.37), shared environment (0.22), and nonshared environment (0.41) variances, confirming that approximately 40% of the variance remaining in onset age is attributable to genes other than the HD gene and 60% is environmental.

Diffusion-weighted magnetic resonance imaging abnormalities in Bartonella encephalopathy

The authors describe 2 patients with new-onset, refractory status epilepticus and serological evidence for Bartonella infection. Brain magnetic resonance imaging (MRI) in patient 1 showed transient diffusion abnormalities in the posterior (pulvinar) thalami. In patient 2, brain MRI showed several enhancing cortical lesions, of which one lesion was bright on diffusion-weighted imaging (DWI). In patients with unexplained, refractory seizures, the presence of DWI abnormalities warrants a search for unusual infectious or inflammatory disorders, like Bartonella encephalitis.

Synthesis and In vitro binding affinities of 1-azabicyclic compounds as muscarinic ligands

Two series of compounds, 2 and 3, were synthesized and their binding affinities were evaluated for the human recombinant muscarinic M(1) receptor subtype expressed in CHO cells. Comparing their binding affinities for the NMS binding sites and the Oxo-M binding sites, they were assumed as agonists. In particular, compound 2e was a good ligand for the agonist binding sites with an IC(50) of 23 nM, which represents over 1585 times stronger binding than for the antagonist binding sites.

Expression of osteopontin mRNA in developing rat brainstem and cerebellum

This study was undertaken to investigate the developmental expression of osteopontin (OPN) in the rat brainstem and cerebellum by Northern blotting and in situ hybridization. The expression of OPN was noted in the mesencephalic Vth nucleus initially at embryonic day 16 (E16). At E20, the labeling extended into other brainstem nuclei including the cochlear, vestibular, facial motor, and hypoglossal nuclei. During the first week of postnatal life, the OPN signal in the brainstem increased markedly, and by P14, OPN expression was found in functionally diverse areas including motor-related areas, sensory relay nuclei, and the reticular formation. The adult labeling pattern was established in central neurons at this time. These results corresponded well with those from Northern blot analysis. On the basis of morphological and distribution criteria, the OPN signal in several nuclei appeared to be contained exclusively within neuronal soma. OPN expression in neurons occurred during the period of neuronal differentiation and increased with maturation. Our results therefore suggest that OPN contributes to developmental processes, including the differentiation and maturation of specific neuronal populations, in the rat brain.

Treatment of vitiligo with suction epidermal grafting by the use of an ultrapulse CO2 laser with a computerized pattern generator

BACKGROUND

Laser ablation is used to remove the recipient epidermis in the suction epidermal grafting in vitiligo surgery.

OBJECTIVE

To evaluate the effectiveness and safety of a suction epidermal grafting method after the removal of the epidermis by the use of the Ultrapulse CO2 laser with a computerized pattern generator.

METHODS

Eleven patients with 34 lesions of refractory stable vitiligo were studied.

RESULTS

Of the 34 lesion sites, excellent repigmentation was seen in 30 and the other 4 had good repigmentation. No complications occurred.

CONCLUSION

The Ultrapulse CO2 laser is particularly well suited for deepithelialization in vitiligo surgery.

Remotivation therapy and Huntington's disease

Huntington's disease (HD) is a genetic, autosomal dominant, neurodegenerative disorder for which there is no known cure. Because remotivation therapy (RmT) has been effective in other neurological conditions and because of the lack of current efficacious treatments for HD, RmT may be a beneficial therapy for persons suffering from the disease. By cultivating a more fertile environment, RmT leads to increased self-awareness, self-esteem, and an improved quality of life, even in late-stage HD. Two recent studies using animal models suggest that exposure of transgenic HD mice to a stimulating, enriched environment helped to prevent the loss of cerebral volume and delay the onset of motor disorders. Six case studies are presented that demonstrate improved physical, mental, and social functioning in persons with HD when a more stimulating environment is provided.

Six cases of confluent and reticulated papillomatosis alleviated by various antibiotics

Confluent and reticulated papillomatosis (CRP) is a relatively rare disorder manifested by persistent papules that are confluent in the center and reticulated at the periphery with a characteristic distribution. Recently, many cases of CRP treated with minocycline have been reported, and their effect seems to be derived from their antibiotic properties. We report 6 cases of CRP alleviated by various antibiotics. The patient described in case 1 is a 16-year-old girl whose disease was alleviated by oral minocycline, 100 mg daily for 8 weeks. Cases 2 and 3 describe an 18-year-old woman and a 17-year-old male adolescent whose disease was reduced by oral fusidic acid, 1000 mg daily for 4 weeks. Case 4 describes a 14-year-old girl who received oral clarithromycin, 500 mg daily for 5 weeks. Case 5 describes a 22-year-old woman whose disease was reduced by oral erythromycin, 1000 mg daily for 6 weeks. Case 5 reports a 24-year-old man who received oral azithromycin, 500 mg daily 3 times per week for 3 weeks. Complete clearing after treatment with antibiotics raises the possibility that CRP is triggered by a bacterial infection and that antibiotics are the treatment of choice for CRP.

A randomized, controlled trial of remacemide for motor fluctuations in Parkinson's disease

BACKGROUND

Preclinical studies suggest that glutamate antagonists help ameliorate motor fluctuations in patients with PD treated with levodopa.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-ranging study, the authors assessed the safety, tolerability, and efficacy of the glutamate receptor blocker remacemide hydrochloride in 279 patients with motor fluctuations treated with levodopa. The primary objective was to assess the short-term tolerability and safety of four dosage levels of remacemide during 7 weeks of treatment. Patients were also monitored with home diaries and the Unified PD Rating Scale (UPDRS) to collect preliminary data on treatment efficacy.

RESULTS

Remacemide was well tolerated up to a dosage of 300 mg/d on a twice daily schedule and 600 mg/d on a four times daily schedule. The most common dosage-related adverse events were dizziness and nausea, as observed in previous studies of remacemide. The percent "on" time and motor UPDRS scores showed trends toward improvement in the patients treated with 150 and 300 mg/d remacemide compared with placebo-treated patients, although these improvements were not significant.

CONCLUSION

Remacemide is a safe and tolerable adjunct to dopaminergic therapy for patients with PD and motor fluctuations. Although this study had limited power to detect therapeutic effects, the observed improvement is consistent with studies of non-human primates with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonian signs and symptoms. Additional studies are warranted to confirm these results over an extended period of observation, and to explore the potential neuroprotective effects of remacemide in slowing the progression of PD.

Glutamate receptor dysregulation in the hippocampus of transgenic mice carrying mutated human amyloid precursor protein

Alzheimer's disease transgenic mice overexpressing human amyloid precursor protein (hAPP) with the Swedish double mutation (hAPP(Sw)) develop age-related amyloid deposition and behavioral and electrophysiologic changes by an unknown mechanism. Analysis of glutamatergic receptor subtypes in 4- and 15-month-old heterozygous hAPP(Sw) transgenic mice revealed a selective increase in AMPA receptor binding in the hippocampus of 15-month-old transgenic mice, which have established cortical and hippocampal amyloid deposits. There were no significant alterations of GluR1, GluR2, and GluR4 protein expression by semiquantitative confocal analysis or GluR1 mRNA by in situ hybridization. There was no significant alteration in NMDA, in group I and II metabotropic glutamate and in muscarinic receptor binding, or in striatal dopamine and adenosine receptor binding in 15-month-old mice. These data suggest that mutant APP overexpression or age-related amyloid deposition produce a subtle specific alteration in hippocampal glutamate receptors with aging.

Ultrasonographic evaluation of the gallbladder: comparison of fundamental, tissue harmonic, and pulse inversion harmonic imaging

The purpose of our study was to compare pulse inversion harmonic imaging, tissue harmonic imaging, and fundamental imaging in the evaluation of normal and diseased gallbladder. Gallbladders in 170 patients were examined with fundamental imaging, tissue harmonic imaging, and pulse inversion harmonic imaging using a 2- to 5-MHz curved array transducer. Images were divided into normal and abnormal groups. The sharpness of the wall and degree of internal artifact were evaluated in normal groups, and lesion conspicuity and internal artifact were evaluated in abnormal groups. In images of both normal and abnormal gallbladder, significant differences were demonstrated among the 3 imaging methods (P < .001), and pulse inversion harmonic imaging provided the best image quality and the least artifact. Tissue harmonic imaging was the next best, providing better image quality and less artifact than fundamental imaging. In conclusion, pulse inversion harmonic imaging provided the best image quality and the least artifact among the 3 ultrasonographic methods in the evaluation of both normal and abnormal gallbladder.

Up-regulated CNTF plays a protective role for retrograde degeneration in the axotomized rat retina

Using reverse transcription-polymerase chain reaction and in situ hybridization, we investigated the expression and cellular localization of ciliary neurotrophic factor receptor alpha (CNTFRalpha) in the rat retina following optic nerve transection (ONT). Following ONT, a signal for CNTFRalpha mRNA appeared in a layer-specific and time-dependent manner. In the ganglion cell layer, the signal showed a peak value 1 day after ONT, and then gradually decreased. In the inner nuclear layer the signal reached a peak value at 14 days of about 500% of control level, but then decreased at 4 weeks. Our findings suggest that CNTF might play a protective role for the retrograde degeneration of retinal cells induced by ganglion cell death in the rat retina following ONT.

A case of classic Kaposi's sarcoma with multiple organ involvement

Kaposi's sarcoma is a systemic, multifocal, angiomatous tumor which can be classified into four clinical variants. Among them, classic Kaposi's sarcoma is rare in Oriental people, and the involvement of internal organs in this variant is reported to be very rare. We present a case of classic Kaposi's sarcoma in a 67-year-old Korean male, who had multiple organ involvement in the skin, lymph node, and stomach. Lesions of Kaposi's sarcoma cleared after treatment with etoposide, but the skin lesions recurred after a three-month symptom-free period. He was treated with doxorubicin, bleomycin, and vincristine, and all the skin lesions were cleared.

Transcriptional dysregulation in Huntington's disease

Although the gene responsible for Huntington's disease was discovered in 1993, the pathogenic mechanisms by which mutant huntingtin causes neuronal dysfunction and death remain unclear. However, increasing evidence suggests that mutant huntingtin disrupts the normal transcriptional program of susceptible neurons. Thus, transcriptional dysregulation might be an important pathogenic mechanism in Huntington's disease.

Preoperative evaluation of Klatskin tumor: accuracy of spiral CT in determining vascular invasion as a sign of unresectability

BACKGROUND

To assess the accuracy of spiral computed tomography (CT) in predicting the resectability of Klatskin tumor as determined by vascular invasion.

METHODS

Twenty-one consecutive patients with Klatskin tumor who had undergone laparotomy were included in this study. The preoperative thin-section (5-mm-thick) spiral CT scans of these patients were assessed for the surgical resectability of tumor by evaluating the vascular invasion. The criterion for vascular invasion indicating unresectability was the tumoral invasion of the proper hepatic artery or main portal vein or simultaneous invasion of one side of the hepatic artery and the other side of the portal vein.

RESULTS

All nine patients with tumors thought to be unresectable on the basis of CT findings had tumors that were unresectable at surgery (positive predictive value, 100%). Of 12 patients with tumors thought to be resectable, six had resectable tumors (negative predictive value, 50%). Spiral CT failed to detect small hepatic metastasis (n = 1), lymph node metastasis (n = 1), extensive tumor (n = 2) and variation of bile duct (n = 2), which precluded surgical resection.

CONCLUSION

Spiral CT is a reliable method for detecting vascular invasion and unresectable tumors. However, it has limitations in detecting variations of the bile duct or the intraductal extent of tumor.

Molecular characterization of key diphtheria toxin:receptor interactions

The major amino acids necessary for diphtheria toxin (DT) binding to its receptor have been identified previously. Studies by W. H. Shen et al. (J. Biol. Chem. 269, 29077-29084, 1994) and by J. H. Cha et al. (Mol. Microbiol. 29 (5), 1275-1284, 1998) suggested that the positively charged nature of the single amino acid residue, (516)Lys of DT, is crucial for binding to the DT receptor, whereas the negatively charged (141)Glu of the DT receptor is the most important residue for toxin binding. Here, we hypothesize that key interactions occur between these two oppositely charged amino acid residues. Reciprocal substitution of the residues at these positions between the toxin and the receptor was performed, which resulted in a partial reconstitution of the toxin:receptor interaction. This study provides the first biological data that characterizes the specific interaction of these two key residues with each other and also the additional interactions between other positively charged residues of DT and (141)Glu of the DT receptor.

Minocycline inhibits caspase-1 and caspase-3 expression and delays mortality in a transgenic mouse model of Huntington disease

Huntington disease is an autosomal dominant neurodegenerative disease with no effective treatment. Minocycline is a tetracycline derivative with proven safety. After ischemia, minocycline inhibits caspase-1 and inducible nitric oxide synthetase upregulation, and reduces infarction. As caspase-1 and nitric oxide seem to play a role in Huntington disease, we evaluated the therapeutic efficacy of minocycline in the R6/2 mouse model of Huntington disease. We report that minocycline delays disease progression, inhibits caspase-1 and caspase-3 mRNA upregulation, and decreases inducible nitric oxide synthetase activity. In addition, effective pharmacotherapy in R6/2 mice requires caspase-1 and caspase-3 inhibition. This is the first demonstration of caspase-1 and caspase-3 transcriptional regulation in a Huntington disease model.

Decreased expression of striatal signaling genes in a mouse model of Huntington's disease

To understand gene expression changes mediated by a polyglutamine repeat expansion in the human huntingtin protein, we used oligonucleotide DNA arrays to profile approximately 6000 striatal mRNAs in the R6/2 mouse, a transgenic Huntington's disease (HD) model. We found diminished levels of mRNAs encoding components of the neurotransmitter, calcium and retinoid signaling pathways at both early and late symptomatic time points (6 and 12 weeks of age). We observed similar changes in gene expression in another HD mouse model (N171-82Q). These results demonstrate that mutant huntingtin directly or indirectly reduces the expression of a distinct set of genes involved in signaling pathways known to be critical to striatal neuron function.

Cell surface monkey CD9 antigen is a coreceptor that increases diphtheria toxin sensitivity and diphtheria toxin receptor affinity

Monkey (Mk) CD9 antigen has been shown previously to increase the diphtheria toxin (DT) sensitivity of cells when co-expressed with Mk proHB-EGF (DT receptor). We have elucidated here the mechanism whereby Mk CD9 influences Mk proHB-EGF and present evidence that Mk CD9 is a coreceptor for DT. We observed that Mk CD9 not only increased the DT sensitivity but also increased the DT receptor affinity of cells. Furthermore, the higher the Mk CD9/Mk proHB-EGF ratio, the higher the affinity. In contrast, mouse (Ms) CD9 did not increase the toxin sensitivity or receptor affinity of cells when co-expressed with Mk proHB-EGF. Using Mk/Ms chimeric CD9 molecules, we determined that the second extracellular domain of Mk CD9 is responsible for both increased sensitivity and receptor affinity. This domain of Mk CD9 also interacts with Mk proHB-EGF in a yeast two-hybrid system. Our findings thus suggest that Mk CD9 has a direct physical interaction with Mk proHB-EGF to form a DT receptor complex and that this contact may change the conformation of the receptor to increase DT binding affinity and consequently increase toxin sensitivity. We thus propose that Mk CD9 is a coreceptor for DT.

Decreased osteopontin expression in the rat kidney on a sodium deficient diet

Osteopontin (OPN) is a secreted phosphoprotein that is constitutively expressed in the normal kidney and is induced by various experimental and pathologic conditions. Several possible functions of OPN have been suggested, however the mechanism and significance of OPN expression are still uncertain. Since high salt concentration or salt crystal have been known to enhance OPN expression in intact kidney or cultured renal cells, in the present study we examined whether or not a low salt condition had an effect on OPN expression in the kidney. Adult male Sprague-Dawley rats were fed either a normal sodium or a sodium deficient diet for 1 week. Kidneys were processed for in situ hybridization using a digoxigenin-labeled riboprobe and for immunohistochemistry using antibodies to OPN, renin, and Na-K-ATPase. In rats fed a normal sodium diet, OPN mRNA and protein were expressed only in the descending thin limbs of Henle's loop (DTL) and in the papillary and pelvic surface epithelium (PSE). In rats fed a sodium deficient diet, there was a marked decrease in OPN immunoreactivity in the DTL, but no changes in PSE. In contrast, no changes were observed in OPN mRNA expression in the DTL by in situ hybridization, indicating that decreased OPN protein expression was a result of translational regulation. As expected, rats fed a sodium deficient diet were associated with increased immunoreactivity for Na-K-ATPase and renin compatible with activation of the renin-angiotensin system. These results suggest that dietary sodium may be involved in the regulation of OPN expression in the DTL of the rat kidney.

Ganglion cells of the rat retina show osteopontin-like immunoreactivity

Osteopontin (OPN) is a negatively charged, highly acidic glycosylated phosphoprotein that contains an GRGDS amino acid sequence, characteristic of proteins that bind to integrin receptors, thereby playing crucial roles in a number of physiological processes. This study was conducted to examine the expression of OPN in the rat retina by Northern blot analysis, Western blot analysis and immunocytochemistry. The expression of OPN was identified in the retina and OPN-like immunoreactivity was present in a number of ganglion cells. Thus, OPN appears to be important in the retinal homeostasis.

Intranuclear inclusions in subtypes of striatal neurons in Huntington's disease transgenic mice

R6/2 transgenic mice express exon 1 of an abnormal human Huntington's disease (HD) gene and develop a neurological phenotype similar to HD. These mice develop ubiquitinated neuronal intranuclear inclusions (NII) which might play a central role in the pathophysiology of HD. We studied the distribution of NII in subpopulations of striatal neurons in 12-week-old R6/2 transgenic mice using fluorescent double label immunohistochemistry. We observed that most of the Calbindin-D28K positive projection neurons (89%) and the Parvalbumin positive interneurons (86%) showed ubiquitinated NII. In interneurons, however, which contain either choline acetyltransferase, neuronal nitric oxide synthase, or Calretinin, the frequency of NII was much lower (22%, 8%, 9%, respectively). Our data suggest that subpopulations of striatal neurons differ remarkably in their capability of forming ubiquitinated NII. Interneurons which are known to resist neurodegeneration in HD show less NII.

Binding affinities of 3-(3-phenylisoxazol-5-yl)methylidene-1-azabicycles to acetylcholine receptors

A series of 3-(3-phenylisoxazol-5-yl)methylidene-1-azabicycles synthesized showed different binding characteristics to acetylcholine receptors depending on the substituents on the phenyl ring. Small polar substituents gave preferential binding affinity to nicotinic receptors, and large hydrophobic substituents to muscarinic receptors.

Expression of osteopontin mRNA in the adult rat brain

Examining the distribution of osteopontin (OPN) in the rat brain using in situ hybridization, it was found that OPN mRNA was restricted to likely neurons in the olfactory bulb and the brain stem; it was not detected in the telencephalon and the diencephalon. In addition, Northern blot analysis showed a confined expression only in the brain stem with higher level in the pons and the medulla than in the midbrain. In the brain stem, it was found in functionally diverse areas including motor-related areas, sensory system and reticular formation. This specific but widespread distribution suggests that OPN may play an important role in the adult rat brain.

[Huntington chorea. Animal models reveal new hypotheses for pathophysiology and therapy]

Huntington's disease (HD) is member of a growing family of neurodegenerative diseases which are caused by a CAG-Triplet expansion in the coding region of their respective genes. The results of the research of the last years is very suggestive of a common pathomechanisms of all these diseases even though their clinical appearance may be quite different. The development of new animal models by transferring the human gene defect into the mouse genome has led to the finding of so-called intranuclear inclusion bodies. This new observation allowed to come closer to solving the problem how this genetic defect causes neurodegeneration. Recent studies on transgenic HD mice could also demonstrate a possible connection between the genetic defect and glutamate exitotoxicity in the neurodegenerative process of HD which had been emphasized by earlier animal models of the disease. Transgenic animal models of HD will have an important impact on the understanding of the disease mechanisms and may contribute to a faster development and testing of new therapeutic approaches.

Transient upregulation of osteopontin mRNA in hippocampus and striatum following global forebrain ischemia in rats

We investigated the spatial and temporal expression of osteopontin (OPN) mRNA following transient forebrain ischemia in rats. Experiments were carried out using a four-vessel occlusion model for forebrain ischemia. The transient induction of OPN mRNA after global ischemia occurred earlier in the striatum than in the hippocampus. It was pronounced in the dorsomedial striatum close to the lateral ventricle and in the CA1 subfield and the subiculum of the hippocampus before microglial cells became more reactive. It also could be detected in the dentate hilus and to a marginal extent in the CA3. Our results suggest that the hippocampus and the striatum following global forebrain ischemia upregulate OPN mRNA in different spatiotemporal profiles.

Molecular cloning and expression analysis of a mouse phospholipase C-delta1

We describe here the molecular cloning and expression analysis of mouse PLC-delta1 (mPLC-delta1), a key enzyme in cell signal transduction. A mouse brain cDNA library was screened in order to isolate the mPLC-delta1 cDNA. The mPLC-delta1 cDNA was 2660 bp in length. The predicted open reading frame encodes a protein of 756 amino acids with an estimated molecular mass of 85 kDa. The deduced amino acid sequence exhibits 96.9% and 92.7% identity with the sequence of rat and human PLC-delta1, respectively. The mPLC-delta1 mRNA was highly expressed in brain, heart, lung, and testis. We found that transcripts of mPLC-delta1 are present in almost all regions of mouse brain examined, implying that the enzyme may play a role in some fundamental cellular process in brain. In male reproductive tract, mPLC-delta1 mRNA was widely expressed in the epididymis as well as in the testis. In situ hybridization studies indicate that distribution of mPLC-delta1 mRNA in mouse testis is discrete and unique. The expression of mPLC-delta1 mRNA was defined in the periphery of each seminiferous tubule, especially in spermatogonia, which might imply that mPLC-delta1 plays a role in proliferation of spermatogonia. To the best our knowledge, this is the first report to demonstrate the high expression of mPLC-delta1 mRNA in spermatogonia of testis. Taken together, these results suggest that mPLC-delta1 may carry out fundamental roles in almost all of mouse tissues, especially in brain and specific roles in testis.

Intracisternal antisense oligonucleotide to growth associated protein-43 blocks the recovery-promoting effects of basic fibroblast growth factor after focal stroke

Focal infarction (stroke) of the lateral cerebral cortex of rats (including the sensorimotor cortex) produces deficits in sensorimotor function of the contralateral limbs that recover partially over time. In previous studies, we found that the intracisternal injection of basic fibroblast growth factor (bFGF), a potent neurotrophic growth factor, starting at 1 day after stroke, significantly enhanced recovery of sensorimotor function of the contralateral forelimb and hindlimb. Moreover, immunoreactivity (IR) for growth-associated protein-43 (GAP-43), a molecular marker of new axonal growth, was increased in the intact contralateral sensorimotor cortex following bFGF treatment. In the current study, we found that the intracisternal administration of antisense, but not missense, oligonucleotide to GAP-43 blocked the recovery-enhancing effects of bFGF and blocked the increase in GAP-43 IR in the contralateral cortex. These results suggest that upregulation of GAP-43 expression and consequent enhanced axonal sprouting in intact uninjured parts of the brain are likely mechanisms for the recovery-promoting effects of bFGF.

Altered neurotransmitter receptor expression in transgenic mouse models of Huntington's disease

Alterations in neurotransmitter receptors are a pathological hallmark of the neurodegeneration seen in Huntington's disease (HD). However, the significance of these alterations has been uncertain, possibly reflecting simply the loss of brain cells. It is not known for certain whether the alteration of neurotransmitter receptors occurs before the onset of symptoms in human HD. Recently we developed transgenic mice that contain a portion of a human HD gene and develop a progressive abnormal neurological phenotype. Neurotransmitter receptors that are altered in HD (receptors for glutamate, dopamine, acetylcholine and adenosine) are decreased in the brain transgenic mice, in some cases before the onset of behavioural or motor symptoms. In transgenic mice, neurotransmitter receptor alterations occur before neuronal death. Further, receptor alterations are selective in that certain receptors, namely N-methyl-D-aspartate and gamma-aminobutyric acid receptors, are unaltered. Finally, receptor decreases are preceded by selective decreases in the corresponding mRNA species, suggesting the altered transcription of specific genes. These results suggest that (i) receptor decreases precede, and therefore might contribute to, the development of clinical symptoms, and (ii) altered transcription of specific genes might be a key pathological mechanism in HD.

Inhibition of caspase-1 slows disease progression in a mouse model of Huntington's disease

Huntington's disease is an autosomal-dominant progressive neurodegenerative disorder resulting in specific neuronal loss and dysfunction in the striatum and cortex. The disease is universally fatal, with a mean survival following onset of 15-20 years and, at present, there is no effective treatment. The mutation in patients with Huntington's disease is an expanded CAG/polyglutamine repeat in huntingtin, a protein of unknown function with a relative molecular mass of 350,000 (M(r) 350K). The length of the CAG/polyglutamine repeat is inversely correlated with the age of disease onset. The molecular pathways mediating the neuropathology of Huntington's disease are poorly understood. Transgenic mice expressing exon 1 of the human huntingtin gene with an expanded CAG/polyglutamine repeat develop a progressive syndrome with many of the characteristics of human Huntington's disease. Here we demonstrate evidence of caspase-1 activation in the brains of mice and humans with the disease. In this transgenic mouse model of Huntington's disease, expression of a dominant-negative caspase-1 mutant extends survival and delays the appearance of neuronal inclusions, neurotransmitter receptor alterations and onset of symptoms, indicating that caspase-1 is important in the pathogenesis of the disease. In addition, we demonstrate that intracerebroventricular administration of a caspase inhibitor delays disease progression and mortality in the mouse model of Huntington's disease.

Expression of vascular endothelial growth factor mRNA following transient forebrain ischemia in rats

Using a reproducible two-vessel occlusion model for forebrain ischemia in rats, we investigated the temporal and spatial changes of vascular endothelial growth factor (VEGF) expression after transient forebrain ischemia with Northern blot analysis and in situ hybridization. Northern blot analysis revealed that VEGF mRNA of the hippocampus was increased from 12 h after reperfusion, with a peak at 1 day. In situ hybridization and double labeling for VEGF mRNA and glial fibrillary acidic protein showed a transient induction of VEGF mRNA in the neurons of the hippocampus from 12 h of reperfusion with a peak at 1 day, and in the astrocytes of the hippocampus, caudoputamen, thalamus and cortical regions at 1 day. After 3 days, no more VEGF signal was detected. Our results demonstrate that astrocytes and neurons each upregulate VEGF mRNA in different temporal and spatial patterns after transient forebrain ischemia in the rat, and these patterns appear to be different from those in transient focal cerebral ischemia.