Unbiased metabolome screen leads to personalized medicine strategy for amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis is a rapidly progressive neurodegenerative disease that affects 1/350 individuals in the United Kingdom. The cause of amyotrophic lateral sclerosis is unknown in the majority of cases. Two-sample Mendelian randomization enables causal inference between an exposure, such as the serum concentration of a specific metabolite, and disease risk. We obtained genome-wide association study summary statistics for serum concentrations of 566 metabolites which were population matched with a genome-wide association study of amyotrophic lateral sclerosis. For each metabolite, we performed Mendelian randomization using an inverse variance weighted estimate for significance testing. After stringent Bonferroni multiple testing correction, our unbiased screen revealed three metabolites that were significantly linked to the risk of amyotrophic lateral sclerosis: Estrone-3-sulphate and bradykinin were protective, which is consistent with literature describing a male preponderance of amyotrophic lateral sclerosis and a preventive effect of angiotensin-converting enzyme inhibitors which inhibit the breakdown of bradykinin. Serum isoleucine was positively associated with amyotrophic lateral sclerosis risk. All three metabolites were supported by robust Mendelian randomization measures and sensitivity analyses; estrone-3-sulphate and isoleucine were confirmed in a validation amyotrophic lateral sclerosis genome-wide association study. Estrone-3-sulphate is metabolized to the more active estradiol by the enzyme 17ß-hydroxysteroid dehydrogenase 1; further, Mendelian randomization demonstrated a protective effect of estradiol and rare variant analysis showed that missense variants within HSD17B1, the gene encoding 17ß-hydroxysteroid dehydrogenase 1, modify risk for amyotrophic lateral sclerosis. Finally, in a zebrafish model of C9ORF72-amyotrophic lateral sclerosis, we present evidence that estradiol is neuroprotective. Isoleucine is metabolized via methylmalonyl-CoA mutase encoded by the gene MMUT in a reaction that consumes vitamin B12. Multivariable Mendelian randomization revealed that the toxic effect of isoleucine is dependent on the depletion of vitamin B12; consistent with this, rare variants which reduce the function of MMUT are protective against amyotrophic lateral sclerosis. We propose that amyotrophic lateral sclerosis patients and family members with high serum isoleucine levels should be offered supplementation with vitamin B12.

Decision-Support Needs of Caregivers Considering Hospice Enrollment for a Family Member With Dementia.

Background: There are few evidence-based interventions to support the growing number of family caregivers of persons living with advanced dementias (PWADs) in surrogate decision-making roles. This study identifies needs for decision support among family caregivers considering hospice enrollment for PWADs, in order to better inform efforts for decision support. Method: Individual and focus group interviews were conducted with caregivers (n = 13) and healthcare professionals (n = 14). Directed content analysis was used to identify and organize themes that emerged from interview transcripts. Results: Analysis revealed 2 themes concerning PWAD caregivers' hospice-related decision-support needs: (1) detailed and practical information about hospice and (2) discussions clarifying meaning around quality of life (QOL) for PWADs. Caregivers needed to know when they should consider hospice, what treatments would be stopped, what services would help caregivers, and what costs would be involved. Caregivers varied in their perceptions of what it might mean for a PWAD to have QOL at the end of life and whether or not hospice would enhance it. Discussion: This study's findings underscore the importance of decision-support tools and patient- and family-centered education for PWADs and caregivers about the trajectory of dementia and end-stage symptoms, along with practical information for hospice care planning and discussions addressing end of life values.

Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) and its association with Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis: a case report.

BACKGROUND: Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a neuro-inflammatory syndrome first described in 2010. It has a relationship with lymphoproliferative disorders that has not been fully elucidated. This case represents an unusual progression of CLIPPERS to Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis (LYG). The exact connection between CLIPPERS and LYG remains poorly understood. CASE PRESENTATION: We present a case of a 75-year-old man who was diagnosed with CLIPPERS with initial response to immunosuppression but later progressed to EBV-related LYG. EBV polymerase chain reaction (PCR) was detected in his cerebrospinal fluid (CSF), and repeat imaging revealed findings that were uncharacteristic for CLIPPERS; thereby prompting a brain biopsy which led to a diagnosis of EBV-related LYG. This case highlights the following learning points: 1) CLIPPERS cases are often part of a spectrum of lymphomatous disease, 2) CLIPPERS can be associated with EBV-related lymphoproliferative disorders such as LYG, and 3) EBV detection in CSF should prompt earlier consideration for brain biopsy in patients. CONCLUSIONS: Our case highlights the difficulty in distinguishing CLIPPERS from other steroid-responsive conditions such as neoplastic and granulomatous diseases. Given the association of CLIPPERS with EBV-related LYG as demonstrated in this case, we recommend testing for EBV in CSF for all patients with suspected CLIPPERS. An early referral for brain biopsy and treatment with rituximab should be considered for patients with suspected CLIPPERS who test positive for EBV in their CSF.

Comparative Cerebroprotective Potential of d- and l-Carnosine Following Ischemic Stroke in Mice.

l-carnosine is an attractive therapeutic agent for acute ischemic stroke based on its robust preclinical cerebroprotective properties and wide therapeutic time window. However, large doses are needed for efficacy because carnosine is rapidly degraded in serum by carnosinases. The need for large doses could be particularly problematic when translating to human studies, as humans have much higher levels of serum carnosinases. We hypothesized that d-carnosine, which is not a substrate for carnosinases, may have a better pharmacological profile and may be more efficacious at lower doses than l-carnosine. To test our hypothesis, we explored the comparative pharmacokinetics and neuroprotective properties of d- and L-carnosine in acute ischaemic stroke in mice. We initially investigated the pharmacokinetics of d- and L-carnosine in serum and brain after intravenous (IV) injection in mice. We then investigated the comparative efficacy of d- and l-carnosine in a mouse model of transient focal cerebral ischemia followed by in vitro testing against excitotoxicity and free radical generation using primary neuronal cultures. The pharmacokinetics of d- and l-carnosine were similar in serum and brain after IV injection in mice. Both d- and l-carnosine exhibited similar efficacy against mouse focal cerebral ischemia. In vitro studies in neurons showed protection against excitotoxicity and the accumulation of free radicals. d- and l-carnosine exhibit similar pharmacokinetics and have similar efficacy against experimental stroke in mice. Since humans have far higher levels of carnosinases, d-carnosine may have more favorable pharmacokinetics in future human studies.

Acute high-fat feeding leads to disruptions in glucose homeostasis and worsens stroke outcome.

Chronic consumption of diets high in fat leads to obesity and can negatively affect brain function. Rodents made obese by long-term maintenance on a high-fat diet have worse outcome after experimental stroke. High-fat consumption for only three days does not induce obesity but has rapid effects on the brain including memory impairment. However, the effect of brief periods of high-fat feeding or high-fat consumption in the absence of obesity on stroke is unknown. We therefore tested the effect of an acute period of high-fat feeding (three days) in C57B/6 mice on outcome after middle cerebral artery occlusion (MCAo). In contrast to a chronic high-fat diet (7.5 months), an acute high-fat diet had no effect on body weight, adipose tissue, lipid profile or inflammatory markers (in periphery and the brain). Three days of high-fat feeding impaired glucose tolerance, increased plasma glucose and insulin and brain expression of the glucose transporter GLUT-1. Ischaemic damage was increased (48%) in mice fed an acute high-fat diet, and was associated with a further reduction in GLUT-1 in the ischaemic hemisphere. These data demonstrate that only a brief period of high-fat consumption has a negative effect on glucose homeostasis and worsens outcome after ischaemic stroke.

Animal models of multiple sclerosis: From rodents to zebrafish.

Multiple sclerosis (MS) is a chronic, immune-mediated demyelinating disease of the central nervous system. Animal models of MS have been critical for elucidating MS pathological mechanisms and how they may be targeted for therapeutic intervention. Here we review the most commonly used animal models of MS. Although these animal models cannot fully replicate the MS disease course, a number of models have been developed to recapitulate certain stages. Experimental autoimmune encephalomyelitis (EAE) has been used to explore neuroinflammatory mechanisms and toxin-induced demyelinating models to further our understanding of oligodendrocyte biology, demyelination and remyelination. Zebrafish models of MS are emerging as a useful research tool to validate potential therapeutic candidates due to their rapid development and amenability to genetic manipulation.

Interdisciplinary Perspectives on an Integrated Behavioral Health Model of Psychiatry in Pediatric Primary Care: A Community-Based Participatory Research Study.

Integrated behavioral health services have positive outcomes for patients and providers, but little is known about providers' perspectives on implementing these services. This community-based participatory research collaboration with a Federally Qualified Health Center examined provider perspectives on implementing a collaborative psychiatry consultation program in pediatric primary care. We interviewed providers (N = 14) from psychiatry, social work, primary care, and psychology regarding their experiences implementing the program, and their recommendations for its sustainability. Providers described interdisciplinary integration arising from the program, with accompanying benefits (e.g., increased access to care for patients with complex diagnostic profiles, increased learning and role satisfaction among providers), and challenges (e.g., increased burden on primary care providers, potential patient discomfort with team-based care). Our results highlight the complexities of implementing collaborative psychiatry consultation in pediatric primary care, and suggest the importance of supporting primary care providers and patients within this context.

Design and fabrication of prototype piezoelectric adjustable X-ray mirrors.

Lynx, a next generation X-ray observatory concept currently under study, requires lightweight, high spatial resolution X-ray mirrors. Here we detail the development and fabrication of one of the candidate technologies for Lynx, piezoelectric adjustable X-ray optics. These X-ray mirrors are thin glass shell mirrors with Cr/Ir X-ray reflective coatings on the mirror side and piezoelectric thin film actuators on the actuator side. Magnetron sputtering was used to deposit metal electrodes and metal-oxide piezoelectric layers. The piezoelectric (Pb0.995(Zr0.52Ti0.48)0.99Nb0.01O3) was divided into 112 independent piezoelectric actuators, with 100% yield achieved. We discuss the fabrication procedure, residual thermal stresses and tuning of the Cr/Ir coating stress for the purposes of stress balancing.

Analysis of total and transferrin-bound iron in human serum for pharmacokinetic studies of iron-sucrose formulations.

BACKGROUND: Patients with iron-deficiency anemia benefit from intravenous iron therapies. Development of these pharmaceutical agents requires pharmacokinetic studies monitoring levels of both the administered agent and transferrin-bound iron (TBI). Successful pharmacokinetic methods must discriminate iron species. RESULTS: Routine colorimetric procedures were used to reliably measure total iron and TBI following iron-sucrose administration. Iron was liberated from iron-sucrose allowing the determination of all circulating iron. Solid-phase sample processing allowed the measurement of TBI. Circulating iron-sucrose could then be calculated as the difference between total iron and TBI. CONCLUSION: A reproducible and robust spectrophotometric method was developed and validated for measuring total iron and TBI in human serum following iron-sucrose therapy.

Utility of MRI before and after uterine fibroid embolization: why to do it and what to look for.

The utility of magnetic resonance imaging (MRI) in the selection, procedure planning, and follow-up of patients undergoing arterial embolization for uterine fibroids is reviewed. Advantages of MRI over ultrasound include multiplanar imaging capability, a larger field of view, increased spatial resolution, improved anatomic detail, and the ability to detect other pelvic disorders. MRI can assess fibroid viability by detecting contrast agent enhancement. Magnetic resonance angiography has a useful role in evaluation of pelvic vasculature. Magnetic resonance parameters such as T1 and T2 relaxation times and diffusion-weighted characteristics have an emerging role in predicting outcome before and after embolization. MRI may be used to evaluate technical success and to image potential complications after embolization.

Papain: a novel urine adulterant.

The estimated number of employees in the United Stated screened annually for illicit drugs is approximately 20 million, with marijuana being the most frequently abused drug. Urine adulterants provide an opportunity for illicit drug users to obtain a false-negative result on commonly used primary drug screening methods such as the enzyme multiplied immunoassay technique and the fluorescence polarized immunoassay technique (FPIA). Typical chemical adulterants such as nitrites are easily detected or render the urine specimen invalid as defined in the proposed SAMHSA guidelines for specimen validity testing based on creatinine, specific gravity, and pH. Papain is a cysteine protease with intrinsic ester hydrolysis capability. The primary metabolite of the psychoactive chemical in marijuana, 11-norcarboxy-Delta9-tetrahydrocannibinol (THC-COOH), was assayed by FPIA in concentrations ranging from 25 to 500 ng/mL, at pH values ranging from 4.5 to 8, over the course of 3 days with papain concentrations ranging from 0 to 10 mg/mL. FPIA analysis of other frequently abused drugs: amphetamines, barbiturates, benzodiazepines, cocaine, opiates, and phencyclidine, along with gas chromatography-mass spectrometry (GC-MS) of THC-COOH and high-pressure liquid chromatography-ultraviolet detection (HPLC-UV) of nordiazepam was performed in order to determine if the mechanism of urine adulteration by papain was analyte specific. Control and adulterated urine specimens (n = 30) were assayed for creatinine, specific gravity, and pH to determine if papain rendered the specimens invalid based on the proposed SAMHSA guidelines. There was a direct pH, temperature, and time-dependent correlate between the increase in papain concentration and the decrease in THC-COOH concentration from the untreated control groups (p < 0.01). The average 72-h THC-COOH concentration decrease at pH 6.2 with a papain concentration of 10 mg/mL was 50%. Papain did not significantly decrease the concentration of the other drugs analyzed with the exception of nordiazepam. GC-MS of THC-COOH and HPLC-UV of nordiazepam revealed a 66% and 24% decrease in concentration of the respective analyte with 10 mg/mL papain after 24 h at room temperature (approximately 23 degrees C). No adulterated specimens were rendered invalid based on the SAMHSA guidelines. Immediate FPIA analysis is suggested to minimize the interfering effects of papain with regards to primary drug screening.

Sevoflurane analysis in serum by headspace gas chromatography with application to various biological matrices.

Sevoflurane is a nonflammable general anesthetic administered by inhalation of vaporized liquid that rapidly partitions out of aqueous biological matrices into a gaseous phase because of its volatility and hydrophobicity. We describe a headspace analysis of sevoflurane that can be performed without the use of an expensive automated headspace analyzer. Sevoflurane standards (0-109 mg/L) and quality control specimens (12.2 and 72.9 mg/L) were prepared and quantitated on an intraday and interday basis. Headspace gas was manually injected (150 degrees C) with a 2.5-mL gas-tight syringe into a Perkin-Elmer model 8500 gas chromatograph equipped with a 6-ft x 2-mm i.d. glass column (100 degrees C) containing 0.2% Carbowax 1500 on Carbopak C packing with a flame-ionization detector (200 degrees C), which allowed for elution of the internal standard, 1-propanol (1.56 min), and sevoflurane (2.92 min). Linear regression of the peak-area ratios of sevoflurane to 1-propanol (6.38 g/L), versus the sevoflurane concentrations yielded an average intraday correlation coefficient of 0.989 (S.D. = 0.003, n = 5) and mean quality control specimen values of 14.19 mg/L (C.V. = 5.1%, n = 5) and 66.72 mg/L (C.V. = 3.3%, n = 5). The average interday standard curve correlation coefficient was 0.987 (S.D. = 0.01, n = 5), and the mean quality control specimen values were 12.22 mg/L (C.V. = 13.7%, n = 5) and 74.27 mg/L (C.V. = 8.7%, n = 5). The chromatographic method described produced accurate and reproducible results with a simple on-column headspace gas injection. This method allows for quantitation of sevoflurane in various biological matrices by chromatographic separation of the headspace gas in a sealed specimen container.

The distribution of sevoflurane in a sevoflurane induced death.

The distribution of sevoflurane (fluoromethyl 2,2,2,-trifluoro-1-(trifluoromethyl) ethyl ether) in blood, urine, liver, kidney, vitreous humor, and tracheal aspirate is presented from a subject with a sevoflurane induced death. Sevoflurane is a nonflammable general anesthetic administered by inhalation of vaporized liquid. Although general inhalation anesthetics have the potential to be fatal if not properly administered, the incidence of abuse is minute in comparison to other illicit drugs. Currently, there are no citations in the literature defining the body distribution of sevoflurane in a sevoflurane induced death. The decedent was found lying in a bed with an oxygen mask containing a gauze pad secured to his face. Three empty bottles and one partially full bottle of Ultane (sevoflurane) were found with the body in addition to two pill boxes containing a variety of prescription and non-prescription drugs. Serum, urine and gastric contents from the deceased were screened for numerous drugs and metabolites using a combination of thin layer chromatographic, colorimetric and immunoassay techniques. Analysis of biological specimens from the deceased revealed the presence of: amphetamine, caffeine, pseudoephedrine, nicotine, nicotine metabolite, and valproic acid. Sevoflurane concentrations were determined by headspace gas chromatography with flame ionization detection and revealed concentrations of 26.2 microg/mL in the blood, 105 microg/mL in the urine, 31.9 microg/mL in the tracheal aspirate, 86.7 microg/mL in the vitreous humor, 30.8 mg/kg in the liver, and 12.8 mg/kg in the kidney. The decedent had pathologies consistent with respiratory suppression including pulmonary atelectasis, pulmonary edema, and neck vein distention. The official cause of death was respiratory suppression by sevoflurane and the manner of death was unclear.

Policy and environment assessment on illicit drug use and HIV risk in Cambodia.

Research on the extent of illicit drug use and its consequences for HIV risk in Cambodia has revealed that government, NGO, and health care systems in that country are unequipped to deal with HIV/AIDS epidemics among injecting drug users.

A fatal drug interaction between oxycodone and clonazepam.

A case is presented of a fatal drug interaction caused by ingestion of oxycodone (Oxycontin) and clonazepam (Klonapin). Oxycodone is an opium alkaloid used in long-term pain management therapy. Clonazepam is a benzodiazepine used for the treatment of seizures and panic disorders. The Drug Abuse Warning Network (DAWN) has reported an increase of 108% in the last two years of emergency department episodes related to Oxycontin. Six billion prescriptions were written for Oxycontin in the year 2000, an 18-fold increase from four years previous (1). Oxycontin has recently gained enormous notoriety at the local and national levels; however, there are very few previously documented cases of lethal drug interactions between oxycodone and clonazepam. Synergistic effects between these two drugs are postulated to arise from different agonistic mechanisms producing similar physiological changes. It is also theorized that clonazepam may inhibit the metabolism of oxycodone. A 38-year-old white female was found dead in Jefferson County, Tennessee in March of 2001. The deceased had physical evidence of previous drug abuse and positive serological findings of hepatitis B and C. Prescription pill bottles filled under the name of the deceased, as well as another name, were found with the body. Serum, urine and gastric contents from the deceased were screened for numerous drugs and metabolites using a combination of thin layer chromatography and immunoassay techniques (EMIT and FPIA). Analysis of biological specimens from the deceased revealed the presence of: benzodiazepines, opiates (oxycodone), and trazodone metabolites in the serum; cannabinoids, benzodiazepines, opiates (oxycodone), trazodone, trazodone metabolites, nicotine, and nicotine metabolite in the urine; and benzodiazepines, opiates (oxycodone), nicotine, and nicotine metabolite in the gastric contents. Quantitative analyses for clonazepam was performed by high performance liquid chromatography (HPLC) and revealed a plasma concentration of 1.41 microg/mL. Plasma oxycodone and urine 11-nor-carboxy-delta-9-tetrahydrocannabinol concentrations were determined by gas chromatography/mass spectrometry and revealed concentrations of 0.60 microg/mL and 27.9 ng/mL, respectively. The deceased had pathologies consistent with severe central nervous system (CNS) and respiratory depression produced by high concentrations of clonazepam and oxycodone including collapsed lungs, aspirated mucus, and heart failure. The pathologies were sufficient to cause death, which was officially attributed to a drug overdose; however, the manner of death was unknown.