Baclofen and Tizanidine Adverse Effects Observed Among Community-Dwelling Adults Above the Age of 50 Years: A Systematic Review.

OBJECTIVE: This review highlights adverse effects of baclofen and tizanidine in older community-dwelling adults. DATA SOURCES: A literature search was conducted, including search terms of "adverse effect," "baclofen," "elderly," "falls," "fractures," and "tizanidine." Studies were included if they described community-dwelling adults aged 50 years and older who received oral baclofen or tizanidine. The Federal Drug Administration Adverse Event Reporting System (FAERS) data were compiled for adverse effect incidence. STUDY SELECTION AND DATA EXTRACTION: The literature search was completed in July 2019 and updated in June 2023. Reviews performed by 2 independent reviewers yielded 15 records. FAERS identified 486 (baclofen) and 305 (tizanidine) adverse effects of interest. DATA SYNTHESIS: Two retrospective cohort studies evaluating baclofen use in older adults showed increased hospitalizations for encephalopathy in chronic kidney disease (7.2% vs 0.1%) and end-stage renal disease (daily dose 20 mg or more; relative risk [RR] 19.8, 95% CI = [14.0-28.0]). Other articles were case reports; 10 articles reported dyskinesias, encephalopathy or disorientation, and drowsiness associated with baclofen, and 5 articles reported bradycardia and/or hypotension with tizanidine. The FAERS Public Dashboard revealed 12.1% and 28.7% overall incidence of adverse effects of interest, with a 27.8% and 29.2% incidence of falls for baclofen and tizanidine, respectively. Baclofen and tizanidine are associated with concerning adverse effects in older adults. Alternative agents should be considered, but, if necessary, providers should start at lower doses and increase slowly. CONCLUSIONS: This review highlights the importance of using baclofen and tizanidine with caution in older adults.

Enhancement of dielectrophoresis-based particle collection from high conducting fluids due to partial electrode insulation.

Dielectrophoresis (DEP) is a successful method to recover nanoparticles from different types of fluid. The DEP force acting on these particles is created by an electrode microarray that produces a nonuniform electric field. To apply DEP to a highly conducting biological fluid, a protective hydrogel coating over the metal electrodes is required to create a barrier between the electrode and the fluid. This protects the electrodes, reduces the electrolysis of water, and allows the electric field to penetrate into the fluid sample. We observed that the protective hydrogel layer can separate from the electrode and form a closed domed structure and that collection of 100 nm polystyrene beads increased when this occurred. To better understand this collection increase, we used COMSOL Multiphysics software to model the electric field in the presence of the dome filled with different materials ranging from low-conducting gas to high conducting phosphate-buffered saline fluids. The results suggest that as the electrical conductivity of the material inside the dome is reduced, the whole dome acts as an insulator which increases electric field intensity at the electrode edge. This increased intensity widens the high-intensity electric field factor zone resulting in increased collection. This informs how dome formation results in increased particle collection and provides insight into how the electric field can be intensified to the increase collection of particles. These results have important applications for increasing the recovery of biologically-derived nanoparticles from undiluted physiological fluids that have high conductance, including the collection of cancer-derived extracellular vesicles from plasma for liquid biopsy applications.

Microbubble-Nanoparticle Complexes for Ultrasound-Enhanced Cargo Delivery.

Targeted delivery of therapeutics to specific tissues is critically important for reducing systemic toxicity and optimizing therapeutic efficacy, especially in the case of cytotoxic drugs. Many strategies currently exist for targeting systemically administered drugs, and ultrasound-controlled targeting is a rapidly advancing strategy for externally-stimulated drug delivery. In this non-invasive method, ultrasound waves penetrate through tissue and stimulate gas-filled microbubbles, resulting in bubble rupture and biophysical effects that power delivery of attached cargo to surrounding cells. Drug delivery capabilities from ultrasound-sensitive microbubbles are greatly expanded when nanocarrier particles are attached to the bubble surface, and cargo loading is determined by the physicochemical properties of the nanoparticles. This review serves to highlight and discuss current microbubble-nanoparticle complex component materials and designs for ultrasound-mediated drug delivery. Nanocarriers that have been complexed with microbubbles for drug delivery include lipid-based, polymeric, lipid-polymer hybrid, protein, and inorganic nanoparticles. Several schemes exist for linking nanoparticles to microbubbles for efficient nanoparticle delivery, including biotin-avidin bridging, electrostatic bonding, and covalent linkages. When compared to unstimulated delivery, ultrasound-mediated cargo delivery enables enhanced cell uptake and accumulation of cargo in target organs and can result in improved therapeutic outcomes. These ultrasound-responsive delivery complexes can also be designed to facilitate other methods of targeting, including bioactive targeting ligands and responsivity to light or magnetic fields, and multi-level targeting can enhance therapeutic efficacy. Microbubble-nanoparticle complexes present a versatile platform for controlled drug delivery via ultrasound, allowing for enhanced tissue penetration and minimally invasive therapy. Future perspectives for application of this platform are also discussed in this review.

Macrophage LRP1 (Low-Density Lipoprotein Receptor-Related Protein 1) Is Required for the Effect of CD47 Blockade on Efferocytosis and Atherogenesis-Brief Report.

OBJECTIVE: Antibody blockade of the "do not eat me" signal CD47 (cluster of differentiation 47) enhances efferocytosis and reduces lesion size and necrotic core formation in murine atherosclerosis. TNF (Tumor necrosis factor)-α expression directly enhances CD47 expression, and elevated TNF-α is observed in the absence of the proefferocytosis receptor LRP1 (low-density lipoprotein receptor-related protein 1), a regulator of atherogenesis and inflammation. Thus, we tested the hypothesis that CD47 blockade requires the presence of macrophage LRP1 to enhance efferocytosis, temper TNF-α-dependent inflammation, and limit atherosclerosis. Approach and Results: Mice lacking systemic apoE (apoE-/-), alone or in combination with the loss of macrophage LRP1 (double knockout), were fed a Western-type diet for 12 weeks while receiving anti-CD47 antibody (anti-CD47) or IgG every other day. In apoE-/- mice, treatment with anti-CD47 reduced lesion size by 25.4%, decreased necrotic core area by 34.5%, and decreased the ratio of free:macrophage-associated apoptotic bodies by 47.6% compared with IgG controls (P<0.05), confirming previous reports. Double knockout mice treated with anti-CD47 showed no differences in lesion size, necrotic core area, or the ratio of free:macrophage-associated apoptotic bodies compared with IgG controls. In vitro efferocytosis was 30% higher when apoE-/- phagocytes were incubated with anti-CD47 compared with IgG controls (P<0.05); however, anti-CD47 had no effect on efferocytosis in double knockout phagocytes. Analyses of mRNA and protein showed increased CD47 expression in anti-inflammatory IL (interleukin)-4 treated LRP1-/- macrophages compared with wild type, but no differences were observed in inflammatory lipopolysaccharide-treated macrophages. CONCLUSIONS: The proefferocytosis receptor LRP1 in macrophages is necessary for anti-CD47 blockade to enhance efferocytosis, limit atherogenesis, and decrease necrotic core formation in the apoE-/- model of atherosclerosis.

Automated fluorescence quantification of extracellular vesicles collected from blood plasma using dielectrophoresis.

Tumor-secreted exosomes and other extracellular vesicles (EVs) in circulation contain valuable biomarkers for early cancer detection and screening. We have previously demonstrated collection of cancer-derived nanoparticles (NPs) directly from whole blood and plasma with a chip-based technique that uses a microelectrode array to generate dielectrophoretic (DEP) forces. This technique enables direct recovery of NPs from whole blood and plasma. The biomarker payloads associated with collected particles can be detected and quantified with immunostaining. Accurately separating the fluorescence intensity of stained biomarkers from background (BG) levels becomes a challenge when analyzing the blood from early-stage cancer patients in which biomarker concentrations are low. To address this challenge, we developed two complementary techniques to standardize the quantification of fluorescently immunolabeled biomarkers collected and concentrated at predictable locations within microfluidic chips. The first technique was an automated algorithm for the quantitative analysis of fluorescence intensity at collection regions within the chip compared to levels at adjacent regions. The algorithm used predictable locations of particle collection within the chip geometry to differentiate regions of collection and BG. We successfully automated the identification and removal of optical artifacts from quantitative calculations. We demonstrated that the automated system performs nearly the same as a human user following a standard protocol for manual artifact removal with Pearson's r-values of 0.999 and 0.998 for two different biomarkers (n = 36 patients). We defined a usable dynamic range of fluorescence intensities corresponding to 1 to 2000 arbitrary units (a.u.). Fluorescence intensities within the dynamic range increased linearly with respect to exposure time and particle concentration. The second technique was the implementation of an internal standard to adjust levels of biomarker fluorescence based on the relative collection efficiency of the chip. Use of the internal standard reduced variability in measured biomarker levels due to differences in chip-to-chip collection efficiency, especially at low biomarker concentrations. The internal standard did not affect linear trends between fluorescence intensity and exposure time. Adjustments using the internal standard improved linear trends between fluorescence intensity and particle concentration. The optical quantification techniques described in this paper can be easily adapted for other lab-on-a-chip platforms that have predefined regions of biomarker or particle collection and that rely on fluorescence detection.

Impact of Behavioral Health Consultation on Hepatitis C Treatment Outcomes at a Federally Qualified Health Center; Philadelphia, PA.

Hepatitis C virus (HCV) infection is a public health issue that claims the lives of 350,000 individuals globally every year. Primary care providers are increasingly prescribing HCV medications with more modern, simplified administrations. Individuals with HCV are disproportionately affected by behavioral health challenges and substance use disorders. Integrated behavioral health providers can work in concert with their patients' primary care teams to provide innovative treatment programs to help support the needs of HCV care. We used simple and multivariable logistic regression to determine the association between receipt of behavioral health consultation and two outcomes on the care continuum: insurance approval for treatment and initiated HCV treatment regimen. These models were fitted using theoretically hypothesized variables and multivariable regression models included age, sex, and race/ethnicity as potential confounders. From January 2015 to May 2017, 189 patients at health centers were referred for onsite HCV primary care treatment. Of these, 142 were approved for participation, and 132 started treatment. Simple regression revealed a significant association between behavioral health consultation and treatment approval; however, behavioral health consultation was non-significant in the multivariable model for treatment approval. For initiating HCV treatment, onsite behavioral health consultation was significantly associated in both the unadjusted and adjusted regression models. Integrating behavioral health services for patients seeking HCV treatment may improve movement across the care continuum, optimizing patient's HCV health outcomes. Behavioral health consultation in primary care settings should be studied further to improve HCV treatment outcomes for patients with behavioral health and substance use disorders.

Integration of Hepatitis C Treatment in a Primary care Federally Qualified Health Center; Philadelphia, Pennsylvania, 2015-2017.

Hepatitis C virus (HCV) infection remains a pressing public health issue. Identification of long term infection in primary care settings and community health centers can facilitate patients' access to appropriate care. Given the increase in HCV prevalence in the United States, improving the HCV care continuum and expanding medication access to disproportionately affected populations can help reduce disease burden, health care system costs, and transmission. Innovative treatment programs developed in the primary care setting are needed to deliver quality care to meet the demand of those engaging in treatment. This article describes an HCV treatment program developed within a primary care federally qualified health center (FQHC) using physician assistants (PAs) and nurse practitioners (NPs) to address the high number of HCV positive patients identified at the clinic. An interdisciplinary care team was established to optimize patient experience around HCV care and treatment, using on-site primary care behavioral health consultants, an HCV treatment coordinator, and a 340B contracted specialty pharmacy. From January 2015 to April 2017, the Public Health Management Corporation (PHMC) Care Clinic medical providers referred 189 patients for HCV treatment. Of those referred, 102 patients successfully obtained a sustained virologic response (SVR), representing a 53.7% success rate from referral to cure. This treatment program successfully integrated HCV treatment in a patient population heavily affected by substance use and mental illness. Support and adoption of similar programs in primary care community health centers testing for HCV can help meet the clinical/behavioral needs of these marginalized populations.

Deletion of Macrophage Low-Density Lipoprotein Receptor-Related Protein 1 (LRP1) Accelerates Atherosclerosis Regression and Increases C-C Chemokine Receptor Type 7 (CCR7) Expression in Plaque Macrophages.

BACKGROUND: We previously showed that mice lacking MΦLRP1-/- (low-density lipoprotein receptor-related protein 1 in macrophages) undergo accelerated atherosclerotic plaque formation due to changes in macrophages including increased apoptosis, decreased efferocytosis, and exaggerated transition to the inflammatory M1 phenotype. Here we sought to explore the role of macrophage low-density lipoprotein receptor-related protein 1 during regression of atherosclerosis since regressing plaques are characterized by transitioning of macrophages to M2 status as inflammation resolves. METHODS: Apolipoprotein E-/- mice on a high-fat diet for 12 weeks were reconstituted with bone marrow from apolipoprotein E-producing wild-type or MΦLRP1-/- mice, and then placed on a chow diet for 10 weeks (n=9 to 11 mice/group). A cohort of apolipoprotein E-/- mice reconstituted with apolipoprotein E-/- bone marrow served as baseline controls (n=9). RESULTS: Plaques of both wild-type and MΦLRP1-/- bone marrow recipients regressed compared with controls (11% and 22%, respectively; P<0.05), and plaques of MΦLRP1-/- recipients were 13% smaller than those of wild-type recipients ( P<0.05). Recipients of MΦLRP1-/- marrow had 36% fewer M1 macrophages ( P<0.01) and 2.5-fold more CCR7 (C-C chemokine receptor type 7)-positive macrophages in the plaque relative to wild-type mice ( P<0.01). Additionally, in vivo studies of cellular egress showed a 4.6-fold increase in 5-ethynyl-2´-deoxyuridine-labeled CCR7+ macrophages in mediastinal lymph nodes. Finally, in vivo studies of reverse cholesterol transport showed a 1.4-fold higher reverse cholesterol transport in MΦLRP1-/- recipient mice ( P<0.01). CONCLUSIONS: Absence of macrophage low-density lipoprotein receptor-related protein 1 unexpectedly accelerates atherosclerosis regression, enhances reverse cholesterol transport, and increases expression of the motility receptor CCR7, which drives macrophage egress from lesions.

Differences in heterocycle basicity distinguish homocysteine from cysteine using aldehyde-bearing fluorophores.

We report the detection of homocysteine over cysteine based upon characteristic differences between 5- and 6-membered heterocyclic amines formed upon reaction with aldehyde-bearing compounds. Homocysteine-derived thiazinane-4-carboxylic acids are more basic than cysteine-derived thiazolidines-4-carboxylic acids. Fluorescence enhancement in response to homocysteine is achieved by tuning pH and excitation wavelength.