OUP accepted manuscript

The routine clinical integration of individualized objective markers of disease activity in those diagnosed with the neurodegenerative disorder amyotrophic lateral sclerosis is a key requirement for therapeutic development. A large, multicentre, clinic-based, longitudinal cohort was used to systematically appraise the leading candidate biofluid biomarkers in the stratification and potential therapeutic assessment of those with amyotrophic lateral sclerosis. Incident patients diagnosed with amyotrophic lateral sclerosis (n = 258), other neurological diseases (n = 80) and healthy control participants (n = 101), were recruited and followed at intervals of 3–6 months for up to 30 months. Cerebrospinal fluid neurofilament light chain and chitotriosidase 1 and blood neurofilament light chain, creatine kinase, ferritin, complement C3 and C4 and C-reactive protein were measured. Blood neurofilament light chain, creatine kinase, serum ferritin, C3 and cerebrospinal fluid neurofilament light chain and chitotriosidase 1 were all significantly elevated in amyotrophic lateral sclerosis patients. First-visit plasma neurofilament light chain level was additionally strongly associated with survival (hazard ratio for one standard deviation increase in log₁₀ plasma neurofilament light chain 2.99, 95% confidence interval 1.65–5.41, P = 0.016) and rate of disability progression, independent of other prognostic factors. A small increase in level was noted within the first 12 months after reported symptom onset (slope 0.031 log₁₀ units per month, 95% confidence interval 0.012–0.049, P = 0.006). Modelling the inclusion of plasma neurofilament light chain as a therapeutic trial outcome measure demonstrated that a significant reduction in sample size and earlier detection of disease-slowing is possible, compared with using the revised Amyotrophic Lateral Sclerosis Functional Rating Scale. This study provides strong evidence that blood neurofilament light chain levels outperform conventional measures of disease activity at the group level. The application of blood neurofilament light chain has the potential to radically reduce the duration and cost of therapeutic trials. It might also offer a first step towards the goal of more personalized objective disease activity monitoring for those living with amyotrophic lateral sclerosis.

Antiarrhythmic Drugs for Nonshockable-Turned-Shockable Out-of-Hospital Cardiac Arrest: The ALPS Study (Amiodarone, Lidocaine, or Placebo)

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) commonly presents with nonshockable rhythms (asystole and pulseless electric activity). It is unknown whether antiarrhythmic drugs are safe and effective when nonshockable rhythms evolve to shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia [VF/VT]) during resuscitation.

METHODS

Adults with nontraumatic OHCA, vascular access, and VF/VT anytime after ≥1 shock(s) were prospectively randomized, double-blind, to receive amiodarone, lidocaine, or placebo by paramedics. Patients presenting with initial shock-refractory VF/VT were previously reported. The current study was a prespecified analysis in a separate cohort that initially presented with nonshockable OHCA and was randomized on subsequently developing shock-refractory VF/VT. The primary outcome was survival to hospital discharge. Secondary outcomes included discharge functional status and adverse drug-related effects.

RESULTS

Of 37 889 patients with OHCA, 3026 with initial VF/VT and 1063 with initial nonshockable-turned-shockable rhythms were treatment-eligible, were randomized, and received their assigned drug. Baseline characteristics among patients with nonshockable-turned-shockable rhythms were balanced across treatment arms, except that recipients of a placebo included fewer men and were less likely to receive bystander cardiopulmonary resuscitation. Active-drug recipients in this cohort required fewer shocks, supplemental doses of their assigned drug, and ancillary antiarrhythmic drugs than recipients of a placebo (P<0.05). In all, 16 (4.1%) amiodarone, 11 (3.1%) lidocaine, and 6 (1.9%) placebo-treated patients survived to hospital discharge (P=0.24). No significant interaction between treatment assignment and discharge survival occurred with the initiating OHCA rhythm (asystole, pulseless electric activity, or VF/VT). Survival in each of these categories was consistently higher with active drugs, although the trends were not statistically significant. Adjusted absolute differences (95% confidence interval) in survival from nonshockable-turned-shockable arrhythmias with amiodarone versus placebo were 2.3% (-0.3, 4.8), P=0.08, and for lidocaine versus placebo 1.2% (-1.1, 3.6), P=0.30. More than 50% of these survivors were functionally independent or required minimal assistance. Drug-related adverse effects were infrequent.

CONCLUSIONS

Outcome from nonshockable-turned-shockable OHCA is poor but not invariably fatal. Although not statistically significant, point estimates for survival were greater after amiodarone or lidocaine than placebo, without increased risk of adverse effects or disability and consistent with previously observed favorable trends from treatment of initial shock-refractory VF/VT with these drugs. Together the findings may signal a clinical benefit that invites further investigation.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01401647.

The Effect of Fish Oil, Vitamin D and Protein on URTI Incidence in Young Active People

Upper respiratory tract infections (URTI) are a frequent illness among athletes. We investigated the effect of a multi-nutrient supplement (vitamin D, fish oil and protein) on the occurrence of URTI in young active people. 42 young recreational athletes were randomly assigned to receive either supplementation (550 mg DHA, 550 mg EPA, 10 µg vitamin D3 and 8 g whey protein) or placebo for 16 weeks. Unstimulated saliva samples were collected by passive drool. Samples were analysed for IgA (sIgA) concentration and the secretion rate extrapolated by multiplying concentration by saliva flow rate. Physical activity levels and URTI incidence were monitored by questionnaire. Training status was not different between the 2 groups. There were no differences in the incidence, severity and duration of URTI. However the number of symptom days was lower in the supplemented compared to the control group (1.72±1.67 vs. 2.79±1.76; P<0.05). sIgA concentration and secretion rate did not differ between groups. This study demonstrates that 16 weeks of supplementation with fish oil, vitamin D and protein did not modify the incidence, severity and duration of URTI, although the total number of symptom days was reduced, in a healthy active population.

Systems Epidemiology: What's in a Name?

Systems biology is an interdisciplinary effort to integrate molecular, cellular, tissue, organ, and organism levels of function into computational models that facilitate the identification of general principles. Systems medicine adds a disease focus. Systems epidemiology adds yet another level consisting of antecedents that might contribute to the disease process in populations. In etiologic and prevention research, systems-type thinking about multiple levels of causation will allow epidemiologists to identify contributors to disease at multiple levels as well as their interactions. In public health, systems epidemiology will contribute to the improvement of syndromic surveillance methods. We encourage the creation of computational simulation models that integrate information about disease etiology, pathogenetic data, and the expertise of investigators from different disciplines.

Regulated autocrine growth of CHO cells

The goal of this work was to engineer a CHO cell line capable ofautocrine growth in a fully defined protein-free medium. Thiswas accomplished by stable integration of the genes encodinginsulin-like growth factor I (IGF-I) and transferrin into thegenome of a CHO-K1 cell line. Thelac operator/repressorsystem was used to regulate the expression of the IGF-I gene with thelac operator sequence being placed upstream ofthe coding sequence for IGF-I. The expression of thelacrepressor protein was driven by a modified metallothioneinpromoter allowing repressor expression to be regulated by theculture medium. The cell line calledSuper CHO(r) (r for regulated) was able to grow in protein-free medium in an autocrine fashion with a doubling time of 20-24 hr,either attached to microcarriers or as aggregate suspensioncultures. Upon addition of metal to the culture medium, therepressor protein was produced and bound to the operatorsequences shutting down the expression of IGF-I and arrestingthe growth of the cells. Expression of the human growth hormone(hGH) gene and production of hGH was induced by the presence ofmetal ions. It was possible to release the cells from growtharrest in the presence of metal by the addition of isopropylbeta-D-thiogalactopyranoside (IPTG), which prevented bindingof the repressor to its operator sequences. The ability to growCHO cells in fully defined protein-free medium and to be able toregulate their growth rate offers a number of advantages for theuse of these cells as hosts for the production of recombinantDNA derived proteins.

Unusual and severe lesions of proventricular dilatation disease in cockatiels (Nymphicus hollandicus) acting as healthy carriers of avian bornavirus (ABV) and subsequently infected with a virulent strain of ABV

A flock of 14 apparently healthy cockatiels, purchased from a single aviary, was tested for the presence of avian bornavirus (ABV). Twelve birds were found to be intermittently shedding ABV, predominantly genotype 4. Four of the cockatiels known to be shedding ABV4 were subsequently challenged with the tissue culture derived, virulent M24 strain of ABV4. The challenged birds remained in apparent good health until day 92 when one was found dead. The remaining three birds began to exhibit severe neurologic signs, ataxia and convulsions on day 110 and were euthanized. On necropsy, all four birds showed mild proventricular enlargement. In contrast, histopathological examination showed unusually severe and widespread tissue lesions. These included massive lymphocytic infiltration and lymphoid nodule formation within and around the ganglia throughout the gastrointestinal tract. There were similar lesions in the medullary cords of the adrenal gland, heart, spleen, liver, kidney, lungs, pancreas, testes and ovary. Immunohistochemistry demonstrated ABV P antigen not only in the cells of the central and autonomic nervous systems, but also within the mononuclear cells infiltrating the various organs. Two healthy cockatiels, one of which was a known ABV carrier, were inoculated with uninfected tissue culture cells and euthanized on day 150. These birds showed no gross lesions of proventricular dilatation disease but had a mild lymphocytic infiltration in their liver, spleen, and kidneys. Prior infection with ABV did not therefore confer significant immunity on these birds, and may have resulted in increased disease severity following challenge.

Evaluation of a mobile phone-based, advanced symptom management system (ASyMS) in the management of chemotherapy-related toxicity

OBJECTIVES

To evaluate the impact of a mobile phone-based, remote monitoring, advanced symptom management system (ASyMS) on the incidence, severity and distress of six chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea) in patients with lung, breast or colorectal cancer.

DESIGN

A two group (intervention and control) by five time points (baseline, pre-cycle 2, pre-cycle 3, pre-cycle 4 and pre-cycle 5) randomised controlled trial.

SETTING

Seven clinical sites in the UK; five specialist cancer centres and two local district hospitals.

PARTICIPANTS

One hundred and twelve people with breast, lung or colorectal cancer receiving outpatient chemotherapy.

INTERVENTIONS

A mobile phone-based, remote monitoring, advanced symptom management system (ASyMS).

MAIN OUTCOME MEASURES

Chemotherapy-related morbidity of six common chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea).

RESULTS

There were significantly higher reports of fatigue in the control group compared to the intervention group (odds ratio = 2.29, 95%CI = 1.04 to 5.05, P = 0.040) and reports of hand-foot syndrome were on average lower in the control group (odds ratio control/intervention = 0.39, 95%CI = 0.17 to 0.92, P = 0.031).

CONCLUSION

The study demonstrates that ASyMS can support the management of symptoms in patients with lung, breast and colorectal cancer receiving chemotherapy.

Utilising handheld computers to monitor and support patients receiving chemotherapy: results of a UK-based feasibility study

GOALS OF WORK

Recent changes in cancer service provision mean that many patients spend a limited time in hospital and therefore experience and must cope with and manage treatment-related side effects at home. Information technology can provide innovative solutions in promoting patient care through information provision, enhancing communication, monitoring treatment-related side effects and promoting self-care.

PATIENTS AND METHODS

The aim of this feasibility study was to evaluate the acceptability of using handheld computers as a symptom assessment and management tool for patients receiving chemotherapy for cancer. A convenience sample of patients (n = 18) and health professionals (n = 9) at one Scottish cancer centre was recruited. Patients used the handheld computer to record and send daily symptom reports to the cancer centre and receive instant, tailored symptom management advice during two treatment cycles. Both patients' and health professionals' perceptions of the handheld computer system were evaluated at baseline and at the end of the project.

MAIN RESULTS

Patients believed the handheld computer had improved their symptom management and felt comfortable in using it. The health professionals also found the handheld computer to be helpful in assessing and managing patients' symptoms.

CONCLUSIONS

This project suggests that a handheld-computer-based symptom management tool is feasible and acceptable to both patients and health professionals in complementing the care of patients receiving chemotherapy.

Erectile dysfunction and its correlates among the Ariaal of northern Kenya

To expand our crosscultural understanding of erectile dysfunction, we investigated erectile dysfunction among Ariaal men, pastoral nomads of northern Kenya. To measure erectile dysfunction, we administered the International Index of Erectile Function (IIEF-5) to 198 men aged 20 y and older during interviews. Marital status and anthropometric measures of body composition were also obtained. Men were classified into 10-y age groups. ANOVA revealed that erectile dysfunction increases with age (P<0.0005), with men 60 y and older showing significantly higher erectile dysfunction compared with men in their 20s, 40s and 50s. In a MANCOVA model, erectile dysfunction increased with age group (P<0.001), was negatively related to right-hand grip strength (P<0.01) and negatively related to number of wives (P<0.05). In addition, there was a significant interaction between age group and marital status (P<0.01). Erectile dysfunction showed no independent relationship to measures of body composition, including body mass index, fat free mass and percentage body fat. These findings provide further evidence of age-related increases in erectile dysfunction, even when factors commonly associated with erectile dysfunction (eg, metabolic complications of obesity, use of medicines causing erectile dysfunction) are absent. The finding that number of wives is negatively related to erectile dysfunction may represent the specific cultural conditions (political power and wealth) associated with polygyny among the Ariaal.

Non-anaemic iron deficiency identified by ZPP test in extremely premature infants: prevalence, dietary risk factors, and association with neurodevelopmental problems

INTRODUCTION

The aims of this study were to determine, in a cohort of extremely premature infants, the prevalence of iron deficiency identified by zinc protoporphyrin/heme ratio (ZPP) testing, and its association with neurodevelopmental problems and dietary risk factors for iron deficiency.

METHODS

Infants of less than 29 weeks' gestation or less than 1000 g birth weight were studied prospectively at a multidisciplinary follow-up clinic. Assessments were made at a corrected age of either 12 months (n=72) or 2 years (n=69). Physical examination, Griffiths Developmental Scale, and neurosensory-motor assessment were administered, information on diet and behaviour was obtained by questionnaire, and a fingerprick ZPP ratio was performed to identify iron deficiency.

RESULTS

18.4% of infants had positive ZPP tests. There was no significant association between a positive ZPP test result and dietary risk factors, or symptoms of lethargy, irritability or poor attention. In children without cerebral palsy, there was no difference on Griffiths scores or neurosensory-motor assessment between ZPP-positive and ZPP-negative groups. The diagnosis of cerebral palsy (n=12) was significantly associated with both a positive ZPP test and a lower Griffiths general quotient (GQ) score.

CONCLUSIONS

Iron deficiency occurs commonly in extremely low birth weight (ELBW) children in early childhood, and is not predicted by dietary risk factors. The prevalence of iron deficiency is increased in ELBW children with cerebral palsy. Non-anaemic iron deficiency (NAID) does not impair development or significantly affect behaviour of ELBW subjects who do not have cerebral palsy.

High levels of nitric oxide synthase activity are associated with nasal polyp tissue from aspirin-sensitive asthmatics

The pathogenesis of aspirin intolerance remains unclear. Inducible nitric oxide synthase (iNOS) expression is upregulated in nasal polyp epithelium, implying a role for nitric oxide (NO) in its formation. We decided to compare iNOS activity in polyp tissue from patients with and without aspirin intolerance. Nasal polyp tissue was collected from 15 patients undergoing routine nasal polypectomy. These patients were classified into three groups: Group A comprised patients with nasal polyps without asthma; Group B contained patients with nasal polyps and asthma; and Group C comprised patients with nasal polyps, asthma and aspirin sensitivity. All subjects in Group C had a history of aspirin-induced reaction and a confirmatory intranasal challenge with lysine-aspirin. NOS activity was measured by the ability of tissue homogenates to convert 3,4-L-arginine to L-citrulline in an L-N(G)-nitro-L-arginine-inhibitable fashion. The iNOS activity (picomoles) in polyp tissue from the 3 groups was: A, 248.72+/-220.79; B, 23.71+/-41.06; and C, 549.71+/-132.11. Thus, nasal polyps from patients with Samter's triad had a significantly higher iNOS activity (p = 0.004; one-way ANOVA). This finding does not correlate simply with disease severity or with the occurrence of asthma and could indicate another important facet of aspirin-induced airways disease.

Mal (MyD88-adapter-like) is required for Toll-like receptor-4 signal transduction

The recognition of microbial pathogens by the innate immune system involves Toll-like receptors (TLRs), which recognize pathogen-associated molecular patterns. Different TLRs recognize different pathogen-associated molecular patterns, with TLR-4 mediating the response to lipopolysaccharide from Gram-negative bacteria. All TLRs have a Toll/IL-1 receptor (TIR) domain, which is responsible for signal transduction. MyD88 is one such protein that contains a TIR domain. It acts as an adapter, being involved in TLR-2, TLR-4 and TLR-9 signalling; however, our understanding of how TLR-4 signals is incomplete. Here we describe a protein, Mal (MyD88-adapter-like), which joins MyD88 as a cytoplasmic TIR-domain-containing protein in the human genome. Mal activates NF-kappaB, Jun amino-terminal kinase and extracellular signal-regulated kinase-1 and -2. Mal can form homodimers and can also form heterodimers with MyD88. Activation of NF-kappaB by Mal requires IRAK-2, but not IRAK, whereas MyD88 requires both IRAKs. Mal associates with IRAK-2 by means of its TIR domain. A dominant negative form of Mal inhibits NF-kappaB, which is activated by TLR-4 or lipopolysaccharide, but it does not inhibit NF-kappaB activation by IL-1RI or IL-18R. Mal associates with TLR-4. Mal is therefore an adapter in TLR-4 signal transduction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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