A phase 2, randomized dose-finding study of tapinarof (GSK2894512 cream) for the treatment of atopic dermatitis

BACKGROUND

Safe and efficacious topical treatments are needed for atopic dermatitis (AD).

OBJECTIVE

We assessed the safety and efficacy of tapinarof cream (2 concentrations and 2 application frequencies) in patients with AD.

METHODS

A double-blind, vehicle-controlled, randomized, 6-arm trial (1:1:1:1:1:1) in patients age 12 to 65 years, with body surface area involvement of at least 5% to 35% and an Investigator's Global Assessment score of 3 or higher (moderate to severe) at baseline. Primary end points included an Investigator's Global Assessment score of clear or almost clear (0 or 1) and a minimum 2-grade improvement (treatment success) at week 12. Secondary analyses included a 75% or greater improvement in Eczema Area and Severity Index score, reduction of numeric rating scale (NRS) score for itch from baseline, and other prespecified end points.

RESULTS

The rates of treatment success with tapinarof cream at week 12 were 53% (a concentration of 1% twice daily), 46% (a concentration of 1% once daily), 37% (a concentration of 0.5% twice daily), 34% (0.5% once daily), 24% (vehicle twice daily), and 28% (vehicle once daily). The rate with a concentration of 1% twice daily (53%) was statistically significantly higher than the rate with vehicle twice daily (24%). Treatment success was maintained for 4 weeks after the end of tapinarof treatment. The rate of treatment-emergent adverse events was higher with tapinarof (93 of 165 [56%]) than with vehicle (34 of 82 [41%]), and the events were mild to moderate in intensity.

LIMITATIONS

Large confirmation trials are needed.

CONCLUSIONS

Tapinarof cream is efficacious and well tolerated in adolescent and adult patients with AD.

A randomized placebo-controlled phase 3 trial of an antisense oligonucleotide, drisapersen, in Duchenne muscular dystrophy

This 48-week, randomized, placebo-controlled phase 3 study (DMD114044; NCT01254019) evaluated efficacy and safety of subcutaneous drisapersen 6 mg/kg/week in 186 ambulant boys aged ≥5 years, with Duchenne muscular dystrophy (DMD) resulting from an exon 51 skipping amenable mutation. Drisapersen was generally well tolerated, with injection-site reactions and renal events as most commonly reported adverse events. A nonsignificant treatment difference (P = 0.415) in the change from baseline in six-minute walk distance (6MWD; primary efficacy endpoint) of 10.3 meters in favor of drisapersen was observed at week 48. Key secondary efficacy endpoints (North Star Ambulatory Assessment, 4-stair climb ascent velocity, and 10-meter walk/run velocity) gave consistent findings. Lack of statistical significance was thought to be largely due to greater data variability and subgroup heterogeneity. The increased standard deviation alone, due to less stringent inclusion/exclusion criteria, reduced the statistical power from pre-specified 90% to actual 53%. Therefore, a post-hoc analysis was performed in 80 subjects with a baseline 6MWD 300-400 meters and ability to rise from floor. A statistically significant improvement in 6MWD of 35.4 meters (P = 0.039) in favor of drisapersen was observed in this subpopulation. Results suggest that drisapersen could have benefit in a less impaired population of DMD subjects.

Adjunctive Maintenance Lamotrigine for Pediatric Bipolar I Disorder: A Placebo-Controlled, Randomized Withdrawal Study

OBJECTIVE

This study aimed to compare the efficacy of lamotrigine versus placebo in 10- to 17-year-olds with bipolar I disorder (BP-I) who were receiving conventional bipolar disorder treatment.

METHOD

In this randomized withdrawal trial, patients with BP-I of at least moderate severity received lamotrigine during an ≤18-week open-label phase. Patients who maintained a stable lamotrigine dose for ≥2 weeks and Clinical Global Impression-Bipolar Severity of Illness (CGI-BP[S]) score of ≤3 for ≥6 consecutive weeks were randomized to double-blind lamotrigine or placebo for ≤36 weeks.

RESULTS

Of 301 patients enrolled, 298 comprised the open-label intention-to-treat population, with 173 (58%) randomized. Of these patients, 41 (24%) completed the study. In the open-label phase, the mean (SD) baseline CGI-BP(S) rating was 4.4 (0.57), and the mean (standard error [SE]) time to stabilization was 101 (1.6) days. During the randomized phase, mean (SE) time to occurrence of a bipolar event (TOBE) for lamotrigine versus placebo (primary endpoint) was 155 (14.7) versus 50 (3.8), 163 (12.2) versus 120 (12.2), and 136 (15.4) versus 107 (13.8) days for the 3 index mood states (depressed, manic/hypomanic, mixed). The primary stratified log-rank analysis of TOBE was not statistically significant (hazard ratio [HR] = 0.63; p = .072); however, the prespecified Cox regression analysis favored lamotrigine (p = .047). In 13- to 17-year-olds, log-rank analysis of TOBE significantly favored lamotrigine (HR = 0.46; p = .015), but not in 10- to 12-year-olds (HR = 0.93; p = .877). Dermatologic events were reported in 4% (open-label phase) and 2% (randomized phase) of patients receiving lamotrigine. Suicidality-related adverse events were reported in 7% (open-label phase) and 7% (randomized phase) of patients receiving lamotrigine.

CONCLUSION

Although the primary analysis failed to detect a benefit of add-on lamotrigine for BP-I in 10- to 17-year-olds, lamotrigine may be effective in a subset of older adolescents. Clinical trial registration information-Lamictal as Add-on Treatment for Bipolar I Disorder in Pediatric Patients; http://clinicaltrials.gov/; NCT00723450.

Safety and efficacy of drisapersen for the treatment of Duchenne muscular dystrophy (DEMAND II): an exploratory, randomised, placebo-controlled phase 2 study

BACKGROUND

Duchenne muscular dystrophy is caused by dystrophin deficiency and muscle deterioration and preferentially affects boys. Antisense-oligonucleotide-induced exon skipping allows synthesis of partially functional dystrophin. We investigated the efficacy and safety of drisapersen, a 2'-O-methyl-phosphorothioate antisense oligonucleotide, given for 48 weeks.

METHODS

In this exploratory, double-blind, placebo-controlled study we recruited male patients (≥5 years of age; time to rise from floor ≤7 s) with Duchenne muscular dystrophy from 13 specialist centres in nine countries between Sept 1, 2010, and Sept 12, 2012. By use of a computer-generated randomisation sequence, we randomly allocated patients (2:2:1:1; block size of six; no stratification) to drisapersen 6 mg/kg or placebo, each given subcutaneously and either continuously (once weekly) or intermittently (nine doses over 10 weeks). The primary endpoint was change in 6-min walk distance (6MWD) at week 25 in patients in the intention-to-treat population for whom data were available. Safety assessments included renal, hepatic, and haematological monitoring and recording of adverse events. This trial is registered with ClinicalTrials.gov, number NCT01153932.

FINDINGS

We recruited 53 patients: 18 were given continuous drisapersen, 17 were given intermittent drisapersen, and 18 were given placebo (continuous and intermittent groups combined). At week 25, mean 6MWD had increased by 31·5 m (SE 9·8) from baseline for continuous drisapersen, with a mean difference in change from baseline of 35·09 m (95% CI 7·59 to 62·60; p=0·014) versus placebo. We recorded no difference in 6MWD changes from baseline between intermittent drisapersen (mean change -0·1 [SE 10·3]) and placebo (mean difference 3·51 m [-24·34 to 31·35]) at week 25. The most common adverse events in drisapersen-treated patients were injection-site reactions (14 patients given continuous drisapersen, 15 patients given intermittent drisapersen, and six given placebo) and renal events (13 for continuous drisapersen, 12 for intermittent drisapersen, and seven for placebo), most of which were subclinical proteinuria. None of the serious adverse events reported (one for continuous, two for intermittent, and two for placebo) resulted in withdrawal from the study.

INTERPRETATION

Continuous drisapersen resulted in some benefit in 6MWD versus placebo at week 25. The safety findings are similar to those from previous studies. Ambulation improvements in this young population with early-stage Duchenne muscular dystrophy are encouraging but need to be confirmed in larger studies.

FUNDING

GlaxoSmithKline, Prosensa Therapeutics BV (a subsidiary of Prosensa Holding NV).

Pharmacokinetics and safety of single doses of drisapersen in non-ambulant subjects with Duchenne muscular dystrophy: results of a double-blind randomized clinical trial

Duchenne muscular dystrophy (DMD) is a progressive, lethal neuromuscular disorder caused by the absence of dystrophin protein due to mutations of the dystrophin gene. Drisapersen is a 2′-O-methyl-phosphorothioate oligonucleotide designed to skip exon 51 in dystrophin pre-mRNA to restore the reading frame of the mRNA. This study assessed safety, tolerability, and pharmacokinetics of drisapersen after a single subcutaneous administration in non-ambulatory subjects. Eligible subjects were non-ambulant boys aged ≥9 years, in wheelchairs for ≥1 to ≤4 years, with a diagnosis of DMD resulting from a mutation correctable by drisapersen treatment. Four dose cohorts were planned (3, 6, 9 and 12 mg/kg), but study objectives were met with the 9 mg/kg dose. Less than proportional increase in exposure was demonstrated over the 3–9 mg/kg dose range, though post hoc analysis showed dose proportionality was more feasible over the 3–6 mg/kg range. Single doses of drisapersen at 3 and 6 mg/kg did not result in significant safety or tolerability concerns; however, at the 9 mg/kg dose, pyrexia and transient elevations in inflammatory parameters were seen. The maximum tolerated dose of 6 mg/kg drisapersen was identified for further characterization in multiple dose studies in the non-ambulant DMD population.

Meta-analysis of efficacy and treatment-emergent suicidality in adults by psychiatric indication and age subgroup following initiation of paroxetine therapy: a complete set of randomized placebo-controlled trials

OBJECTIVE

This meta-analysis of placebo-controlled paroxetine trials examines suicidality incidence in adults, focusing on disorder and age as potential risk factors. The findings are put in context with an efficacy meta-analysis of the same trial datasets.

DATA SOURCES

GlaxoSmithKline paroxetine clinical trial database(s).

STUDY SELECTION

All double-blind, randomized, placebo-controlled, parallel-group studies of paroxetine therapy in adults enrolling at least 30 patients total were included in the analysis. The dataset comprised 14,911 patients from 61 trials.

DATA EXTRACTION

Possible cases of suicidality were identified and blindly categorized by an expert panel, using methodology previously used by the US Food and Drug Administration. Incidences of suicidal behavior (preparatory act, suicide attempt, or completed suicide) and any suicidality (suicidal behavior or ideation) were compared between paroxetine and placebo. Efficacy assessments were based on standard depression rating scales (eg, Hamilton Depression Rating Scale or Montgomery-Asberg Depression Rating Scale) and Clinical Global Impressions Improvement scale (CGI-I) scores.

RESULTS

In the primary dataset, ie, all disorders combined, there were no significant differences between paroxetine and placebo for overall suicidality (suicidal behavior or ideation: n/n = 83/8,958 [0.93%] vs n/n = 65/5,953 [1.09%], respectively; OR = 0.9 [95% CI, 0.7-1.3]; P = .649) or for suicidal behavior specifically (n/n = 50/8,958 [0.56%] vs n/n = 40/5,953 [0.67%], respectively; OR = 1.2 [95% CI, 0.8-1.9]; P = .483). However, in patients with major depressive disorder (MDD), a greater incidence of suicidal behavior occurred in paroxetine-treated patients than in placebo-treated patients (n/n = 11/3,455 [0.32%] vs n/n = 1/1,978 [0.05%], respectively; OR = 6.7 [95% CI, 1.1-149.4]; P = .058). Across all indications, a higher incidence of suicidal behavior occurred in paroxetine-treated versus placebo-treated adults aged 18 to 24 years (n/n = 17/776 [2.19%] vs n/n = 5/542 [0.92%], respectively; OR = 2.4 [95% CI, 0.9-7.3]). In older age groups, no increase in suicidality was observed. Efficacy was demonstrated in all disorders evaluated, including MDD.

CONCLUSIONS

Across all disorders, overall suicidality incidence was similar between paroxetine and placebo. However, a higher frequency of suicidal behavior occurred with paroxetine in MDD, which was largely explained by the higher incidence in young adults. These data support the efficacy of paroxetine therapy; however, they also highlight the need for careful monitoring of suicidality during antidepressant therapy, particularly in younger adults.

Clinical features of patients with treatment-emergent suicidal behavior following initiation of paroxetine therapy

BACKGROUND

Understanding suicidal behavior is an important component of assessing suicidality in psychiatric patients. GlaxoSmithKline (GSK) conducted a meta-analysis of randomized, placebo-controlled trials to compare suicidality in adult patients treated with paroxetine vs. placebo. The goal was to identify emergent clinical characteristics of patients with definitive suicidal behavior (DSB: preparatory act, suicide attempt, completed suicide).

METHODS

The dataset comprised 14,911 patients from 57 placebo-controlled paroxetine trials. Possible cases of suicidality were identified and were blindly reviewed by an expert panel, which categorized cases as suicidal or non-suicidal. DSB incidences were compared between paroxetine and placebo. Clinical narratives and case report forms for major depressive disorder (MDD) and anxiety disorder patients with DSB were reviewed. For MDD, rating scale items relating to suicidality, insomnia, agitation, and anxiety were examined.

RESULTS

Overall (all indications) there were no differences between paroxetine and placebo for DSB (50/8958 [0.56%] vs. 40/5953 [0.67%], respectively; OR=1.2 [CI 0.8, 1.9]; p=0.483). However, in patients with major depressive disorder (MDD), the incidence of DSB was greater for paroxetine (11/3455 [0.32%] vs. 1/1978 [0.05%], OR=6.7 [CI 1.1, 149.4]; p=0.058). Review of the 11 paroxetine MDD cases revealed common clinical features: symptomatic improvement; younger age (18-30 years); psychosocial stressors; overdose as method; and absent/mild suicidal ideation at the visit prior to the event. There was no evidence for a consistent adverse event profile or onset of akathisia/agitation or a manic/mixed state. Anxiety disorder patients with DSB had a heterogeneous clinical picture.

LIMITATIONS

Limitations to the study include the relatively small number of cases and the retrospective nature of the study.

CONCLUSIONS

DSB incidence was similar between paroxetine and placebo overall, but a higher frequency of DSB was found for paroxetine in MDD patients, driven by young adults aged < or =30 years. Most MDD patients with DSB improved prior to the attempt and experienced a psychosocial stressor. Patients should receive careful monitoring for suicidality during paroxetine therapy.

Differences in medication adherence and healthcare resource utilization patterns: older versus newer antidepressant agents in patients with depression and/or anxiety disorders

BACKGROUND

Given the number of antidepressants available and their rising costs, healthcare payers have initiated restrictive reimbursement policies for newer antidepressants, without consideration for differences in their effectiveness or tolerability.

OBJECTIVE

The objective of this study was to comprehensively compare medication adherence rates and associated healthcare utilization costs for patients using later-generation versus earlier-generation antidepressants in a managed care setting. Antidepressants launched after 2002 were deemed third-generation antidepressants, while antidepressants available prior to 2002 were deemed first-generation (TCAs and MAOIs) and second-generation (serotonin and noradrenaline [norepinephrine]-dopamine reuptake inhibitors).

STUDY DESIGN

Retrospective database analysis using medical and pharmacy data from over 75 managed care plans covering 55 million lives.

SETTING/PATIENTS

All patients receiving an antidepressant between 1 January 2002 and 30 September 2004 were identified. The index date for patients was the date of their first antidepressant prescription within this time period. Patients had to (i) have a diagnosis of depression or anxiety disorder, or depression and anxiety disorder within 6 months prior to or 30 days after their index prescription; (ii) be at least 18 years of age, without having taken antidepressant therapy for 6 months prior to their index date; and (iii) be continuously eligible for 6 months prior to their index date and during their 6-month follow-up period. Patients were excluded if they had a diagnosis of psychosis-related disease, Alzheimer's or Parkinson's disease, or were initiated on psychosis-related medications. INTERVENTION/MAIN OUTCOME MEASURE: Patients meeting selection criteria were followed for 6 months to assess rates of antidepressant adherence, therapy change rates and medical healthcare costs.

STUDY POPULATION

A total of 266 665 patients met the study criteria. Approximately 66% were female, with a mean age of 39 years. About 63% had a diagnosis of depression, 31% had an anxiety disorder diagnosis and 6% had diagnoses for both an anxiety disorder and depression. Therapy change: Therapy change within 6 months occurred in 18% of patients receiving third-generation agents compared with 21% and 40% for second- and first-generation agents, respectively. The odds of a therapy change were significantly lower with third-generation antidepressants compared with both older agent cohorts. Adherence: Of patients receiving third-generation antidepressants, 33.6% were adherent compared with 29.3% and 12.4% of patients receiving second- and first-generation antidepressants, respectively. Newer agents also had better adherence rates across all diagnostic cohorts. After adjusting for baseline differences, the odds of being adherent to therapy were significantly lower for those taking second- and first-generation agents versus newer antidepressants. Among the newer agents, the proportion of patients adherent to their therapy was: venlafaxine extended release 38%, paroxetine controlled release (CR) 35%, escitalopram 34%, duloxetine 32% and bupropion extended release (XL) 31%. Healthcare utilization: Of the patients taking older antidepressants, 13% (second generation) and 21% (first generation) were hospitalized at least once for any reason compared with 12% of patients taking newer agents. Overall, the odds of all-cause hospitalization within 6 months of therapy initiation were significantly higher for patients taking older antidepressants. Among the newer agents, hospitalization rates ranged from 15.9% for duloxetine to 12.5% for paroxetine CR and bupropion XL. The unadjusted 6-month total medical costs (not including pharmacy costs) per patient were $US 3514 for second-generation, $US 5744 for first-generation and $US 3284 for newer antidepressants. After controlling for baseline differences, patients receiving second- and first-generation antidepressants incurred 12% and 44% higher costs, respectively. The unadjusted 6-month medical costs for the newer agents ranged from $US 2715 for paroxetine CR to $US 6042 for duloxetine.

CONCLUSION

The results of this study provide essential information for healthcare decision makers about the potential advantages of newer generation antidepressants versus older generation antidepressants, as well as the differences between the specific newer agents, with respect to improved rates of adherence and therapy change, reduced hospitalizations and healthcare costs.

Managing treatment resistant violent adolescents: a step forward by substituting seclusion for mechanical restraint?

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint.

Olanzapine versus risperidone in newly admitted acutely ill psychotic patients

OBJECTIVE

Risperidone and olanzapine are the 2 most widely prescribed second-generation anti-psychotics. The purpose of this study was to compare the efficacy of risperidone and olanzapine using duration of hospitalization as the primary outcome measure. This outcome was selected as it is an indirect measure of how well patients are responding to the medication and represents a "real world" endpoint relevant to practicing hospital psychiatrists.

METHOD

The study was done at a large state psychiatric hospital in North Carolina from 2001 to 2003. Subjects were eligible for inclusion if they required treatment with an antipsychotic (e.g., positive symptoms) and were able to provide informed consent. Eighty-five patients entered the study and were randomly assigned to risperidone (N = 40) or olanzapine (N = 45) as their initial antipsychotic. Treatment was naturalistic, and dosing was based on the discretion of the treating physician.

RESULTS

There was no significant difference in the mean durations of hospitalization for the risperidone group (7.9 days) as compared to the olanzapine group (8.1 days). There were no significant differences in the demographics of either treatment group, but, during the study, risperidone-treated patients used more antihistamines (chi(2) = 4.0, p = .05). Eighty percent of each group (N = 36, olanzapine; N = 32, risperidone) remained on the study medication at discharge.

CONCLUSIONS

Risperidone and olanzapine were equally efficacious, suggesting that measures other than "efficacy" (e.g., side effects, cost) should be considered when determining overall "effectiveness" of treatment.

Morphogenesis of galls induced by Baccharopelma dracunculifoliae (Hemiptera: Psyllidae) on Baccharis dracunculifolia (Asteraceae) leaves

The commonest insect gall on Baccharis dracunculifolia (Asteraceae) leaves is induced by Baccharopelma dracunculifoliae (Hemiptera, Psyllidae). The gall-inducing insect attacks young leaves in both the unfolded and the fully expanded stages. Four developmental phases were observed in this type of gall: 1) A folding phase, during which the leaf lamina folded upward alongside the midrib and the edges of the upper portion of the leaf approached each other, forming a longitudinal slit. A single chamber was formed on the adaxial surface of the leaf; 2) A swelling phase, in which the folded leaf tissues thickened and the edges of the leaf drew closer together, narrowing the slit. In this phase the gall matured, turning succulent, fusiform and pale green. The single nymphal chamber was lined with white wax and was able to house from one to several nymphs; 3) A dehiscence phase, characterized by the opening of the slit to release inducers; and 4) A senescence phase, when the gall turned dark and dry. The dermal system of the mature gall was composed of a single-layered epidermis. The mesophyll was swollen, and the swelling was due mainly to hyperplasia of the parenchyma. The vascular tissues along the midrib vein were conspicuous and the perivascular fibers resembled parenchymal cells. The hypertrophied secretory cavities contained low lipophylic content. This gall does not form nutritive tissue, but salivary sheaths left by the inducers were observed near the parenchyma, vascular bundles and secretory cavities. This study complements our current knowledge of gall biology and sheds further light on the plasticity of plant tissues stimulated by biotic factors.

Implementing a Smoking Ban in an Acute Psychiatric Admissions Unit

In contrast to general medical hospitals, psychiatric hospitals often allow patients to smoke cigarettes. In addition to obvious health concerns, smoking can also interfere with clinical assessments and therapeutic activities, Implementation of a smoking ban on an acute male admissions unit did not result in any increase in aggressive behaviors. In addition, staff attitudes following the ban improved, and most staff members believed the ban was both ethical and beneficial to patients. Our research indicates that banning smoking on an acute admissions unit is feasible and well tolerated by patients and staff, although it may require extra vigilance for smoking-related contraband.

Clozapine reduces violent behavior in heterogeneous diagnostic groups

Violent behavior is a significant problem in the psychiatric hospital setting. Persistently violent patients often require seclusion and/or restraints and typically receive high doses of medication and polypharmacy. Clozapine has been found to be effective in reducing aggression in patients with psychosis. Thus, we examined the effects of clozapine in a heterogeneous group of persistently violent patients. A chart review of the effect of clozapine in persistently violent patients was performed. Changes in the number of violent episodes and the need for seclusion and restraint were assessed for a 3-month period before and after receiving clozapine. In this group of five, carefully selected, persistently violent patients, clozapine treatment resulted in marked decreases in violent episodes and the use of seclusion and restraint. These data suggest a role for clozapine in the treatment of persistently violent patients irrespective of DSM-IV diagnosis.

Neurosyphilis in newly admitted psychiatric patients: three case reports

BACKGROUND

Neurosyphilis, also known as "general paresis of the insane," at one time accounted for a large portion of admissions to state psychiatric facilities. With the introduction of antibiotics, neurosyphilis is now considered very rare.

METHOD

Chart review was performed on patients diagnosed with neurosyphilis who were admitted to a state psychiatric hospital in Raleigh, N.C., during 2002.

RESULTS

We identified 3 cases of confirmed neurosyphilis, representing 0.1% of adult admissions, diagnosed in newly admitted psychiatric patients. None of the patients were immunocompromised. Response to antibiotic treatment was poor.

CONCLUSIONS

Given the increase in primary and secondary syphilis reported in the 1980s and early 1990s, routine screening of psychiatric patients for the presence of syphilis should be considered.

Characteristics of violent behavior in a large state psychiatric hospital

Violent behavior is a significant problem in psychiatric hospitals. The authors reviewed hospital incident reports to identify the characteristics of violent behavior in a large state psychiatric hospital. They found that a very small percentage of patients accounted for a majority of violent episodes, that rates of violent behavior varied among hospital units, that assaultive behavior was more common than self-harm in the long-term units, and that most commonly the assault victims were other patients. The data support earlier studies demonstrating that a small number of patients are responsible for a majority of violent episodes in a hospital setting.

Effects of topiramate on aggressive, self-injurious, and disruptive/destructive behaviors in the intellectually disabled: an open-label retrospective study

This study reviews the treatment response to the antiepileptic drug topiramate (Topamax-mean dose 202 mg/d, range 150-350 mg/d) of a group of 22 institutionalized intellectually disabled adults (8 males, 14 females, mean age 46.5 years, age range 25-70 years). These individuals were predominantly classified as having severe or profound intellectual disability and as having a mood disorder. The individuals studied were treated for aggression, self-injurious behaviors, destructive/disruptive behaviors or a combination of these, and/or other challenging and maladaptive behaviors. All subjects were receiving concurrent psychotropic and/or anticonvulsant medications. Effectiveness was determined by retrospective review of summaries of quarterly multidisciplinary Neuropsychiatric Behavioral Reviews. Assignment of global severity scores and evaluation of longitudinal behavioral graphs of target symptoms occurred. Overall, statistically significant decreases in global severity scores and in the cumulative aggression and worst behavior rates occurred in the subjects, especially when the 3 months before and the 3 to 6 months after starting topiramate were compared. The overall subject group showed no significant weight changes. One subject developed delirium, 1 developed hypoglycemia, 1 developed sedation, and 2 developed constipation. The results suggest that topiramate may have a role in the treatment of challenging/maladaptive behaviors in intellectually disabled individuals.

Morphology and anatomy of leaf mine in Richterago riparia Roque (Asteraceae) in the campos rupestres of Serra do Cipó, Brazil

The leaf mine in Richterago riparia is caused by a lepidopteran larva (lepidopteronome). The leaves of R. riparia show campdodrome venation; the epidermis is unistratified, with stomata and glandular trichomes in adaxial and abaxial surfaces. The mesophyll is bilateral and the vascular system is collateral. During the formation of the mine, the larva consumes the chlorenchyma of the mesophyll and the smaller vascular bundles (veins of third and fourth orders). Structural alterations in the tissues of the host plant were not observed, except for the formation of a wound meristem and the presence of cells with phenolic substances next to the mine. Three cephalic exuviae of the miner were found in the mesophyll. This lepidopteronome is parenchymatic and the epidermis remains intact, but forms a protective layer for the mining insect.

Sensitization phenomena in psychiatric illness: lessons from the kindling model

Sensitization or "kindling-like" phenomena have been implicated in the pathophysiology of a number of psychiatric illnesses. A basic understanding of the prototypical sensitization phenomenon, the kindling model of epilepsy, is thus of increasing significance for the psychiatrist. This article presents a summary of the kindling model, with particular emphasis on glutamatergic mechanisms in general and plasticity of the N-methyl-D-aspartate (NMDA) receptor in specific. Findings from the kindling model are then discussed in light of their potential relevance to psychiatric illness. Finally, a speculative model is proposed in which opposing molecular processes lead to NMDA receptor hyperfunction in kindling and hypofunction in schizophrenia.

Serotonergic basis of antipsychotic drug effects in schizophrenia

Recent attention has been focused on the involvement of serotonin (5-HT) in the pathophysiology of schizophrenia and its role in mediating antipsychotic drug effects. There are two reasons for the new emphasis: the tremendous success of the so-called "atypical" antipsychotic drugs (a common feature of which is their high affinity for specific 5-HT receptor subtypes); and the elucidation of a complex family of 5-HT receptors whose function and pharmacology is only beginning to be understood. This paper will review the evidence that pertains to the role of 5-HT in mediating antipsychotic drug effects. The interaction of dopamine and 5-HT systems will be reviewed, and the mechanisms of action of atypical antipsychotic drugs will be evaluated in this context. The impact of serotonin on neurodevelopment, and the involvement of serotonin in the psychotomimetic and psychotogenic properties of hallucinogens, will be discussed. Together, these facts will be placed into the context of changes in serotonergic function in schizophrenia.

Measurement of NMDA receptor protein subunits in discrete hippocampal regions of kindled animals

Kindling refers to a phenomenon in which repeated application of initially subconvulsive electrical stimulations produces limbic and clonic motor seizures of progressively increasing severity. Once established, the increased excitability is lifelong. A diversity of studies demonstrate that kindling results in long lasting (28 days) alterations of the functional and pharmacologic properties of NMDA receptors, indicating that kindling may cause changes intrinsic to the NMDA receptor itself. Our previous studies disclosed no differences in NMDA receptor subunit gene or splice isoform mRNA expression between control and kindled animals 28 days after the last kindled seizure. Here, we extend those earlier studies by measuring levels of subunit protein for NMDAR1, NR2A, and NR2B in the hippocampus of control and kindled animals, 28 days after the last kindled seizure. We report that kindling does not effect long-lasting changes in the levels of NMDA receptor subunit protein. Together these findings support the idea that alterations in NMDA receptor protein expression do not contribute to the novel properties of NMDA receptors induced by kindling.

Astra blue and basic fuchsin double staining of plant materials

Methods for double staining plant materials using astra blue and basic fuchsin are described here. These methods can be applied to free hand and microtome sections embedded in paraffin, paraplast or historesin. Also, they can be used to study isolated epidermal peels and pollen preparations. Temporary, semipermanent and permanent preparations were studied. Astra blue stained polysaccharides of the cell wall such as cellulose and pectins. Basic fuchsin showed an affinity for lignified, suberized or cutinized walls. The easy preparation of the reagents, excellent color contrast of the histological preparations, and brief staining times of some methods makes them useful for both routine research and didactic purposes. Also, excellent color or black and white photomicrography can be obtained after the double staining described here.

Regulation of alternative splicing of NMDAR1 in the kindling model

Kindling refers to a phenomenon in which repeated application of initially subconvulsive electrical stimulations produces limbic and clonic motor seizures of progressively increasing severity. Once established, the increased excitability is lifelong. Several lines of investigation suggest that the N-methyl-D-aspartate (NMDA) subtype of glutamate receptor participates in the expression of the increased neuronal excitability of the kindled brain. Many studies demonstrate that kindling results in altered NMDA receptor functional and pharmacological properties, indicating that kindling may cause changes intrinsic to the NMDA receptor itself. It is possible that altered expression of NMDA receptor subunit genes and splice isoforms of genes leads to subunit combinations resulting in the novel NMDA receptor properties identified in the hippocampus of kindled animals. To begin to address this possibility, we previously examined the hippocampal expression of known NMDA receptor genes and found no differences in expression between control and kindled animals either 24 h or 28 days after the last kindled seizure. Here, we extend that earlier study by examining the expression of NMDAR1 splice isoforms in the hippocampus of control and kindled animals. We report that kindling induces the transient reduction of specific splice isoforms of NMDAR1 containing the first of the carboxy-terminal splice cassettes (exon 21). We discuss the potential significance of this regulation in terms of its relevance to previous findings in the kindling model and possible effects on NMDA receptor function.

Clinical relevance of defects in signalling pathways

This review discusses seven diseases of the human nervous system that have been linked to defects in signal transduction. Recent molecular genetic analyses of rare monogenic disorders have led to the identification of mutant genes in six of the seven diseases. The molecules implicated are an enzyme (superoxide dismutase) and ion channels gated by either voltage or ligands.

Kindling induces the long-lasting expression of a novel population of NMDA receptors in hippocampal region CA3

Kindling refers to a phenomenon in which repeated application of initially subconvulsive electrical stimulations produces limbic and clonic motor seizures of progressively increasing severity. Once established, the increased excitability is lifelong. Enhanced function of synapses using the NMDA subtype of glutamate receptor could contribute to the expression of the increased excitability. We previously found that CA3 pyramidal cells of hippocampus of kindled animals exhibit a selective and long-lasting (1 month) increased sensitivity to NMDA-evoked depolarization. The goal of this study was to develop a molecular explanation of the enhanced sensitivity to NMDA. We used radioligand binding studies of membranes isolated from microdissected regions of hippocampus including fascia dentata, CA3, and CA1. We also used quantitative in situ hybridization with subtype-specific riboprobes or oligonucleotides to determine whether increased expression of one or more of the genes encoding NMDA receptors was present in hippocampal granule and pyramidal cells of kindled animals. When studied 28 d after the last evoked seizure, we found that kindling induced a 2.8-fold increase in the number of binding sites for the competitive NMDA receptor antagonist 3-[(+/-)-2-(carboxypiperazine-4-yl)][1,2-3H-]propyl-1-phosphonic acid (3H-CPP). This increase was confined to region CA3 within the hippocampus. Similar, though much smaller, changes were detected 24 hr after the last evoked seizure. Surprisingly, no changes in the binding of another competitive NMDA receptor antagonist, cis-4-(phosphonomethyl)-2-3H-piperidinecarboxylate (3H-CGS-19755), were detected at either time point in any hippocampal region. Transcript levels of the NMDA receptor genes NMDAR1, NR2A, NR2B, NR2C, and NR2D and a glutamate-binding protein (GBP) were not altered by kindling. These findings demonstrate that kindling induces the expression of an NMDA receptor that is novel in that it is recognized by 3H-CPP but not by 3H-CGS-19755. The molecular basis of this novel NMDA receptor is not determined by differential expression of mRNA transcripts of known NMDA receptor genes. The direction, time course, and location of the kindling-induced increase in 3H-CPP binding suggest that this novel receptor may underlie the increased sensitivity of CA3 neurons to NMDA observed in kindled animals.