Psychosine, a marker of Krabbe phenotype and treatment effect.

Newborn screening (NBS) for Krabbe disease, a rare neurodegenerative disorder caused by deficient galactocerebrosidase (GALC) enzyme activity, has recently been implemented in a number of US states. However, the spectrum of phenotypic manifestations associated with deficient GALC activity complicates the management of screen-positive newborns and underscores the need to identify clinically relevant biomarkers. Earlier studies with a small number of patients identified psychosine, a substrate of the GALC enzyme, as a potential biomarker for Krabbe disease. In this study, we provide, for the first time, longitudinal data on dried blood spot (DBS) psychosine concentrations in different Krabbe disease phenotypes for both untreated patients and those treated with hematopoietic stem cell transplantation (HSCT). Our cohort included patients previously identified by NBS to be at high risk to develop Krabbe disease. Substantially elevated DBS psychosine concentration during the newborn period was found to be a highly specific marker for infantile Krabbe disease. This finding supports the use of DBS psychosine concentration as a second-tier NBS test to aid in the identification of patients who require urgent evaluation for HSCT. In addition, longitudinal assessments showed that both natural disease progression and treatment with HSCT were associated with decreases in DBS psychosine concentrations. Based on these findings we provide recommendations for the interpretation of psychosine concentrations in DBS specimens collected during the first year of life. Future studies should aim to better delineate the relationship between DBS psychosine concentration and disease onset in patients with later-onset forms of Krabbe disease.

Newborn screening for X-linked adrenoleukodystrophy in New York State: diagnostic protocol, surveillance protocol and treatment guidelines.

PURPOSE: To describe a diagnostic protocol, surveillance and treatment guidelines, genetic counseling considerations and long-term follow-up data elements developed in preparation for X-linked adrenoleukodystrophy (X-ALD) newborn screening in New York State. METHODS: A group including the director from each regional NYS inherited metabolic disorder center, personnel from the NYS Newborn Screening Program, and others prepared a follow-up plan for X-ALD NBS. Over the months preceding the start of screening, a series of conference calls took place to develop and refine a complete newborn screening system from initial positive screen results to long-term follow-up. RESULTS: A diagnostic protocol was developed to determine for each newborn with a positive screen whether the final diagnosis is X-ALD, carrier of X-ALD, Zellweger spectrum disorder, acyl CoA oxidase deficiency or D-bifunctional protein deficiency. For asymptomatic males with X-ALD, surveillance protocols were developed for use at the time of diagnosis, during childhood and during adulthood. Considerations for timing of treatment of adrenal and cerebral disease were developed. CONCLUSION: Because New York was the first newborn screening laboratory to include X-ALD on its panel, and symptoms may not develop for years, long-term follow-up is needed to evaluate the presented guidelines.

Safety and efficacy of weekly nab®-paclitaxel in combination with carboplatin as first-line therapy in elderly patients with advanced non-small-cell lung cancer.

BACKGROUND: This analysis evaluates safety and efficacy in elderly (≥ 70 years old) versus younger patients enrolled in a phase III advanced non-small-cell lung cancer (NSCLC) trial. PATIENTS AND METHODS: Untreated stage IIIB/IV patients with PS 0/1 were randomly assigned (1:1) to carboplatin AUC6, day 1 every 3 weeks, and either nab-paclitaxel (Abraxane) 100 mg/m(2) weekly (nab-P/C) or solvent-based paclitaxel (Taxol) 200 mg/m(2) day 1 every 3 weeks (sb-P/C). The primary end-point was overall response rate (ORR). RESULTS: Fifteen percent of 1052 enrolled patients were elderly: nab-P/C, n = 74; sb-P/C, n = 82. In both age cohorts, the ORR was higher with nab-P/C versus sb-P/C (age ≥ 70: 34% versus 24%, P = 0.196; age <70: 32% versus 25%, P = 0.013). In elderly patients, progression-free survival (PFS) trended in favor of nab-P/C (median 8.0 versus 6.8 months, hazard ratio (HR) 0.687, P = 0.134), and overall survival (OS) was significantly improved (median 19.9 versus 10.4 months, HR 0.583, P = 0.009). In younger patients, PFS (median 6.0 versus 5.8 months, HR 0.903, P = 0.256) and OS (median 11.4 versus 11.3 months, HR 0.999, P = 0.988) were similar in both arms. Adverse events were similar in both age groups, with less neutropenia (P = 0.015), neuropathy (P = 0.001), and arthralgia (P = 0.029), and increased anemia (P = 0.007) with nab-P/C versus sb-P/C. CONCLUSIONS: In elderly NSCLC patients, nab-P/C as first-line therapy was well tolerated and improved the ORR and PFS, with substantially longer OS versus sb-PC.

Safety and efficacy analysis by histology of weekly nab-paclitaxel in combination with carboplatin as first-line therapy in patients with advanced non-small-cell lung cancer.

BACKGROUND: This analysis compared the efficacy and safety outcomes by histology of nab-paclitaxel (nab-P) plus carboplatin (C) versus solvent-based paclitaxel (sb-P) plus C in patients with advanced non-small-cell lung cancer (NSCLC) based on preplanned stratification factors specified in the phase III trial protocol. PATIENTS AND METHODS: Patients with untreated stage III/IV NSCLC received 100 mg/m(2) nab-P weekly and C (area under the curve, AUC = 6) every 3 weeks (q3w) or 200 mg/m(2) sb-P plus C (AUC = 6) q3w. Primary end point was objective overall response rate (ORR). RESULTS: nab-P/C versus sb-P/C produced a significantly higher ORR (41% versus 24%; response rate ratio [RRR] 1.680; P < 0.001) in patients with squamous cell (SCC) NSCLC. For nab-P/C versus sb-P/C, ORRs were 26% versus 27% (RRR 0.966; P = 0.814) in patients with adenocarcinoma, 33% versus 15% (RRR 2.167; P = 0.323) in patients with large cell carcinoma (LC), and 24% versus 15% (RRR 1.593; P = 0.372) in patients with not otherwise specified histology. Median overall survival for nab-P/C versus sb-P/C in patients with SCC was 10.7 versus 9.5 months (HR 0.890; P = 0.310), and 12.4 versus 10.6 months (HR 1.208; P = 0.721) for patients with LC. nab-P/C produced significantly (P < 0.05) less grade 3/4 neuropathy and arthralgia, whereas sb-P/C produced less thrombocytopenia and anemia. CONCLUSION(S): First-line nab-P/C demonstrated a favorable risk-benefit profile in patients with NSCLC regardless of histology.

Krabbe disease: clinical, biochemical and molecular information on six new patients and successful retrospective diagnosis using stored newborn screening cards.

PURPOSE: To present clinical, biochemical and molecular information on six new clinically diagnosed Krabbe disease patients and assess the sensitivity of retrospective galactocerebrosidase measurement in their newborn screening samples. METHODS: Medical records were reviewed. Galactocerebrosidase activity was measured in leukocytes and, retrospectively, in the patients' newborn screening cards (stored for 1.4 to 13.5 years). GALC gene mutation analysis was performed. RESULTS: Five patients with Krabbe disease, one of whom also had hydrocephalus, became symptomatic during infancy. A sixth patient presented with seizures and developmental regression at age two and had a protracted disease course. Galactocerebrosidase activity in leukocytes ranged from 0.00 to 0.20 nmol/h/mg protein. Low galactocerebrosidase activity (range: 3.2% to 11.1% of the daily mean), consistent with Krabbe disease, was detected in each of the newborn screening samples. GALC molecular analysis identified six previously unreported mutations and two novel sequence variants. CONCLUSION: Our cases highlight the clinical variability of Krabbe disease. Galactocerebrosidase activity in newborn dried blood spots is a highly sensitive test, even when samples have been stored for many years. The high frequency of private mutations in the GALC gene may limit the use of genetic information for making treatment decisions in the newborn period.

Equine cheek tooth extraction: Comparison of outcomes for five extraction methods.

BACKGROUND: Post-operative complications are reported for all methods of equine cheek tooth extraction but not all methods carry the same risks. An outcome comparison for commonly used methods is needed so that clinicians can make informed treatment decisions. OBJECTIVES: We conducted a side-by-side comparison of five cheek tooth extraction methods, comparing types and incidence of complications among oral extraction, tooth repulsion (three surgical approaches) and lateral buccotomy techniques. STUDY DESIGN: Retrospective clinical study using hospital medical records. METHODS: Medical records of all horses undergoing cheek tooth extraction between 1997 and 2013 were reviewed. Logistic regression was used to determine the likelihood of various post-operative complications, comparing oral extraction, tooth repulsion by maxillary and mandibular trephination or maxillary sinus bone flap, and lateral buccotomy. RESULTS: The study included 137 horses and 162 cheek teeth extractions. Oral extraction was successful in 71% of patients in which it was attempted. Oral extraction (n = 55) had the lowest incidence of complications (20%) and repulsion by sinus bone flap (n = 20) the highest (80%). Complication rates for repulsion by maxillary (n = 19) and mandibular trephination (n = 28), and extraction by lateral buccotomy (n = 15) were 42, 54 and 53%, respectively. Cheek tooth repulsion by sinus bone flap significantly increased the odds of damage to adjacent teeth, post-operative sinusitis, damage to alveolar bone, delayed alveolar granulation and orosinus fistulation. Repulsion by maxillary trephination significantly increased the odds of superficial incisional surgical site infection; and extraction by lateral buccotomy significantly increased the odds of facial nerve neuropraxia. Post-operative pyrexia was more common in all repulsion methods. MAIN LIMITATIONS: Some clinically relevant differences may have been missed due to small group numbers in several categories. CONCLUSIONS: Oral extraction was associated with fewer post-operative complications than any other methods. Standing oral extraction remains the preferred choice, and recent surgical advances promise to further improve its success rate.

Cryptococcal infection presenting as cellulitis in a renal transplant recipient.

Opportunistic infections of skin and soft tissue represent a rare but serious complication following solid organ transplantation. We report a case of severe soft tissue infection caused by Cryptococcus neoformans in a renal transplant recipient. Physicians need to consider the possibility of opportunistic pathogens when managing infections in immunocompromised hosts, especially when symptoms persist despite seemingly appropriate empiric antimicrobial therapy. Tissue sampling for histological and microbiological evaluation is usually necessary to establish a diagnosis.

A comparison of seven methods for continuous therapeutic cooling of the equine digit.

REASONS FOR PERFORMING STUDY: Digital hypothermia may be effective for laminitis prophylaxis and therapy, but the efficacy of cooling methods used in clinical practice requires evaluation. OBJECTIVES: To use hoof wall surface temperature (HWST) to compare several cooling methods used in clinical practice. STUDY DESIGN: Experimental crossover design with a minimum washout period of 72 h. METHODS: Seven cooling methods (commercially available ice packs, wraps and boots) and one prototypical dry-sleeve device were applied to a single forelimb in 4 horses for 8 h, during which HWST of the cooled forelimb and the uncooled (control) forelimb was recorded hourly. Results were analysed descriptively. RESULTS: The median (range) HWST from 2-8 h was lowest for the ice and water immersion methods that included the foot and extended proximally to at least include the pastern: 5.2°C (range: 4.8-7.8°C) for the fluid bag and 2.7°C (2.4-3.4°C) for the ice boot. An ice boot that included the distal limb but not the foot resulted in a median HWST of 25.7°C (20.6-27.2°C). Dry interface applications (ice packs) confined to the foot only resulted in a median HWST of 21.5°C (19.5-25.5°C) for the coronet sleeve and 19.8°C (17.6-23°C) for a commercial ice pack. For the dry interface applications that included the foot and distal limb, the median HWST was much higher for the ice pack device, 19.9°C (18.7-23.1°C), compared with the perfused cuff prototype of 5.4°C (4.2-7°C). CONCLUSIONS: Immersion of the foot and at least the pastern region in ice and water achieved sustained HWST <10°C as did a prototype perfused cuff device with a dry interface. Variation between cooling methods may have a profound effect on HWST and therefore efficacy in clinical cases where laminitis prophylaxis or therapy is the goal.

Clinical treatment and prognosis of equine odontoclastic tooth resorption and hypercementosis.

REASONS FOR PERFORMING STUDY: Equine odontoclastic tooth resorption and hypercementosis is an infrequent and underdiagnosed form of severe dental disease in horses that can affect quality of life. The study was performed to compare the clinical, radiographic, histological and prognostic findings specific to equine odontoclastic tooth resorption and hypercementosis in horses. Removal of affected teeth is currently the best treatment. OBJECTIVES: The goals are to report salient clinical and histological features of the disease and its management in a case series describing an under-reported syndrome in horses and the long-term prognosis. STUDY DESIGN: Retrospective case series. METHODS: Medical records from New Bolton Center, University of Pennsylvania from January 2000 to December 2012 were reviewed from horses that had a diagnosis of 'cementoma' or 'hypercementosis' and any associated dental-related diagnosis affecting the teeth and oral cavity. Radiographic, surgical and histological reports were collated and the clinical cases compared and tabulated to provide a better description of the equine disease. RESULTS: A total of 18 cases were identified, 17 of which were geldings and one of which was a nonbreeding stallion; no mares had the disease. The mean age at diagnosis was 24 years, with a range of 17-29 years. There was no breed predilection, and varied clinical signs relating to the mouth were found. Some teeth involved had only radiographic changes of disease and not gross clinical evidence. The mandibular incisors were generally affected earlier than the maxillary incisors, but the disease is progressive, and eventually, all of the incisors and sometimes the canines are involved. No premolars or molars were affected in this case series. CONCLUSIONS: Based on this case series, all teeth, and particularly the incisors, should be examined for signs of gingivitis and hypercementosis and subsequently radiographed for an early diagnosis and management. When compared with our hospital population, older geldings were more likely to be affected with cementoma formation and its accompanying resorptive process. Removal of clinically and radiographically affected teeth carries a good prognosis for improved quality of life.

Solitary tract nucleus sensitivity to moderate changes in glucose level.

Many neurons in the caudal nucleus tractus solitarii (NTS) recorded in vivo respond to moderate glycemic fluctuations through the local action of glucose molecules. To investigate this sensitivity in vitro, the extracellular activity of 112 neurons was recorded in hindbrain slices: 57 changed in firing rate when the glucose level in the bathing medium was increased by 2 mM. Since the glucose-responding neurons were located in catecholaminergic regions and depressed by the alpha-2 adrenoceptor agonist clonidine, they were likely to be adrenergic or noradrenergic. A comparison of the responses to glucose and 2-deoxy-D-glucose suggested that the bioenergetic metabolism is involved in NTS sensitivity to glucose.

Hypothalamic neurons responsive to increased plasma level of testosterone in the male rat.

Unitary activity was recorded from several forebrain structures. Out of 108 cells, 35 reacted to a testosterone i.v. injection by an increase (24 cells) or a decrease (11 cells) of firing rate. This response was early (latency: 5.0 +/- 0.6 min), lasted 25.7 +/- 1.9 min and was reproducible. Responsive neurons were found to be significantly more numerous in the lateral hypothalamic area than in other structures.

Radioautographic analysis of [14C]2-deoxyglucose uptake in hippocampal formation of the rat during enforced locomotor activity-induced theta.

The [14C]2-deoxyglucose ( [14C]2-DG) uptake in the hippocampal formation of the rat was studied following enforced locomotor activity-induced theta (M theta). M theta was found to be essentially associated with an increase in 2-DG uptake in the stratum oriens of the hippocampal CA1-CA2 areas. These data contrast with our previous findings that physostigmine-induced theta (I theta) is specifically associated with a decrease in 2-DG uptake in the stratum lacunosum moleculare of hippocampal CA1-CA2 areas. When both of our sets of radioautographic data are considered together, M theta and I theta appear to have a distinct neurophysiological basis.

Neuronal responses to delta 9-tetrahydrocannabinol in the solitary tract nucleus.

The effects of delta 9-tetrahydrocannabinol on single-unit activity in the subpostremal division of the nucleus tractus solitarii were investigated by extracellular recording in rat brain slices. The spontaneous firing rate of 54.8% of the recorded neurons was significantly changed after bath applications of delta 9-tetrahydrocannabinol. Putative nutrition-related neurons responding to a moderate increase in glucose concentration were selectively sensitive to delta 9-tetrahydrocannabinol. The delta 9-tetrahydrocannabinol-sensitive neurons were depressed by clonidine and are therefore likely to be adrenergic or noradrenergic. These observations suggest that some catecholaminergic, glucose-responsive neurons in the subpostremal nucleus tractus solitarii might mediate the influence of cannabinoids on feeding behaviour. Furthermore, most delta 9-tetrahydrocannabinol-sensitive neurons in the nucleus tractus solitarii showed opposite responses to delta 9-tetrahydrocannabinol and the 5-HT3 receptor agonist 1-phenylbiguanide, and might therefore be involved in the nausea-reducing effects of cannabinoids.

Neuronal responses to cannabinoid receptor ligands in the solitary tract nucleus.

Our previous study showed many neurons in the subpostremal division of the nucleus tractus solitarii to be cannabinoid-sensitive. In order to further investigate this sensitivity, single unit activity was recorded extracellularly in rat hindbrain slices, and the effects of bath application of delta9-tetrahydrocannabinol and of two synthetic cannabinoid receptor agonists were analysed and compared to each other. Approximately half the recorded neurons responded to agonists, and most of the neurons exposed to two of the agonists reacted similarly to both. The involvement of cannabinoid CB receptors in neuronal sensitivity to delta9-tetrahydrocannabinol is supported by these data and by the effects of N-piperidin-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-3-p yrazole-carboxamide, hydrochloride (SR 141716A), a compound which is considered to be a selective antagonist and/or a selective inverse agonist of this receptor type.

Involvement of adenosine triphosphate-sensitive K+ channels in glucose-sensing in the rat solitary tract nucleus.

The presence of adenosine triphosphate-sensitive (ATP-sensitive) K+ channels (K(ATP) channels) in the caudal nucleus tractus solitarii (NTS), and their possible involvement in glucose-sensing, were assessed by extracellular recording of neuronal activity in rat hindbrain slices. In 21 out of 36 recorded cells, firing was increased by sulfonylureas and decreased by K+ channel opener (KCO), indicating the existence of K(ATP) channels in the caudal NTS. In seven out of the nine neurons activated by a 2 mM increase in the glucose level, the effects of sulfonylureas and KCO were consistent with the involvement of K(ATP) channels in the glucose response. Conversely, the mechanism(s) underlying the response of glucose-depressed neurons remains to be clarified. Finally, the presence of K(ATP) channels was also detected in some neurons that were unresponsive to a 2 mM change in the glucose level. Thus, K(ATP) channels were pharmacologically identified in the caudal NTS, where they may be partly involved in glucose sensing.

The neocortex of rats behaving in a driven rotating wheel shows a band characterized by preferential uptake of deoxyglucose.

In comparison with control rats placed in a glass chamber, the neocortex of experimental rats performing in a motor-driven activity wheel shows a limited region of high metabolic activity, as revealed by the deoxyglucose radioautographic method. This region consists of a bilateral band located in the somesthetic area SI. An overlap of this labeling with the sensory and/or motor cortical representation of the head, and especially a correlation with head posture and movements, is discussed.

Direct effects of androgens on lateral hypothalamic neuronal activity in the male rat: II. A pressure ejection study.

Direct excitatory effects of sex steroids on lateral hypothalamic-medial forebrain bundle (LHA-MFB) neurons have been demonstrated in a previous study using the microiontophoretic ejection of charged hormone derivatives. In the present study neuronal discharge frequency was recorded during the local pressure ejection of the physiologically active form of these hormones. Of 56 neurones studied, 12 increased in activity due to testosterone application. Twenty-eight of these cells were tested with both testosterone and estradiol. Five were activated by both hormones, 4 were specifically excited by 17 Beta-estradiol, 3 were specifically excited by testosterone, and 16 were unaffected. The short latency of neuronal responses and the efficacy of nanomolar hormonal concentrations suggest the existence of high affinity specific sites in the plasma membrane of responsive neurons. The physiological significance of these neurons is discussed.

Responses of lateral hypothalamic neurons recorded in vitro to moderate changes in glucose concentration.

Single unit neuronal activity of lateral hypothalamic neurons was recorded extracellularly in hypothalamic slices. Glucose concentration in the perfusate was modified in small amounts to simulate normal physiological glycemic fluctuations associated with feeding. Several neurons responded reliably under these conditions. These data on simulated small glycemic changes, based on observations in the whole animal, suggest that the modulation of neuronal activity reported in this study is a result of a direct action of glucose on cells in this region of the hypothalamus.

Catecholaminergic projections from the solitary tract nucleus to the perifornical hypothalamus.

The source of adrenergic and other catecholaminergic fibers innervating the perifornical lateral hypothalamus was localized in the medulla after combination of Fluoro-Gold retrograde tracing and immunohistochemistry for either tyrosine-hydroxylase or phenylethanolamine-N-methyltransferase. Following perifornical injections, Fluoro-Gold-labeled neurons were observed mainly in regions including the noradrenergic and adrenergic cell groups. In the caudal solitary tract nucleus, two kinds of doubly labeled neurons were found: a) numerous noradrenergic neurons in the A2 group at the level of, or caudal to the area postrema; b) some adrenergic neurons in the C2 group at a level immediately rostral to the area postrema. These catecholaminergic neurons connecting the caudal solitary tract nucleus to the perifornical hypothalamus might convey feeding relevant information such as glycemic level or satiety signals.

Local versus indirect action of glucose on the lateral hypothalamic neurons sensitive to glycemic level.

The neuronal activity in the lateral hypothalamus may be affected by moderate changes in blood glucose. The present study aimed to specify the direct or indirect origin of this sensitivity to glycemia, by recording the unit responses in this area to both local glucose application (by means of microelectrophoresis) and hyperglycemia (induced by an IV glucose injection). The activity of approximately 25% of the recorded LHA neurons was modified by topically ejected glucose. However, a large majority of these neurons sensitive to local glucose failed to respond to hyperglycemia. Conversely, only 1/3 of the glycemia-sensitive cells responded in the same direction to systemic and local glucose administration. Therefore, the response to IV glucose of the other 2/3 glycemia-sensitive cells could not result from the direct action of glucose molecules on these neurons, but probably involved an indirect afferent pathway conveying the glycemic cues from some central or peripheral glucose sensors to the cell under investigation.