1
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Ramari C, D'hooge M, Dalgas U, Feinstein A, Amato MP, Brichetto G, Chataway J, Chiaravalloti ND, Cutter GR, DeLuca J, Farrell R, Filippi M, Freeman J, Inglese M, Meza C, Motl RW, Rocca MA, Sandroff BM, Salter A, Kos D, Feys P. Prevalence and Associated Clinical Characteristics of Walking-Related Motor, Cognitive, and Fatigability in Progressive Multiple Sclerosis: Baseline Results From the CogEx Study. Neurorehabil Neural Repair 2024; 38:327-338. [PMID: 38426484 DOI: 10.1177/15459683241236161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND People with progressive multiple sclerosis (PMS) present motor (eg, walking) and cognitive impairments, and report fatigue. Fatigue encompasses fatigability which is objectively measured by the capacity to sustain a motor or cognitive task. OBJECTIVE To investigate the prevalence of walking and cognitive fatigability (CF) and the associated clinical characteristics in a large sample of PMS patients. METHODS PMS patients (25-65 years old) were included from 11 sites (Europe and North America), having cognitive impairment (1.28 standard deviation below normative data for the symbol digit modality test [SDMT]). Walking fatigability (WF) was assessed using the distance walk index (DWI) and CF using the SDMT (scores from the last 30 seconds compared to the first 30 seconds). Additional measures were: cognitive assessment-Brief International Cognitive Assessment for multiple sclerosis (MS), cardiorespiratory fitness, 6-minute walk, physical activity, depressive symptoms, perceived fatigue-Modified Fatigue Impact Scale (MFIS), MS impact-MSIS-29, and walking ability. RESULTS Of 298 participants, 153 (51%) presented WF (DWI = -28.9 ± 22.1%) and 196 (66%) presented CF (-29.7 ± 15%). Clinical characteristics (EDSS, disease duration, and use of assistive device) were worse in patients with versus without WF. They also presented worse scores on MSIS-29 physical, MFIS total and physical and reduced physical capacity. CF patients scored better in the MSIS-29 physical and MFIS psychosocial, compared to non-CF group. Magnitude of CF and WF were not related. CONCLUSIONS Half of the cognitively-impaired PMS population presented WF which was associated with higher disability, physical functions, and fatigue. There was a high prevalence of CF but without strong associations with clinical, cognitive, and physical functions. TRIAL REGISTRATION NUMBER The "CogEx-study," www.clinicaltrial.gov identifier number: NCT03679468.
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Affiliation(s)
- Cintia Ramari
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Limburg, Belgium
- UMSC University MS Center Hasselt Pelt, Hasselt Pelt, Belgium
| | - Mieke D'hooge
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Limburg, Belgium
- National MS Center, Melsbroek, Belgium
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anthony Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Genoa, Italy
- AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Nancy D Chiaravalloti
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John DeLuca
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rachel Farrell
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, IRCSS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCSS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Devon, UK
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cecilia Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, IRCSS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Brian M Sandroff
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Peter Feys
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Limburg, Belgium
- UMSC University MS Center Hasselt Pelt, Hasselt Pelt, Belgium
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Martin-Gutierrez L, Waddington KE, Maggio A, Coelewij L, Oppong A, Yang N, Adriani M, Nytrova P, Farrell R, Pineda-Torra I, Jury EC. Dysregulated Lipid Metabolism Networks Modulate T-cell Function in People with Relapsing Remitting Multiple Sclerosis. Clin Exp Immunol 2024:uxae032. [PMID: 38625017 DOI: 10.1093/cei/uxae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Indexed: 04/17/2024] Open
Abstract
Altered cholesterol, oxysterol, sphingolipid, and fatty acid concentrations are reported in blood, cerebrospinal fluid, and brain tissue of people with relapsing remitting multiple sclerosis (RRMS) and are linked to disease progression and treatment responses. CD4+ T cells are pathogenic in RRMS, and defective T cell function could be mediated in part by liver X receptors (LXRs) - nuclear receptors that regulate lipid homeostasis and immunity. RNA-sequencing and pathway analysis identified that genes within the 'lipid metabolism' and 'signalling of nuclear receptors' pathways were dysregulated in CD4+ T cells isolated from RRMS patients compared with healthy donors. While LXRB and genes associated with cholesterol metabolism were upregulated, other T cell LXR-target genes, including genes involved in cellular lipid uptake (inducible degrader of the LDL receptor, IDOL), and the rate-limiting enzyme for glycosphingolipid biosynthesis (UDP-glucosylceramide synthase, UGCG) were downregulated in T cells from patients with RRMS compared to healthy donors. Correspondingly, plasma membrane glycosphingolipids were reduced, and cholesterol levels increased in RRMS CD4+ T cells, an effect partially recapitulated in healthy T cells by in vitro culture with T cell receptor stimulation in the presence of serum from RRMS patients. Notably, stimulation with LXR-agonist GW3965 normalised membrane cholesterol levels, and reduced proliferation and IL17 cytokine production in RRMS CD4+ T-cells. Thus, LXR-mediated lipid metabolism pathways were dysregulated in T cells from patients with RRMS and could contribute to RRMS pathogenesis. Therapies that modify lipid metabolism could help restore immune cell function.
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Affiliation(s)
- Lucia Martin-Gutierrez
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Kirsty E Waddington
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Annalisa Maggio
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Leda Coelewij
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Alexandra Oppong
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Nina Yang
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Marsilio Adriani
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
| | - Petra Nytrova
- Department of Neurology and Centre of Clinical, Neuroscience, First Faculty of Medicine, General University Hospital and First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Rachel Farrell
- Department of Neuroinflammation, University College London and Institute of Neurology and National Hospital of Neurology and Neurosurgery, United Kingdom
| | - Inés Pineda-Torra
- Centre for Experimental & Translational Medicine, Division of Medicine, University College London, United Kingdom
| | - Elizabeth C Jury
- Centre for Rheumatology, Division of Medicine, University College London, United Kingdom
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Farrell R, Zaunders J, Poynten IM, Anderson L, Evans L. Concurrent nonavalent human papillomavirus (HPV) vaccination and immune stimulation with imiquimod to treat recalcitrant HPV-associated high grade vaginal intra-epithelial neoplasia. Gynecol Oncol Rep 2024; 52:101350. [PMID: 38445009 PMCID: PMC10912037 DOI: 10.1016/j.gore.2024.101350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/07/2024] Open
Abstract
This is the first report describing detailed T cell responses to viral-like proteins contained in an HPV specific vaccine given in combination with Imiquimod for treatment of persistent VAIN2/3. We postulate that stimulation of the innate immune system with Imiquimod and the specific CD4 and CD8T cell responses following HPV vaccination with Gardasil9@ combined to induce clinical remission in a woman with treatment-refractory disease.
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Affiliation(s)
- R. Farrell
- Chris O'Brien Lifehouse Hospital, Camperdown, Sydney, New South Wales 2050, Australia
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
| | - J. Zaunders
- NSW State Reference Labaoratory for HIV, Centre for Applied Medical Research, St Vincents Hospital, New South Wales, Australia
- HIV Epidemiology and Prevention Program, The Kirby Institute, University of NSW Kensington, Sydney, New South Wales 2052, Australia
| | - IM. Poynten
- HIV Epidemiology and Prevention Program, The Kirby Institute, University of NSW Kensington, Sydney, New South Wales 2052, Australia
| | - L. Anderson
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
- NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales 2050, Australia
| | - L. Evans
- University of NSW Kensington, Sydney, New South Wales 2052, Australia
- Department of Clinical Immunology, Allergy and HIV, Liverpool Hospital, South Western Sydney Local Health District, Liverpool Sydney, New South Wales 2170, Australia
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4
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Oppong AE, Coelewij L, Robertson G, Martin-Gutierrez L, Waddington KE, Dönnes P, Nytrova P, Farrell R, Pineda-Torra I, Jury EC. Blood metabolomic and transcriptomic signatures stratify patient subgroups in multiple sclerosis according to disease severity. iScience 2024; 27:109225. [PMID: 38433900 PMCID: PMC10907838 DOI: 10.1016/j.isci.2024.109225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/20/2023] [Accepted: 02/08/2024] [Indexed: 03/05/2024] Open
Abstract
There are no blood-based biomarkers distinguishing patients with relapsing-remitting (RRMS) from secondary progressive multiple sclerosis (SPMS) although evidence supports metabolomic changes according to MS disease severity. Here machine learning analysis of serum metabolomic data stratified patients with RRMS from SPMS with high accuracy and a putative score was developed that stratified MS patient subsets. The top differentially expressed metabolites between SPMS versus patients with RRMS included lipids and fatty acids, metabolites enriched in pathways related to cellular respiration, notably, elevated lactate and glutamine (gluconeogenesis-related) and acetoacetate and bOHbutyrate (ketone bodies), and reduced alanine and pyruvate (glycolysis-related). Serum metabolomic changes were recapitulated in the whole blood transcriptome, whereby differentially expressed genes were also enriched in cellular respiration pathways in patients with SPMS. The final gene-metabolite interaction network demonstrated a potential metabolic shift from glycolysis toward increased gluconeogenesis and ketogenesis in SPMS, indicating metabolic stress which may trigger stress response pathways and subsequent neurodegeneration.
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Affiliation(s)
- Alexandra E. Oppong
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Leda Coelewij
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Georgia Robertson
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Lucia Martin-Gutierrez
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Kirsty E. Waddington
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Pierre Dönnes
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
- Scicross AB, Skövde, Sweden
| | - Petra Nytrova
- Department of Neurology and Centre of Clinical, Neuroscience, First Faculty of Medicine, General University Hospital and First Faculty of Medicine, Charles University in Prague, 500 03 Prague, Czech Republic
| | - Rachel Farrell
- Department of Neuroinflammation, University College London and Institute of Neurology and National Hospital of Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Inés Pineda-Torra
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
| | - Elizabeth C. Jury
- Division of Medicine, Department of Inflammation, University College London, London WC1E 6JF, UK
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5
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Feinstein A, Amato MP, Brichetto G, Chataway J, Chiaravalloti ND, Cutter G, Dalgas U, DeLuca J, Farrell R, Feys P, Filippi M, Freeman J, Inglese M, Meza C, Motl RW, Rocca MA, Sandroff BM, Salter A. Cognitive rehabilitation and aerobic exercise for cognitive impairment in people with progressive multiple sclerosis (CogEx): a randomised, blinded, sham-controlled trial. Lancet Neurol 2023; 22:912-924. [PMID: 37739574 DOI: 10.1016/s1474-4422(23)00280-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Cognitive dysfunction in people with relapsing-remitting multiple sclerosis can improve with cognitive rehabilitation or exercise. Similar effects have not been clearly shown in people with progressive multiple sclerosis. We aimed to investigate the individual and synergistic effects of cognitive rehabilitation and exercise in patients with progressive multiple sclerosis. METHODS CogEx was a randomised, sham-controlled trial completed in 11 hospital clinics, universities, and rehabilitation centres in Belgium, Canada, Denmark, Italy, UK, and USA. Patients with progressive multiple sclerosis were eligible for inclusion if they were aged 25-65 years and had an Expanded Disability Status Scale (EDSS) score of less than 7. All had impaired processing speed defined as a performance of 1·282 SD or greater below normative data on the Symbol Digit modalities Tests (SDMT). Participants were randomly assigned (1:1:1:1), using an interactive web-response system accessed online from each centre, to cognitive rehabilitation plus exercise, cognitive rehabilitation plus sham exercise, exercise plus sham cognitive rehabilitation, or sham exercise plus sham cognitive rehabilitation. The study statistician created the randomisation sequence that was stratified by centre. Participants, outcome assessors, and investigators were blinded to group allocation. The study statistician was masked to treatment during analysis only. Interventions were conducted two times per week for 12 weeks: cognitive rehabilitation used an individualised, computer-based, incremental approach to improve processing speed; sham cognitive rehabilitation consisted of internet training provided individually; the exercise intervention involved individualised aerobic training using a recumbent arm-leg stepper; and the sham exercise involved stretching and balance tasks without inducing cardiovascular strain. The primary outcome measure was processing speed measured by SDMT at 12 weeks; least squares mean differences were compared between groups using linear mixed model in all participants who had a 12-week assessment. The trial is registered with ClinicalTrials.gov, NCT03679468, and is completed. FINDINGS Between Dec 14, 2018, and April 2, 2022, 311 people with progressive multiple sclerosis were enrolled and 284 (91%) completed the 12-week assessment (117/311 [38%] male and 194/311 [62%] female). The least squares mean group differences in SDMT at 12 weeks did not differ between groups (p=0·85). Compared with the sham cognitive rehabilitation and sham exercise group (n=67), differences were -1·30 (95% CI -3·75 to 1·16) for the cognitive rehabilitation plus exercise group (n=70); -2·78 (-5·23 to -0·33) for the sham cognitive rehabilitation plus exercise group (n=71); and -0·71 (-3·11 to 1·70) for the cognitive rehabilitation plus sham exercise group (n=76). 11 adverse events possibly related to the interventions occurred, six in the exercise plus sham cognitive rehabilitation group (pain, dizziness, and falls), two in the cognitive rehabilitation plus sham exercise group (headache and pain), two in the cognitive rehabilitation and exercise group (increased fatigue and pain), and one in the dual sham group (fall). INTERPRETATION Combined cognitive rehabilitation plus exercise does not seem to improve processing speed in people with progressive multiple sclerosis. However, our sham interventions were not inactive. Studies comparing interventions with a non-intervention group are needed to investigate whether clinically meaningful improvements in processing speed might be attainable in people with progressive multiple sclerosis. FUNDING MS Canada.
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Affiliation(s)
- Anthony Feinstein
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation, Genoa, Italy; AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Nancy D Chiaravalloti
- Kessler Foundation, East Hanover, NJ, USA; Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - John DeLuca
- Kessler Foundation, East Hanover, NJ, USA; Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rachel Farrell
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Peter Feys
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Belgium; UMSC University MS Center Hasselt Pelt, Belgium
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCSS San Raffaele Scientific Institute, Milan, Italy; Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy; Neurorehabilitation Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy; Neurophysiology Service, IRCSS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Devon, UK
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cecilia Meza
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCSS San Raffaele Scientific Institute, Milan, Italy; Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Brian M Sandroff
- Kessler Foundation, East Hanover, NJ, USA; Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
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Veldkamp R, D'hooge M, Sandroff BM, DeLuca J, Kos D, Salter A, Feinstein A, Amato MP, Brichetto G, Chataway J, Farrell R, Chiaravalloti ND, Dalgas U, Filippi M, Freeman J, Motl RW, Meza C, Inglese M, Rocca MA, Cutter G, Feys P. Profiling cognitive-motor interference in a large sample of persons with progressive multiple sclerosis and impaired processing speed: results from the CogEx study. J Neurol 2023; 270:3120-3128. [PMID: 36881147 DOI: 10.1007/s00415-023-11636-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Performing cognitive-motor dual tasks (DTs) may result in reduced walking speed and cognitive performance. The effect in persons with progressive multiple sclerosis (pwPMS) having cognitive dysfunction is unknown. OBJECTIVE To profile DT-performance during walking in cognitively impaired pwPMS and examine DT-performance by disability level. METHODS Secondary analyses were conducted on baseline data from the CogEx-study. Participants, enrolled with Symbol Digit Modalities Test 1.282 standard deviations below normative value, performed a cognitive single task ([ST], alternating alphabet), motor ST (walking) and DT (both). Outcomes were number of correct answers on the alternating alphabet task, walking speed, and DT-cost (DTC: decline in performance relative to the ST). Outcomes were compared between EDSS subgroups (≤ 4, 4.5-5.5, ≥ 6). Spearman correlations were conducted between the DTCmotor with clinical measures. Adjusted significance level was 0.01. RESULTS Overall, participants (n = 307) walked slower and had fewer correct answers on the DT versus ST (both p < 0.001), with a DTCmotor of 15.8% and DTCcognitive of 2.7%. All three subgroups walked slower during the DT versus ST, with DTCmotor different from zero (p's < 0.001). Only the EDSS ≥ 6 group had fewer correct answers on the DT versus ST (p < 0.001), but the DTCcognitive did not differ from zero for any of the groups (p ≥ 0.039). CONCLUSION Dual tasking substantially affects walking performance in cognitively impaired pwPMS, to a similar degree for EDSS subgroups.
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Affiliation(s)
- R Veldkamp
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium.
- UMSC, Hasselt-Pelt, Belgium.
| | - M D'hooge
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- UMSC, Hasselt-Pelt, Belgium
- National MS Center Melsbroek, Steenokkerzeel, Belgium
| | - B M Sandroff
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - J DeLuca
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - D Kos
- National MS Center Melsbroek, Steenokkerzeel, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - A Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - A Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - M P Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - G Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Via Operai 40, 16149, Genoa, Italy
- AISM Rehabilitation Service, Italian Multiple Sclerosis Society (AISM), Via Operai 30, 16149, Genoa, Italy
| | - J Chataway
- Queen Square MS Centre, Department of Neuroinflammation, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - R Farrell
- Queen Square MS Centre, Department of Neuroinflammation, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - N D Chiaravalloti
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - U Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Dalgas Avenue 4, 8000, Aarhus, Denmark
| | - M Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, and Neurology Unit, IRCCS, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - J Freeman
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, UK
| | - R W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - C Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - M Inglese
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - M A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, and Neurology Unit, IRCCS, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - G Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - P Feys
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- UMSC, Hasselt-Pelt, Belgium
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7
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Romanò F, Motl RW, Valsasina P, Amato MP, Brichetto G, Bruschi N, Chataway J, Chiaravalloti ND, Cutter G, Dalgas U, DeLuca J, Farrell R, Feys P, Freeman J, Inglese M, Meza C, Salter A, Sandroff BM, Feinstein A, Rocca MA, Filippi M. Abnormal thalamic functional connectivity correlates with cardiorespiratory fitness and physical activity in progressive multiple sclerosis. J Neurol 2023; 270:3213-3224. [PMID: 36933030 DOI: 10.1007/s00415-023-11664-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Altered thalamic volumes and resting state (RS) functional connectivity (FC) might be associated with physical activity (PA) and cardiorespiratory fitness (CRF) in people with progressive multiple sclerosis (PMS). OBJECTIVES To assess thalamic structural and functional alterations and investigate their correlations with PA/CRF levels in people with PMS. METHODS Seven-day accelerometry and cardiopulmonary exercise testing were used to assess PA/CRF levels in 91 persons with PMS. They underwent 3.0 T structural and RS fMRI acquisition with 37 age/sex-matched healthy controls (HC). Between-group comparisons of MRI measures and their correlations with PA/CRF variables were assessed. RESULTS PMS people had lower volumes compared to HC (all p < 0.001). At corrected threshold, PMS showed decreased intra- and inter-thalamic RS FC, and increased RS FC between the thalamus and the hippocampus, bilaterally. At uncorrected threshold, decreased thalamic RS FC with caudate nucleus, cerebellum and anterior cingulate cortex (ACC), as well as increased thalamic RS FC with occipital regions, were also detected. Lower CRF, measured as peak oxygen consumption (VO2peak), correlated with lower white matter volume (r = 0.31, p = 0.03). Moreover, lower levels of light PA correlated with increased thalamic RS FC with the right hippocampus (r = - 0.3, p = 0.05). DISCUSSION People with PMS showed widespread brain atrophy, as well as pronounced intra-thalamic and thalamo-hippocampal RS FC abnormalities. White matter atrophy correlated with CRF, while increased thalamo-hippocampal RS FC was associated to worse PA levels. Thalamic RS FC might be used to monitor physical impairment and efficacy of rehabilitative and disease-modifying treatments in future studies.
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Affiliation(s)
- Francesco Romanò
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Robert W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - Paola Valsasina
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Maria Pia Amato
- Section Neurosciences, Department NEUROFARBA, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Via Operai 40, 16149, Genoa, Italy.,AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Via Operai 30, 16149, Genoa, Italy
| | - Nicolò Bruschi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Jeremy Chataway
- Faculty of Brain Sciences, Queen Square MS Centre, UCL Queen Square Institute of Neurology, UCL, London, UK.,Biomedical Research Centre, National Institute for Health Research, University College London Hospitals, London, UK
| | - Nancy D Chiaravalloti
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine & Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Dalgas Avenue 4, 8000, Aarhus, Denmark
| | - John DeLuca
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine & Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Rachel Farrell
- Faculty of Brain Sciences, Queen Square MS Centre, UCL Queen Square Institute of Neurology, UCL, London, UK
| | - Peter Feys
- Faculty of Rehabilitation Sciences, REVAL, Hasselt University, Diepenbeek, Belgium.,UMSC Hasselt, Pelt, Belgium
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Devon, UK
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cecilia Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - Amber Salter
- Section on Statistical Planning and Analysis, Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brian M Sandroff
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine & Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Anthony Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. .,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Vita-Salute San Raffaele University, Milan, Italy. .,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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8
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Lakra C, Higgins R, Beare B, Farrell R, Ajina S, Burns S, Lee M, Swayne O. Managing painful shoulder after neurological injury. Pract Neurol 2023; 23:229-238. [PMID: 36882323 DOI: 10.1136/pn-2022-003576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 03/09/2023]
Abstract
Shoulder pain is common after neurological injury and can be disabling, lead to poor functional outcomes and increase care costs. Its cause is multifactoral and several pathologies contribute to the presentation. Astute diagnostic skills and a multidisciplinary approach are required to recognise what is clinically relevant and to implement appropriate stepwise management. In the absence of large clinical trial data, we aim to provide a comprehensive, practical and pragmatic overview of shoulder pain in patients with neurological conditions. We use available evidence to produce a management guideline, taking into account specialty opinions from neurology, rehabilitation medicine, orthopaedics and physiotherapy.
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Affiliation(s)
- Celine Lakra
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rachel Higgins
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Benjamin Beare
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rachel Farrell
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neuro-inflammation, Queen Square Institute of Neurology, University College London, London, UK
| | - Sara Ajina
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sophia Burns
- Department of Orthopaedics, University College London, London, UK
| | - Marcus Lee
- Department of Orthopaedics, University College London, London, UK
| | - Orlando Swayne
- Department of Therapy and Rehabilitation, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
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9
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Preziosa P, Rocca MA, Pagani E, Valsasina P, Amato MP, Brichetto G, Bruschi N, Chataway J, Chiaravalloti ND, Cutter G, Dalgas U, DeLuca J, Farrell R, Feys P, Freeman J, Inglese M, Meani A, Meza C, Motl RW, Salter A, Sandroff BM, Feinstein A, Filippi M. Structural and functional magnetic resonance imaging correlates of fatigue and dual-task performance in progressive multiple sclerosis. J Neurol 2023; 270:1543-1563. [PMID: 36436069 DOI: 10.1007/s00415-022-11486-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Frontal cortico-subcortical dysfunction may contribute to fatigue and dual-task impairment of walking and cognition in progressive multiple sclerosis (PMS). PURPOSE To explore the associations among fatigue, dual-task performance and structural and functional abnormalities of frontal cortico-subcortical network in PMS. METHODS Brain 3 T structural and functional MRI sequences, Modified Fatigue Impact Scale (MFIS), dual-task motor and cognitive performances were obtained from 57 PMS patients and 10 healthy controls (HC). The associations of thalamic, caudate nucleus and dorsolateral prefrontal cortex (DLPFC) atrophy, microstructural abnormalities of their connections and their resting state effective connectivity (RS-EC) with fatigue and dual-task performance were investigated using random forest. RESULTS Thirty-seven PMS patients were fatigued (F) (MFIS ≥ 38). Compared to HC, non-fatigued (nF) and F-PMS patients had significantly worse dual-task performance (p ≤ 0.002). Predictors of fatigue (out-of-bag [OOB]-accuracy = 0.754) and its severity (OOB-R2 = 0.247) were higher Expanded Disability Status scale (EDSS) score, lower RS-EC from left-caudate nucleus to left-DLPFC, lower fractional anisotropy between left-caudate nucleus and left-thalamus, higher mean diffusivity between right-caudate nucleus and right-thalamus, and longer disease duration. Microstructural abnormalities in connections among thalami, caudate nuclei and DLPFC, mainly left-lateralized in nF-PMS and more bilateral in F-PMS, higher RS-EC from left-DLPFC to right-DLPFC in nF-PMS and lower RS-EC from left-caudate nucleus to left-DLPFC in F-PMS, higher EDSS score, higher WM lesion volume, and lower cortical volume predicted worse dual-task performances (OOB-R2 from 0.426 to 0.530). CONCLUSIONS In PMS, structural and functional frontal cortico-subcortical abnormalities contribute to fatigue and worse dual-task performance, with different patterns according to the presence of fatigue.
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Affiliation(s)
- Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Pagani
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Valsasina
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Genoa, Italy.,AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Nicolò Bruschi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research, Biomedical Research Centre, University College London Hospitals, London, UK
| | - Nancy D Chiaravalloti
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - John DeLuca
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Rachel Farrell
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research, Biomedical Research Centre, University College London Hospitals, London, UK
| | - Peter Feys
- REVAL, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Plymouth, UK
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandro Meani
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cecilia Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brian M Sandroff
- Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers NJ Medical School, Newark, NJ, USA
| | - Anthony Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Vita-Salute San Raffaele University, Milan, Italy.
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10
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Farrell R, Liauw WS, Morris DL. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer in an Australian institution: lessons from 20 years' experience. BMC Surg 2022; 22:338. [PMID: 36096791 PMCID: PMC9469563 DOI: 10.1186/s12893-022-01786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives We report the 20-year experience of the largest Australian unit performing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer and reflect on learning opportunities. Methods A retrospective review of all cases of CRS for ovarian cancer at St George Peritonectomy Unit from Jan 1998 to Jan 2018 was performed. Prospectively collected data include age, stage, histology, disease extent (PCI), completeness of cytoreduction (CC score), HIPEC regime, 30-day surgical morbidity, disease recurrence, and death. Survival was computed using Kaplan–Meier method and analysed using log-rank tests and Cox-proportional hazards models. Results Forty-one women with advanced ovarian cancer (11 primary stage III/IV, 30 recurrent) underwent CRS, 29 (71%) with HIPEC. Most (68%) had high-volume disease (PCI > 15). In 98%, CC0/CC1 (residual < 2.5 mm) was achieved. Fourteen (34%) had grade 3/4 complications, 1 patient (2%) died within 30 days and 2 patients (5%) died within 90 days. Progression-free and median overall survival was 30.0 and 67.0 months for primary cancer, and 6.7 and 18.1 months for recurrent cancer. Survival was associated with platinum-sensitivity, PCI ≤ 15, and CC score 0, but not HIPEC. Conclusion This study reports outcomes for patients with advanced ovarian cancer patients treated in an Australian centre offering CRS and HIPEC. Whilst survival and morbidity outcomes were good for primary disease, they were poorer than predicted from the literature for cases of recurrent disease. The incorporation of evidence-based predictors of survival and multidisciplinary input are essential to achieve the best survival outcomes.
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Affiliation(s)
- R Farrell
- Chris O'Brien Lifehouse Hospital, Camperdown, Sydney, NSW, 2050, Australia. .,The University of Sydney, Sydney, NSW, 2006, Australia. .,Department of Surgery, UNSW, Sydney, NSW, 2033, Australia. .,Prince of Wales Private Hospital, Suite 30, Level 7, Randwick Sydney, 2031, Australia.
| | - W S Liauw
- Department of Surgery, UNSW, Sydney, NSW, 2033, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, 2217, Australia
| | - D L Morris
- Department of Surgery, UNSW, Sydney, NSW, 2033, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, 2217, Australia
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11
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Farrell R, Colglazier E, Parker C, Stevens L, Austin ED, Fineman JR. Case Report: Caveolin‐1 Associated with Severe (Pediatric‐onset) Presentation of Pulmonary Arterial Hypertension. Pulm Circ 2022; 12:e12100. [PMID: 35864912 PMCID: PMC9294289 DOI: 10.1002/pul2.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
There has been a growing interest in the role that genetic factors influence pediatric pulmonary vascular disease. In fact, data suggests that genetic factors contribute to ~42% of pediatric‐onset pulmonary hypertension. Although animal and human studies suggest that aberrations in Caveolin1 (CAV1) signaling participate in the development of pulmonary vascular disorders, limited reports of CAV1‐associated heritable pulmonary arterial hypertension (HPAH) exist. This is a case report of a 2‐year‐old female with late recognition of HPAH due to a CAV1 pathogenic variant: c.474del, (p.Leu159Serfs*22)(NM_001753.5). The pedigree demonstrates autosomal dominant transmission with reduced penetrance of PAH, suggestive that additional genetic or environmental factors modify PAH development. Genetic testing and the discovery of rare genetic alterations in PAH during infancy and childhood may aid in identifying disease etiologies, guide therapeutic decisions, and ultimately identify novel therapeutic targets. Moreover, CAV1 genetics implicate variable expressivity and incomplete penetrance for HPAH and underscores the utility of predictive genetic testing for unaffected family members no matter their age.
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Affiliation(s)
- R Farrell
- Department of Pediatrics UCSF Benioff Children's Hospital, San Francisco California
| | - E Colglazier
- Department of Pediatrics UCSF Benioff Children's Hospital, San Francisco California
| | - C Parker
- Department of Pediatrics UCSF Benioff Children's Hospital, San Francisco California
| | - L Stevens
- Department of Pediatrics UCSF Benioff Children's Hospital, San Francisco California
| | - ED Austin
- Department of Pediatrics Vanderbilt University Medical Center
| | - JR Fineman
- Department of Pediatrics UCSF Benioff Children's Hospital, San Francisco California
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12
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Chiaravalloti ND, DeLuca J, Salter A, Amato MP, Brichetto G, Chataway J, Dalgas U, Farrell R, Feys P, Filippi M, Freeman J, Inglese M, Meza C, Moore NB, Motl RW, Rocca MA, Sandroff BM, Cutter G, Feinstein A. The relationship between processing speed and verbal and non-verbal new learning and memory in progressive multiple sclerosis. Mult Scler 2022; 28:1783-1792. [DOI: 10.1177/13524585221088190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Processing speed (PS) deficits are the most common cognitive deficits in multiple sclerosis (MS), followed by learning and memory deficits, and are often an early cognitive problem. It has been argued that impaired PS is a primary consequence of MS, which in turn decreases learning. The current analysis examined the association between PS and learning in a large cohort of individuals with progressive MS. Methods: Baseline data from a randomized clinical trial on rehabilitation taking place at 11 centers across North America and Europe were analyzed. Participants included 275 individuals with clinically definite progressive MS (primary, secondary) consented into the trial. Results: Symbol Digit Modalities Test (SDMT) significantly correlated with California Verbal Learning Test-II (CVLT-II) ( r = 0.21, p = 0.0003) and Brief Visuospatial Memory Test–Revised (BVMT-R) ( r = 0.516, p < 0.0001). Receiver operating characteristic (ROC) analysis of the SDMT z score to distinguish between impaired and non-impaired CVLT-II performance demonstrated an area under the curve (AUC) of 0.61 (95% confidence interval (CI): 0.55–0.68) and a threshold of −1.62. ROC analysis between SDMT and BVMT-R resulted in an AUC of 0.77 (95% CI: 0.71–0.83) and threshold of −1.75 for the SDMT z score to predict impaired BVMT-R. Conclusion: Results indicate little ability beyond chance to predict CVLT-II from SDMT (61%), albeit statistically significant. In contrast, there was a 77% chance that the model could distinguish between impaired and non-impaired BVMT-R. Several potential explanations are discussed.
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Affiliation(s)
- Nancy D Chiaravalloti
- Kessler Foundation, East Hanover, NJ, USA/Department of Physical Medicine Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - John DeLuca
- Kessler Foundation, East Hanover, NJ, USA/Department of Physical Medicine Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amber Salter
- Section on Statistical Planning and Analysis, Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Genoa, Italy/AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Rachel Farrell
- Department of Neurorehabilitation, National Hospital for Neurology and Neurosurgery, London, UK/Department Neuroinflammation, UCL Queen Square Institute of Neurology, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK
| | - Peter Feys
- REVAL, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Freeman
- Faculty of Health, School of Health Professions, University of Plymouth, Devon, UK
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Cecilia Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Robert W Motl
- Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Maria Assunta Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy
| | - Brian M Sandroff
- Kessler Foundation, East Hanover, NJ, USA/Department of Physical Medicine Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gary Cutter
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anthony Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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13
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Sandroff BM, Motl RW, Amato MP, Brichetto G, Chataway J, Chiaravalloti ND, Cutter GR, Dalgas U, DeLuca J, Farrell R, Feys P, Filippi M, Freeman J, Inglese M, Meza C, Rocca MA, Salter A, Feinstein A. Cardiorespiratory fitness and free-living physical activity are not associated with cognition in persons with progressive multiple sclerosis: Baseline analyses from the CogEx study. Mult Scler 2021; 28:1091-1100. [PMID: 34595972 DOI: 10.1177/13524585211048397] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Aerobic exercise training (physical activity for improving cardiorespiratory fitness) represents a promising approach for managing cognitive impairment in multiple sclerosis (MS). However, there is limited evidence that levels of physical activity and fitness are associated with cognition in progressive MS. OBJECTIVE We examined associations among cardiorespiratory fitness, moderate-to-vigorous physical activity (MVPA), and cognitive performance in a large, international progressive MS sample. METHODS Two hundred forty European and North American persons with progressive MS underwent cardiorespiratory fitness measurement on a recumbent stepper, wore an ActiGraph GT3X + accelerometer for 7 days for measuring MVPA, and underwent the Brief International Cognitive Assessment in MS. RESULTS Cardiorespiratory fitness was not significantly correlated with Symbol Digit Modalities Test (SDMT; r = -0.01; r = -0.04), California Verbal Learning Test-II (CVLT-II; r = 0.05; r = 0.05), or Brief Visuospatial Memory Test-Revised (BVMT-R; r = -0.14; r = -0.14) z-scores controlling for age, sex, and education. MVPA and SDMT (r = 0.05), CVLT-II (r = -0.07), and BVMT-R (r = 0.01) z-scores were not significantly correlated. CONCLUSION Cardiorespiratory fitness and MVPA were not associated with cognition in this large progressive MS sample, yet these outcomes represent critical manipulation checks for documenting the success of the CogEx trial. This highlights the importance of examining other exercise-related mechanisms-of-action for improving cognition in progressive MS.
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Affiliation(s)
- Brian M Sandroff
- Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA.,Kessler Foundation, West Orange, NJ, USA/Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Robert W Motl
- Department of Physical Therapy, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy/Fondazione IRCCS Don Carlo Gnocchi ONLUS, Florence, Italy
| | - Giampaolo Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Genoa, Italy/AISM Rehabilitation Service, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, Biomedical Research Centre, University College London Hospitals, London, UK
| | - Nancy D Chiaravalloti
- Kessler Foundation, West Orange, NJ, USA/Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gary R Cutter
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - John DeLuca
- Kessler Foundation, West Orange, NJ, USA/Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rachel Farrell
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Peter Feys
- Rehabilitation Research Center (REVAL), Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, Neurology Unit, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cecilia Meza
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, Neurology Unit, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Amber Salter
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anthony Feinstein
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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14
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Farrell R, Summers M, Doogan C, Mulhert N, Keenan E, Buchanan K, Lee H, Padilla H, Stevenson VL. Evaluation of the cognitive benefits of intrathecal baclofen pump implantation in people with intractable multiple sclerosis related spasticity. Mult Scler Relat Disord 2021; 50:102831. [PMID: 33618123 DOI: 10.1016/j.msard.2021.102831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Spasticity is a common problematic symptom in Multiple Sclerosis with over one third of patients failing first line therapies. Intrathecal baclofen is a safe and efficacious option for treatment resistant spasticity. Anecdotally patients report improved concentration/cognitive performance when switching to intrathecal baclofen (ITB) from systemic medications. AIM To explore whether subjects who proceed with ITB pump implantation for spasticity management and reduce oral anti-spasticity agents will have improved cognitive function. METHODS Subjects were admitted for trial of ITB via lumbar puncture and subsequent pump implantation. Spasticity and cognitive measures before ITB trial and 3 months post implant were recorded. Paired t-test or Wilcoxon Signed Ranks test was used for within subject change and effect sizes (Cohen's dz) were calculated. Subgroup analysis of those on ≥2, or ≤ 1 spasticity medications at baseline was performed. RESULTS 27 subjects with MS completed per protocol. Mean age 46 years [26 - 56], disease duration 15 years [6 - 26], RRMS = 3, SPMS = 17 and PPMS=7. The majority were on multiple spasticity medications. Spasticity scores significantly improved post pump implant. Mean ITB dose at 3 months was 143 mcg / day and 19 discontinued all other treatments for spasticity. There was no deterioration on any cognitive or mood measure. An improvement of moderate effect size was found in Backwards Digit Span (d=0.41, p=0.059) and HADS - anxiety (d=0.37, p=0.097). Fatigue Severity Scale score decreased substantially (d=0.81, p=0.005). Small improvements in Symbol Digit Modalities Test score (d=0.24) and Sustained Attention to Response Task response time (d=0.23) were non-significant. Performance on other measures did not change. Effect sizes were larger in subgroup on ≥2 oral spasticity medications at baseline, compared to the group on ≤1 medication (SDMT, d=0.42 vs d=0.07; Backwards digit span 0.45 vs 0.28; HADS-anxiety 0.39 vs 0.32; HADS-depression d=0.32 vs 0.05 and FSS, d= 1.14 vs 0.42). CONCLUSIONS In a pilot study exploring the impact of ITB on cognition, spasticity scores improved universally and beneficial effects on some measures of fatigue, anxiety, auditory attention and verbal working memory were found. Improvement of speed of processing in those withdrawing higher doses of oral medication was also demonstrated suggesting that switching to ITB has added cognitive and psychological benefits for people with MS.
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Affiliation(s)
- R Farrell
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London; Department of Neuroinflammation, Queen Square, Institute of Neurology, University College London; NIHR University College London Hospitals, Biomedical Research Centre.
| | - M Summers
- Department of Clinical Neuropsychology, National Hospital for Neurology & Neurosurgery, London, United Kingdom
| | - C Doogan
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
| | - N Mulhert
- Division of Neuroscience and Experimental Psychology, University of Manchester, United Kingdom
| | - E Keenan
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
| | - K Buchanan
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
| | - H Lee
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
| | - H Padilla
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
| | - V L Stevenson
- Department of Rehabilitation, The National Hospital for Neurology & Neurosurgery, University College London Hospitals (UCLH), London
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15
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Pineda-Torra I, Siddique S, Waddington KE, Farrell R, Jury EC. Disrupted Lipid Metabolism in Multiple Sclerosis: A Role for Liver X Receptors? Front Endocrinol (Lausanne) 2021; 12:639757. [PMID: 33927692 PMCID: PMC8076792 DOI: 10.3389/fendo.2021.639757] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/22/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic neurological disease driven by autoimmune, inflammatory and neurodegenerative processes leading to neuronal demyelination and subsequent degeneration. Systemic lipid metabolism is disturbed in people with MS, and lipid metabolic pathways are crucial to the protective process of remyelination. The lipid-activated transcription factors liver X receptors (LXRs) are important integrators of lipid metabolism and immunity. Consequently, there is a strong interest in targeting these receptors in a number of metabolic and inflammatory diseases, including MS. We have reviewed the evidence for involvement of LXR-driven lipid metabolism in the dysfunction of peripheral and brain-resident immune cells in MS, focusing on human studies, both the relapsing remitting and progressive phases of the disease are discussed. Finally, we discuss the therapeutic potential of modulating the activity of these receptors with existing pharmacological agents and highlight important areas of future research.
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Affiliation(s)
- Inés Pineda-Torra
- Centre for Cardiometabolic and Vascular Medicine, Department of Medicine, University College London, London, United Kingdom
- *Correspondence: Elizabeth C. Jury, ; Inés Pineda-Torra,
| | - Sherrice Siddique
- Centre for Rheumatology, Department of Medicine, University College London, London, United Kingdom
| | - Kirsty E. Waddington
- Centre for Cardiometabolic and Vascular Medicine, Department of Medicine, University College London, London, United Kingdom
- Centre for Rheumatology, Department of Medicine, University College London, London, United Kingdom
| | - Rachel Farrell
- Department of Neuroinflammation, Institute of Neurology and National Hospital of Neurology and Neurosurgery, University College London, London, United Kingdom
| | - Elizabeth C. Jury
- Centre for Rheumatology, Department of Medicine, University College London, London, United Kingdom
- *Correspondence: Elizabeth C. Jury, ; Inés Pineda-Torra,
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16
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Brant A, Batur P, Arrigain S, Lopez R, Farrell R. P55 Demographic and social factors associated with out-of-pocket expenditures for contraceptive prescriptions in the US during medicaid expansion. Contraception 2020. [DOI: 10.1016/j.contraception.2020.07.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Waddington KE, Papadaki A, Coelewij L, Adriani M, Nytrova P, Kubala Havrdova E, Fogdell-Hahn A, Farrell R, Dönnes P, Pineda-Torra I, Jury EC. Using Serum Metabolomics to Predict Development of Anti-drug Antibodies in Multiple Sclerosis Patients Treated With IFNβ. Front Immunol 2020; 11:1527. [PMID: 32765529 PMCID: PMC7380268 DOI: 10.3389/fimmu.2020.01527] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Neutralizing anti-drug antibodies (ADA) can greatly reduce the efficacy of biopharmaceuticals used to treat patients with multiple sclerosis (MS). However, the biological factors pre-disposing an individual to develop ADA are poorly characterized. Thus, there is an unmet clinical need for biomarkers to predict the development of immunogenicity, and subsequent treatment failure. Up to 35% of MS patients treated with beta interferons (IFNβ) develop ADA. Here we use machine learning to predict immunogenicity against IFNβ utilizing serum metabolomics data. Methods: Serum samples were collected from 89 MS patients as part of the ABIRISK consortium-a multi-center prospective study of ADA development. Metabolites and ADA were quantified prior to and after IFNβ treatment. Thirty patients became ADA positive during the first year of treatment (ADA+). We tested the efficacy of six binary classification models using 10-fold cross validation; k-nearest neighbors, decision tree, random forest, support vector machine and lasso (Least Absolute Shrinkage and Selection Operator) logistic regression with and without interactions. Results: We were able to predict future immunogenicity from baseline metabolomics data. Lasso logistic regression with/without interactions and support vector machines were the most successful at identifying ADA+ or ADA- cases, respectively. Furthermore, patients who become ADA+ had a distinct metabolic response to IFNβ in the first 3 months, with 29 differentially regulated metabolites. Machine learning algorithms could also predict ADA status based on metabolite concentrations at 3 months. Lasso logistic regressions had the greatest proportion of correct classifications [F1 score (accuracy measure) = 0.808, specificity = 0.913]. Finally, we hypothesized that serum lipids could contribute to ADA development by altering immune-cell lipid rafts. This was supported by experimental evidence demonstrating that, prior to IFNβ exposure, lipid raft-associated lipids were differentially expressed between MS patients who became ADA+ or remained ADA-. Conclusion: Serum metabolites are a promising biomarker for prediction of ADA development in MS patients treated with IFNβ, and could provide novel insight into mechanisms of immunogenicity.
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Affiliation(s)
- Kirsty E. Waddington
- Centre for Rheumatology, University College London, London, United Kingdom
- Centre for Cardiometabolic and Vascular Medicine, University College London, London, United Kingdom
| | - Artemis Papadaki
- Centre for Rheumatology, University College London, London, United Kingdom
| | - Leda Coelewij
- Centre for Rheumatology, University College London, London, United Kingdom
- Centre for Cardiometabolic and Vascular Medicine, University College London, London, United Kingdom
| | - Marsilio Adriani
- Centre for Rheumatology, University College London, London, United Kingdom
| | - Petra Nytrova
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University in Prague, Prague, Czechia
| | - Eva Kubala Havrdova
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University in Prague, Prague, Czechia
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Center for Molecular Medicine (CMM), Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Rachel Farrell
- Department of Neuroinflammation, University College London, Institute of Neurology and National Hospital of Neurology and Neurosurgery, London, United Kingdom
| | - Pierre Dönnes
- Centre for Rheumatology, University College London, London, United Kingdom
- Scicross AB, Skövde, Sweden
| | - Inés Pineda-Torra
- Centre for Cardiometabolic and Vascular Medicine, University College London, London, United Kingdom
| | - Elizabeth C. Jury
- Centre for Rheumatology, University College London, London, United Kingdom
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18
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Stevenson V, Farrell R, Ramdharry G, Swayne O, Ward N, Leary S, Holmes S. Hospital based rehabilitation services; Rising to the challenge of the COVID-19 pandemic. ACNR 2020. [DOI: 10.47795/cigb9925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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19
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Balaratnam MS, Donnelly A, Padilla H, Simeoni S, Bahadur S, Keenan L, Lee H, Farrell R, Curtis C, Brownstone RM, Murphy M, Grieve J, Shieff C, Nayar M, Pitceathly RDS, Christofi G, Stevenson VL. Reducing Intrathecal Baclofen Related Infections: Service Evaluation and Best Practice Guidelines. Neuromodulation 2019; 23:991-995. [PMID: 31828902 DOI: 10.1111/ner.13071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/24/2019] [Accepted: 09/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Intrathecal baclofen (ITB) pumps are an effective treatment for spasticity; however infection rates have been reported in 3-26% of patients in the literature. The multidisciplinary ITB service has been established at The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square, London for over 20 years. Our study was designed to clarify the rate of infection in our ITB patient cohort and secondly, to formulate and implement best practice guidelines and to determine prospectively, whether they effectively reduced infection rates. METHODS Clinical record review of all patients receiving ITB pre-intervention; January 2013-May 2015, and following practice changes; June 2016-June 2018. RESULTS Four of 118 patients receiving ITB during the first time period (3.4%, annual incidence rate of infection 1.4%) developed an ITB-related infection (three following ITB pump replacement surgery, one after initial implant). Infections were associated with 4.2% of ITB-related surgical procedures. Three of four pumps required explantation. Following change in practice (pre-operative chlorhexidine skin wash and intraoperative vancomycin wash of the fibrous pocket of the replacement site), only one of 160 ITB patients developed infection (pump not explanted) in the second time period (0.6%, annual incidence rate 0.3%). The infection rate related to ITB surgical procedures was 1.1%. In cases of ITB pump replacement, the infection rate was reduced to 3.3% from 17.6%. CONCLUSIONS This study suggests that a straightforward change in clinical practice may lower infection rates in patients undergoing ITB therapy.
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Affiliation(s)
- Michelle S Balaratnam
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK.,UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Ann Donnelly
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Honey Padilla
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Sara Simeoni
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Sardar Bahadur
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Liz Keenan
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Heesook Lee
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Rachel Farrell
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK.,UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Carmel Curtis
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Robert M Brownstone
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK.,UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Mary Murphy
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Joan Grieve
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Colin Shieff
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Meenakshi Nayar
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Robert D S Pitceathly
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Gerry Christofi
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
| | - Valerie L Stevenson
- The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square London, WC1N 3BG, UK
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20
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Wallace AC, Talelli P, Crook L, Austin D, Farrell R, Hoad D, O'Keeffe AG, Marsden JF, Fitzpatrick R, Greenwood R, Rothwell JC, Werring DJ. Exploratory Randomized Double-Blind Placebo-Controlled Trial of Botulinum Therapy on Grasp Release After Stroke (PrOMBiS). Neurorehabil Neural Repair 2019; 34:51-60. [PMID: 31747825 DOI: 10.1177/1545968319887682] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. OnabotulinumtoxinA injections improve upper-limb spasticity after stroke, but their effect on arm function remains uncertain. Objective. To determine whether a single treatment with onabotulinumtoxinA injections combined with upper-limb physiotherapy improves grasp release compared with physiotherapy alone after stroke. Methods. A total of 28 patients, at least 1 month poststroke, were randomized to receive either onabotulinumtoxinA or placebo injections to the affected upper limb followed by standardized upper-limb physiotherapy (10 sessions over 4 weeks). The primary outcome was time to release grasp during a functionally relevant standardized task. Secondary outcomes included measures of wrist and finger spasticity and strength using a customized servomotor, clinical assessments of stiffness (modified Ashworth Scale), arm function (Action Research Arm Test [ARAT], Nine Hole Peg Test), arm use (Arm Measure of Activity), Goal Attainment Scale, and quality of life (EQ5D). Results. There was no significant difference between treatment groups in grasp release time 5 weeks post injection (placebo median = 3.0 s, treatment median = 2.0 s; t(24) = 1.20; P = .24; treatment effect = -0.44, 95% CI = -1.19 to 0.31). None of the secondary measures passed significance after correcting for multiple comparisons. Both groups achieved their treatment goals (placebo = 65%; treatment = 71%), and made improvements on the ARAT (placebo +3, treatment +5) and in active wrist extension (placebo +9°, treatment +11°). Conclusions. In this group of stroke patients with mild to moderate spastic hemiparesis, a single treatment with onabotulinumtoxinA did not augment the improvements seen in grasp release time after a standardized upper-limb physiotherapy program.
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Affiliation(s)
| | | | - Lucinda Crook
- UCL Institute of Neurology, Queen Square, London, UK
| | - Duncan Austin
- UCL Institute of Neurology, Queen Square, London, UK
| | - Rachel Farrell
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Damon Hoad
- UCL Institute of Neurology, Queen Square, London, UK
| | | | | | | | - Richard Greenwood
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | | - David J Werring
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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21
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Farrell R, Baker D. An expert opinion: Optimisation of pharmacological management of multiple sclerosis related spasticity. ACNR 2019. [DOI: 10.47795/kaib7737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Spasticity is a frequent symptom in people with Multiple Sclerosis. Whilst many respond to first-line therapies it is estimated that 30-40% will have suboptimal treatment response requiring more specialised management. Such strategies include combination of oral medications, botulinum toxin, nabiximols and consideration of intrathecal therapies; baclofen or phenol. Early expert intervention as outlined in this review can have a positive impact on functional ability and quality of life for people with MS.
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22
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Farrell R. Clinical commentary on “De novo convulsive status epilepticus in patients with multiple sclerosis treated with dalfampridine”. Mult Scler 2019; 25:621-622. [DOI: 10.1177/1352458518810661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rachel Farrell
- University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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23
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Farrell R, Jain S, Shiels P, Workman G, Crowther K, Mitchell D. EP-2155 Optimising HDR Prostate Implant, Planning and delivery. A new centre experience. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Donnelly A, Balaratnam M, Murphy M, Bahadur S, Padilla H, Keenan E, Farrell R, Stevenson V. WP1-12 Reducing infection rates in an intrathecal baclofen service; closing the audit cycle. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
ObjectivesIntrathecal baclofen (ITB) is a recognised treatment strategy for the management of spasticity. We have 30 years of experience, and 160 patients currently receiving treatment.DesignAn audit (Jan 13 – Jul 15) demonstrated complication rates of 4.4% (infection) and 4.92% (catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We present a re-audit of the service.SubjectsAll patients admitted for ITB pump surgery between June 2016 and June 2018.MethodsThe database of patients was used, from which the patient notes were reviewed with information relating to each surgical procedure recorded.ResultsThere were 92 surgical procedures and 78 patients (M 30, F 48). 12 patients had complications, requiring 18 surgical procedures. Out of 18 surgical procedures, 10 were catheter- and 7 pump-related). Our infection rate was lower at 1% of all surgeries (compared with 4.4%), or 0.6% of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate was 6.25% of all patients per year. Our annual incidence rate of all complications was 5.6% in both groups.ConclusionsThe infection risk is lower and complication rate remains stable. We will discuss factors which may influence the risk of complication, and consider recommendations for the future.
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Hobart J, Ziemssen T, Feys P, Linnebank M, Goodman AD, Farrell R, Hupperts R, Blight AR, Englishby V, McNeill M, Chang I, Lima G, Elkins J. Assessment of Clinically Meaningful Improvements in Self-Reported Walking Ability in Participants with Multiple Sclerosis: Results from the Randomized, Double-Blind, Phase III ENHANCE Trial of Prolonged-Release Fampridine. CNS Drugs 2019; 33:61-79. [PMID: 30535670 PMCID: PMC6328522 DOI: 10.1007/s40263-018-0586-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Walking impairment is a hallmark of multiple sclerosis (MS). It affects > 90% of individuals over time, reducing independence and negatively impacting health-related quality of life, productivity, and daily activities. Walking impairment is consistently reported as one of the most distressing impairments by individuals with MS. Prolonged-release (PR)-fampridine previously has been shown to improve objectively measured walking speed in walking-impaired adults with MS. The impact of PR-fampridine from the perspective of the individual with MS warrants full and detailed examination. OBJECTIVE The objective of this study was to evaluate whether PR-fampridine has a clinically meaningful effect on self-reported walking ability in walking-impaired participants with MS. METHODS ENHANCE was a phase III, randomized, double-blind, placebo-controlled study of PR-fampridine 10 mg twice daily in walking-impaired individuals age 18-70 years with either relapsing or progressive forms of MS and an Expanded Disability Status Scale (EDSS) score of 4.0-7.0 at screening. Participants were stratified by EDSS score (≤ 6.0 or 6.5-7.0) at randomization to ensure a balanced level of disability in the treatment groups. The primary endpoint was the proportion of participants with a mean improvement in the 12-item Multiple Sclerosis Walking Scale (MSWS-12) score exceeding the predefined threshold for clinically meaningful improvement (≥ 8 points) over 24 weeks. Secondary endpoints included the proportion with ≥ 15% improvement in Timed Up and Go (TUG) speed, and mean changes in Multiple Sclerosis Impact Scale physical impact subscale (MSIS-29 PHYS), Berg Balance Scale (BBS), and ABILHAND scores over 24 weeks. RESULTS In total, 636 participants with MS were randomized (PR-fampridine, n = 317; placebo, n = 319; modified intention-to-treat sample: PR-fampridine, n = 315; placebo, n = 318). At baseline in the PR-fampridine and placebo groups, 46% and 51% had a progressive form of MS, median [range] EDSS scores were 6.0 [4.0-7.0] and 5.5 [4.0-7.0], mean [range] MSWS-12 scores were 63.6 [0-100] and 65.4 [0-100], and mean [range] TUG speed was 0.38 [0.0-1.0] and 0.38 [0.0-1.2] feet/s, respectively. A significantly higher percentage of PR-fampridine-treated participants (136/315 [43.2%]) had clinically meaningful improvement in MSWS-12 score over 24 weeks versus placebo (107/318 [33.6%]; odds ratio 1.61 [95% confidence interval 1.15-2.26]; p = 0.006). For PR-fampridine versus placebo, significantly more participants had a ≥ 15% improvement in TUG speed, and there was significantly greater mean improvement in MSIS-29 PHYS score (p < 0.05); numerical improvements that were not statistically significant were observed in BBS/ABILHAND. Adverse events that were more common in the PR-fampridine group than placebo group (difference ≥ 3%) by Medical Dictionary for Regulatory Activities (MedDRA®) Preferred Term were urinary tract infection and insomnia. There were no seizures reported. CONCLUSIONS PR-fampridine treatment resulted in sustained, clinically meaningful improvements over 24 weeks in self-reported walking and functional ability in walking-disabled participants with MS. CLINICALTRIALS. GOV IDENTIFIER NCT02219932.
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Affiliation(s)
- Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, University Hospitals Plymouth NHS Trust, N13 ITTC Building, Plymouth Science Park, Plymouth, Devon, PL6 8BX, UK.
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Clinic, Technical University of Dresden, Dresden, Germany
| | - Peter Feys
- BIOMED-REVAL, University of Hasselt, Diepenbeek, Belgium
| | - Michael Linnebank
- HELIOS Klinik Hagen-Ambrock, University Witten/Herdecke, Hagen, Germany
| | - Andrew D. Goodman
- School of Medicine and Dentistry, University of Rochester, Rochester, NY USA
| | - Rachel Farrell
- National Hospital for Neurology and Neurosurgery, University College London Hospitals and University College London Institute of Neurology, London, UK
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Albrecht P, Bjørnå IK, Brassat D, Farrell R, Feys P, Hobart J, Hupperts R, Linnebank M, Magdič J, Oreja-Guevara C, Pozzilli C, Salgado AV, Ziemssen T. Prolonged-release fampridine in multiple sclerosis: clinical data and real-world experience. Report of an expert meeting. Ther Adv Neurol Disord 2018; 11:1756286418803248. [PMID: 30305850 PMCID: PMC6174649 DOI: 10.1177/1756286418803248] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/25/2018] [Indexed: 01/07/2023] Open
Abstract
Prolonged-release (PR) fampridine is the only approved medication to improve walking in multiple sclerosis (MS), having been shown to produce a clinically meaningful improvement in walking ability in the subset of MS patients with Expanded Disability Status Scale 4-7. Recent responder subgroup analyses in the phase III ENHANCE study show a large effect size in terms of an increase of 20.58 points on the patient-reported 12-item MS Walking Scale in the 43% of patients classified as responders to PR-fampridine, corresponding to a standardized response mean of 1.68. Use of PR-fampridine in clinical practice varies across Europe, depending partly on whether it is reimbursed. A group of European MS experts met in June 2017 to discuss their experience with using PR-fampridine, including their views on the patient population for treatment, assessment of treatment response, re-testing and re-treatment, and stopping criteria. This article summarizes the experts' opinions on how PR-fampridine can be used in real-world clinical practice to optimize the benefits to people with MS with impaired walking ability.
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Affiliation(s)
- Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225 Duesseldorf, Germany
| | | | - David Brassat
- Centre de Resource et de Competence-SEP CHU-Toulouse et UMR1043, Université de Toulouse III, Toulouse, France
| | - Rachel Farrell
- Department of Neuroinflammation, UCL Institute of Neurology, London and National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, UK
| | - Peter Feys
- REVAL/BIOMED, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Jeremy Hobart
- Department of Clinical Trials and Health Research: Translational & Stratified Medicine, Plymouth
| | - Raymond Hupperts
- Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, Netherlands
| | - Michael Linnebank
- Department of Neurology, Helios Clinic Hagen-Ambrock, Hagen, Germany
| | - Jožef Magdič
- Department of Neurology, University Medical Center Maribor, Maribor, Slovenia
| | - Celia Oreja-Guevara
- Neurología, Hospital Clínico San Carlos, Departamento de Medicina, Universidad Complutense de Madrid, Spain
| | - Carlo Pozzilli
- Department of Neurology, University La Sapienza, Rome, Italy
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, MS Center Dresden, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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Barr M, Farrell R, Singh S, Foley E, He Y, Brady L, Young V, Ryan R, Nicholson S, Leonard N, Cuffe S, Finn S. MA06.09 XRCC6BP1: A DNA Repair Gene in Cisplatin Resistant Lung Cancer Stem Cells That May Predict Survival Outcomes in Patients. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Barr M, Singh S, Farrell R, Foley E, He Y, Nicholson S, Leonard N, Brady L, Cuffe S, Finn S. PO-510 XRCC6BP1: a novel role in the DNA repair of platinum resistant NSCLC cells. ESMO Open 2018. [DOI: 10.1136/esmoopen-2018-eacr25.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ewe R, Louissaint H, Bull K, Allen J, Farrell R. PO125 Pr-fampridine improves walking speed and quality of life in ms. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Trane SD, Buchanan K, Keenan L, Valentine C, Liddicut M, Stevenson V, Farrell R. PO123 Thc:cbd (nabiximols) has a beneficial effect on multiple sclerosis related spasticity and delays the need for intrathecal baclofen. J Neurol Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Samra K, Maryam Z, Swayne O, Farrell R. PO212 Prevalence of vitamin d deficiency in a complex neurological rehabilitation unit: a pilot study. J Neurol Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Baird V, Drake A, Corrigan K, Clarke J, McGivern U, Byrne M, Workman G, Farrell R. Image guided high dose rate brachytherapy in cervical cancer. Clin Oncol (R Coll Radiol) 2017. [DOI: 10.1016/j.clon.2017.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bauer A, Farrell R, Goldblum D. The geography of forest diversity and community changes under future climate conditions in the eastern United States. Écoscience 2016. [DOI: 10.1080/11956860.2016.1213107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Murphy A, Parihar V, Shahin A, Farrell R. Imitation, The Greatest Form of Flattery? Ir Med J 2016; 109:322. [PMID: 26904782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Komath D, Jabbar S, Farrell R, Gilhooly M, Messiha A, Shorafa M, Visavadia B, McCaul J. Primary and metastatic Merkel cell carcinoma of parotid. Br J Oral Maxillofac Surg 2015. [DOI: 10.1016/j.bjoms.2015.08.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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36
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Niemi AK, Kim IK, Krueger CE, Cowan TM, Baugh N, Farrell R, Bonham CA, Concepcion W, Esquivel CO, Enns GM. Treatment of methylmalonic acidemia by liver or combined liver-kidney transplantation. J Pediatr 2015; 166:1455-61.e1. [PMID: 25771389 DOI: 10.1016/j.jpeds.2015.01.051] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 01/13/2015] [Accepted: 01/28/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess biochemical, surgical, and long-term outcomes of liver (LT) or liver-kidney transplantation (LKT) for severe, early-onset methylmalonic acidemia/acid (MMA). STUDY DESIGN A retrospective chart review (December 1997 to May 2012) of patients with MMA who underwent LT or LKT at Lucile Packard Children's Hospital at Stanford. RESULTS Fourteen patients underwent LT (n = 6) or LKT (n = 8) at mean age 8.2 years (range 0.8-20.7). Eleven (79%) were diagnosed during the neonatal period, including 6 by newborn screening. All underwent deceased donor transplantation; 12 (86%) received a whole liver graft. Postoperative survival was 100%. At a mean follow-up of 3.25 ± 4.2 years, patient survival was 100%, liver allograft survival 93%, and kidney allograft survival 100%. One patient underwent liver re-transplantation because of hepatic artery thrombosis. After transplantation, there were no episodes of hyperammonemia, acidosis, or metabolic decompensation. The mean serum MMA at the time of transplantation was 1648 ± 1492 μmol/L (normal <0.3, range 99-4420). By 3 days, post-transplantation levels fell on average by 87% (mean 210 ± 154 μmol/L), and at 4 months, they were 83% below pre-transplantation levels (mean 305 ± 108 μmol/L). Developmental delay was present in 12 patients (86%) before transplantation. All patients maintained neurodevelopmental abilities or exhibited improvements in motor skills, learning abilities, and social functioning. CONCLUSIONS LT or LKT for MMA eradicates episodes of hyperammonemia, results in excellent long-term survival, and suggests stabilization of neurocognitive development. Long-term follow-up is underway to evaluate whether patients who undergo early LT need kidney transplantation later in life.
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Affiliation(s)
- Anna-Kaisa Niemi
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA.
| | - Irene K Kim
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Casey E Krueger
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Tina M Cowan
- Department of Pathology, Stanford University, Stanford, CA
| | - Nancy Baugh
- Lucile Packard Children's Hospital at Stanford, Stanford, CA
| | - Rachel Farrell
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA; Prenatal Diagnostics, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA
| | - Clark A Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Waldo Concepcion
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Gregory M Enns
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA
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Farrell R, Hawkins A, Barragan D, Hudgins L, Taylor J. Knowledge, understanding, and uptake of noninvasive prenatal testing among Latina women. Prenat Diagn 2015; 35:748-53. [PMID: 25846645 DOI: 10.1002/pd.4599] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 03/21/2015] [Accepted: 03/26/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study is to assess Latina patient understanding of noninvasive prenatal testing (NIPT) and identify what factors influence uptake/refusal to NIPT to adapt counseling to the needs and interests of this population. METHODS Mixed-methods survey in English and Spanish administered to pregnant Latina patients throughout pregnancy. RESULTS Sixty-three women participated in our study (67% response rate); 34.9% chose to do NIPT, and 65.1% declined. Approximately half of participants (44%) had an NIPT knowledge score of ≤3 out of six total questions. Two of the most significant factors influencing uptake of NIPT were a higher reported educational level (p = 0.015) and a higher NIPT knowledge score (p = 0.014); 42.9% of participants knew that NIPT only screens for certain chromosomal conditions; 39% of women who declined NIPT would never consider NIPT in the future. CONCLUSIONS One-third of Latina women elected NIPT; a higher reported educational level and language were most predictive of this choice. Overall knowledge was significantly lower for women who declined NIPT. Lower knowledge may suggest that not all women are making informed decisions because of varying degrees of informed consent. Providing culturally tailored information can help women navigate the complexities of prenatal testing in order to make decisions most aligned with their values.
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Affiliation(s)
- Rachel Farrell
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Prenatal Diagnostics, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA, USA
| | - Anne Hawkins
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Perinatal Genetics Clinic, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA, USA.,Women's and Newborn's Health Service, Genetic Services of Western Australia, Department of Health, Government of Western Australia, Perth, Australia
| | - Deborah Barragan
- Perinatal Genetics Clinic, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA, USA.,Fetal Care and Genetics Center, University of California, San Diego, San Diego, CA, USA
| | - Louanne Hudgins
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Perinatal Genetics Clinic, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA, USA
| | - Joanne Taylor
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Perinatal Genetics Clinic, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA, USA
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Wong G, Awad Z, Wong P, Wood S, Farrell R. Clinical applicability of the Thy3a cytological category in thyroid nodules aspirates. Our experience in one hundred and fifty-seven patients with Thy3 cytology. Clin Otolaryngol 2014; 39:393-6. [DOI: 10.1111/coa.12307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 11/29/2022]
Affiliation(s)
- G. Wong
- Department of Otolaryngology, Head and Neck Surgery; Northwick Park Hospital; Middlesex UK
| | - Z. Awad
- Department of Otolaryngology, Head and Neck Surgery; Northwick Park Hospital; Middlesex UK
| | - P.Y. Wong
- Department of Otolaryngology, Head and Neck Surgery; Northwick Park Hospital; Middlesex UK
| | - S. Wood
- Department of Otolaryngology, Head and Neck Surgery; Wexham Park Hospital; Slough Berkshire UK
| | - R. Farrell
- Department of Otolaryngology, Head and Neck Surgery; Northwick Park Hospital; Middlesex UK
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Gunderson C, Farrell R, Slaughter K, Ding K, Lauer J, Perry L, McMeekin D, Moore K. The influence of obesity on disease characteristics and survival among patients with epithelial ovarian cancer. Gynecol Oncol 2014. [DOI: 10.1016/j.ygyno.2014.03.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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40
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Slaughter K, Gunderson C, Perry L, Thomas E, Farrell R, Lauer J, Ding K, McMeekin D, Moore K. Acquired platinum resistance among women with high-grade serous epithelial ovarian cancer. Gynecol Oncol 2014. [DOI: 10.1016/j.ygyno.2014.03.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gunderson C, Thomas E, Slaughter K, Farrell R, Ding K, Lauer J, Perry L, McMeekin D, Moore K. Venous thromboembolism carries a particularly grave prognosis with epithelial ovarian cancer. Gynecol Oncol 2014. [DOI: 10.1016/j.ygyno.2014.03.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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42
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Shakil J, Piracha N, Prasad N, Kopacz J, Tarasuk A, Farrell R, Urban C, Mariano N, Wang G, Segal-Maurer S. Use of outpatient parenteral antimicrobial therapy for transrectal ultrasound-guided prostate biopsy prophylaxis in the setting of community-associated multidrug-resistant Escherichia coli rectal colonization. Urology 2014; 83:710-3. [PMID: 24680441 DOI: 10.1016/j.urology.2013.12.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To study the use of ertapenem delivered in an outpatient parenteral antimicrobial therapy (OPAT) hospital-based unit setting for targeted transrectal ultrasound-guided prostate biopsy (TRUSPBx) prophylaxis in the setting of multidrug-resistant (MDR) Escherichia coli rectal colonization. E coli is the pathogen most commonly associated with post-TRUSPBx complications, and there is increasing prevalence of community-associated MDR E coli. METHODS Prospective data analysis of all patients admitted to the OPAT unit for administration of intravenous antibiotics for prophylaxis for TRUSPBx over 18-month period was performed. Patients had identification of MDR E coli in rectal swab cultures and/or intolerance to available oral agents. Microbiologic data and tolerability of administered antibiotics and outcome after TRUSPBx were tabulated. RESULTS Nine patients (median age 74 years) were referred because of antibiotic-resistant E coli from rectal swabs (all fluoroquinolone resistant, 7 MDR). All patients received ertapenem 1 g intravenously 1 day before TRUSPBx and the day of the procedure before TRUSPBx. None of the patients experienced infectious complications immediately after TRUSPBx or several weeks or months later, and no patient was lost to urologic follow-up. CONCLUSION Increasing worldwide reports of prostatitis, urinary tract infections, and septicemia after TRUSPBx because of MDR E coli suggest rectal screening before procedure may be useful in decreasing complications. Targeted prophylaxis in these instances is necessary. Although carbapenems are used for treatment, they are not routinely used for prophylaxis. We report successful use of ertapenem delivered in a hospital-based OPAT unit for TRUSPBx prophylaxis.
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Affiliation(s)
- J Shakil
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY
| | - N Piracha
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY
| | - N Prasad
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY
| | - J Kopacz
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY
| | - A Tarasuk
- Urology Division, Department of Surgery, New York Hospital Queens, Flushing, NY
| | - R Farrell
- Urology Division, Department of Surgery, New York Hospital Queens, Flushing, NY
| | - C Urban
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - N Mariano
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY; Department of Patient Care Services, New York Hospital Queens, Flushing, NY
| | - G Wang
- Urology Division, Department of Surgery, New York Hospital Queens, Flushing, NY
| | - S Segal-Maurer
- The Dr. James J. Rahal Jr. Division of Infectious Diseases, Department of Medicine, New York Hospital Queens, Flushing, NY; Department of Medicine, Weill Cornell Medical College, New York, NY.
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Gafson A, Worthington V, Lakdawala N, Giovannoni G, Farrell R. NEUTRALISING ANTIBODIES TO INTERFERON–BETA PREDICT CONVERSION TO SECONDARY PROGRESSIVE MULTIPLE SCLEROSIS IN PATIENTS WITH MULTIPLE SCLEROSIS. J Neurol Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Thomas E, Slaughter K, Gunderson C, Perry L, Lauer J, Farrell R, Ding K, McMeekin D, Moore K. The use of biologic agents and clinical trials may prolong survival for women with primary platinum resistant ovarian carcinoma. Gynecol Oncol 2013. [DOI: 10.1016/j.ygyno.2013.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gunderson C, Slaughter K, Thomas E, Farrell R, Ding K, Lauer J, Perry L, McMeekin D, Moore K. Timing of venous thromboembolism: Does it impact survival with serous carcinoma of the ovary? Gynecol Oncol 2013. [DOI: 10.1016/j.ygyno.2013.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gunderson C, Slaughter K, Thomas E, Farrell R, Ding K, Lauer J, Perry L, McMeekin D, Moore K. Is leukocytosis a harbinger of poor prognosis in ovarian cancer akin to thrombocytosis? Gynecol Oncol 2013. [DOI: 10.1016/j.ygyno.2013.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gunderson C, Dinh B, Farrell R, Thomas E, Vesely S, Chopra S, McMeekin D, Moore K. Inpatient versus outpatient management of neutropenic fever in gynecologic oncology patients: Does cost really matter? Gynecol Oncol 2013. [DOI: 10.1016/j.ygyno.2013.04.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dooraghi AA, Vu NT, Silverman RW, Farrell R, Shah KS, Wang J, Heath JR, Chatziioannou AF. Betabox: a beta particle imaging system based on a position sensitive avalanche photodiode. Phys Med Biol 2013; 58:3739-53. [PMID: 23656911 DOI: 10.1088/0031-9155/58/11/3739] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A beta camera has been developed that allows planar imaging of the spatial and temporal distribution of beta particles using a 14 × 14 mm(2) position sensitive avalanche photodiode (PSAPD). This camera system, which we call Betabox, can be directly coupled to microfluidic chips designed for cell incubation or other biological applications. Betabox allows for imaging the cellular uptake of molecular imaging probes labeled with charged particle emitters such as (18)F inside these chips. In this work, we investigate the quantitative imaging capabilities of Betabox for (18)F beta particles, in terms of background rate, efficiency, spatial resolution, and count rate. Measurements of background and spatial resolution are considered both at room temperature (21 °C ± 1 °C) and at an elevated operating temperature (37 °C ± 1 °C), as is often required for biological assays. The background rate measured with a 4 keV energy cutoff is below 2 cph mm(-2) at both 21 and 37 °C. The absolute efficiency of Betabox for the detection of (18)F positron sources in contact with a PSAPD with the surface passivated from ambient light and damage is 46% ± 1%. The lower detection limit is estimated using the Rose Criterion to be 0.2 cps mm(-2) for 1 min acquisitions and a 62 × 62 µm(2) pixel size. The upper detection limit is approximately 21 000 cps. The spatial resolution at both 21 and 37 °C ranges from 0.4 mm FWHM at the center of the field of view (FOV), and degrades to 1 mm at a distance of 5 mm away from center yielding a useful FOV of approximately 10 × 10 mm(2). We also investigate the effects on spatial resolution and sensitivity that result from the use of a polymer based microfluidic chip. For these studies we place varying layers of low-density polyethylene (LDPE) between the detector and the source and find that the spatial resolution degrades by ∼180 µm for every 100 µm of LDPE film. Sensitivity is reduced by half with the inclusion of ∼200 µm of additional LDPE film. Lastly, we demonstrate the practical utilization of Betabox, with an imaging test of its linearity, when coupled to a polydimethylsiloxane microfluidic chip designed for cell based assays.
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Affiliation(s)
- A A Dooraghi
- Crump Institute for Molecular Imaging, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
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Sato DK, Nakashima I, Fukazawa T, Shimizu Y, Tomizawa Y, Yokoyama K, Misu T, Creeke PI, Farrell R, Giovannoni G, Itoyama Y, Fujihara K, Aoki M. Neutralizing antibodies are associated with a reduction of interferon-β efficacy during the treatment of Japanese multiple sclerosis patients. TOHOKU J EXP MED 2013; 228:85-92. [PMID: 22976494 DOI: 10.1620/tjem.228.85] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated inflammatory demyelinating disease of the central nervous system. Interferon-β (IFN-β) has been used as the first line therapy for MS treatment in Japan, but patients treated with IFN-β may develop antibodies, known as neutralizing antibodies (NAbs), which abrogate its therapeutic effects. Intramuscular IFN-β 1a and subcutaneous IFN-β 1b are currently available in Japan, but large-scale studies evaluating the prevalence and clinical implications of NAbs against these IFN-β preparations in MS patients have only been performed in Caucasian populations. NAbs positivity has been reported to be associated with HLA-DRB1 alleles, suggesting that the positivity might differ among populations with distinct genetic backgrounds. Clinical information and sera were collected from 229 consecutive MS patients treated with IFN-β in 4 centers in Japan. Sera were tested for NAbs using a luciferase reporter gene assay. In total, 5.2% of IFN-β-1a-treated patients (4/77) and 30.3% of IFN-β-1b-treated patients (46/152) were positive for Nabs. The frequency of NAbs was highest in patients treated for 13 to 24 months. Clinical relapse and contrast-enhancing lesions in the magnetic resonance imaging increased together with NAbs titers in this group. In conclusion, the prevalence of NAbs in Japanese MS patients is similar to that in Caucasian populations and is associated with an increase in disease activity. Therefore, routine NAbs testing is recommended also in Asian populations to ensure the early identification of patients who would benefit from a change in therapy.
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Affiliation(s)
- Douglas Kazutoshi Sato
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
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Abstract
INTRODUCTION Floseal® (Baxter, Hayward, CA, US) can be of value in reducing blood loss and haematoma rates. The manufacturer’s warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal® is safe to use in various head and neck surgery (HNS) procedures. METHODS A prospective trial was conducted using Floseal® in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output. RESULTS No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with. CONCLUSIONS Floseal® is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.
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Affiliation(s)
- A Ujam
- North West London Hospitals NHS Trust, UK.
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