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Copyright © 2019 Ravi Ranjan Pradhan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of vasculitis disorder which involves multiple organ systems and is characterized by asthma, pulmonary infiltrates, sinusitis, neuropathy, and peripheral eosinophilia. It also has an effect on the heart, skin, kidneys, and gastrointestinal tract. Interlukin-5 (IL-5) is involved in maturation and activation of eosinophil, the production of which is increased in the EGPA. Treatments of EGPA are limited to systemic corticosteroids and immunomodulators. These drugs are associated with significant side effects. Besides this, the response of patients to these drugs may be disappointing. Frequent relapses, the need for long-term medium-to-high-dose glucocorticoid therapy, and failure to achieve remission are not uncommon findings. There is a need for noble agents that could reduce frequent relapses and the dose of systemic glucocorticoids and maintain a sustained remission without significant side effects. Mepolizumab is IL-5 antagonist and may have value in treating patients with EGPA. Therefore, we did a systematic review to evaluate the efficacy and safety of mepolizumab in patients with EGPA.
Eosinophilic granulomatosis with polyangiitis (EGPA), which was previously recognized as Churg–Strauss syndrome (CSS), was first described in 1951 by Churg and Strauss. It is a small-vessel necrotizing vasculitis characterized by multisystemic manifestations like asthma, lung infiltrations, extravascular necrotizing granuloma, and hypereosinophilia . The most commonly involved organ is the lung, followed by the skin. EGPA can virtually affect any organ systems, including cardiovascular, gastrointestinal, renal, and central nervous system . Vasculitis of extrapulmonary organs is largely responsible for the morbidity and mortality in patients with EGPA.
EGPA typically occurs in several phases. The prodromal phase is characterized by asthma and/or allergic rhinitis, which usually begins when the individual is in their second to third decade of life. The eosinophilic infiltration phase is characterized by peripheral eosinophilia and eosinophilic tissue infiltration of different organs. The third phase is the vasculitic phase and it is associated with constitutional signs and symptoms like fever, malaise, fatigue, and weight loss.
Treatments of EGPA are limited to systemic corticosteroids and immunomodulators. These drugs are associated with significant side effects. Despite treatment, the response to disease is limited. Frequent relapses, need for long-term medium-to-high-dose glucocorticoid therapy, and failure to achieve remission are not uncommon findings.
The exact pathogenesis of EGPA is poorly understood. Antineutrophil cytoplasmic antibodies (ANCA) are detected in about 40 to 60 percent of patients with EGPA and are classified among the ANCA-positive vasculitides . In addition, EGPA is characterized by several other abnormalities of immune function such as heightened Th2 and Th1 immunity (suggested by prominence of allergic features and pulmonary angiocentric granulomatosis, resp.) and altered humoral immunity (suggested by increased serum IgE level) [4, 5]. Studies suggest a direct pathogenic effect of eosinophilic infiltration in the different tissues [4, 6, 7]. Interlukin-5 (IL-5) mediates proliferation, maturation, differentiation, tissue survival, and activation of eosinophil [8, 9]. Levels of IL-5 are increased in patients with EGPA and might correlate with disease activity . Therefore, neutralization of IL-5 offers a rational therapeutic approach for managing a case of EGPA. Mepolizumab is an anti-IL-5 monoclonal antibody that binds to IL-5 and prevents the interaction of IL-5 with its receptor on the surface of eosinophil. Mepolizumab is found to be effective in reducing peripheral eosinophil counts in different hypereosinophilic syndrome [10–12]. In this review, we reviewed the current evidence for the efficacy and safety of mepolizumab in patients with EGPA.
The PRISMA statement for reporting systematic reviews recommended by the Cochrane Collaboration was followed for conducting this systematic review [Figure 1]. PubMed, Google Scholar, CENTRAL, and EMBASE were searched for peer-reviewed research published between July 2005 and July 2018. Databases were searched using the search terms under two search themes and combined using the Boolean operator "AND". For the theme "Mepolizumab", we used the following text words: mepolizumab, IL-5 antagonist, and monoclonal antibody. For the theme "Eosinophilic granulomatosis with polyangiitis", we used the following text words: Eosinophilic granulomatosis with polyangiitis, Churg-Strauss Syndrome, EGPA, and CSS .
Figure 1: PRISMA diagram detailing the study identification and selection process.
Studies published in the English language were included in the review if they aimed to assess efficacy and safety of mepolizumab in patients with EGPA. Studies that aimed to assess efficacy and safety of mepolizumab in disease conditions other than EGPA, like asthma, hypereosinophilic syndrome, and eosinophilic esophagitis, were excluded. In addition, case reports, case series, editorials, and correspondences were also excluded . Diagram detailing the study identification and selection process is given in Figure 1.
The authors (RRP and GN) independently screened the articles based on the inclusion and exclusion criteria. Full texts were obtained for articles that met inclusion criteria. The authors developed a data abstraction spreadsheet using Microsoft Excel version 2013 (Microsoft Corp., Redmond, WA, USA) and included the following information: author, year of publication, journal, country where the study was done, study design, sample size, baseline characteristics of the patients, dose, frequency, and the route of administration of the drug, efficacy in the terms of period of remission, relapse, and reduced dose of steroid, and the safety of the drug. Any discrepancies were solved by consultation with a third author (SM) .
The study characteristics are represented in Table 1. All the three articles included in this review were of good quality, considering the presence of clear objectives, a clearly mentioned study design, and clearly described statistical analysis. Three trials were included in this systematic review, with a total of 153 subjects. All the studies have used their own exclusion and inclusion criteria. Wechsler et al. and Moosig et al. have used separate criteria for remission, but Kim et al. have not included criteria for remission in their study.
Table 1: Key methodological characteristics of selected studies.
The patient characteristics of the study are shown in Table 2. The mean age of patients in Wechsler et al.'s work was 49 years and 48 years for case and control, respectively. Similarly, the mean age of the patients included in Kim et al.'s work and Moosig et al.'s work was 45 years and 62 years, respectively. Mean forced expiratory volume in one second (FEV1) and Birmingham Vasculitis Activity Score (BVAS) were similar in Kim et al.'s and Moosig et al.'s studies.
Table 2: Baseline characteristics of patients included in selected studies.
The studies conducted by Kim et al. and Moosig et al. used mepolizumab 750 mg intravenous infusion once in every four to six weeks. Wechsler et al. examined a dose of mepolizumab as 300 mg subcutaneously every 4 weeks. In all the three studies, glucocorticoid was tapered gradually according to a standardized recommended tapering schedule few weeks after starting mepolizumab.
The outcomes of all studies were remission, relapse, an average daily dose of prednisolone or prednisone, and the safety of mepolizumab. However, remission was not included in the study of Kim et al.
Wechsler et al. established that treatment with mepolizumab led to significantly more accrued weeks of remission than placebo (28% versus 3% of the participants had ≥ 24 weeks of accrued remission; odds ratio, 5.91; 95% confidence interval [CI], 2.68 to 13.03; p < 0.001) and a significantly higher percentage of participants were in remission at both weeks 36 and 48 compared to placebo (32% versus 3%; odds ratio, 16.74; 95% CI, 3.61 to 77.56; p < 0.001). Overall, 44% of mepolizumab-treated subjects were able to taper prednisolone or prednisone to 4 milligram (mg) or less per day, compared with 7% of subjects taking placebo. The time to first relapse over 52-week period was longer in mepolizumab than in placebo (56% versus 82%; hazard ratio, 0.32; 95% CI, 0.21 to 0.50; p < 0.001). In the same study, most commonly reported adverse events were headache (32% in mepolizumab group and 18% in placebo group), nasopharyngitis (18% versus 24%), arthralgia (22% versus18%), sinusitis (21% versus 16%), upper respiratory tract infection (21% versus 16%), exacerbation or worsening of asthma (3% versus 6%), and local injection-site reactions (similar in the two groups). One patient in mepolizumab group died from cardiac arrest during this study; however, this participant had a prior history of coronary artery disease .
In the study performed by Kim et al., there was significantly lower exacerbation rate during the treatment period (0.14 events per week, two events during a 14-week period) compared to the nontreatment period (0.69 events per week, 18 events over a 26-week period). In this study, they found that mepolizumab effectively served as a corticosteroid-sparing therapy. The mean dose at baseline was 12.9 milligrams (mg) per day, which was reduced to 4.6 mg per day after 12 weeks of therapy (study week 16), that is, 64% reduction in corticosteroid dose (p=0.0001) after 4 doses of mepolizumab. As per this study, mepolizumab was safe to use, and there were no severe adverse events noted during the study period. The common adverse events were mild transient headache (n= 3), mild pruritus (n=1), and loose stool (n=1). In the same study, participants experienced wheeze or cough (n=4), sore throat (n=4), nausea or abdominal discomfort (n=3), sinusitis (n=6), and arthritis (n=1) during the trial. However, these adverse events were not due to mepolizumab; rather they were presumably related to corticosteroid tapering, signs of EGPA activity, or both .
In a similar study conducted by Moosig et al., out of 10 patients, eight reached remission, one had BVAS of zero but did not achieve glucocorticoid dose less than 7.5 mg/day, and one reached remission but was excluded because of nonadherence. There was no relapse noted with mepolizumab therapy. The daily dose of glucocorticoid was reduced significantly at week 32 (median, 19 mg at baseline to 4 mg at week 32; p=0.006). Mepolizumab was well tolerated and the most common adverse events associated with mepolizumab therapy were eczema, edema, swelling of left hand, urinary tract infection, dentalgia, abdominal pain, wound infection, otitis media, bronchitis, herpes zoster, and herpes simplex. Severe adverse events like anaphylaxis (n=1), norovirus infection (n=1), cerebral micro embolism (n=1), and de Quervain thyroiditis (n=1) were noted. However, these serious adverse events were probably unrelated to mepolizumab therapy .
The present work is, to the best of our knowledge, the first systematic review of the latest three trials, allowing the direct comparison of efficacy and safety of mepolizumab in patients with EGPA.
Based on the studies analyzed, we found that mepolizumab allows substantial corticosteroid tapering at the cost of maintaining clinical stability. In all the studies, there was a significant decrease in mean corticosteroid dose few weeks after start of therapy with mepolizumab. We also found a significantly higher proportion of remission and a lower rate of relapse with mepolizumab therapy. Mepolizumab does not only control the asthma symptoms but also has an effect on systemic vasculitis manifestations as suggested by decreased BVAS in all the three studies. The safety of mepolizumab is well established from the three studies, except for few minor side effects. The serious adverse events also occurred during the trials; however, those events were probably unrelated to mepolizumab therapy. In all the three studies, the pattern of exacerbation, clinical symptoms, and dose of corticosteroid improved while patients were under mepolizumab therapy but worsened after it was withdrawn. Given the substantial adverse effects of long-term systemic corticosteroid, such as weight gain, impaired blood sugar, iatrogenic Cushing syndrome, thinning of skin, osteoporosis, adrenal suppression, and increased risk of infection, mepolizumab could establish itself as a noble agent in treating patients with EGPA.
A meta-analysis of randomized placebo-controlled trials of mepolizumab in patients with eosinophilic asthma found significantly decreased exacerbation risk compared to placebo (OR, 0.30; 95%CI, 0.13 to 0.67; p= 0.004) and a significant improvement in the scores on the Asthma Quality of Life Questionnaire (AQLQ) (mean difference, 0.26; 95% CI, 0.03 to 0.49; p = 0.03). The same study found that mepolizumab was well tolerated. Some serious adverse events reported such as cerebrovascular disorder, asthma exacerbation, and gastrointestinal disturbance were not considered by the investigators to be related to study medication. The common adverse events were headache, chest pain, facial flushing, erectile or ejaculatory dysfunction, rash, conjunctivitis, fatigue, upper respiratory tract infection, rhinitis, bronchitis, sinusitis, viral infection, injury, nausea, and pharyngitis .
A study conducted by Nair et al. in patients with prednisone-dependent asthma with sputum eosinophilia found that the rate of exacerbation was significantly lower in mepolizumab group compared to placebo group. Patients who received mepolizumab were able to reduce their prednisone dose by a mean (±SD) of 83.8±33.4% of their maximum possible dose, as compared with 47.7±40.5% in the placebo group (p=0.04). The use of mepolizumab was associated with a significant decrease in the number of sputum and blood eosinophils. There were no serious adverse events .
A randomized controlled trial done by Rothenberg et al. in patients with negative FIP1L1–PDGFRA fusion gene hypereosinophilic syndrome with mepolizumab discovered that mepolizumab treatment enabled clinically significant reductions in corticosteroid dose and often corticosteroid discontinuation .
Studies have shown that mepolizumab is associated with marked decreases in peripheral blood and esophageal eosinophilia in patients with eosinophilic esophagitis and improved clinical outcomes [20, 21].
Treatment of EGPA remains a challenge for physicians because the current available therapies, corticosteroids and immunomodulators, do not always control symptoms and are often associated with significant morbidity and relapses. The long-term use of high-dose corticosteroid is associated with potential adverse effects like impaired blood sugar, increased risk of infection, Cushing syndrome, glaucoma, weight gain, and adrenal suppression. So it is necessary to find an alternative to corticosteroids and immunomodulators. Mepolizumab is a potential alternative that binds to IL-5 and prevents its interaction with its receptor on the eosinophil surface. Besides EGPA, mepolizumab is also found to be effective in other hypereosinophilic syndromes. The safety of mepolizumab is well established from different studies.
The result of our systematic review should be considered with caution, owing to limited number of available studies and subjects. The sample size was small to reach a convincing conclusion. Secondly, the drug dose and treatment duration differing in the trials involved in our review made it difficult to determine the optimal dose of mepolizumab which would be mostly appropriate for patients with EGPA.
To conclude, this review has found that mepolizumab is efficacious and safer to use in patients with EGPA. It has an effect on asthma symptoms as well as systemic vasculitis manifestations. It might improve the rate of remission, decreases relapse rate, and allow for reduced glucocorticoid use, at cost of any serious adverse drug effects.
Ravi Ranjan Pradhan, Gaurav Nepal, and Shobha Mandal contributed to writing and reviewing data, data extraction, analysis of the results, and screening articles. Ravi Ranjan Pradhan and Gaurav Nepal supervised and conceptualized the project. Specifically, all authors have (i) made substantial contributions to conception and design or acquisition of data or analysis and interpretation of data, (ii) been involved in drafting the manuscript or revising it critically for important intellectual content, (iii) given final approval of the version to be published, and (iv) agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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Original Investigations|Articles in Press
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Diagnostic Accuracy of Noninvasive Bone Turnover Markers in Renal Osteodystrophy
Hanne Skou Jørgensen, MD, PhD
Hanne Skou Jørgensen
Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
Geert Behets, PhD
Geert Behets
Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
Liesbeth Viaene, MD, PhD
Liesbeth Viaene
Department of Nephrology, Az Groeninge, Kortrijk, Belgium
Bert Bammens, MD, PhD
Bert Bammens
Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
Kathleen Claes, MD, PhD
Kathleen Claes
Bjorn Meijers, MD, PhD
Bjorn Meijers
Maarten Naesens, MD, PhD
Maarten Naesens
Ben Sprangers, MD, PhD
Ben Sprangers
Dirk Kuypers, MD, PhD
Dirk Kuypers
Etienne Cavalier, MD, PhD
Etienne Cavalier
Department of Clinical Chemistry, Université de Liège, Liège, Belgium
Patrick D'Haese, PhD
Patrick D'Haese
Pieter Evenepoel, MD, PhD
Pieter Evenepoel
Corresponding author: Peter Evenepoel, Division of Nephrology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
Published:October 25, 2021DOI:https://doi.org/10.1053/j.ajkd.2021.07.027
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Rationale & Objective
Bone biopsy remains the gold standard for diagnosing renal osteodystrophy as comparable non-invasive alternatives have yet to be established. The aim of this study was to investigate the diagnostic accuracy of biochemical markers of skeletal remodeling to predict bone turnover.
Cross-sectional retrospective diagnostic test study.
Setting & Participants
Patients with chronic kidney disease stages G4-G5D and kidney transplant recipients with successful transiliac bone biopsies.
Tests Compared
Bone turnover as determined by bone histomorphometry was compared to the following biochemical markers: Full-length (1-84) parathyroid hormone (PTH), bone-specific alkaline phosphatase (BsAP), intact procollagen type I N-terminal propeptide (PINP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b).
Diagnostic performance was evaluated by area under the receiver operator characteristics curve (AUC), sensitivity, specificity, and negative and positive predictive values. Optimal diagnostic cutoffs were determined in an exploration cohort (n=100) and validated in a separate cohort (n=99).
All biomarkers differed across categories of low 33 (17%), normal 109 (55%), and high 57 (29%) bone turnover. AUC values were in the range of 0.75 – 0.85. High negative predictive values (≥90%) were found for both high and low bone turnover, indicating the ability to rule out both conditions using the suggested biomarker cutoffs. The highest diagnostic performances were seen with combinations of biomarkers, with overall diagnostic accuracies of 90% for high turnover, and 78% for low turnover. Results were comparable for kidney transplant candidates and recipients in a sensitivity analysis.
The single-center approach and heterogeneity of the study cohort are main limitations of this study.
We conclude that the diagnostic performance of biochemical markers of bone turnover is acceptable, with clinical utility in ruling out both high and low turnover bone disease.
Bone histomorphometry
Chronic kidney disease – mineral and bone disorder
Sensitivity and specificity
Tartrate-Resistant Acid Phosphatase
The transiliac bone biopsy remains the gold standard for diagnosing renal osteodystrophy.
Moe S.
Drüeke T.
Cunningham J.
Definition, evaluation, and classification of renal osteodystrophy: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO).
Kidney Int. 2006; 69: 1945-1953https://doi.org/10.1038/sj.ki.5000414
However, due to its invasive nature, a bone biopsy is not recommended as part of routine clinical workup.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group
KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD).
Kidney Int Suppl. 2017; 7: 1-59https://doi.org/10.1016/j.kisu.2017.04.001
Rather, it is reserved for the in-depth evaluation of bone disease in select patients, e.g. in cases of skeletal fractures or bone pain, inconsistencies in biochemical parameters of mineral metabolism, prior to referrals for parathyroidectomy, or initiation of anti-resorptive therapy.
Torres P.U.
Bover J.
Mazzaferro S.
de Vernejoul M.C.
Cohen-Solal M.
When, how, and why a bone biopsy should be performed in patients with chronic kidney disease.
Semin Nephrol. 2014; 34: 612-625https://doi.org/10.1016/j.semnephrol.2014.09.004
Suitable alternatives to the bone biopsy for evaluating renal osteodystrophy in everyday clinical practice have yet to be established.
In the most recent Kidney Disease – Improving global outcomes (KDIGO) guidelines on mineral and bone disorder in chronic kidney disease (CKD),
circulating levels of parathyroid hormone (PTH) and bone-specific alkaline phosphatase (BsAP) are suggested as surrogate markers of bone turnover in CKD stages 3-5D, with the specification that both may predict bone turnover at markedly high or low levels. As a biomarker, however, PTH has several limitations, including a high biological variability and assay standardization issues.
Cavalier E.
Souberbielle J.-C.
PTH determination in hemodialyzed patients-A laboratory perspective.
Semin Dial. 2019; 32: 490-492https://doi.org/10.1111/sdi.12844
Further, skeletal sensitivity to PTH may be reduced in CKD,
Evenepoel P.
Ureña Torres P.
Parathyroid hormone metabolism and signaling in health and chronic kidney disease.
Kidney Int. 2016; 90: 1184-1190https://doi.org/10.1016/j.kint.2016.06.041
and this PTH hyporesponsiveness may depend on kidney function. Despite these limitations, PTH has long been the preferred marker of bone turnover in clinical practice, and novel biomarkers so far failed to show diagnostic superiority, at least in patients with kidney failure.
Sprague S.M.
Bellorin-Font E.
Jorgetti V.
Diagnostic Accuracy of Bone Turnover Markers and Bone Histology in Patients With CKD Treated by Dialysis.
Am J Kidney Dis. 2016; 67: 559-566https://doi.org/10.1053/j.ajkd.2015.06.023
Couttenye M.M.
D'Haese P.C.
Van Hoof V.O.
Low serum levels of alkaline phosphatase of bone origin: a good marker of adynamic bone disease in haemodialysis patients.
de Oliveira R.A.
Barreto F.C.
Mendes M.
Peritoneal dialysis per se is a risk factor for sclerostin-associated adynamic bone disease.
Kidney Int. 2015; 87 ([doi]): 1039-1045https://doi.org/10.1038/ki.2014.372
In contrast to PTH, which is a key regulator of bone metabolism, bone turnover markers are specifically released from bone cells during the skeletal remodeling process. BsAP is secreted by osteoblasts in the process of biomineralization,
Nizet A.
Stenvinkel P.
Haarhaus M.
Magnusson P.
Bone alkaline phosphatase: An important biomarker in chronic kidney disease – mineral and bone disorder.
Clin Chim Acta. 2020; 501: 198-206https://doi.org/10.1016/j.cca.2019.11.012
and procollagen type I N-terminal propeptide (PINP) is a fragment released as collagen is deposited in the bone matrix;
Koivula M.-K.
Risteli L.
Risteli J.
Measurement of aminoterminal propeptide of type I procollagen (PINP) in serum.
Clin Biochem. 2012; 45: 920-927https://doi.org/10.1016/j.clinbiochem.2012.03.023
both are considered markers of bone formation. Importantly, monomeric fragments of PINP accumulate in CKD, necessitating the use of assays specific for the intact, trimeric form.
Melkko J.
Hellevik T.
Smedsrød B.
Clearance of NH2-terminal propeptides of types I and III procollagen is a physiological function of the scavenger receptor in liver endothelial cells.
J Exp Med. 1994; 179: 405-412https://doi.org/10.1084/jem.179.2.405
Tartrate-resistant acid phosphatase isoform 5b (TRAP5b) is an enzyme originating from osteoclasts, and considered a highly specific marker of bone resorption.
Halleen J.M.
Alatalo S.L.
Suominen H.
Cheng S.
Janckila A.J.
Väänänen H.K.
Tartrate-resistant acid phosphatase 5b: a novel serum marker of bone resorption.
J Bone Miner Res. 2000; 15: 1337-1345https://doi.org/10.1359/jbmr.2000.15.7.1337
As neither of these biomarkers are influenced by kidney function, they may be particularly well suited for use in patients with CKD.
Bone biomarkers in de novo renal transplant recipients.
The primary aim of the present study was to investigate the diagnostic accuracy of a panel of biochemical markers of skeletal remodeling as compared to biointact PTH, using the histomorpometric evaluation of bone turnover as the diagnostic standard. We hypothesized that biochemical markers of bone turnover would outperform PTH for a diagnosis of high or low bone turnover in patients with CKD.
Patients with CKD and a tetracycline (TC)-labelled bone biopsy of sufficient quality for a full histomorphometric analysis were eligible to be included. All patients had agreed to participate in a prospective, observational study on the natural history of mineral and bone disorder after kidney transplantation (clinical trial identifier: NCT01886950). Use of anti-osteoporotic treatment was the only exclusion criterion. All bone biopsies were performed between April 2011 and Sept 2018 at Leuven University Hospitals (Leuven, Belgium).
Relevant demographic variables and details of medical therapy were extracted from electronic patient files. For kidney transplant recipients, immunosuppression was achieved with glucocorticoids, a calcineurin inhibitor, and an antimetabolite. Methylprednisolone was administered intravenously on the day of transplantation (500 mg) and the first post-operative day (40 mg), followed by a daily dose of 16 mg prednisolone orally, tapered gradually over the first 3 months. The clinical course, together with findings on a protocolled kidney graft biopsy at month 3 determined if glucocorticoids were discontinued.
All clinical and research activities reported are consistent with the Principles of the Declaration of Istanbul on Organ Trafficking and Transplant Tourism. The study adhered to the principles of the Declaration of Helsinki and was approved by the Ethical Committee of KU Leuven (study identifier: S52091). All participants provided written informed consent.
Biochemical analyses
Blood samples were taken after an overnight fast, on the day of the bone biopsy procedure. Whole blood samples were stored for less than 2 hours at 5°C before arrival at the laboratory, where they were centrifuged at 3000 rpm for 10 minutes, after which serum samples were aliquoted, and stored at –80°C until analysis. Creatinine, hemoglobin, phosphate, total calcium, and total alkaline phosphatase (AP) were measured using standard laboratory techniques. The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation.
Ann Intern Med. 2009; 150: 604-612https://doi.org/10.7326/0003-4819-150-9-200905050-00006
Serum 25-hydroxy vitamin D (calcidiol) was measured using a radioimmunoassay.
Bouillon R.
Van Herck E.
Jans I.
Tan B.K.
Van Baelen H.
De Moor P.
Two direct (nonchromatographic) assays for 25-hydroxyvitamin D.
Serum concentrations of full-length, "biointact" PTH was determined by an in-house immunoradiometric assay (normal range 3–40 ρg/mL).
Coopmans W.
Degroote D.E.
Radoux D.
Eliard P.H.
Immunoradiometric assay of parathyrin with polyclonal and monoclonal region-specific antibodies.
Clin Chem. 1990; 36: 271-276
Bone-specific alkaline phosphatase (BsAP; normal range 6.1–25.5 ug/L, assay range 1–75 μg/L), trimeric procollagen type I N-terminal propeptide (PINP; normal range 12.8–82.6 ng/mL, assay range 2–230 ng/mL), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b; normal range 1.1–6.9 U/L; assay range 0.9–14.0 U/L) were measured with the ImmunoDiagnostic Systems iSYS instrument (IDS, Boldon, UK). Inter- and intra-assay variation were below 10% for all assays used. Values of BsAP, Intact PINP, and TRAP5b above the upper limit of quantification of the respective assays were determined after dilution.
The bone biopsy was performed as an outpatient procedure under light sedation with local anesthesia. Using an 8G trephine with an outer/inner diameter of 4.50/3.55 mm (Biopsybell [Mirandola, Italy]), the sample was retrieved from a site 2 cm posterior and 2 cm inferior to the anterior iliac spine. Complications occurred in 7 patients and included prolonged post-procedural pain (n = 6) and bleeding requiring transfusion (n = 1). All biopsies were preceded by double- TC-labeling by the following protocol: TC was administered orally (500 mg x 2 daily for 3 days) for two sessions with a TC-free interval of 11 days, and the bone biopsy was scheduled 4 days after the last intake of TC. To avoid a systematic bias caused by lack of TC labels in very low bone turnover, biopsies without visible TC labels were included if the patient was noted to have taken TC and static histomorphometry was consistent with low turnover. In such cases, the bone formation rate by total tissue volume (BFR/TV) was set arbitrarily at 1 μm³/cm³/year (n = 12).
Dempster D.W.
Compston J.E.
Drezner M.K.
Histomorphometry Nomenclature: A 2012 Update of the Report of the ASBMR Histomorphometry Nomenclature David.
J Bone Miner Res. 2014; 28: 2-17https://doi.org/10.1002/jbmr.1805.Standardized
Similarly, patients with a very high bone turnover and diffuse, unmeasurable labels (n = 2) were not excluded, and a value of 712 μm³/cm³/year was set for the BFR, corresponding to 20% above the highest measured BFR in this cohort (594 μm³/cm³/year).
Bone cores were fixed in 70% ethanol and embedded in a methylmethacrylate resin. Un-decalcified 5-μm thick sections were stained by the Goldner method to determine static bone parameters, and unstained 10-μm thick sections were mounted in 100% glycerol for fluorescence microscopy to visualize tetracycline labels and determine the dynamic parameters. All bone histomorphometric analyses were performed at the Laboratory of Pathophysiology, University of Antwerp, Belgium, running a custom program on the commercially available image analysis software AxioVision (version 4.51, Zeiss Microscopy, Zeiss, Germany). Bone histomorphometric parameters are reported in two dimensions using standardized nomenclature,
Standardized nomenclature, symbols, and units for bone histomorphometry: A 2012 update of the report of the ASBMR Histomorphometry Nomenclature Committee.
J Bone Miner Res. 2013; 28: 2-17https://doi.org/10.1002/jbmr.1805
following the recommended approach of evaluating bone turnover, mineralization, and volume.
Patients were categorized as having low, normal, or high bone turnover based on the BFR/TV, using a normal range of 11.5 – 110 mm³/cm³/year, as previously determined in an adult reference population.
Monier-Faugere M.C.
Mawad H.
Qi Q.
Friedler R.M.
Malluche H.H.
High prevalence of low bone turnover and occurrence of osteomalacia after kidney transplantation.
J Am Soc Nephrol. 2000; 11: 1093-1099https://doi.org/10.1681/ASN.V1161093
Behets G.J.
Spasovski G.
Sterling L.R.
Bone histomorphometry before and after long-term treatment with cinacalcet in dialysis patients with secondary hyperparathyroidism.
Kidney Int. 2015; 87: 846-856https://doi.org/10.1038/ki.2014.349
Descriptive statistics are presented as mean ± SD, median [IQR], or n (%), as appropriate. Differences in biomarker levels across categories of bone turnover were tested by one-way analysis of variance (ANOVA), followed by Student's t test against the "Normal" group, using the natural logarithms of biomarkers to achieve normal distribution. The diagnostic ability of biomarkers were evaluated by area under the receiver operator characteristics curve (AUC) statistics,
Hanley J.A.
McNeil B.J.
The meaning and use of the area under a receiver operating characteristic (ROC) curve.
Radiology. 1982; 143: 29-36https://doi.org/10.1148/radiology.143.1.7063747
running a non-parametric and bootstrapped estimation for each biomarker. AUC values were designated as poor (<0.6), fair (0.6–0.7), good (0.7–0.8), very good (0.8–0.9), or excellent (>0.90). Optimal cutoffs were determined by Liu's method,
Liu X.
Classification accuracy and cut point selection.
Stat Med. 2012; 31: 2676-2686https://doi.org/10.1002/sim.4509
as the biomarker level resulting in the maximum product of sensitivity and specificity. To avoid model optimism, we randomly split the cohort into separate exploration (n = 100) and validation (n = 99) subsets. Estimation of the optimal cutoff of each biomarker was performed in the exploration cohort, and the diagnostic performances of these cutoffs were subsequently evaluated in the validation cohort. To account for the effect of disease prevalence on test performance, we adjusted the negative and positive predictive values for pre-test probability (i.e. prevalence of disease) according to Bayes' theorem.
Spiegelhalter D.J.
Myles J.P.
Jones D.R.
Abrams K.R.
Methods in health service research. An introduction to bayesian methods in health technology assessment.
BMJ. 1999; 319: 508-512https://doi.org/10.1136/bmj.319.7208.508
Finally, as a sensitivity analysis, we conducted AUC analyses for patients biopsied before or after kidney transplantation as two separate groups. Statistical analyses were performed using the commercially available STATA IC version 16.1 (StataCorp LP, College Station, TX, USA).
Out of 286 available biopsies, 19 were of insufficient quality for a full histomorphometric analysis, and 22 were without successful TC labeling. Further, 35 patients were excluded to avoid duplicates, 4 due to bisphosphonate use, 4 due to recent fracture (<6 months), and 3 due to missing biochemistry, leaving a cohort of 199 patients for analysis (Figure S1). The majority of bone biopsies were performed solely as part of a research protocol (n = 187, 95%), while the remaining 12 patients were biopsied on indication.
Mean age was 55 ± 13 years, two-thirds were men (67%), and 23% had diabetes mellitus. The cause of CKD was as follows: Cystic or hereditary disease (n = 49, 25%), glomerulonephritis or vasculitis (n = 49, 25%), hypertension or large vessel disease (n = 17, 8.5%), diabetic nephropathy (n = 15, 7.5%), interstitial nephritis (n = 15, 7.5%), miscellaneous (n = 7, 3.5%), or unknown (n = 47, 24%). Demographic data for participating kidney transplant candidates (n = 80) and recipients (n = 119) are given in Table 1. Kidney transplant candidates were CKD stage G4 (n = 7), CKD stage G5 (n = 7), or CKD stage G5D (n = 66). Among patients with CKD stage G5D, 44 received chronic intermittent hemodialysis therapy and 22 continuous peritoneal dialysis treatment, with a median dialysis vintage of 15 [9, 26] months. Kidney transplant recipients were mainly biopsied at 12 months post-transplant (n = 103), with 6 patients biopsied earlier and 10 patients later than this time-point. Transplant recipients had a mean eGFR of 50±15 ml/min/1.73m
; 8 patients had an eGFR <30, and none <15. The immunosuppressive regimen consisted of a calcineurin inhibitor in combination with mycophenolate mofetil (MMF) for the majority (n = 110, 92%); 8 patients received a calcineurin inhibitor without MMF, and 1 patient received MMF alone. Tacrolimus was the most common calcineurin inhibitor used, with only two patients receiving cyclosporine A. Prednisolone had been halted in 33 (28%) patients, and for the remaining, daily doses were ≤ 4 mg (n = 85), with a single patient receiving 10 mg. The median cumulative steroid dose at 12 months post-transplant was 2.54 [1.81, 3.14] g.
Table 1Demographic data in the overall cohort and separated by time of bone biopsy before or after kidney transplantation
CKD G4-G5D (n = 80)
Kidney transplant recipients (n = 119)
Age, years 53 ± 14 57 ± 11
Gender, male 49 (61%) 85 (71%)
Diabetes mellitus, any type 8 (10%) 37 (31%)
Previous parathyroidectomy 5 (6%) 16 (14%)
Body mass index, kg/m2 24.4 ± 4.6 25.3 ± 4.8
Bone turnover
Low 6 (8%) 27 (23%)
Normal 38 (47%) 71 (60%)
High 36 (45%) 21 (18%)
Biointact PTH, ρg/mL 277 [111; 461] 59 [40; 110]
Total AP, U/L 112 [91; 168] 79 [59; 98]
Total calcium, mg/dL 9.46 ± 0.76 9.87 ± 0.79
Phosphate, mg/dL 5.66 ± 1.70 3.09 ± 0.83
Calciciol, ng/mL 38 ± 17 36 ± 14
BsAP, ug/L 37.2 [24.7; 58.3] 21.8 [14.2; 31.7]
Intact PINP, ng/mL 108.2 [61.1; 167.3] 55.0 [30.1; 98.8]
TRAP5b, U/L 6.1 [4.4; 8.3] 3.5 [2.5; 4.9]
Cinacalcet hydrochloride 6 (8%) 2 (2%)
Vitamin D 55 (69%) 53 (45%)
Active vitamin D 42 (53%) 20 (17%)
Methylprednisolone 18 (23%) 88 (74%)
Data are mean ± SD, median [IQR], or n (%)
Abbr.: AP=alkaline phosphatase, BFR=Bone formation rate, BsAP=bone-specific alkaline phosphatase, PINP=pro-collagen type I pro-peptide, PTH=parathyroid hormone, TRAP5b=tartrate resistant acid phosphatase isoform 5b
Biochemical markers of bone turnover
Bone turnover was classified as low in 33 (17%), normal in 109 (55%), and high in 57 (29%) patients. Levels of biochemical markers by categories of bone turnover are given in Table 2 and Figure 1. Highly significant differences in circulating levels were seen for all markers across bone turnover categories, although with a noticeable overlap in biomarker range, particularly between patients with low and normal bone turnover.
Table 2Biochemical markers by category of bone turnover
Low (n = 33)
Normal (n = 109)
High (n = 57)
Biointact PTH, ρg/mL 3–40 53.2 [36.8; 86.5] 77.6 [43.4; 175.0] 249.0 [114.5; 428.6] <0.001
Biointact PTH, xUNL <1 1.3 [0.9; 2.2] 1.9 [1.1; 4.4] 6.2 [2.9; 10.7] <0.001
Total AP, U/L 35–130 63.0 [47.2; 86.8] 86.7 [69.0; 109.0] 125.0 [101.0; 182.1] <0.001
BsAP, ug/L 6.1–25.5 15.3 [11.1; 22.1] 24.7 [16.3; 34.2] 47.4 [33.8; 66.8] <0.001
Intact PINP, ng/mL 12.8–82.6 31.5 [23.1; 44.7] 66.1 [39.7; 95.0] 154.7 [119.0; 219.8] <0.001
TRAP5b, U/L 1.1–6.9 2.7 [1.9; 3.4] 4.1 [2.8; 5.8] 6.4 [5.1; 8.5] <0.001
Data are median [IQR] with p values by Kruskal Wallis equality-of-populations rank test
Abbr.: AP=alkaline phosphatase, BsAP=bone-specific alkaline phosphatase, PINP=pro-collagen type I pro-peptide, PTH=parathyroid hormone, TRAP5b=tartrate resistant acid phosphatase type 5b, xUNL=times the upper limit of normal range
Figure 1Distribution of biointact parathyroid hormone (PTH), bone-specific alkaline phosphatase (BsAP), procollagen type I N-terminal propeptide (PINP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) across categories of low, normal, and high bone turnover as evaluated by bone histomorphometry.
Moderate, highly significant correlations were seen between the levels of biochemical markers and dynamic and static parameters of remodeling (Table 3). The bone turnover markers were all significantly correlated to PTH (rho 0.45 – 0.52, p < 0.001), and to each other (rho 0.76 – 0.79, p < 0.001).
Table 3Correlations between biochemical markers of bone turnover and bone histomorphometry
Biointact PTH, ρg/mL
Total AP, U/L
BsAP, μg/L
Intact PINP, ng/mL
TRAP5b, U/L
Bone formation rate/Total tissue area, μm
/mm2/day 0.509*** 0.520*** 0.631*** 0.693*** 0.615***
Osteoblast/Bone perimeter, % 0.505*** 0.262* 0.393*** 0.434*** 0.404***
Eroded/Bone perimeter, % 0.443*** 0.269*** 0.293*** 0.366*** 0.478***
Osteoclast/Bone perimeter, % 0.438*** 0.260** 0.320*** 0.374*** 0.459***
Mineralization lag time, days -0.149 -0.201 -0.211 -0.317*** -0.305***
Osteoid/Bone area, % 0.409*** 0.344*** 0.450*** 0.396*** 0.378***
Osteoid/Bone perimeter, % 0.452*** 0.305** 0.426*** 0.397*** 0.359***
Osteoid width, μm 0.216* 0.318*** 0.342*** 0.332*** 0.274**
Spearman's rho with *p<0.05, **p<0.01, ***p<0.001 after Bonferroni adjustment for multiple comparisons
Abbr.: AP=alkaline phosphatase, BsAP=bone-specific alkaline phosphatase, PINP=procollagen type I N-terminal propeptide, PTH=parathyroid hormone, TRAP5b=tartrate resistant acid phosphatase type 5b
Diagnostic performance of biomarkers
Figure 2 shows areas under the receiver operator characteristics curve (AUCs) for separating high vs non-high, and low vs non-low bone turnover in the overall cohort. Discriminatory ability was consistently very good for both high and low bone turnover with AUCs>0.80 for the bone turnover markers while slightly lower (AUCs>0.75) for biointact PTH and total AP. Compared to biointact PTH, intact PINP was a significantly better predictor of high turnover (AUC 0.88 vs. 0.78, p = 0.006), and TRAP5b was a better predictor for low turnover (AUC 0.82 vs. 0.73, p = 0.04).
Figure 2Areas under the receiver operator characteristics curves for the diagnosis of bone turnover by biochemical markers biointact parathyroid hormone (PTH), total and bone-specific alkaline phosphatase (tAP and BsAP), procollagen type I N-terminal propeptide (PINP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) in the overall cohort (n = 199); * marks p < 0.05 compared to biointact PTH
To evaluate diagnostic performance, we randomly split the cohort into separate exploration (n = 100) and validation (n = 99) subsets. The distribution of bone turnover categories, demographic characteristics, and levels of biochemical markers were balanced between the exploration and validation cohorts (Table S1).
Optimal diagnostic cutoffs for high vs non-high and low vs non-low bone turnover were determined based on ROC curves in the exploration cohort, and then applied to the validation cohort to evaluate diagnostic performance. Results are shown in Table 4. Negative predictive values were high, indicating the ability to rule out both high and low bone turnover by using the suggested cutoffs. Combinations of bone turnover markers resulted in slightly higher diagnostic performance, with overall accuracies of 90% for high turnover, using the combination of Intact PINP and TRAP5b, and 78% for low turnover with the combination of BsAP and TRAP5b. Combinations of markers also resulted in high positive predictive values for a diagnosis of high turnover, indicating greater surety of the diagnosis with two biomarkers above the cutoffs.
Table 4Diagnostic performance of biochemical markers for a diagnosis of high or low bone turnover
Exploration cohort (n = 100)
Validation cohort (n = 99)
High turnover AUC Cutoff Sensitivity Specificity PPV NPV Accuracy
Biointact PTH, ρg/mL 0.78 (0.67, 0.86) >143.5 70% 74% 57% 84% 73%
Total AP, U/L 0.77 (0.65, 0.86) >97 76% 77% 61% 87% 77%
BsAP, ug/L 0.83 (0.73, 0.91) >33.7 73% 86% 71% 88% 82%
Intact PINP, ng/mL 0.85 (0.74, 0.93) >120.7 73% 94% 85% 89% 88%
TRAP5b, U/L 0.78 (0.66, 0.86) >5.05 77% 76% 59% 88% 76%
BsAP + Intact PINP 0.84 (0.74. 0.94) As above 63% 97% 90% 85% 86%
BsAP + TRAP5b 0.79 (0.70, 0.88) As above 63% 91% 76% 85% 82%
PINP + TRAP5b 0.84 (0.74. 0.94) As above 82% 94% 88% 91% 90%
Low turnover
Biointact PTH, ρg/mL 0.77 (0.65, 0.86) <90.5 69% 52% 19% 91% 54%
Total AP, U/L 0.76 (0.63, 0.85) <87 64% 57% 21% 90% 58%
BsAP, ug/L 0.82 (0.72, 0.90) <24.2 87% 58% 28% 96% 63%
Intact PINP, ng/mL 0.83 (0.72, 0.91) <49.8 80% 70% 33% 95% 72%
TRAP5b, U/L 0.84 (0.74, 0.91) <3.44 73% 74% 34% 94% 74%
BsAP + Intact PINP 0.84 (0.75, 0.93) As above 73% 74% 34% 94% 74%
Area under the receiver operator characteristics curve (AUC) and cutoffs as determined by Liu's method were -calculated using the exploration cohort only. Sensitivity, specificity, negative and positive predictive values (NPV, PPV) were calculated for the validation cohort only, using the specified cutoffs. For combined biochemical markers, both markers were above/below the cutoff for a positive test result, while either above/below were counted as a negative test result
Abbr.: AP=alkaline phosphatase, BsAP=bone-specific alkaline phosphatase, PINP=pro-collagen type I pro-peptide, PTH=parathyroid hormone, TRAP5b=tartrate resistant acid phosphatase type 5b
As a sensitivity analysis, we repeated the AUC analysis separating kidney transplant candidates and recipients. Results are shown in Table 5. The discrimination of high bone turnover was similar comparing patients with CKD stage G4-G5D and kidney transplant recipients, while for low bone turnover, AUC values were numerically lower in patients biopsied after kidney transplantation, particularly for biointact PTH.
Table 5Discriminatory ability of biochemical markers for high and low bone turnover stratified by kidney transplantation status
High turnover
CKD stage G4-G5D (36 vs 44)
Kidney transplant recipients (21 vs 98)
CKD stage G4-G5D (6 vs 74)
Biointact PTH, ρg/mL 0.66 (0.54, 0.79) 0.76 (0.63, 0.89) 0.82 (0.64, 0.99) 0.61 (0.49, 0.74)
Total AP, U/L 0.69 (0.57, 0.81) 0.74 (0.60, 0.89) 0.85 (0.73, 0.97) 0.69 (0.56, 0.81)
BsAP, ug/L 0.78 (0.67, 0.89) 0.80 (0.68, 0.92) 0.94 (0.86, 1.00) 0.74 (0.64, 0.84)
Intact PINP, ng/mL 0.84 (0.75, 0.93) 0.87 (0.77, 0.97) 0.89 (0.77, 1.00) 0.77 (0.67, 0.87)
TRAP5b, U/L 0.75 (0.64, 0.86) 0.78 (0.65, 0.91) 0.93 (0.87, 1.00) 0.74 (0.65, 0.84)
Data are area under the receiver operator characteristics curve for high vs non-high, and low vs non-low bone turnover
Finally, to account for the effect of disease prevalence on diagnostic test interpretation, we calculated negative and positive predictive values for any possible prevalence of high and low bone turnover, i.e. from 0 to 100%. Results are shown in Figure S2. The ability to rule out high and low bone turnover using biomarker cutoffs was found to be acceptable (>90%) with prevalence of either condition below 30%.
The key finding of this study is, that biochemical markers of skeletal remodeling show acceptable diagnostic accuracy for bone turnover, both in patients with CKD stages G4-G5D and in kidney transplant recipients. High negative predictive values suggest that measurement of biochemical markers of skeletal remodeling might rule out the presence of high and low bone turnover, which could potentially decrease the need for an invasive bone biopsy.
The discriminatory abilities of all biochemical markers were good, with AUC values >0.80 for both high and low bone turnover using the bone turnover markers, and slightly lower values for biointact PTH and total AP. The calculated cutoffs in the exploration cohort resulted in sensitivities and specificities in the range of 70 – 95% for high turnover disease, and 60 – 85% for low turnover disease, with the highest numerical values for BsAP, Intact PINP, and TRAP5b. These results are largely in accordance with what have been published previously.
Salam S.
Gallagher O.
Gossiel F.
Paggiosi M.
Khwaja A.
Eastell R.
Diagnostic accuracy of biomarkers and imaging for bone turnover in renal osteodystrophy.
J Am Soc Nephrol. 2018; 29: 1557-1565https://doi.org/10.1681/ASN.2017050584
Lima F.
El-Husseini A.A.
Davenport D.L.
Serum bone markers in ROD patients across the spectrum of decreases in GFR: Activin A increases before all other markers.
Clin Nephrol. 2019; 91: 222-230https://doi.org/10.5414/CN109650
Predictive values of negative and positive test-results are often given to illustrate clinical usefulness. High negative predictive values were seen for both high and low bone turnover, suggesting that either condition might be ruled out using the suggested cutoffs. Further, with two markers above the cutoffs, positive predictive values up towards 90% were seen for high bone turnover. This could find clinical utility as an aid to treatment-decisions, for example by ruling out the presence of low turnover disease when considering initiation of anti-resorptive treatment, or estimating the likelihood of high bone turnover when considering whether to intensify treatment for secondary hyperparathyroidism. Positive predictive values for low turnover, however, were consistently very poor and did not improve by combining markers.
While BsAP has been extensively investigated,
Ureña P.
Hruby M.
Ferreira A.
Ang K.S.
Plasma total versus bone alkaline phosphatase as markers of bone turnover in hemodialysis patients.
J Am Soc Nephrol. 1996; 7: 506-512https://doi.org/10.1681/ASN.V73506
Fletcher S.
Jones R.G.
Rayner H.C.
Assessment of renal osteodystrophy in dialysis patients: use of bone alkaline phosphatase, bone mineral density and parathyroid ultrasound in comparison with bone histology.
Nephron. 1997; 75: 412-419https://doi.org/10.1159/000189578
Bervoets A.R.J.
Spasovski G.B.
Useful biochemical markers for diagnosing renal osteodystrophy in predialysis end-stage renal failure patients.
Am J Kidney Dis. 2003; 41: 997-1007https://doi.org/10.1016/S0272-6386(03)00197-5
Lehmann G.
Ott U.
Kaemmerer D.
Schuetze J.
Wolf G.
Bone histomorphometry and biochemical markers of bone turnover in patients with chronic kidney disease Stages 3 - 5.
Clin Nephrol. 2008; 70: 296-305
only a few studies previously examined the diagnostic value of the more novel markers Intact PINP and TRAP5b.
Sprague et al
included PINP in their multicenter study of diagnostic accuracy of biomarkers in patients with kidney failure, but did not measure the intact, trimeric form. As monomers of PINP accumulate in CKD, the total PINP analysis is affected by kidney function;
Lukas P.
Carlisi A.
Gadisseur R.
Aminoterminal propeptide of type I procollagen (PINP) in chronic kidney disease patients: the assay matters.
in the study by Sprague et al, any residual kidney function in the participating dialysis patients could have affected the results. Salam et al
reported the diagnostic performance of a panel of bone turnover markers in patients with CKD stages G4-G5D. Discrimination of low turnover was found to be good, particularly for BsAP, Intact PINP, and TRAP5b (AUCs 0.79 – 0.80) while significantly less so for intact PTH (AUC 0.56). We note that the calculated cutoffs for high and low turnover reported by Salam et al.
were very similar to what we demonstrate in the present study, which shows consistency across different study populations.
We hypothesized that the bone turnover markers would provide a better diagnostic performance when compared to PTH. As BsAP, PINP and TRAP5b are released from the bone tissue during the skeletal remodeling process, they have the potential to deliver highly specific information on whole-skeletal bone turnover. In contrast, PTH is a main regulator of skeletal remodeling, and may be competing with other effectors on the bone, such as hypogonadism, steroid exposure, inflammation, and uremic toxins,
Jørgensen H.S.
David K.
Traditional and Non-traditional Risk Factors for Osteoporosis in CKD.
Calcif Tissue Int. 2021; 108: 496-511https://doi.org/10.1007/s00223-020-00786-0
leading to a poorer prediction of the current skeletal remodeling rate. However, while there were indications of better diagnostic accuracy for the bone turnover markers, with higher AUC values, the differences in diagnostic performance as judged by the values of negative and positive test results, were negligible. Similarly, Salam et al.
found significantly better prediction of low bone turnover by bone turnover markers as compared to intact PTH in patients with CKD stage G4-G5D, but again, the effect on test performance was small. The intact PTH assay captures not only the full-length 1-84 PTH, but also various PTH fragments, and as these are retained in CKD,
Brossard J.H.
Cloutier M.
Roy L.
Lepage R.
Gascon-Barré M.
D'Amour P.
Accumulation of a non-(1-84) molecular form of parathyroid hormone (PTH) detected by intact PTH assay in renal failure: importance in the interpretation of PTH values.
J Clin Endocrinol Metab. 1996; 81: 3923-3929https://doi.org/10.1210/jcem.81.11.8923839
Einbinder Y.
Benchetrit S.
Golan E.
Zitman-Gal T.
Comparison of Intact PTH and Bio-Intact PTH Assays Among Non-Dialysis Dependent Chronic Kidney Disease Patients.
Ann Lab Med. 2017; 37: 381-387https://doi.org/10.3343/alm.2017.37.5.381
PTH measured by the intact assay could be expected to perform less well, particularly in cohorts spanning different CKD stages. As we measured biointact 1-84 PTH in this study, any accumulation of fragments should not affect our results. It remains uncertain whether there is a benefit of measuring the complete hormone; in the before-mentioned study by Sprague et al.
, no difference in diagnostic accuracy for bone turnover was found for biointact vs. intact PTH.
Diagnostic performance of biomarkers for high bone turnover was comparable for patients in CKD stage G4 to G5D and kidney transplant recipients – but with numerically lower AUCs for low bone turnover in post-transplant patients. The post-transplant bone phenotype is a composite of renal osteodystrophy pre-transplant, resolving or ongoing disturbances of mineral metabolism, and effects of immunosuppressants on bone. Profound alterations in mineral metabolism occur after kidney transplantation, and although kidney function and biochemical parameters generally stabilize by 3 months,
Meijers B.K.I.
de Jong H.
Recovery of hyperphosphatoninism and renal phosphorus wasting one year after successful renal transplantation.
Clin J Am Soc Nephrol. 2008; 3: 1829-1836https://doi.org/10.2215/CJN.01310308
Wolf M.
Weir M.R.
Kopyt N.
A Prospective Cohort Study of Mineral Metabolism After Kidney Transplantation.
Transplantation. 2016; 100: 184-193https://doi.org/10.1097/TP.0000000000000823
persistent disturbances are seen in subsets of patients throughout the first post-transplant year.
Claes K.
Kuypers D.
Maes B.
Bammens B.
Vanrenterghem Y.
Natural history of parathyroid function and calcium metabolism after kidney transplantation: A single-centre study.
Nephrol Dial Transplant. 2004; 19: 1281-1287https://doi.org/10.1093/ndt/gfh128
Meijers B.
Natural history of mineral metabolism, bone turnover and bone mineral density in de novo renal transplant recipients treated with a steroid minimization immunosuppressive protocol.
Nephrol Dial Transplant. 2020; 35: 697-705https://doi.org/10.1093/ndt/gfy306
Marked variability in the histomorphometric pattern, even within the same bone sample, has been demonstrated in kidney transplant recipients,
Neves C.L.
Dos Reis L.M.
Batista D.G.
Persistence of bone and mineral disorders 2 years after successful kidney transplantation.
Transplantation. 2013; 96: 290-296https://doi.org/10.1097/TP.0b013e3182985468
and may reflect a slow transition to a new skeletal steady state. In contrast, biochemical markers of bone turnover are highly dynamic, as seen by the rapid changes in circulating levels in response to fracture
Højsager F.D.
Rand M.S.
Pedersen S.B.
Nissen N.
Jørgensen N.R.
Fracture-induced changes in biomarkers CTX, PINP, OC, and BAP—a systematic review.
Osteoporos Int. 2019; 30: 2381-2389https://doi.org/10.1007/s00198-019-05132-1
and anti-osteoporotic treatment
Szulc P.
The role of bone turnover markers in monitoring treatment in postmenopausal osteoporosis.
. This time lag between bone turnover as evaluated by histomorphometry vs biochemistry may contribute to a lower diagnostic accuracy of biomarkers in the post-transplant setting. A steroid-minimization protocol was utilized in the study period. Still, 74% of patients received oral prednisolone at the time of the bone biopsy. Glucocorticoids result in a sustained depression of osteoblast function, with more transient increase in osteoclast activity.
Buckley L.
Humphrey M.B.
Glucocorticoid-Induced Osteoporosis.
N Engl J Med. 2018; 379: 2547-2556https://doi.org/10.1056/NEJMcp1800214
Thus, the effect of glucocorticoids may contribute to a more severe phenotype of low bone turnover post-transplant.
The main strength of this study is the considerable number of bone biopsies available for evaluation. Further, we limited our analyses to high quality, successfully labelled bone biopsies, and all histomorphometric analyses were performed at the same laboratory, avoiding variability in sample processing, reference cutoffs, and diagnostic practice. To reduce optimism bias when evaluating diagnostic performance, we used an explorative subset of patients for estimating the diagnostic cutoffs, which were then validated in a separate subset. However, no external validation was performed which, together with the single-center approach, and ethnically homogenous cohort, may reduce the reproducibility of our findings. The heterogeneity in our cohort may be considered a limitation, as we included patients in CKD stage G4-G5, patients receiving dialysis therapy, as well as kidney transplant recipients. However, we are not aware that the stage of CKD should affect the relationship between skeletal remodeling and release of biomarkers from the bone tissue, and as already detailed, the biomarkers included in this study do not accumulate with decreasing kidney function.
Blood sampling in patients with CKD stage G5D was random with regards to the last dialysis session, but the effect of hemodialysis therapy on circulating levels of bone turnover markers has previously been shown to be limited.
Ueda M.
Inaba M.
Okuno S.
Clinical usefulness of the serum N-terminal propeptide of type I collagen as a marker of bone formation in hemodialysis patients.
Am J Kidney Dis. 2002; 40 ([doi]): 802-809https://doi.org/10.1053/ajkd.2002.35692
Shidara K.
Serum levels of TRAP5b, a new bone resorption marker unaffected by renal dysfunction, as a useful marker of cortical bone loss in hemodialysis patients.
Calcif Tissue Int. 2008; 82: 278-287https://doi.org/10.1007/s00223-008-9127-4
Any effect of peritoneal dialysis treatment on circulating biomarker levels has, to our knowledge, not yet been investigated; but considering the continuous nature of this treatment, it should likewise be minimal.
An inherent limitation to these analyses is the consideration that the circulating bone turnover markers must represent whole skeletal metabolism, including both the central and distal skeleton and cortical and trabecular bone compartments. In contrast, the bone biopsy is representative of a single skeletal site only and the trabecular bone compartment specifically. In accordance, rather weak correlations were found between bone biomarkers and histomorphometric parameters in post-menopausal women.
Chavassieux P.
Portero-Muzy N.
Roux J.P.
Garnero P.
Chapurlat R.
Are biochemical markers of bone turnover representative of bone histomorphometry in 370 postmenopausal women?.
J Clin Endocrinol Metab. 2015; 100: 4662-4668https://doi.org/10.1210/jc.2015-2957
Recent pilot trials highlight the potential of bone turnover markers to deliver dynamic information, with changes in circulating levels reflecting the treatment effects on skeletal remodeling
Marques I.D.B.
Araújo M.J.C.L.N.
Graciolli F.G.
A randomized trial of zoledronic acid to prevent bone loss in the first year after kidney transplantation.
J Am Soc Nephrol. 2019; 30: 355-365https://doi.org/10.1681/ASN.2018060656
Hiramatsu R.
Ubara Y.
Sawa N.
Sakai A.
Hypocalcemia and bone mineral changes in hemodialysis patients with low bone mass treated with denosumab: a 2-year observational study.
Nephrol Dial Transplant. 2021; : 1-8https://doi.org/10.1093/ndt/gfaa359
; a clear advantage as opposed to the bone biopsy, which cannot easily be repeated. Lastly, the predictive ability of these markers on relevant clinical outcomes is yet to be established and will likely require the collaborative effort of multiple centers with expertize within this field.
D'Haese P.
Bacchetta J.
Bone biopsy practice patterns across Europe: the European renal osteodystrophy initiative-a position paper.
Nephrol Dial Transplant. 2017; 32: 1608-1613https://doi.org/10.1093/ndt/gfw468
Authors' Contributions: Research idea and study design: PE, EC, PD'H; data acquisition: LV, BB, KC, BM, MN, BS, DK; data analysis/interpretation: HSJ, PD'H, EC, PE; statistical analysis: HSJ; supervision or mentorship: PE. GB was not available to confirm coauthorship; PD'H affirms that he contributed to data acquisition and data analysis/interpretation and vouches for his coauthorship status; all other authors approved the final author list. Except as noted, each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate.
Support: HSJ is supported by an ERA-EDTA long-term fellowship, and received financial support from the Augustinus Foundation and Kornings Fund. LV is supported by a grant from FWO Onderzoeksproject. BS and MN are senior clinical investigators of The Research Foundation Flanders (1842919N and 1844019N, respectively). HSJ is supported by an ERA-EDTA long-term fellowship in the CKD-MBD working group. No funders had any role in study design, data collection, data analysis, draft preparation, or the decision to submit this paper for publication.
Financial Disclosure: HSJ reports grant from ERA-EDTA during the conduct of this study. LV reports grants from FWO Onderzoeksproject, during the conduct of the study, and personal fees from Amgen, outside the submitted work. BB reports grants and other support from Otsuka Pharmaceutical, and other support from Baxter, outside the submitted work. KC reports other support from Astellas, Astra Zeneca, and Alexion, outside the submitted work. BM reports grants and personal fees from Nipro and personal fees from Astra Zeneca, Baxter, and Bayer, outside the submitted work. EC reports other support from IDS, DiaSorin, Fujirebio, Menarini, and bioMérieux, outside the submitted work. PE reports personal and other fees from Amgen, outside the submitted work. BS and MN are senior clinical investigators of The Research Foundation Flanders (1842919N and 1844019N, respectively). The remaining authors (GB, PDH, DK) declare that they have no relevant financial interests.
Acknowledgments: The authors would like to acknowledge the excellent technical support of Marc Dekens and Henriette de Loor, and also thank the centers of the Leuven Collaborative Group for Renal Transplantation, the clinicians and surgeons, nursing staff, and the patients.
Peer Review: Received February 18, 2021. Evaluated by 3 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form July 23, 2021.
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Plain-Language Summary
Skeletal remodeling is disturbed in chronic kidney disease, and knowledge of the bone turnover status may help guide treatment decisions. Currently, a bone biopsy is the diagnostic standard to evaluate bone turnover, but this invasive procedure is not well suited for everyday clinical practice. This study investigates the diagnostic potential of non-invasive, biochemical bone turnover markers for a diagnosis of high or low bone turnover in patients with chronic kidney disease. Our results suggest that biomarkers may be used to rule out the presence of both high and low bone turnover with a high degree of certainty. The clinical implications of these findings are that biochemical bone turnover markers may aid treatment decisions and potentially decrease the need for invasive bone biopsies in patients with chronic kidney disease.
© 2021 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.
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Malignant Neoplasm of the Ovary
Ovarian cancer (OC) may correspond to distinct types of malignant ovarian neoplasms. The most common type of OC is epithelial ovarian cancer, which accounts for about 90% of all cases. The course of the disease is characterized by a prolonged period of non-specific, mild to moderate gastrointestinal and genitourinary symptoms, which are often ignored the affected women and their physicians. Accordingly, the majority of patients is diagnosed with advanced-stage OC, when distant metastases have formed. Metastatic OC is associated with a poor prognosis, and every possible effort should be made to facilitate the early detection of ovarian malignancies.
The clinical presentation does neither allow for the diagnosis of OC, nor the identification of the specific type of neoplasm. What's more, women may be diagnosed incidentally when suspicious findings are noted on preventive examination or imaging. This is due to most patients being free of symptoms for prolonged periods of time.
Symptomatic patients present with non-specific complaints, which are mostly of insidious onset. Women may claim pain in the lower abdomen or pelvic region, and constitutional symptoms such as fever, night sweats, chills, loss of appetite and weight may be reported. Functional OC may induce distinct symptoms, depending on its endocrine profile, the patient's age and reproductive status. Menstrual disorders and irregular uterine bleeding are the most common [1].
Furthermore, ovarian neoplasms may displace or exert pressure on adjacent structures, thereby provoking digestive disorders and changes in the urinary frequency. Gastrointestinal, genitourinary, and gynecological symptoms may also be produced by metastatic OC. Tumor cells shed from the ovarian surface tend to implant on the serous membranes lining the peritoneal cavity, and additional mass lesions may become palpable. Ascites may occur with metastatic OC or may be present earlier [1].
About 70% of OC patients are only diagnosed when metastases have formed in the upper abdomen or beyond the abdominal cavity. Yet, retrospective studies have shown that most women do present symptoms long before reaching this stage of the disease [2]. It is thus of utmost importance to determine the cause of persistent abdominal or pelvic pain, nausea, early satiety, bloating, urinary urgency, and pollakisuria [3].
[…] increased abdominal size/persistent bloating Eating - difficulty eating or feeling full quickly Pain - in pelvic or abdominal areas Urinary symptoms - urgency or frequency Occasionally there can be other symptoms such as changes in bowel habits, extreme fatigue [ovariancanada.org]
[…] following are often identified by women as some of the signs and symptoms of ovarian cancer: Bloating Pelvic or abdominal pain Trouble eating or feeling full quickly Feeling the need to urinate urgently or often Other symptoms of ovarian cancer can include: Fatigue [ovarian.org]
Symptoms include abdominal or pelvic pressure or pain, swelling or bloating, nausea, persistent fatigue, urinary urgency or frequency, and abnormal vaginal bleeding. [radiologyinfo.org]
Side effects of pelvic radiation therapy may include diarrhea, fatigue, skin irritation, premature menopause, bladder irritation, or a narrowing of the vagina due to the buildup of scar tissue. [britannica.com]
[…] loss of appetite Pelvic or abdominal pain (that's your tummy and below) Urinary symptoms (needing to wee more urgently or more often than usual) Occasionally there can be other symptoms: Changes in bowel habit (eg diarrhoea or constipation) Extreme fatigue [targetovariancancer.org.uk]
Symptoms may include A heavy feeling in the pelvis Pain in the lower abdomen Bleeding from the vagina Weight gain or loss Abnormal periods Unexplained back pain that gets worse Gas, nausea, vomiting, or loss of appetite To diagnose ovarian cancer, doctors [medlineplus.gov]
gain These symptoms can be caused by other conditions but if you are experiencing any of these symptoms, contact your local doctor. [cancer.org.au]
Symptoms of ovarian cancer may include bloating and weight gain, pain during intercourse, or a change in bowel habits. [verywellhealth.com]
gain or loss pain during intercourse vaginal bleeding in post-menopausal women Diagnosis In the best-case scenario a woman is diagnosed with ovarian cancer while it is still contained in just one ovary. [medical-dictionary.thefreedictionary.com]
Lifestyles Physical Activity Nutrition and Weight Management Supplement Use Immunizations and Infections Late Effects/Long-Term Psychosocial and Physical Problems Anthracycline-Induced Cardiac Toxicity Anxiety and Depression Cognitive Function Fatigue Lymphedema [nccn.org]
[…] addition, exercise will instill you with the motivation and the drive for optimal wellness. [14] Physical therapy also provides: Massage Therapy, which recent studies show can decrease stress, anxiety, depression, and pain, and increase alertness [15] Lymphedema [physio-pedia.com]
Respiratoric
Staging investigations for patients with a high RMI score include: blood tests – FBC (for anaemia), U E (for renal function), LFTs (for metastases) imaging – CXR to check for pleural effusion or lung metastases, CT /- MRI abdomen and pelvis to assess [geekymedics.com]
One third of patients with ascites also have a pleural effusion. Ovarian cancers metastasise to pelvic and peri-aortic lymph nodes, as well as over the pelvic and abdominal peritoneum. [patient.info]
In the case of fibromas, these solid tumors have normal hormonal tumor markers but may present with ascites and pleural effusions as part of Meigs syndrome, which can confuse the clinician who may suspect advanced-stage epithelial cancer especially as [mdedge.com]
Stage 4: Distant metastases other than peritoneal metastases are detected, or the patient is found to suffer from malignant pleural effusion. [symptoma.com]
Common symptoms may include: Abdominal bloating, indigestion or nausea Changes in appetite, such as a loss of appetite or feeling full sooner Pressure in the pelvis or lower back A more frequent or urgent need to urinate and/or constipation Changes in [cancercenter.com]
Ovarian Cancer Overview Ovarian cancer warning signs include ongoing pain or cramps in the belly or back, abnormal vaginal bleeding, nausea, and bloating. Depending on the cancer stage, ovarian cancer treatment includes surgery and chemotherapy. [webmd.com]
[…] swollen tummy discomfort in your tummy or pelvic area feeling full quickly when eating, or loss of appetite needing to pee more often or more urgently than normal Other symptoms Other symptoms of ovarian cancer can include: persistent indigestion or nausea [nhs.uk]
The following are often identified by women as some of the signs and symptoms of ovarian cancer: Bloating Pelvic or abdominal pain Trouble eating or feeling full quickly Feeling the need to urinate urgently or often Other symptoms of ovarian cancer can [ovarian.org]
Persistent bloating - not bloating that comes and goes Feeling full quickly and/or loss of appetite Pelvic or abdominal pain (that's your tummy and below) Urinary symptoms (needing to wee more urgently or more often than usual) Occasionally there can [targetovariancancer.org.uk]
In these cases symptoms may include: Abdominal pain Trouble urinating or frequent urination Low back pain Pain with sexual intercourse Bad cramps with a woman's periods Feeling full quickly after eating, or no appetite Nausea or vomiting. [cancer.coloradowomenshealth.com]
If the stromal tumor starts to bleed, it can cause sudden, severe abdominal pain. [cancer.org]
Early symptoms are often vague, such as abdominal discomfort, abdominal distension or bloating, urinary frequency or dyspepsia. Constitutional symptoms include fatigue, weight loss, anorexia and depression. [patient.info]
distension (often misdiagnosed as "middle-aged spread") increasing tumour size results in pressure effects causing chronic abdominal, pelvic or back pain, urinary frequency/urgency (pressure on bladder), constipation/altered bowel habit/bowel obstruction [geekymedics.com]
Most cases are diagnosed late when the symptoms such as abdominal distension become apparent. [mjdrdypu.org]
Symptoms that come later include the following: Pelvic pain or pressure Pain with intercourse Abdominal swelling and bloating Urinary frequency Constipation Ascites : Collection of fluid in the abdomen, contributing to abdominal distension and shortness [emedicinehealth.com]
Often these masses are large enough to cause bloating, abdominal distension, constipation, and changes in bladder habits. In the more uncommon ovarian types (stromal and germ cell tumors), symptoms are similar. [medicinenet.com]
Early symptoms (eg, dyspepsia, bloating, early satiety, gas pains, backache) are nonspecific. If cancer is being considered, do CT, measure tumor markers (eg, CA 125), and surgically stage tumors. [merckmanuals.com]
A history of nonspecific gastrointestinal complaints, including : nausea, dyspepsia, and altered bowel habits, is particularly common abdominal distention as a result of ascites are generally signs of advanced disease. A change in bowel habits [slideshare.net]
[…] cell carcinoma Clinical features from OMIM: 133239 UMLS symptoms related to Esophageal Cancer: nausea and vomiting, constipation, abdominal pain, diarrhea, tinnitus, snoring, sore throat, icterus, coughing, vertigo/dizziness, equilibration disorder, dyspepsia [malacards.org]
Patients with advanced carcinomas usually present with vague abdominal swelling or discomfort, abdominal bloating, dyspepsia and early satiety, lack of appetite, malaise, urinary frequency and weight change (either gain or loss). [atlasgeneticsoncology.org]
It's also appropriate to code any functional activity, such as one of the following: • other ovarian dysfunction (256.8); • hirsutism (704.1); • hyperestrogenism (256.0); • other ovarian hyperfunction (256.1); • precocious sexual development and puberty [fortherecordmag.com]
A case of hirsutism due to bilateral diffuse ovarian Leydig cell hyperplasia in a post-menopausal woman. Eur J Intern Med. 2003;14(7):432-3. Serov SF, Scully RE, Sobin LH. Histological typing of ovarian tumours. Geneva: WHO; 1973. [revistas.pucsp.br]
These patients usually have menstrual cycle irregularities and either typical clinical signs of hirsutism, obesity, infertility, acne, male balding pattern or biochemically show increased androgen levels. [radiologyassistant.nl]
The most common presenting symptom in children and adolescents is abdominal pain, although precocious puberty, irregular menses, or hirsutism may also be present. 18 Patients with ovarian cancer may have abdominal pain, swelling, or nonspecific gastrointestinal [aafp.org]
The patient's medical and family history provide the backbone of OC diagnosis. When obtaining information regarding the occurrence of cancer in family members, it should be kept in mind that those mutations associated with hereditary OC may also predispose to breast cancer, prostate cancer, pancreatic cancer, and melanoma [4]. Notwithstanding, the international standard of care is to offer genetic testing to all women in whom OC is diagnosed, regardless of age, medical and family history [5].
Sonography is the methods of choice to assess ovarian lesions, and it may be complemented by more sophisticated imaging techniques such as computed tomography and magnetic resonance imaging. Diagnostic imaging not only allows for the evaluation of the ovaries but also the fallopian tubes, uterus, adjacent tissues, lymph nodes, and distant organs. It should be kept in mind that the sensitivity of imaging techniques may be insufficient for the detection of early-stage OC. Concurrent measurements of tumor markers may support the tentative diagnosis of OC, with common panels including cancer antigen 125, carcinoembryonic antigen, and carbohydrate antigen 19-9 [3].
Finally, tissue samples have to be obtained to confirm the diagnosis, to determine the tumor's cellular origin, grade, and histotype. Core biopsy specimens are preferred to this end, but fine-needle aspiration samples from mass lesions or ascitic fluid may be used if the former are not feasible [3].
The FIGO staging system is applied to determine the patient's prognosis and to allow for a well-founded decision regarding treatment strategies [1]:
Stage 0: Tumor in situ
Stage 1: OC involves one (1A) or both (1B) ovaries, whose capsule remains intact. There are no tumor cells on the ovarian surface, and peritoneal washings yield negative results. If the capsule is raptured or tumor cells are detected on the ovarian surface or washings are positive, stage 1C has been reached.
Stage 2: Pelvic extension can be confirmed. Metastases have formed in the uterus or fallopian tubes (2A) or other pelvic structures (2B). Positive peritoneal washings warrant the diagnosis of OC stage 2C.
Stage 3: Peritoneal implants are detected outside the pelvis and/or regional lymph nodes are involved. Stages 3A, 3B, and 3C are assigned according to the size of peritoneal metastases.
Stage 4: Distant metastases other than peritoneal metastases are detected, or the patient is found to suffer from malignant pleural effusion.
Laparoscopic assessment may be necessary to define the stage of OC and to determine whether primary resection is feasible.
Debulking surgery, performed as bilateral salpingo-oophorectomy or total hysterectomy, has long since been the foundation of OC management. Unilateral salpingo-oophorectomy may be considered in women who wish to preserve fertility but should be carefully weighed against the risks of recurrence. In any case, surgery aims at the complete resection of degenerated tissues, which is associated with the best outcomes. Subsequently, patients are referred for chemotherapy with carboplatin and paclitaxel. These drugs are administered intravenously every 3 weeks. Paclitaxel may be replaced by pegylated liposomal doxorubicin if taxane-free regimens are required. By derogation to the aforedescribed standard procedure of surgery plus adjuvant chemotherapy, patients may benefit from neoadjuvant chemotherapy if the complete resection of neoplasms cannot be achieved by up-front surgery [5].
In recent years, biological agents have increasingly been used to complement the therapy of OC:
Bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor A, is a potent inhibitor of angiogenesis and has been approved for the treatment of advanced OC [6].
Similarly, PARP inhibitors olaparib and rucaparib may be used to treat advanced-stage and recurrent OC [7].
Other compounds are currently tested regarding their safety and efficacy in OC therapy. Research currently focuses on combination approaches, antibody-drug conjugates, and immunotherapy [5].
Most patients will achieve remission, but many will eventually experience a recurrence of OC. In order to reduce the risk of relapses, maintenance therapies are often incorporated into the therapeutic paradigm. Maintenance strategies comprise the single use of bevacizumab or PARP inhibitors, although no guidelines have yet been established to this end. As a general rule, patients with poor prognostic factors are most likely to benefit from maintenance [3].
The lack of a premalignant phase and effective strategies for early detection combined with the non-specific presentation of the disease result in detrimental diagnostic delays. Most patients are diagnosed with advanced-stage OC, which is associated with a poor prognosis. The overall five-year survival rate has been estimated at 44% for all stages - the worst prognosis among all types of gynecological malignancies [8]. Favorable outcomes are mainly observed when the tumor is detected during early stages of the disease.
The precise causes of OC remain largely unknown and most likely comprise a series of environmental and genetic factors. Concerning the former, estrogen replacement therapy has repeatedly been shown to augment the risk of OC in postmenopausal women, while the prolonged reduction of estrogen levels, namely during pregnancy or under oral contraceptives, is ascribed a protective role in OC. These facts argue in favor of a role of ovulation in the etiology of ovarian malignancies, and it has been hypothesized that repeated damage and trauma to the ovarian epithelium during ovulatory cycles may increase the likelihood of mutations and malignant degeneration [9]. Beyond that, obesity, smoking, and the genital use of talcum powder may predispose to OC [10].
Strong genetic influences are most easily recognized in patients suffering from family cancer syndromes such as BRCA-associated hereditary breast and ovarian cancer syndrome, whose lifetime risk of developing malignancies of the ovaries may be as high as 63% [4]. Other hereditary conditions predisposing to OC include Lynch syndrome, Li-Fraumeni syndrome, and mutations in genes like CHEK2, RAD51C, RAD51D, BRIP1, BARD1, PALB2, MRE11, MLH1, PMS2, MSH2, MSH6, and NBN [5] [11]. In sum, about 20% of OC cases can be related to genetic factors, and three-quarters of these patients carry mutations in the BRCA1 or BRCA2 genes [8].
OC accounts for about 30% of all malignancies of the female genital system and is the leading cause of death from gynecological cancers. In Western Europe and North America, where age-adjusted incidence rates are highest, 90% of affected women are diagnosed with epithelial OC. Higher shares of germ cell tumors are reported in some Asian countries [1].
In general, the individual risk of developing OC increases with age, and the mean age at the time of diagnosis is 62 years [3]. Notwithstanding, some types of OC preferentially affect younger patients: Germ cell OC tends to occur in teenage girls and young women, and patients developing OC due to hereditary conditions are typically diagnosed in their fourth or fifth decade of life [4].
The pathogenesis of OC is a complex process that has yet to be fully explored. It certainly involves host genetic factors, which serve as a basis for the interplay of hormones, inflammatory mediators, and environmental influences [9]. According to the hypothesis of incessant ovulation, as mentioned above, repetitive injury to the ovarian surface epithelium may predispose to inflammation and is associated with changes in hormone levels, thereby leading to oxidative stress and DNA damage. Then again, epithelium harboring unresolved DNA damage would represent a prime target for neoplastic transformation. This hypothesis has not been unchallenged, though: High-grade serous ovarian carcinoma, the most common type of OC, may not even arise from the ovarian surface epithelium. Fallopian tube secretory cells have been identified as their cells of origin, and they are not subjected to the repetitive trauma associated with ovulation [12].
These observations allow for the following conclusions:
Further research is required to shed more light on the pathogenesis of OC, as our understanding of this process is still very limited.
OC may develop under different circumstances, may originate from distinct cell types. There is no one pathogenesis of OC.
High parity and the prolonged use of oral contraceptives are generally associated with reduced risks of developing epithelial OC [13]. The use of genital talcum powder should be avoided, and medical conditions that may predispose to OC, such as endometriosis and pelvic inflammatory disease, should be treated accordingly [9].
Moreover, the risk of OC can be substantially reduced by bilateral oophorectomy [9]. While this procedure is not routinely carried out, it should seriously be considered in patients known to carry gene defects that are associated with a very high lifetime risk of ovarian malignancies. Alternatively, these women should be included in surveillance programs comprising regular clinical examinations, laboratory analyses for tumor markers, and diagnostic imaging. Such ovarian cancer screenings should be carried out from the age of 35, and all patients should be informed about its limitations: As implied above, the sensitivity of available techniques for detecting early-stage OC may be non-satisfactory [11].
The current classification of the World Health Organization considers a large number of OC types. There are five main groups of ovarian neoplasms, namely surface epithelial-stromal tumors, sex cord-stromal tumors, germ cell tumors, tumors of the rete ovarii, and miscellaneous tumors. Each group comprises multiple subtypes of neoplasias, which differ with regards to their tissue of origin, histological features, and malignant potential. Additionally, lymphoid and hematopoietic tumors may affect the ovaries [1]. It is beyond the scope of this article to provide a detailed description of all types of OC, which is why it will focus on the general aspects of the more common variants of ovarian malignancies.
Malignant ovarian neoplasm refers to any type of ovarian cancer, a rather common disease in industrialized nations. Women suffering from ovarian cancer may be asymptomatic for prolonged periods of time, or they may experience non-specific gastrointestinal and genitourinary complaints. Lower abdominal or pelvic pain, nausea, early satiety, bloating, and changes in the urinary frequency are most common. In case of persistent discomfort, it is paramount to clarify the causes of these symptoms: If patients are during the early stages of the disease, their prognosis is significantly better than that of women with advanced-stage ovarian cancer. Indeed, the outcome of metastatic ovarian cancer is generally poor.
Tavassoli F, Devilee P., eds. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Breast and Female Genital Organs. Lyon, France: IARC Press; 2003.
Bast RC, Jr., Hennessy B, Mills GB. The biology of ovarian cancer: new opportunities for translation. Nat Rev Cancer. 2009; 9(6):415-428.
Orr B, Edwards RP. Diagnosis and Treatment of Ovarian Cancer. Hematol Oncol Clin North Am. 2018; 32(6):943-964.
Petrucelli N, Daly MB, Pal T. BRCA1- and BRCA2-Associated Hereditary Breast and Ovarian Cancer. In: Adam MP, Ardinger HH, Pagon RA, et al., eds. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018.
Matulonis UA. Management of newly diagnosed or recurrent ovarian cancer. Clin Adv Hematol Oncol. 2018; 16(6):426-437.
Musella A, Vertechy L, Romito A, et al. Bevacizumab in Ovarian Cancer: State of the Art and Unanswered Questions. Chemotherapy. 2017; 62(2):111-120.
Sabatucci I, Maltese G, Lepori S, Tripodi E, Bogani G, Lorusso D. Rucaparib: a new treatment option for ovarian cancer. Expert Opin Pharmacother. 2018; 19(7):765-771.
Toss A, Tomasello C, Razzaboni E, et al. Hereditary ovarian cancer: not only BRCA 1 and 2 genes. Biomed Res Int. 2015; 2015:341723.
Sueblinvong T, Carney ME. Current understanding of risk factors for ovarian cancer. Curr Treat Options Oncol. 2009; 10(1-2):67-81.
Olsen CM, Nagle CM, Whiteman DC, et al. Obesity and risk of ovarian cancer subtypes: evidence from the Ovarian Cancer Association Consortium. Endocr Relat Cancer. 2013; 20(2):251-262.
Andrews L, Mutch DG. Hereditary Ovarian Cancer and Risk Reduction. Best Pract Res Clin Obstet Gynaecol. 2017; 41:31-48.
Kroeger PT, Jr., Drapkin R. Pathogenesis and heterogeneity of ovarian cancer. Curr Opin Obstet Gynecol. 2017; 29(1):26-34.
Peres LC, Risch H, Terry KL, et al. Racial/ethnic differences in the epidemiology of ovarian cancer: a pooled analysis of 12 case-control studies. Int J Epidemiol. 2018; 47(2):460-472.
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Perhaps these issues may have a longer range of impact on the human body than just the acute or active stage that a disease may be in. They can disrupt or weaken functioning and one's immune response.
In my experience viruses such as Mononeucleosis and Lyme's disease can have longer term disruptive effects on the body's immune system as well as various body system problems like migraine headaches, chronic aches and pains, fibromyalgia, chronic fatigue, and so on.
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At all of our child care locations, we only charge one low monthly fee. There are no weekly or bi-weekly bills, because you only pay once a month.
We are fully licensed by the Ministry of Education and the CCEYA (2014) As a non-profit organization, we operate under the guidance of a Board of Directors, comprised of parents and citizens concerned with the provision of quality child care.
Paris Child Care, Inc. offers assistance with child care fees through the Corporation of the City of Brantford, Child Care Services.
Please contact Child Care Services at (519) 759-3330.
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Early childhood development sets the foundation for lifelong learning, behaviour and health.
The Continuum of Development identifies root skills that emerge and are practiced in the early years and are important both in their own right and as foundations of later development.
A skill may appear in infant, toddler, preschool and school-age groups, indicating pathways that emerge early and are elaborated over time.
2. Partnerships with families and communities strengthen the ability of early childhood settings to meet the needs of young children.
Using the Continuum of Development, families and early childhood professionals can exchange information about children's early development.
3. Demonstrating respect for diversity, equity and inclusion are prerequisites for optimal development and learning.
At the core of respecting diversity is the flexible creation of curriculum that is responsive to individuals. The Continuum of Development makes it possible for practitioners to observe a child's development and then create curriculum to extend and expand learning.
4. A planned curriculum supports early learning.
Understanding development supports the ongoing observation and documentation of children's learning for the purpose of planning curriculum.
Planning involves the planning of strategies or ways to support skills.
The Continuum of Development includes interactions with examples of strategies that support the practice and extension of the skill.
5. Play is a means to early learning that capitalizes on children's natural curiosity and exuberance.
Understanding child development leads to an appreciation of the role of play.
The Continuum of Development identifies skills that are leaned and practiced in play and gives examples of adult interactions that support early learning in the context of play.
6. Knowledgeable, responsive early childhood professionals are essential.
The Continuum of Development builds on early childhood professionals existing knowledge of children in their programs and the pedagogy of play.
Through ongoing observation and use of the Continuum of Development early childhood professionals extend their knowledge of development and learning.
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Biomarker Research
Targeted proteomics-derived biomarker profile develops a multi-protein classifier in liquid biopsies for early detection of esophageal squamous cell carcinoma from a population-based case-control study
Xiaorong Yang1,2 na1,
Chen Suo3 na1,
Tongchao Zhang4,
Xiaolin Yin4,
Jinyu Man4,
Ziyu Yuan5,
Jingru Yu6,
Li Jin5,7,
Xingdong Chen5,7,
Ming Lu ORCID: orcid.org/0000-0002-8685-63221,2,5 &
Weimin Ye5,6,8
Biomarker Research volume 9, Article number: 12 (2021) Cite this article
Early diagnosis of esophageal squamous cell carcinoma (ESCC) remains a challenge due to the lack of specific blood biomarkers. We aimed to develop a serum multi-protein signature for the early detection of ESCC.
We selected 70 healthy controls, 30 precancerous patients, 60 stage I patients, 70 stage II patients and 70 stage III/IV ESCC patients from a completed ESCC case-control study in a high-risk area of China. Olink Multiplex Oncology II targeted proteomics panel was used to simultaneously detect the levels of 92 cancer-related proteins in serum using proximity extension assay.
We found that 10 upregulated and 13 downregulated protein biomarkers in serum could distinguish the early-stage ESCC from healthy controls, which were validated by the significant dose-response relationships with ESCC pathological progression. Applying least absolute shrinkage and selection operator (LASSO) regression and backward elimination algorithm, ANXA1 (annexin A1), hK8 (kallikrein-8), hK14 (kallikrein-14), VIM (vimentin), and RSPO3 (R-spondin-3) were kept in the final model to discriminate early ESCC cases from healthy controls with an area under curve (AUC) of 0.936 (95% confidence interval: 0.899 ~ 0.973). The average accuracy rates of the five-protein classifier were 0.861 and 0.825 in training and test data by five-fold cross-validation.
Our study suggested that a combination of ANXA1, hK8, hK14, VIM and RSPO3 serum proteins could be considered as a potential tool for screening and early diagnosis of ESCC, especially with the establishment of a three-level hierarchical screening strategy for ESCC control.
The International Agency for Research on Cancer estimated that there were 572,034 new esophageal cancer cases and 508,585 deaths from esophageal cancer worldwide in 2018, and the mortality-to-incidence ratios in most countries were more than 0.8 [1]. The 5-year overall survival rate of esophageal cancer ranges from 15 to 25% because most patients are diagnosed at an advanced stage with a dismal prognosis [2, 3]. Evidence demonstrates that the population-based screening programs for upper gastrointestinal cancers in East Asia could efficiently identify precancerous lesions and early cancers which leads to improved prognosis due to timely treatment [4, 5]. The government-sponsored endoscopic screening program is also conducted for asymptomatic adults in high incidence area for esophageal cancer in China, but the ongoing program introduced a large burden for public health: only a small part of residents could participate in the gastroscopy screening program and even among this small proportion of population long-term follow-up for high-risk subjects is becoming increasingly burdensome as regards endoscopic management [6]. Thus, a cost-effective and fast blood-based screening test (liquid biopsy) is an ideal solution for risk stratification in order to identify a truly high-risk population for endoscopy [7].
At present, various blood biomarkers including mutations and methylation status in cell-free DNA, cell-free RNA, noncoding RNAs, proteins, and so on, have been explored to fulfill the purpose of early detection of multiple cancer types via different detection platforms [8,9,10,11]. Esophageal squamous cell carcinoma (ESCC) is the dominant histological subtype of esophageal cancer (> 80% proportion), especially in Asia and Eastern African, [12] showing contrasting risk factors and molecular features with esophageal adenocarcinoma. To date, few effective biomarkers for screening early ESCC are established in clinical applications, because the area under curve (AUC) of most potential biomarkers is usually lower than 80% [8, 13].
In order to identify novel protein biomarkers, the development of proximity extension assays (PEA) has enabled simultaneous quantification of multiple targeted protein biomarkers for a bunch of samples in every experiment, thereby enabling quick screening of possible biomarkers. PEA innovatively combines the specificity of antibody-linked detection methods with the sensitivity of the polymerase chain reaction (PCR), permitting multiplex biomarker detection and quantification with reliable assay precision using only microliter quantities of sera [14]. Based on a prospectively designed population-based case-control study of upper gastrointestinal cancer in Taixing (with a population of about 1.13 million), a high-incidence area in China, this study applied the PEA technology to identify candidate serum protein biomarkers for early-stage ESCC.
Study design and participants
The research design of this large population-based case-control study has been delineated in our previous studies [15,16,17,18]. In brief, we attempted to recruit all newly diagnosed esophageal cancer cases from October 2010 to September 2013 in Taixing, and the inclusion criteria were limited to 40–85 year-old participants who had lived in Taixing at least 5 years. In the endoscopic units of the local four largest hospitals (covering almost 90% of local clinical diagnoses), the participants were invited to complete a questionnaire by trained interviewers and provided biological samples, if they were suspected of having an upper gastrointestinal tumor. Moreover, we further enrolled missed esophageal cancer patients in the endoscopy units by matching with the local Cancer Registry system. We finally recruited 1401 suspected esophageal cases from the hospitals' endoscopy units and 280 reported esophageal cases via the local Cancer Registry system during 3 y. After reviewing the pathological sections and surgical pathology reports for those without pathological sections, 33 patients with precancerous lesions (high grade intraepithelial neoplasia, in-situ carcinoma, and high grade dysplasia) and 1418 ESCC patients were included in this study. Through evaluating the tumor stage of the 1418 ESCC patients via inpatient medical records based on the American Joint Commission on Cancer Staging Manual, 8th edition [19], we found additional 4 precancerous patients (reclassified from ESCC), 84 patients with stage I, 333 patients with stage II, 158 patients with stage III, 145 patients with stage IV and remaining 694 patients with unknown tumor stage. During the same period, we applied a frequency-matched method by sex and 5-year age groups to select control participants for the cases of upper gastrointestinal cancers. Finally, 1992 eligible controls participated in our study (participation rate: 70.4%).
The significant level of the hypothesis test was set as 0.001 for 92 proteins and the statistical power was set as 90%. As this study was dedicated to identifying high-efficiency serum protein biomarkers, it was estimated that the difference for significant biomarkers between patient group and control group should be at least 0.8 times of the standard deviation. The sample size of each group was calculated as 69, and we planned to select 70 subjects for each group.
For this study, we further limited suitable blood samples as those collected before clinical treatment and without moderate hemolysis. After excluding hemolytic samples and samples after treatment, the remaining 30 precancerous patients and 60 stage I patients were included. We then first randomly selected 70 patients from stage II ESCC patients, and randomly selected 70 advanced patients (stage III or stage IV) and 70 healthy controls by matching sex and 5-year age groups with stage II ESCC patients. If the sample size of patients in an age group was insufficient, it was supplemented from an adjacent age group.
We finally enrolled 30 precancerous patients, 60 stage I patients, 70 stage II patients, 70 stage III/IV patients and 70 healthy controls in the biomarker study (Fig. 1). The early-stage ESCC was defined as precancerous lesions and stage I cancer in our study because of mini-invasive treatment, better prognosis and small sample size, and early screening requirement in community-based practice [20]. Without external validation, we performed a dose-response relationship between serum protein levels and ESCC pathological progression to further illustrate the reliability of the identified biomarkers.
Selection diagram of participants enrolled in this study. ESCC, esophageal squamous cell carcinoma
Olink multiplex oncology II targeted proteomics panel
Serum proteins were analyzed using Olink Oncology II 96-well in which 92 oligonucleotide-labeled antibody probe pairs bind to their specific targeted proteins based on PEA technology [14, 21]. The precision, reproducibility and scalability of the PEA assay have been documented by the manufacturer (http://www.olink.com) and relevant articles [14, 21]. The protein names, gene names, and abbreviations for the 92 proteins of the Olink Oncology II panel are delineated in Table S1.
Sample processing and detection
Blood samples have been stored in the − 80 °C refrigerator before shipment. The serum samples were shipped to Olink Proteomics AB (Uppsala, Sweden) using cold chains and the samples were randomly placed in four 96-well plates. On each plate, we included three "Inter-plate controls" for data normalization between plates and three "Negative controls" to establish background levels. Data generated from the plates were analyzed, including normalization and linearization, per manufacturer's protocol. The protein levels were expressed as Normalized Protein eXpression (NPX) values, a relative quantification on a log scale, which are cycle threshold values normalized by the subtraction of values for the extension control. All assay characteristics including detection limits and measurements of assay performance and validation are available from the manufacturer's website (http://www.olink.com/products/).
Chi-squared test or one-way ANOVA test were performed for testing the difference of the distributions of categorical or continuous variables in subgroups. An exploratory multivariate analysis (principal component analysis, PCA) was applied to test for potential clustering of study groups. The association between each protein NPX value and early ESCC was investigated using unconditional logistic regression, and the P value was adjusted by the Benjamini-Hochberg method for controlling the false discovery rate (FDR < 0.01). For the potential protein biomarkers, we further applied Spearman correlation to assess the dose-response relationship between protein levels and stages of ESCC, and the P value was also adjusted by the Benjamini-Hochberg method. For all preliminarily verified proteins, unsupervised clustering methods were applied to the data to identify clusters of proteins and visually evaluate their association with disease status. The Protein-Protein Interactions Network analysis of identified proteins was performed using the STRING database (https://string-db.org/). The online ConsensusPathDB-human interaction network database (http://cpdb.molgen.mpg.de/) was used for gene ontology (GO) enrichment analysis and pathway enrichment analysis of identified protein biomarkers. Three GO enrichment categories were checked, i.e. biological process, cellular component and molecular function.
For developing a multi-biomarker classifier to discriminate early ESCC cases from healthy controls, we used the least absolute shrinkage and selection operator (LASSO) regression to select optimal proteins. Moreover, we further used the backward elimination logistic regression model to build a more concise and efficient classification model. The specificity and sensitivity of the classifier were evaluated using the receiver operating characteristic (ROC) curve and the optimal cutoff points were selected using Youden's index, which maximizes the sum of sensitivity and specificity. The AUC was applied to summarize the classification accuracy of diagnostic models and 95% confidence intervals (CI) were estimated by the non-parametric bootstrap. Five-fold cross-validation was used to estimate the validity of our multiple-protein model on the same data that was used to build the classifier. All statistical analyses and figure drawing were conducted using R (version 3.6.2).
Patient overview and assay performance characteristics
The age and gender distribution were homogeneous among healthy controls and four groups of ESCC cases with different cancer stages in Table S2. The average intra-assay and inter-assay coefficient of variation (CV) based on quality control samples were 5 and 23% across the four plates, respectively.
Prinicipal component analysis
The results from principal component analysis of 70 healthy controls, 30 precancerous patients, 60 stage I patients, 70 stage II patients and 70 stage III/IV patients are shown in Fig. 2a. The numbers on the axes represent the variation captured by each principal component. The levels of 92 serum proteins were explained 40.2% by the first two principal components (PC1 27.9%, PC2 12.3%, respectively), and healthy controls were separated from ESCC patients with PC2. Thus, the PC2 distribution across various groups is illustrated in Fig. 2b, and ANOVA analysis found a significant difference among five groups (P = 2.5e-10) and pairwise comparison showed the healthy controls were significantly distinct from each ESCC group.
The distributions of proteins in different groups of participants. a, Distribution of dimension 1 (PC 1) and dimension 2 (PC 2) based on principal component analysis (PCA) of 92 proteins. b, ANOVA pairwise comparison with principal component 2 (PC2), compared with healthy controls
Evaluation of diagnostic efficiency of each protein
To identify potential protein biomarkers of early ESCC, the P value adjusted by FDR (Q value) and AUC of each protein for distinguishing healthy controls from early ESCC cases are shown in Fig. 3. According to the criterion of Q value less than 0.01, 26 potential proteins were discerned preliminarily, namely (sorting by Q value), ANXA1, hK8, CDKN1A, ABL1, SCAMP3, EGF, LYN, MetAP2, PVRL4, KLK13, ADAMTS15, hK14, VIM, TXLNA, GPC1, RSPO3, hK11, TRAIL, 5NT, CPE, FADD, TGFR2, SEZ6L, CD160, FCRLB, and ESM 1. The largest and smallest AUC of the 26 proteins were 0.770 for ANXA1 and 0.652 for ESM 1, respectively.
Dot plot of 92 proteins for distinguishing early esophageal squamous cell carcinoma from healthy controls, which presents P value, Q value adjusted by Benjamini-Hochberg method, and area of curve (AUC) for each protein
For assessing the dose-response relationship between the levels of protein and the progression from healthy controls to advanced ESCC, the violin plots of different groups and P value of Spearman correlation adjusted by FDR (Q value) for these 26 proteins are displayed in Fig. 4. According to the criterion of Q values less than 0.01, remaining 10 upregulated (ANXA1, CDKN1A, ABL1, SCAMP3, EGF, LYN, MetAP2, VIM, TXLNA and FADD) and 13 downregulated (hK8, KLK13, ADAMTS15, hK14, GPC1, RSPO3, hK11, TRAIL, 5NT, CPE, TGFR2, SEZ6L and CD160) protein biomarkers in serum were authenticated as potential ESCC biomarkers.
The distribution of 26 preliminarily identified proteins among five groups. Q value adjusted by Benjamini-Hochberg method stands for Spearman correlation between serum level of each protein and esophageal squamous cell carcinoma stages. Y-axis is NPX value of serum protein level of each value
Protein interaction network and GO enrichment analyses
The protein interaction network analysis (Fig. S1) of 23 preliminarily authenticated proteins showed that 5NT, ABL1, ANXA1, CDKN1A, EGF, GPC1, hK11, hK14, hK8, KLK13, LYN, TGFR2, and VIM shared potential interactions. GO enrichment analysis further revealed that signaling receptor binding and catalytic activity, were the top ontologies for the 'molecular function' category, while extracellular space and extracellular organelle were the top ontologies for the 'cellular component' category, and negative regulation of response to stimulus and regulation of response to stimulus were the top enriched ontologies for the 'biological process' category (Table S3). Pathway enrichment analysis revealed that TP53 Network and Glypican 1 network were the top two enriched pathways (Table S4). An unsupervised hierarchical clustering analysis of 23 preliminarily authenticated proteins showed a significant distinction for early ESCC cases from healthy controls (Fig. S2).
Creation of multi-protein diagnostic model
Considering the complex relationship of these 23 proteins and clinical feasibility for using these biomarkers, LASSO regression was performed to select optimal proteins based on dimensionality reduction in order to develop a compact multi-protein classifier (Fig. S3). Remaining 11 proteins, namely, ANXA1, hK8, CDKN1A, MetAP2, hK14, VIM, GPC1, RSPO3, TRAIL, 5NT, and SEZ6L were used to construct a multiple logistic regression model with an AUC of 0.950 (95%CI:0.918 ~ 0.982, Fig. 5 red line). Because the model still had the problem of multicollinearity and redundant protein biomarkers, a backward elimination algorithm was further applied to construct a brief and efficient multi-protein model. Finally, ANXA1, hK8, hK14, VIM and RSPO3 were kept to discriminate early ESCC cases from healthy controls with an AUC of 0.936 (95%CI:0.899 ~ 0.973, Fig. 5 black line). The specificity and sensitivity of the classifier were 78.6 and 96.7% at optimal Youden's index, and the classified accuracy was 0.888. Besides, the average accuracy rates of the five- protein model were 0.861 and 0.825 in training and test data by 5-fold cross-validation. For intuitive understanding, the results from logistic regression analysis for protein levels (quartiles) are shown in Table 1, and an easy-to-use predictive nomogram tool was created to evaluate the individual ESCC risk based on the five-protein panel (Fig. S4).
Receiver operating characteristic (ROC) curve for selected multiple protein classifier. The red line and area under the curve (AUC) value was fitted by 11 proteins model, namely, ANXA1, hK8, CDKN1A, MetAP2, hK14, VIM, GPC1, RSPO3, TRAIL, 5NT, SEZ6L. The black line with 95% confidence interval (CI) and AUC value was fitted by 5 compact proteins model, namely ANXA1, hK8, hK14, VIM and RSPO3. Diagnosis models were built by using logistic regression
Table 1 The association of serum concentrations of five selected proteins with the risk of early ESCC
The overall results did not change substantially, after conducting a sensitivity analysis by adjusting for age and sex in logistic regression models.
Protein signatures comparing with existent studies
Proteomic studies have been conducted to explore potential biomarkers for ESCC diagnosis by using different biological samples, such as body fluids (plasma, serum, etc.), tumor tissues (fresh frozen tissues or formalin-fixed-paraffin-embedded tissues) and cells in vitro. In 2016, Harada et al. summarized 18 non-targeted proteomic studies with limited sample sizes for ESCC diagnosis based on mass spectrometry technology using serum, tissue and cell line samples, and identified several novel ESCC diagnostic markers, such as Apolipoprotein A-I, Tubulin beta chain filamin A alpha, HSP70, and so on [22]. Blood-based diagnostic studies have been extensively used as a cost-effective and fast screening tool for understanding diseases and medication treatment efficiency over the years, and organ-specific proteins in plasma could mirror organ dysfunction [23]. Development of a liquid biopsy method for early ESCC detection would significantly improve the efficiency of subsequent gastroscopy examination, especially for asymptomatic high-risk population.
Recently, a study identified 13 protein biomarkers in serum using the protein chip AAH-BLG-507 from RayBiotech for discriminating 10 early ESCC patients from 10 healthy controls in China [24]. Liao et al. reported that a combination of plasma FAPα plus traditional biomarker (CEA, CYFRA211, SCCA) using ELISA could significantly discriminate (AUC = 0.745) ESCC (n = 151, stage I: 29 + stage II: 59 + stage III/IV: 63) from non-malignancy controls (n = 230, healthy: 194 + benign:36) [25]. Huang et al. reported an AUC of 0.725 for serum IGFBP7 based on a study including 107 controls and 37 early ESCC patients [26]. Xu et al. reported the serum autoantibody panel (p53, MMP-7, HSP70, Prx VI and Bmi-1) could distinguish early-stage ESCC patients (n = 76) from normal controls (n = 134) with sensitivity of 45% and specificity of 96% in a validation cohort [13]. In our study, 23 proteins, namely, ANXA1, hK8, CDKN1A, ABL1, SCAMP3, EGF, LYN, MetAP2, KLK13, ADAMTS15, hK14, VIM, TXLNA, GPC1, RSPO3, hK11, TRAIL, X5NT, CPE, FADD, TGFR2, SEZ6L and CD160, showed potential diagnostic utility for distinguishing early ESCC from controls and their serum levels showed a significant dose-response relationship with ESCC stages. However, few overlapped proteins were found in the above-mentioned studies, which may be due to differences of candidate protein signatures, sample sizes, ESCC stages, biological nature of samples (plasma vs. serum) and detection methods (PEA vs. protein chip vs. ELISA) used in various studies.
This is the first study to estimate the efficiency of Olink Oncology II panel for the early diagnosis of ESCC. Although this panel was not designed specifically for identifying ESCC patients, the majority of the proteins on the Oncology II panel are secreted proteins that show abnormal expression in the tissues or sera of multiple types of cancer [21, 27, 28]. Especially, several proteins, such as, ANXA1, CEACAM5 (aka CEA), VIM, ALB1 and IL6, have been reported to be potential biomarkers in the diagnosis of ESCC, [24, 25, 29,30,31,32] however, most proteins on the Oncology II panel have not yet been examined for their expression in ESCC blood samples.
Model performance
In order to avoid overfitting and consider the clinical feasibility for early diagnosis of ESCC, a concise multi-protein classifier containing ANXA1, hK8, hK14, VIM and RSPO3 was created. The AUC of the five-protein classifier for differentiating early ESCC from controls was 0.936 (95%CI:0.899 ~ 0.973). The specificity and sensitivity were 78.6 and 96.7% at optimal Youden's index, and the classification accuracy was 0.888. We used five-fold cross-validation to estimate the average accuracy rate of the five-protein classifier, and the corresponding figure was 0.861 and 0.825 in the discovery set and validation set, respectively. Overall, the differentiation efficiency of our multi-protein classifier was relatively superior to other studies [13, 25, 26, 33].
Biological functions
In our study, 92 tumor-related candidate proteins were detected in serum from various stage ESCC patients and healthy controls to predict cancer status, and 23 proteins were preliminarily identified as potential diagnostic protein biomarkers for ESCC. Functional enriched pathway analyses of these 23 proteins showed that they were involved in signaling receptor binding, extracellular space, regulation of response to stimulus and TP53 network implicated in development of ESCC. Thus, their compositions in serum could mirror the pro-tumorigenic ESCC microenvironment and can be used to monitor the progression of ESCC.
In our final diagnostic classifier for early stage ESCC, ANXA1, hK8, hK14, VIM and RSPO3 were selected. The serum levels of ANXA1 and VIM were over-expressed in ESCC patients, on the contrary, the serum levels of hK8, hK14 and RSPO3 were decreased.
ANXA1 (annexin A1), known as an endogenous anti-inflammatory protein, has now been recognized to be closely related to tumor cell proliferation, invasion, differentiation, apoptosis, metastasis and chemotherapy sensitivity via modulation of various cancer-associated pathways [34, 35]. Moreover, ANXA1 shows contrasting expression profiles in various cancer types: over-expressed in lung cancer, colorectal cancer, and pancreatic cancer, and so on, by the contrary, lack of expression in cervical cancer, prostate cancer, nasopharyngeal carcinoma, etc. [34, 36] We found a high level of ANXA1 in serum of ESCC patients, which is consistent with the finding of a previous study showing upregulated levels of ANXA1 in ESCC tissues versus matching normal tissues [30]. However, most previous studies reported that ANXA1 expression was significantly downregulated in cell lines and tissues from ESCC patients compared with adjacent normal tissues [29, 32, 37,38,39]. Further studies are needed to examine the correlation of tumor ANXA1 expression with serum level.
VIM (vimentin), one of class-III intermediated filament proteins, is involved with cytoskeletal integrity, cell adhesion and cell migration via epithelial-mesenchymal transition, [40, 41] and upregulated VIM levels in tissues have been reported as a potential diagnostic and prognostic marker of multiple types of cancers, such as prostate cancer, breast cancer, malignant melanoma and lung cancer [42]. The over-expressed VIM was reported in ESCC tissues compared with adjacent normal tissues, [30] which was somewhat consistent with the results of our study. The biological expression of vimentin is regulated by the transcription factors Twist, Zeb1, Snail, and Slug, which are induced by TGF-β signal transduction [43].
Dysregulation of kallikrein-related peptidases (KLKs) is related to differential expression signatures in various types of cancers, [44, 45] but little is known about its role in ESCC development. Four proteins from kallikrein-related peptidase family, namely, hK8(kallikrein-8), hK11(kallikrein-11), KLK13(kallikrein-13) and hK14(kallikrein-14), were detected by Olink Oncology II panel, and we found all of them had low levels in serum in ESCC patients regardless tumor stage, compared with healthy controls. KLKs, the largest secreted serine protease family, are involved in cancer cell growth, migration, invasion, and chemo-resistance by activation of PARs, the release of active growth factors, modulation of the proteolytic network, and activation of androgen receptor signaling [45, 46].
RSPO3 (R-spondin-3), an activator of the canonical Wnt signaling pathway and PI3K/AKT pathway as a key regulator of angiogenesis and epithelial-mesenchymal transition, has shown low expression in colorectal cancer, squamous cell carcinoma of the lung and prostate cancer, but upregulated expression in bladder cancer, ovarian cancer and lung adenocarcinoma [47,48,49,50]. Our study showed that RSPO3 level in serum was inversely associated with ESCC progression.
Limitations and future perspectives
The results of our models should be interpreted with caution. First, the study was conducted in an ESCC high-risk area of China, which might weaken the generalization of our five-protein prediction classifier to other relatively normal-risk areas. Second, although we found the overall good dose-response relationship between the serum levels of identified biomarkers and ESCC stages, the trends of certain proteins were not perfect, which recommends that external, independent studies are needed to validate and generalize our findings. Moreover, the identified protein biomarkers for ESCC were generally universal biomarkers for multiple types of tumors. Further work is needed to determine the specificity of our five-protein classifier for ESCC diagnosis versus other cancer types. Considering a three-level hierarchical screening strategy, i.e. "environment exposure + blood biopsy + esophagogastroduodenoscopy", to be established in ESCC high-incidence area, our serum multi-protein classifier with high sensitivity and specificity would have a promising application value in high-risk population. The identified ESCC biomarkers are also involved in ESCC progression, which highlights their possible application also as prognostic biomarkers.
In summary, we identified and established a multi-protein classifier for discriminating early ESCC patients from healthy controls, which might contribute to improving the three-level hierarchical screening strategy for decreasing the ESCC burden in high-incidence areas. However, the results need to be further validated in prospective cohort studies.
All data that support the findings of this study are available from the corresponding authors upon a reasonable request.
ESCC:
LASSO:
Least absolute shrinkage and selection operator
ANXA1:
Annexin A1
hK8:
Kallikrein-8
hK14:
Kallikrein-14
VIM:
RSPO3:
R-spondin-3
AUC:
Area under curve
PEA:
Proximity extension assays
NPX:
Normalized Protein eXpression
FDR:
False discovery rate
GO:
ROC:
Receiver operating characteristic
Coefficient of variation
Principal components
KLK13:
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.
Njei B, McCarty TR, Birk JW. Trends in esophageal cancer survival in United States adults from 1973 to 2009: a SEER database analysis. J Gastroenterol Hepatol. 2016;31(6):1141–6.
Zeng H, Zheng R, Guo Y, Zhang S, Zou X, Wang N, et al. Cancer survival in China, 2003-2005: a population-based study. Int J Cancer. 2015;136(8):1921–30.
Shen L, Shan YS, Hu HM, Price TJ, Sirohi B, Yeh KH, et al. Management of gastric cancer in Asia: resource-stratified guidelines. Lancet Oncol. 2013;14(12):e535–47.
Chiu Y, Uedo N, Singh R, Gotoda T, Ng W, Yao K, et al. An Asian consensus on standards of diagnostic upper endoscopy for neoplasia. Gut. 2019;68(2):186–97.
Lao-Sirieix P, Fitzgerald RC. Screening for oesophageal cancer. Nat Rev Clin Oncol. 2012;9(5):278–87.
di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the esophagus: screening, diagnosis, and therapy. Gastroenterology. 2018;154(2):421–36.
Cohen JD, Li L, Wang Y, Thoburn C, Afsari B, Danilova L, et al. Detection and localization of surgically resectable cancers with a multi-analyte blood test. Science. 2018.
Mader S, Pantel K. Liquid biopsy: current status and future perspectives. Oncol Res Treat. 2017;40(7–8):404–8.
Brucher BL, Li Y, Schnabel P, Daumer M, Wallace TJ, Kube R, et al. Genomics, microRNA, epigenetics, and proteomics for future diagnosis, treatment and monitoring response in upper GI cancers. Clin Transl Med. 2016;5(1):13.
Chen X, Gole J, Gore A, He Q, Lu M, Min J, et al. Non-invasive early detection of cancer four years before conventional diagnosis using a blood test. Nat Commun. 2020;11(1):3475.
Arnold M, Soerjomataram I, Ferlay J, Forman D. Global incidence of oesophageal cancer by histological subtype in 2012. Gut. 2015;64(3):381–7.
Xu YW, Peng YH, Chen B, Wu ZY, Wu JY, Shen JH, et al. Autoantibodies as potential biomarkers for the early detection of esophageal squamous cell carcinoma. Am J Gastroenterol. 2014;109(1):36–45.
Assarsson E, Lundberg M, Holmquist G, Bjorkesten J, Thorsen SB, Ekman D, et al. Homogenous 96-plex PEA immunoassay exhibiting high sensitivity, specificity, and excellent scalability. PLoS One. 2014;9(4):e95192.
Yang X, Chen X, Zhuang M, Yuan Z, Nie S, Lu M, et al. Smoking and alcohol drinking in relation to the risk of esophageal squamous cell carcinoma: a population-based case-control study in China. Sci Rep. 2017;7(1):17249.
Yang X, Ni Y, Yuan Z, Chen H, Plymoth A, Jin L, et al. Very hot tea drinking increases esophageal squamous cell carcinoma risk in a high-risk area of China: a population-based case-control study. Clin Epidemiol. 2018;10:1307–20.
Yang X, Zhang T, Yin X, Yuan Z, Chen H, Plymoth A, et al. Adult height, body mass index change, and body shape change in relation to esophageal squamous cell carcinoma risk: a population-based case-control study in China. Cancer Med. 2019;8(12):5769–78.
Ekheden I, Yang X, Chen H, Chen X, Yuan Z, Jin L, et al. Associations between gastric atrophy and its interaction with poor Oral health and the risk for esophageal squamous cell carcinoma in a high-risk region of China: a population-based case-control study. Am J Epidemiol. 2020;189(9):931–41.
Rice TW, Ishwaran H, Ferguson MK, Blackstone EH, Goldstraw P. Cancer of the esophagus and Esophagogastric junction: an eighth edition staging primer. J Thorac Oncol. 2017;12(1):36–42.
Rice TW, Gress DM, Patil DT, Hofstetter WL, Kelsen DP, Blackstone EH. Cancer of the esophagus and esophagogastric junction-major changes in the American joint committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(4):304–17.
Skubitz APN, Boylan KLM, Geschwind K, Cao Q, Starr TK, Geller MA, et al. Simultaneous measurement of 92 serum protein biomarkers for the development of a multiprotein classifier for ovarian Cancer detection. Cancer Prev Res (Phila). 2019;12(3):171–84.
Harada K, Mizrak Kaya D, Shimodaira Y, Song S, Baba H, Ajani JA. Proteomics approach to identify biomarkers for upper gastrointestinal cancer. Expert Rev Proteomics. 2016;13(11):1041-53.
Malmström E, Kilsgård O, Hauri S, Smeds E, Herwald H, Malmström L, et al. Large-scale inference of protein tissue origin in gram-positive sepsis plasma using quantitative targeted proteomics. Nat Commun. 2016;7:10261.
Tong Q, Wang XL, Li SB, Yang GL, Jin S, Gao ZY, et al. Combined detection of IL-6 and IL-8 is beneficial to the diagnosis of early stage esophageal squamous cell cancer: a preliminary study based on the screening of serum markers using protein chips. Onco Targets Ther. 2018;11:5777–87.
Liao Y, Xing S, Xu B, Liu W, Zhang G. Evaluation of the circulating level of fibroblast activation protein alpha for diagnosis of esophageal squamous cell carcinoma. Oncotarget. 2017;8(18):30050–62.
Huang X, Hong C, Peng Y, Yang S, Huang L, Liu C, et al. The diagnostic value of serum IGFBP7 in patients with esophageal squamous cell carcinoma. J Cancer. 2019;10(12):2687–93.
Bhardwaj M, Weigl K, Tikk K, Benner A, Schrotz-King P, Brenner H. Multiplex screening of 275 plasma protein biomarkers to identify a signature for early detection of colorectal cancer. Mol Oncol. 2020;14(1):8–21.
Berggrund M, Enroth S, Lundberg M, Assarsson E, Stalberg K, Lindquist D, et al. Identification of candidate plasma protein biomarkers for cervical Cancer using the multiplex proximity extension assay. Mol Cell Proteomics. 2019;18(4):735–43.
Zhang J, Wang K, Zhang J, Liu SS, Dai L, Zhang JY. Using proteomic approach to identify tumor-associated proteins as biomarkers in human esophageal squamous cell carcinoma. J Proteome Res. 2011;10(6):2863–72.
Chen JY, Xu L, Fang WM, Han JY, Wang K, Zhu KS. Identification of PA28β as a potential novel biomarker in human esophageal squamous cell carcinoma. Tumour Biol. 2017;39(10):1010428317719780.
Mao YS, Zhang DC, Zhao XH, Wang LJ, Qi J, Li XX. Significance of CEA, SCC and Cyfra21-1 serum test in esophageal cancer. Chin J Oncol. 2003;25(5):457–60.
Moghanibashi M, Jazii FR, Soheili ZS, Zare M, Karkhane A, Parivar K, et al. Proteomics of a new esophageal cancer cell line established from Persian patient. Gene. 2012;500(1):124–33.
Xu YW, Liu CT, Huang XY, Huang LS, Luo YH, Hong CQ, et al. Serum autoantibodies against STIP1 as a potential biomarker in the diagnosis of esophageal squamous cell carcinoma. Dis Markers. 2017:5384091.
Foo SL, Yap G, Cui J, Lim LHK. Annexin-A1 - a blessing or a curse in Cancer? Trends Mol Med. 2019;25(4):315–27.
Ganesan T, Sinniah A, Ibrahim ZA, Chik Z, Alshawsh MA. Annexin A1: A Bane or a Boon in Cancer? A Systematic Review. Molecules. 2020;25:16.
Fu Z, Zhang S, Wang B, Huang W, Zheng L, Cheng A. Annexin A1: a double-edged sword as novel cancer biomarker. Clin Chim Acta. 2020;504:36–42.
Xia S-H, Hu L-P, Hu H, Ying W-T, Xu X, Cai Y, et al. Three isoforms of annexin I are preferentially expressed in normal esophageal epithelia but down-regulated in esophageal squamous cell carcinomas. Oncogene. 2002;21(43):6641–8.
Chung JY, Braunschweig T, Hu N, Roth M, Traicoff JL, Wang QH, et al. A multiplex tissue immunoblotting assay for proteomic profiling: a pilot study of the normal to tumor transition of esophageal squamous cell carcinoma. Cancer Epidemiol Biomark Prev. 2006;15(7):1403–8.
Hu N, Flaig MJ, Su H, Shou J-Z, Roth MJ, Li W-J, et al. Comprehensive characterization of annexin I alterations in esophageal squamous cell carcinoma. Clin Cancer Res. 2004;10(18 Pt 1):6013–22.
Sharma P, Alsharif S, Fallatah A, Chung BM. Intermediate filaments as effectors of Cancer development and metastasis: a focus on keratins, Vimentin, and nestin. Cells. 2019;8(5):497.
Chen Z, Fang Z, Ma J. Regulatory mechanisms and clinical significance of vimentin in breast cancer. Biomed Pharmacother. 2021;133:111068.
Satelli A, Li S. Vimentin in cancer and its potential as a molecular target for cancer therapy. Cell Mol Life Sci. 2011;68(18):3033–46.
Strouhalova K, Přechová M, Gandalovičová A, Brábek J, Gregor M, Rosel D. Vimentin Intermediate Filaments as Potential Target for Cancer Treatment. Cancers (Basel). 2020;12:1.
Tailor PD, Kodeboyina SK, Bai S, Patel N, Sharma S, Ratnani A, et al. Diagnostic and prognostic biomarker potential of kallikrein family genes in different cancer types. Oncotarget. 2018;9(25):17876–88.
Kryza T, Silva ML, Loessner D, Heuzé-Vourc'h N, Clements JA. The kallikrein-related peptidase family: Dysregulation and functions during cancer progression. Biochimie. 2016;122:283–99.
Filippou PS, Karagiannis GS, Musrap N, Diamandis EP. Kallikrein-related peptidases (KLKs) and the hallmarks of cancer. Crit Rev Clin Lab Sci. 2016;53(4):277–91.
Wu L, Zhang W, Qian J, Wu J, Jiang L, Ling C. R-spondin family members as novel biomarkers and prognostic factors in lung cancer. Oncol Lett. 2019;18(4):4008–15.
Mesci A, Lucien F, Huang X, Wang EH, Shin D, Meringer M, et al. RSPO3 is a prognostic biomarker and mediator of invasiveness in prostate cancer. J Transl Med. 2019;17(1):125.
Chen Z, Zhou L, Chen L, Xiong M, Kazobinka G, Pang Z, et al. RSPO3 promotes the aggressiveness of bladder cancer via Wnt/β-catenin and hedgehog signaling pathways. Carcinogenesis. 2019;40(2):360–9.
Gu H, Tu H, Liu L, Liu T, Liu Z, Zhang W, et al. RSPO3 is a marker candidate for predicting tumor aggressiveness in ovarian cancer. Ann Transl Med. 2020;8(21):1351.
The authors would like to acknowledge the interviewers and technicians at Fudan University Taizhou Institute of Health Sciences, for their invaluable contribution to data collection and sample preparation, the staff at the Taixing Center for Disease Control and Prevention for their help in organization of field work, and the staff at Taixing People's Hospital for their assistance with sample collection.
This work was supported by the National Natural Science Foundation of China (81973116, 82073637, 91846302 and 81573229), National Key Research and Development program of China (2017YFC0907002 and 2017YFC0907003), International S&T Cooperation Program of China (2015DFE32790), European Research Council (682663), and Shandong Provincial Natural Science Foundation (ZR2020QH302).
Xiaorong Yang and Chen Suo contributed equally to this work.
Clinical Epidemiology Unit, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
Xiaorong Yang & Ming Lu
Clinical Research Center of Shandong University, Qilu Hospital of Shandong University, Jinan, China
Department of Epidemiology and Health Statistics, School of Public Health, Fudan University, Shanghai, China
Chen Suo
Department of Epidemiology and Health Statistics, School of Public Health, Shandong University, Jinan, China
Tongchao Zhang, Xiaolin Yin & Jinyu Man
Fudan University Taizhou Institute of Health Sciences, Taizhou, China
Ziyu Yuan, Li Jin, Xingdong Chen, Ming Lu & Weimin Ye
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
Jingru Yu & Weimin Ye
State Key Laboratory of Genetic Engineering, Human Phenome Institute, and School of Life Sciences, Fudan University, Songhu Road 2005, Shanghai, 200438, China
Li Jin & Xingdong Chen
Department of Epidemiology and Health Statistics & Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
Weimin Ye
Xiaorong Yang
Tongchao Zhang
Xiaolin Yin
Jinyu Man
Ziyu Yuan
Jingru Yu
Xingdong Chen
XRY and CS: collected research datasets, analyzed data and drafted the manuscript; TCZ, XLY, JYM and ZYY: participated in samples collection and medical records assessment; JRY and WMY organized the protein detection in Sweden; ML, XDC, WMY and LJ initiated, organized and supervised the study; ML, XDC and WMY: critically revised the manuscript; ML and XDC: provided technical support. All authors read and approved the final version of the manuscript.
Correspondence to Xingdong Chen or Ming Lu.
The study protocol was approved by the Institutional Review Boards of the School of Life Sciences, Fudan University (date: February 19, 2009), Qilu Hospital, Shandong University (date: March 8, 2010), and Stockholm Ethical Vetting Board (2018/357–31). The study was carried out in accordance with the approved protocol, and all participants provided written informed consent.
We have received consents from all participants involving in this study. The consent forms will be provided upon request.
The authors declare no potential conflicts of interest.
92 proteins from the Olink multiplex Oncology II panel. Table S2. The general information of selected participants, controls and cases based on different cancer stages. Figure S1. The protein interaction of 23 preliminarily authenticated proteins. Each node represents a protein, and the gene name is marked at the top right of the node. Table S3. Gene ontology enrichment analysis of the identified 23 proteins that were differentially expressed between early ESCC and controls, covering three categories, i.e. molecular function, cellular component, and biological process. Top 5 gene ontologies in each enrichment category were selected. Data were obtained from the online ConsensusPathDB- human interaction network database http://cpdb.molgen.mpg.de/. Table S4. Pathway enrichment analysis of the identified 23 proteins that were differentially expressed between early ESCC and controls. Top 7 enriched pathway were selected. Data were obtained from the online ConsensusPathDB- human interaction network database http://cpdb.molgen.mpg.de/. Figure S2. An unsupervised hierarchical clustering analysis of 23 preliminarily authenticated proteins for discriminating early esophageal squamous cell carcinoma (ESCC) from healthy controls. Figure S3. The selection feature of least absolute shrinkage and selection operator (LASSO) via tenfold cross-validation based on area under the ROC curve (AUC). Selection of the tuning parameter (λ) in the LASSO model was via tenfold cross-validation based on minimum standard error. The y-axis indicates AUC. The lower x-axis indicates the log(λ). Numbers along the upper x-axis represent the average number of predictors. Red dots indicate average AUC values for each model with a given λ, and vertical bars through the red dots show the upper and lower values of AUC. The vertical black lines define the optimal values of λ, where the model provides its best fit to the data. Figure S4. A nomogram to predict individual ESCC risk based on the identified five-protein panel.
Yang, X., Suo, C., Zhang, T. et al. Targeted proteomics-derived biomarker profile develops a multi-protein classifier in liquid biopsies for early detection of esophageal squamous cell carcinoma from a population-based case-control study. Biomark Res 9, 12 (2021). https://doi.org/10.1186/s40364-021-00266-z
DOI: https://doi.org/10.1186/s40364-021-00266-z
Diagnostic biomarkers
Affinity proteomics
Proximity extension assay
Submission enquiries: [email protected]
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Meniscal Allograft Transplantation: A Systematic Review of Patient Reported Outcomes
Nick Anthony Smith, MSc, MRCS, BMBS, BMedSci, Solihull, West Midlands UNITED KINGDOM
Ioannis Pengas, MBChB, MRCS, MPhil, MD, FRCS (T&O), Truro, Cornwall UNITED KINGDOM
Tim Spalding, FRCS(Orth), Coventry and London UNITED KINGDOM
University of Warwick, Coventry, West Midlands, UNITED KINGDOM
Summary: This systematic review reports the results of patient reported outcome measures following meniscal allograft transplantation, showing a consistent improvement in the medium term.
Meniscal allograft transplantation has now been performed for over 30 years in humans. There have been a number of potentially significant changes to the intervention over the years, with a possible associated change in clinical outcome for patients. The primary objective of this study was to provide an up-to-date systematic review of the literature, with pooling of patient reported outcome measures in patients undergoing meniscal allograft transplantation. The secondary objective was to identify recent trend changes in meniscal allograft transplantation by reviewing the indications, associated procedures, operative technique, rehabilitation, failures, complications, radiological outcomes and graft healing.
Published and unpublished studies were identified using the databases of Medline, Embase and CENTRAL, as well as trials registries and the Web of Science. Pre-defined eligibility criteria were used and the study protocol was published prior to performing the searches, in order to reduce the risk of bias. Lysholm, IKDC and Tegner scores, as well as failures and complications were pooled from included studies. All eligible studies were also qualitatively assessed to identify trend changes to the intervention.
There were 1332 patients in 35 studies, with a mean follow up of 5.1 years. There were no randomised controlled trials. Across all studies Lysholm scores improved from 55.7 to 81.3, IKDC scores from 47.0 to 70.0 and Tegner activity scores from 3.1 to 4.7 between pre-operative and final follow up assessments respectively. The mean failure rate across all studies was 10.6% at 4.8 years and complication rate was 13.9% at 4.7 years. There was a trend change from the use of cryopreserved allografts to fresh frozen allografts. Bone block or bone bridge fixation remains the most common method of root fixation, but an all suture technique is also commonly performed.
The most important finding is that there were clinically relevant improvements in all mean patient reported outcome measures at final follow up. This study suggests that meniscal allograft transplantation is a reasonable treatment option for the symptomatic relief of compartmental knee pain in patients with a history of total or subtotal meniscectomy. This should ideally be confirmed with a randomised controlled trial.
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Molecular diagnosis of Burkitt's lymphoma
Sandeep S. Dave, Kai Fu, George W. Wright, Lloyd T. Lam, Philip Kluin, Evert Jan Boerma, Timothy C. Greiner, Dennis D. Weisenburger, Andreas Rosenwald, German Ott, Hans Konrad Müller-Hermelink, Randy D. Gascoyne, Jan Delabie, Lisa M. Rimsza, Rita M. Braziel, Thomas M. Grogan, Elias Campo, Elaine S. Jaffe, Bhavana J. Dave, Warren SangerMartin Bast, Julie M. Vose, James O. Armitage, Joseph M. Connors, Erlend B. Smeland, Stein Kvaloy, Harald Holte, Richard I. Fisher, Thomas P. Miller, Emilio Montserrat, Wyndham H. Wilson, Manisha Bahl, Hong Zhao, Liming Yang, John Powell, Richard Simon, Wing C. Chan, Louis M. Staudt
BACKGROUND: The distinction between Burkitt's lymphoma and diffuse large-B-cell lymphoma is crucial because these two types of lymphoma require different treatments. We examined whether gene-expression profiling could reliably distinguish Burkitt's lymphoma from diffuse large-B-cell lymphoma. METHODS: Tumor-biopsy specimens from 303 patients with aggressive lymphomas were profiled for gene expression and were also classified according to morphology, immunohistochemistry, and detection of the t(8;14) c-myc translocation. RESULTS: A classifier based on gene expression correctly identified all 25 pathologically verified cases of classic Burkitt's lymphoma. Burkitt's lymphoma was readily distinguished from diffuse large-B-cell lymphoma by the high level of expression of c-myc target genes, the expression of a subgroup of germinal-center B-cell genes, and the low level of expression of major-histocompatibility-complex class I genes and nuclear factor-.B target genes. Eight specimens with a pathological diagnosis of diffuse large-B-cell lymphoma had the typical gene-expression profile of Burkitt's lymphoma, suggesting they represent cases of Burkitt's lymphoma that are difficult to diagnose by current methods. Among 28 of the patients with a molecular diagnosis of Burkitt's lymphoma, the overall survival was superior among those who had received intensive chemotherapy regimens instead of lower-dose regimens. CONCLUSIONS: Gene-expression profiling is an accurate, quantitative method for distinguishing Burkitt's lymphoma from diffuse large-B-cell lymphoma.
New England Journal of Medicine
https://doi.org/10.1056/NEJMoa055759
10.1056/NEJMoa055759
Dive into the research topics of 'Molecular diagnosis of Burkitt's lymphoma'. Together they form a unique fingerprint.
Burkitt Lymphoma Medicine & Life Sciences 100%
Lymphoma, Large B-Cell, Diffuse Medicine & Life Sciences 58%
Gene Expression Profiling Medicine & Life Sciences 21%
Gene Expression Medicine & Life Sciences 18%
Lymphoma Medicine & Life Sciences 17%
MHC Class I Genes Medicine & Life Sciences 14%
myc Genes Medicine & Life Sciences 12%
Germinal Center Medicine & Life Sciences 12%
Dave, S. S., Fu, K., Wright, G. W., Lam, L. T., Kluin, P., Boerma, E. J., Greiner, T. C., Weisenburger, D. D., Rosenwald, A., Ott, G., Müller-Hermelink, H. K., Gascoyne, R. D., Delabie, J., Rimsza, L. M., Braziel, R. M., Grogan, T. M., Campo, E., Jaffe, E. S., Dave, B. J., ... Staudt, L. M. (2006). Molecular diagnosis of Burkitt's lymphoma. New England Journal of Medicine, 354(23), 2431-2442. https://doi.org/10.1056/NEJMoa055759
Molecular diagnosis of Burkitt's lymphoma. / Dave, Sandeep S.; Fu, Kai; Wright, George W. et al.
In: New England Journal of Medicine, Vol. 354, No. 23, 08.06.2006, p. 2431-2442.
Dave, SS, Fu, K, Wright, GW, Lam, LT, Kluin, P, Boerma, EJ, Greiner, TC, Weisenburger, DD, Rosenwald, A, Ott, G, Müller-Hermelink, HK, Gascoyne, RD, Delabie, J, Rimsza, LM, Braziel, RM, Grogan, TM, Campo, E, Jaffe, ES, Dave, BJ, Sanger, W, Bast, M, Vose, JM, Armitage, JO, Connors, JM, Smeland, EB, Kvaloy, S, Holte, H, Fisher, RI, Miller, TP, Montserrat, E, Wilson, WH, Bahl, M, Zhao, H, Yang, L, Powell, J, Simon, R, Chan, WC & Staudt, LM 2006, 'Molecular diagnosis of Burkitt's lymphoma', New England Journal of Medicine, vol. 354, no. 23, pp. 2431-2442. https://doi.org/10.1056/NEJMoa055759
Dave SS, Fu K, Wright GW, Lam LT, Kluin P, Boerma EJ et al. Molecular diagnosis of Burkitt's lymphoma. New England Journal of Medicine. 2006 Jun 8;354(23):2431-2442. doi: 10.1056/NEJMoa055759
Dave, Sandeep S. ; Fu, Kai ; Wright, George W. et al. / Molecular diagnosis of Burkitt's lymphoma. In: New England Journal of Medicine. 2006 ; Vol. 354, No. 23. pp. 2431-2442.
@article{4401d55e2ad24b539c948ddb25c5e5c0,
title = "Molecular diagnosis of Burkitt's lymphoma",
abstract = "BACKGROUND: The distinction between Burkitt's lymphoma and diffuse large-B-cell lymphoma is crucial because these two types of lymphoma require different treatments. We examined whether gene-expression profiling could reliably distinguish Burkitt's lymphoma from diffuse large-B-cell lymphoma. METHODS: Tumor-biopsy specimens from 303 patients with aggressive lymphomas were profiled for gene expression and were also classified according to morphology, immunohistochemistry, and detection of the t(8;14) c-myc translocation. RESULTS: A classifier based on gene expression correctly identified all 25 pathologically verified cases of classic Burkitt's lymphoma. Burkitt's lymphoma was readily distinguished from diffuse large-B-cell lymphoma by the high level of expression of c-myc target genes, the expression of a subgroup of germinal-center B-cell genes, and the low level of expression of major-histocompatibility-complex class I genes and nuclear factor-.B target genes. Eight specimens with a pathological diagnosis of diffuse large-B-cell lymphoma had the typical gene-expression profile of Burkitt's lymphoma, suggesting they represent cases of Burkitt's lymphoma that are difficult to diagnose by current methods. Among 28 of the patients with a molecular diagnosis of Burkitt's lymphoma, the overall survival was superior among those who had received intensive chemotherapy regimens instead of lower-dose regimens. CONCLUSIONS: Gene-expression profiling is an accurate, quantitative method for distinguishing Burkitt's lymphoma from diffuse large-B-cell lymphoma.",
author = "Dave, {Sandeep S.} and Kai Fu and Wright, {George W.} and Lam, {Lloyd T.} and Philip Kluin and Boerma, {Evert Jan} and Greiner, {Timothy C.} and Weisenburger, {Dennis D.} and Andreas Rosenwald and German Ott and M{\"u}ller-Hermelink, {Hans Konrad} and Gascoyne, {Randy D.} and Jan Delabie and Rimsza, {Lisa M.} and Braziel, {Rita M.} and Grogan, {Thomas M.} and Elias Campo and Jaffe, {Elaine S.} and Dave, {Bhavana J.} and Warren Sanger and Martin Bast and Vose, {Julie M.} and Armitage, {James O.} and Connors, {Joseph M.} and Smeland, {Erlend B.} and Stein Kvaloy and Harald Holte and Fisher, {Richard I.} and Miller, {Thomas P.} and Emilio Montserrat and Wilson, {Wyndham H.} and Manisha Bahl and Hong Zhao and Liming Yang and John Powell and Richard Simon and Chan, {Wing C.} and Staudt, {Louis M.}",
doi = "10.1056/NEJMoa055759",
journal = "New England Journal of Medicine",
publisher = "Massachussetts Medical Society",
T1 - Molecular diagnosis of Burkitt's lymphoma
AU - Dave, Sandeep S.
AU - Fu, Kai
AU - Wright, George W.
AU - Lam, Lloyd T.
AU - Kluin, Philip
AU - Boerma, Evert Jan
AU - Greiner, Timothy C.
AU - Weisenburger, Dennis D.
AU - Rosenwald, Andreas
AU - Ott, German
AU - Müller-Hermelink, Hans Konrad
AU - Gascoyne, Randy D.
AU - Delabie, Jan
AU - Rimsza, Lisa M.
AU - Braziel, Rita M.
AU - Grogan, Thomas M.
AU - Campo, Elias
AU - Jaffe, Elaine S.
AU - Dave, Bhavana J.
AU - Sanger, Warren
AU - Bast, Martin
AU - Vose, Julie M.
AU - Armitage, James O.
AU - Connors, Joseph M.
AU - Smeland, Erlend B.
AU - Kvaloy, Stein
AU - Holte, Harald
AU - Fisher, Richard I.
AU - Miller, Thomas P.
AU - Montserrat, Emilio
AU - Wilson, Wyndham H.
AU - Bahl, Manisha
AU - Zhao, Hong
AU - Yang, Liming
AU - Powell, John
AU - Simon, Richard
AU - Chan, Wing C.
AU - Staudt, Louis M.
N2 - BACKGROUND: The distinction between Burkitt's lymphoma and diffuse large-B-cell lymphoma is crucial because these two types of lymphoma require different treatments. We examined whether gene-expression profiling could reliably distinguish Burkitt's lymphoma from diffuse large-B-cell lymphoma. METHODS: Tumor-biopsy specimens from 303 patients with aggressive lymphomas were profiled for gene expression and were also classified according to morphology, immunohistochemistry, and detection of the t(8;14) c-myc translocation. RESULTS: A classifier based on gene expression correctly identified all 25 pathologically verified cases of classic Burkitt's lymphoma. Burkitt's lymphoma was readily distinguished from diffuse large-B-cell lymphoma by the high level of expression of c-myc target genes, the expression of a subgroup of germinal-center B-cell genes, and the low level of expression of major-histocompatibility-complex class I genes and nuclear factor-.B target genes. Eight specimens with a pathological diagnosis of diffuse large-B-cell lymphoma had the typical gene-expression profile of Burkitt's lymphoma, suggesting they represent cases of Burkitt's lymphoma that are difficult to diagnose by current methods. Among 28 of the patients with a molecular diagnosis of Burkitt's lymphoma, the overall survival was superior among those who had received intensive chemotherapy regimens instead of lower-dose regimens. CONCLUSIONS: Gene-expression profiling is an accurate, quantitative method for distinguishing Burkitt's lymphoma from diffuse large-B-cell lymphoma.
AB - BACKGROUND: The distinction between Burkitt's lymphoma and diffuse large-B-cell lymphoma is crucial because these two types of lymphoma require different treatments. We examined whether gene-expression profiling could reliably distinguish Burkitt's lymphoma from diffuse large-B-cell lymphoma. METHODS: Tumor-biopsy specimens from 303 patients with aggressive lymphomas were profiled for gene expression and were also classified according to morphology, immunohistochemistry, and detection of the t(8;14) c-myc translocation. RESULTS: A classifier based on gene expression correctly identified all 25 pathologically verified cases of classic Burkitt's lymphoma. Burkitt's lymphoma was readily distinguished from diffuse large-B-cell lymphoma by the high level of expression of c-myc target genes, the expression of a subgroup of germinal-center B-cell genes, and the low level of expression of major-histocompatibility-complex class I genes and nuclear factor-.B target genes. Eight specimens with a pathological diagnosis of diffuse large-B-cell lymphoma had the typical gene-expression profile of Burkitt's lymphoma, suggesting they represent cases of Burkitt's lymphoma that are difficult to diagnose by current methods. Among 28 of the patients with a molecular diagnosis of Burkitt's lymphoma, the overall survival was superior among those who had received intensive chemotherapy regimens instead of lower-dose regimens. CONCLUSIONS: Gene-expression profiling is an accurate, quantitative method for distinguishing Burkitt's lymphoma from diffuse large-B-cell lymphoma.
U2 - 10.1056/NEJMoa055759
DO - 10.1056/NEJMoa055759
JO - New England Journal of Medicine
JF - New England Journal of Medicine
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Global climate change has already resulted in an increase in oceanic water temperatures in some areas and is predicted to lead to further increases throughout much of the world in the foreseeable future. One possible response of cetacean species to these increases in water temperature is that species' ranges may change. Here, I provide a framework for assessing which cetacean species' ranges are likely to change as a result of increases in water temperature and whether they will expand, shift poleward or contract based on their current distributions. Based on this framework, it is predicted that the ranges of 88% of cetaceans may be affected by changes in water temperature resulting from global climate change. For 47% of species, these changes are anticipated to have unfavourable implications for their conservation, and for 21% the changes may put at least one geographically isolated population of the species at high risk of extinction. This framework suggests that certain characteristics put some species at greater risk from such changes than others. These include a range that is restricted to non-tropical waters (including temperate species) and a preference for shelf waters. These characteristics are shared by most porpoises and Lagenorhynchus species and by all members of the genus Cephalorhynchus. As a result, species in these taxa are potentially at particular risk from changes in range in response to increasing water temperatures. However, further research is required to assess whether these predictions are, indeed, correct.
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Your sea water
Sea water is a valuable resource for our body, containing more than 50 different types of mineral salts. Calcium, magnesium, potassium, iodine, iron and many others, each of them has essential characteristics and contributes to our body health.
AQUAMARIS
For example, calcium supports the correct functioning of the nervous system and, together with magnesium and phosphorus, acts on muscles; chlorine plays a fundamental role in digestion; iodine, instead, is essential for the functioning of the thyroid gland and for a correct development of the central nervous system.
The need of mineral salts increases in certain circumstances as stress periods, pregnancy and during workout. Minerals also help preventing risk of degenerative diseases, and to relieve and to treat situations of fatigue, hair or nails brittle and to alleviate muscle and bone pain.
The perfect ingredient for your recipes
Thanks to its natural mineral profile, Sea water enables athletes to get a faster hydration recover after intense workout sessions.
The excess of sodium is one of the major causes of arterial hypertension and risk factor in cardiovascular and coronary heart disease. The World Health Organization recommends to take no more than 2 grams of sodium per day, the equivalent of 5 grams or one teaspoon of cooking salt, and about 3,5 grams per day of potassium for its beneficial effect on blood pressure, on the bones and in reducing the risk of cardiovascular disease.
A proper use of sea water in cookery allows to reduce by about 30% sodium and support the regular assumption of essential minerals, and enhances the natural taste of all the ingredients.
Dr. Vincenzo De Geronimo
Endocrinology specialist *taking as a sample 10 gr of cooking salt for 1000ml of soft water compared to 300ml of Sea water and 700ml of soft water
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Real-world data on patient outcomes and treatment patterns in multiple myeloma (MM) are limited.
The present noninterventional, observational, retrospective analysis of prospectively collected Czech patient medical record data from the Registry of Monoclonal Gammopathies estimated real-world outcomes in adults with a diagnosis of symptomatic MM made between May 2007 and June 2014.
In total, 2446 patients had initiated first-line treatment. The median overall survival since the diagnosis (primary endpoint) was 50.3 months (95% confidence interval, 46.1-54.5 months) and decreased with each successive treatment line. A similar trend was observed for progression-free survival and the depth of response. In line with European guidelines and clinical practice, bortezomib-, thalidomide-, and lenalidomide-based regimens were most commonly used across all treatment lines (42.3%, 28.9%, and 18.4%, respectively). In the first line, bortezomib and thalidomide were used most often, with lenalidomide the most commonly used agent in the relapse setting (second to fourth lines). Exploratory analyses revealed that younger age (? 65 years), lower international staging system stage, and previous stem cell transplantation were associated with significant improvements in overall and progression-free survival, especially in the early treatment lines.
The present study is the first analysis of Czech data from the Registry of Monoclonal Gammopathies, and it provides important insights into the real-world management of MM for physicians and healthcare providers.
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Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa)
Madelyn Pandorf, George Hochmuth, Treavor Boyer
Engineering, Ira A. Fulton Schools of (IAFSE)
The main reason for implementing human urine diversion is to produce a local and renewable source of fertilizer for agriculture. Accordingly, the goal of this research was to compare human urine fertilizer and synthetic fertilizer in the cultivation of snap beans and turnips by evaluating the yield, plant tissue chemical composition, nutrient uptake efficiency, soil nutrient content, and leachate nutrient content between plots. Four fertilizer treatments were evaluated: (1) synthetic fertilizer, (2) urine supplemented with synthetic fertilizer, (3) urine only, and (4) a no-fertilizer control, referred to as treatments 1, 2, 3, and 4, respectively. Plants fertilized by treatments 1 and 2 produced the highest yield for fall turnips and spring snap beans. The turnip yield for the urine-only treatment was significantly higher than the no-fertilizer control. Overall, the results showed that supplemented urine fertilizer can be used as an alternative to synthetic fertilizer with comparable yields, and urine-only fertilizer can significantly increase yields over the no-fertilizer control. The results also suggest that nutrients in urine are available in a form favorable for plant uptake.
https://doi.org/10.1021/acs.jafc.8b06011
Phaseolus
nutrient content
plant architecture
leachates
nutrient uptake
plant tissues
human urine fertilizer
leachate
snap beans
Pandorf, M., Hochmuth, G., & Boyer, T. (2019). Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa). Journal of Agricultural and Food Chemistry, 67(1), 50-62. https://doi.org/10.1021/acs.jafc.8b06011
Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa). / Pandorf, Madelyn; Hochmuth, George; Boyer, Treavor.
In: Journal of Agricultural and Food Chemistry, Vol. 67, No. 1, 09.01.2019, p. 50-62.
Pandorf, M, Hochmuth, G & Boyer, T 2019, 'Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa)', Journal of Agricultural and Food Chemistry, vol. 67, no. 1, pp. 50-62. https://doi.org/10.1021/acs.jafc.8b06011
Pandorf M, Hochmuth G, Boyer T. Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa). Journal of Agricultural and Food Chemistry. 2019 Jan 9;67(1):50-62. https://doi.org/10.1021/acs.jafc.8b06011
Pandorf, Madelyn ; Hochmuth, George ; Boyer, Treavor. / Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa). In: Journal of Agricultural and Food Chemistry. 2019 ; Vol. 67, No. 1. pp. 50-62.
@article{aefaee852cd847aba15e545c11205acc,
title = "Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa)",
abstract = "The main reason for implementing human urine diversion is to produce a local and renewable source of fertilizer for agriculture. Accordingly, the goal of this research was to compare human urine fertilizer and synthetic fertilizer in the cultivation of snap beans and turnips by evaluating the yield, plant tissue chemical composition, nutrient uptake efficiency, soil nutrient content, and leachate nutrient content between plots. Four fertilizer treatments were evaluated: (1) synthetic fertilizer, (2) urine supplemented with synthetic fertilizer, (3) urine only, and (4) a no-fertilizer control, referred to as treatments 1, 2, 3, and 4, respectively. Plants fertilized by treatments 1 and 2 produced the highest yield for fall turnips and spring snap beans. The turnip yield for the urine-only treatment was significantly higher than the no-fertilizer control. Overall, the results showed that supplemented urine fertilizer can be used as an alternative to synthetic fertilizer with comparable yields, and urine-only fertilizer can significantly increase yields over the no-fertilizer control. The results also suggest that nutrients in urine are available in a form favorable for plant uptake.",
keywords = "human urine fertilizer, leachate, lettuce, snap beans",
author = "Madelyn Pandorf and George Hochmuth and Treavor Boyer",
doi = "10.1021/acs.jafc.8b06011",
T1 - Human Urine as a Fertilizer in the Cultivation of Snap Beans (Phaseolus vulgaris) and Turnips (Brassica rapa)
AU - Pandorf, Madelyn
AU - Hochmuth, George
AU - Boyer, Treavor
N2 - The main reason for implementing human urine diversion is to produce a local and renewable source of fertilizer for agriculture. Accordingly, the goal of this research was to compare human urine fertilizer and synthetic fertilizer in the cultivation of snap beans and turnips by evaluating the yield, plant tissue chemical composition, nutrient uptake efficiency, soil nutrient content, and leachate nutrient content between plots. Four fertilizer treatments were evaluated: (1) synthetic fertilizer, (2) urine supplemented with synthetic fertilizer, (3) urine only, and (4) a no-fertilizer control, referred to as treatments 1, 2, 3, and 4, respectively. Plants fertilized by treatments 1 and 2 produced the highest yield for fall turnips and spring snap beans. The turnip yield for the urine-only treatment was significantly higher than the no-fertilizer control. Overall, the results showed that supplemented urine fertilizer can be used as an alternative to synthetic fertilizer with comparable yields, and urine-only fertilizer can significantly increase yields over the no-fertilizer control. The results also suggest that nutrients in urine are available in a form favorable for plant uptake.
AB - The main reason for implementing human urine diversion is to produce a local and renewable source of fertilizer for agriculture. Accordingly, the goal of this research was to compare human urine fertilizer and synthetic fertilizer in the cultivation of snap beans and turnips by evaluating the yield, plant tissue chemical composition, nutrient uptake efficiency, soil nutrient content, and leachate nutrient content between plots. Four fertilizer treatments were evaluated: (1) synthetic fertilizer, (2) urine supplemented with synthetic fertilizer, (3) urine only, and (4) a no-fertilizer control, referred to as treatments 1, 2, 3, and 4, respectively. Plants fertilized by treatments 1 and 2 produced the highest yield for fall turnips and spring snap beans. The turnip yield for the urine-only treatment was significantly higher than the no-fertilizer control. Overall, the results showed that supplemented urine fertilizer can be used as an alternative to synthetic fertilizer with comparable yields, and urine-only fertilizer can significantly increase yields over the no-fertilizer control. The results also suggest that nutrients in urine are available in a form favorable for plant uptake.
KW - human urine fertilizer
KW - leachate
KW - lettuce
KW - snap beans
U2 - 10.1021/acs.jafc.8b06011
DO - 10.1021/acs.jafc.8b06011
10.1021/acs.jafc.8b06011
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A20 (TNFAIP3) is a pleiotropic NFκB-dependent gene that terminates NFκB activation in response to inflammatory stimuli. The potent anti-inflammatory properties of A20 are well characterized in several organs. However, little is known about its role in the brain. In this study, we investigated the brain phenotype of A20 heterozygous (HT) and knockout (KO) mice.
The inflammatory status of A20 wild type (WT), HT and KO brain was determined by immunostaining, quantitative PCR, and Western blot analysis. Cytokines secretion was evaluated by ELISA. Quantitative results were statistically analyzed by ANOVA followed by a post-hoc test.
Total loss of A20 caused remarkable reactive microgliosis and astrogliosis, as determined by F4/80 and GFAP immunostaining. Glial activation correlated with significantly higher mRNA and protein levels of the pro-inflammatory molecules TNF, IL-6, and MCP-1 in cerebral cortex and hippocampus of A20 KO, as compared to WT. Basal and TNF/LPS-induced cytokine production was significantly higher in A20 deficient mouse primary astrocytes and in a mouse microglia cell line. Brain endothelium of A20 KO mice demonstrated baseline activation as shown by increased vascular immunostaining for ICAM-1 and VCAM-1, and mRNA levels of E-selectin. In addition, total loss of A20 increased basal brain oxidative/nitrosative stress, as indicated by higher iNOS and NADPH oxidase subunit gp91phox levels, correlating with increased protein nitration, gauged by nitrotyrosine immunostaining. Notably, we also observed lower neurofilaments immunostaining in A20 KO brains, suggesting higher susceptibility to axonal injury. Importantly, A20 HT brains showed an intermediate phenotype, exhibiting considerable, albeit not statistically significant, increase in markers of basal inflammation when compared to WT.
This is the first characterization of spontaneous neuroinflammation caused by total or partial loss of A20, suggesting its key role in maintenance of nervous tissue homeostasis, particularly control of inflammation. Remarkably, mere partial loss of A20 was sufficient to cause chronic, spontaneous low-grade cerebral inflammation, which could sensitize these animals to neurodegenerative diseases. These findings carry strong clinical relevance in that they question implication of identified A20 SNPs that lower A20 expression/function (phenocopying A20 HT mice) in the pathophysiology of neuroinflammatory diseases.
Neuroinflammation is a common pathogenic culprit of several neurodegenerative diseases including Alzheimer's Disease (AD) , Parkinson's Disease (PD) , multiple sclerosis (MS) , stroke and neuropsychiatric diseases such as depression, schizophrenia and autism [5, 6]. Injury to the central nervous system (CNS), whether metabolic, structural, auto-immune, ischemic, infectious or mechanical, results in increased production of pro-inflammatory cytokines such as TNF, IL-1β and IL-6, and of neurotoxic molecules such as nitric oxide (NO), by activated microglia and astrocytes. Such pro-inflammatory environment culminates in cell death and cerebral tissue damage [7, 8].
Anti-inflammatory therapies including IL-1 receptor antagonist, IL-1β inhibitors and NSAIDs have shown some benefit in reducing post-stroke neurodegenerative lesions, and in decreasing incidence of AD or PD [9–11]. However, widespread use of these therapies must be cautioned by their inhibitory effect on NFκB, a transcription factor that regulates expression of many pro-inflammatory mediators, all the while promoting the upregulation of protective and regenerative molecules in the CNS . Therefore, a better understanding of the molecular signature of neuroinflammatory diseases is required in order to identify safe, effective and possibly disease-specific therapeutic targets.
A20 (TNF alpha-induced protein 3, TNFAIP3), a pleiotropic NFκB-dependent gene expressed in a variety of tissues and cell types, including the human brain , encodes a ubiquitin-editing enzyme that is essential for termination of NFκB activation in response to multiple stimuli such as IL-1β, TNF, IL-6, CD40 and lipopolysaccharide (LPS) [15–17]. The potent anti-inflammatory role of A20 is exemplified by the phenotype of A20 knockout (KO) mice. These mice rapidly become cachectic and die within three to five weeks of age, as a result of uncontrolled inflammation in several organs . In contrast to its ubiquitous anti-inflammatory function, A20's effect on apoptosis is cell type specific. A20 exhibits potent anti-apoptotic properties in endothelial cells (EC), hepatocytes and pancreatic β-cells, through several mechanisms including blockade of the caspase cascade at the level of caspase 8, and preservation of mitochondrion integrity . On the other hand, A20 promotes vascular smooth muscle cells apoptosis through a NO-dependent mechanism . In addition, overexpression of A20 protects livers and kidneys from ischemia reperfusion injury, in part by upregulating peroxisome proliferator associated receptor alpha, channeling lipid metabolism away from lipid peroxidation towards mitochondrial β-oxidation, which results in increased ATP generation [21, 22].
Little is known about the role of A20 in the CNS. Evidence from the literature suggest that increased expression of A20 is neuroprotective in animal models of epilepsy and of focal cerebral ischemia, in part by limiting ischemic damage and containing TNF-induced neuronal apoptosis . However, these gain-of-function studies did not address the physiological role of A20 nor its involvement in maintaining homeostasis and, in particular, containing inflammation in the CNS. In more recent studies, mice with neuroectodermal (astrocytes, neurons and oligodendrocytes) specific A20 KO failed to show increased CNS inflammation at baseline and did not demonstrate larger ischemic infarcts following middle cerebral artery occlusion , when compared to their wild type (WT) littermates. However, CNS specific A20 KO did develop an aggravated form of auto-immune encephalomyelitis, which was attributed to astrocytic loss of A20, further fueling controversy about A20's function in the CNS . In order to better delineate the physiological role of A20 in modulating CNS inflammation, we phenotyped the cerebral inflammatory pattern of full A20 KO and heterozygous (HT) mice. We reasoned that this approach carries greater clinical relevance than cell type-specific KO of this gene, as it would enable us to gauge the impact of A20 on CNS generators of inflammation (microglial cells, astrocytes), as well as CNS targets of inflammation (neurons, endothelial cells). This study is timely given the many A20 single SNPs causing decreased expression or function of this gene that have been associated with numerous auto-immune and inflammatory diseases [25, 27–30].
Reagents: Human recombinant TNF was purchased from R&D Systems (Minneapolis, MN, USA). LPS (Lipopolysaccharides from Escherichia coli 055:B5), and FBS were obtained from Sigma-Aldrich Co. (St. Louis, MO, USA).
Four to five-week-old A20 KO, HT and WT littermate control mice were used for forebrain isolation. Following anesthesia, mice were sacrificed by decapitation, and their brains recovered and fixed for analysis by immunohistochemistry (IHC) and immunofluorescence (IF). Alternatively, cerebral cortex (CX) and hippocampus (HC) were isolated for mRNA and protein isolation. For primary astrocyte isolation and culture, brains from one to three-day-old pups were used. Animals received humane care according to the criteria outlined in the Guide for the Care and Use of Laboratory Animals. Beth Israel Deaconess Medical Center Institutional Animal Care and Use Committee approved all research protocols.
Primary astrocytes were prepared from forebrain of neonatal mice (one to three-day-old) according to a modified method of McCarthy and De Vellis . Purity of astrocyte preparation was > 95%. In brief, cerebral hemispheres were freed from the meninges and the forebrain was dissociated mechanically using fire-polished Pasteur pipets. Mixed brain cells were plated in DMEM containing 10% FBS, and antibiotics (Mediatech, Inc., Manassas, VA, USA). Cells were cultured for seven to ten days until confluent in a humidified atmosphere enriched with 5% CO2. Contaminating oligodendrocytes and microglial cells were eliminated from the astrocytic monolayer by placing culture flasks on a rotary shaker at 800 rpm overnight. Astrocyte monolayers were then trypsinized and cells plated in 24-well plates and cultured to confluency for seven to ten days before being used in experiments. The mouse microglia cell line N13 (kind gift of Dr. Di Virgilio, University of Ferrara, Italy) and mouse primary astrocytes purchased from ScienCell Research Laboratories (Carlsbad, CA, USA) were used in RNA silencing experiments.
Tissue lysates (40 to 60 μg protein) were separated under reducing conditions by SDS-PAGE (Bio-Rad Laboratories, Hercules, CA, USA) , and transferred to Polyvinylidene fluoride (PVDF) membranes (PerkinElmer Life Science, Whaltham, MA, USA) by semi-dry electroblotting. Membranes were probed with mouse anti-gp91phox (BD Pharmigen, San Diego, CA, USA), mouse anti-glyceraldehyde 3-phosphate dehydrogenase (GAPDH) (EMD chemicals), mouse anti-βactin and rabbit anti-IκBα (Santa Cruz Biotechnology, Inc., Santa Cruz, CA, USA). Appropriate secondary horseradish peroxidase (HRP)-conjugated antibodies were used (Thermo Scientific, Rockford, IL, USA). Protein bands were detected with enhanced chemiluminescence kit (ECL) (PerkinElmer Life Science, Waltham, MA, USA) followed by exposure to the autoradiography film. Immunoblots were scanned and the intensity of the bands was quantified by densitometry using ImageJ 1.41 (US National Institutes of Health, Bethesda, MD, USA).
N13 microglia cells and mouse primary astrocytes (ScienCell Research Laboratories, Carlsbad, CA, USA) were transfected with predesigned A20 silencing RNA probes (A20 siRNA) or All Start Negative Control siRNA (C siRNA), using Hiperfect transfection reagent purchased from Qiagen (Valencia, CA, USA). Transfections were carried out according to the manufacturer's transfection protocol. Experiments were performed 24 hours after transfection. Efficiency of gene knockdown was evaluated by qPCR in non-treated and LPS (1 μg/mL for 1 hour) treated cells.
Cell culture medium was changed to serum-free medium, then cells were stimulated with either TNF or LPS in order to mimic inflammation. Supernatants were then recovered, and analyzed for IL-6 and TNF content by ELISA, using mouse IL-6 and TNF ELISA Ready-SET-Go! (eBioscience, San Diego, CA, USA), according to manufacturer's instruction. Results were normalized by protein content. Cell cultures incubated in medium alone were used as non-stimulated controls.
mRNA from CX and HC and from primary astrocytes and the mouse microglia cell line N13 was isolated using RNAse spin columns (Qiagen, Valencia, CA, USA), and cDNA was synthesized using iScript cDNA synthesis kit (Bio-Rad, Hercules, CA, USA). Real-time PCR (qPCR) was performed using iTaq Fast SYBR Green Supermix with ROX (Bio-Rad, Hercules, CA, USA) and gene specific primers (Table 1) or TaqMan Mm00627280_m1 (tnfaip3), Mm00607939_s1 (βactin), and ABI 7500 Fast Real-time PCR System (Applied Biosystems, Inc., Foster City, CA, USA). Comparative threshold cycle (Ct) method was used to perform relative quantification of qPCR results. mRNA expression of target genes A1, TNF, IL-6, inducible NOS (iNOS), endothelial NO synthase (eNOS), neuronal NO synthase (nNOS), E-selectin, monocyte chemoattractant protein 1 (MCP-1), glial fibrillary acidic protein (GFAP), nuclear factor erythroid 2 related factor 2 (Nrf2), IκBα, gp91phox and heme oxygenase-1 (HO-1) was normalized to that of the housekeeping gene βactin. Data are expressed as fold change of levels noted in WT mice.
Brains were processed for IHC and IF as described . In brief, 2,000-μm coronal slices were zinc-fixed (BD Pharmigen, San Diego, CA, USA) for 48 hours at room temperature, dehydrated in a tissue processor and embedded in paraffin for sectioning, before being sectioned into 6-μm thickness. For IHC, sections were de-paraffinized, rehydrated, fixed with cold acetone:formalin 95:5 (vol/vol) for 3 minutes, then incubated with horse serum (7% in PBS) prior to overnight incubation at 4°C with hamster anti-ICAM-1 and rat anti-VCAM-1 (BD Pharmigen, San Diego, CA, USA), rabbit anti-iNOS and anti-IL-6 (Abcam Inc., Cambridge, MA, USA), and rabbit anti-GFAP (Dako, Carpinteria, CA, USA). Alternatively, sections were fixed with cold 2% paraformaldehyde for 10 minutes prior to overnight incubation with mouse anti-nitrotyrosine (Santa Cruz Biotechnology, Inc., Santa Cruz, CA, USA), rat anti-F4/80 (AbDSerotec, Raleigh, NC, USA), rabbit anti-TNF alpha (Novus Biologicals, Littleton, CO) and hamster anti-MCP-1 (BD Pharmigen, Franklin Lakes, NJ, USA). Sections were then treated with H2O2 1:100 in PBS for 10 minutes, incubated with the appropriate secondary IgG antibodies followed by ABC (avidin-biotin complex) reagent (Vector Laboratories, Burlingame, CA, USA), then detected by ImmPACT 3,3'-diaminobenzidine tetrahydrochloride (DAB) peroxidase substrate (Vector Laboratories, Burlingame, CA, USA). Negative controls using only secondary antibodies confirm the absence of non-specific immunostaining (Additional file 1: Figure S1). For IF, sections were fixed with 2% cold paraformaldehyde for 10 minutes prior to overnight incubation with rabbit anti-Nrf2 (Abcam plc., Cambridge, MA, USA), rabbit anti-IL-6, rat anti-F4/80 and goat anti-GFAP (Santa Cruz, Biotechnology, inc., Dallas, TX, USA), followed by appropriate Alexa Fluor 488 (green) and 594 (red) conjugated secondary antibodies (Invitrogen, Carlsbad, CA, USA).
Results are presented as mean ± standard error of mean (SEM). Statistical analysis was performed on Prism 5 for Mac (GraphPad Software, Inc., La Jolla, CA, USA). Data were analyzed by one or two way analysis of variance (ANOVA) followed by post-hoc Tukey or Bonferroni, respectively, when F was significant. Alternatively, results were analyzed by a non-parametric Kruskal-Wallis analysis followed by Dunn's multiple comparison tests when variances differed significantly. Differences between groups were rated significant at a probability error (P) < 0.05.
We first probed for expression and distribution of A20 in normal and A20 deficient mouse brain. By qPCR, we demonstrated that A20 mRNA was detected in comparable amounts in CX and HC of WT mice (Figure 1A). As expected, A20 mRNA was undetectable in the brain of KO mice and showed 50% reduction in the brain of HT mice (Figure 1A). A20 wipeout correlated with higher NFκB activation in cerebral cortex and hippocampus of KO versus WT mice, as evidenced by remarkably lower IκBα protein levels, indicative of amplified degradation (Figure 1B) while IκBα protein levels were intermediate in CX and HC of HT mice. Corroborating heightened NFκB activation in the brains of A20 KO mice, we noted significantly higher mRNA levels of IκBα, itself a prime NFκB-dependent gene, when compared to WT brains, with again HT brains showing intermediate results (Figure 1C).
Baseline A20 mRNA expression in mouse cerebral cortex and hippocampus. (A) A20 and (C) IκBα mRNA levels in cerebral cortex (CX) and hippocampus (HC) of wild type (WT), A20 heterozygous (HT) and A20 knockout (KO) mice, measured by qPCR. Graph shows relative mRNA levels after normalization with mRNA levels of housekeeping gene βactin. Results are expressed as mean ± SEM of three to four animals per genotype. **P < 0.01. ND: not detectable. (B) Western blot (WB) analysis of IκBα expression in CX and HC of A20 WT, HT and KO mice. Immunoblotting for the housekeeping protein βactin was used to control for loading. Results are representative of three animals per genotype.
Having confirmed absence and decreased expression of A20 in brains of KO and HT mice, respectively, we evaluated the impact of total or partial loss of A20 on microglia and astrocytes activation. Microglia, the resident macrophages of the CNS, and astrocytes, the most abundant glial cell population, respond to injury and inflammation by assuming an activated phenotype defined by characteristic changes in morphology and gene expression, and by increased propensity for migration and proliferation [34, 35].
Immunohistochemistry analysis of mouse brain sections using a macrophage/microglia cell surface marker F4/80 revealed increased number of activated microglia throughout the A20 KO brain, as evidenced by their typical hypertrophied phenotype, that is enlarged cells with shorter and thicker branched processes (Figure 2A). This picture totally contrasted with WT brains that showed resting/quiescent microglia harboring a ramified morphology with slender sensing arms. We confirmed the activation status of microglia by probing for mRNA levels of the microglial activation marker A1 [38, 39]. A1 mRNA levels were significantly higher in CX and HC (approximately seven-fold) of A20 KO as compared to WT mice (Figure 2B). Astrocyte activation in the brain of A20 KO mice was also evident, as demonstrated by enhanced GFAP immunoreactivity . Astrocytes displaying thick cell bodies and processes characteristic of astrocyte reactivity were especially marked in the outer layers of the CX and throughout the HC (Figure 2C). Astrocyte activation was confirmed at the mRNA levels by qPCR. GFAP mRNA levels were significantly (approximately 1.8-fold) higher in the CX and HC of A20 KO mice as compared to WT (Figure 2D). Brains from HT mice showed an intermediate phenotype with a consistent trend for greater microglia and astrocyte activation when compared to WT mice, and for significantly lower microglia and astrocyte activation when compared to KO mice, as showed by IHC and qPCR (Figure 2).
Loss of A20 leads to spontaneous microglia and astrocyte activation. Representative (A) F4/80 and (C) GFAP immunohistochemistry (brown) in the cerebral cortex (CX) and hippocampus (HC) of A20 wild type (WT), heterozygous (HT) and knockout (KO) mice. Yellow arrows indicate hypertrophied activated microglia, noted by their stout, dense appearance with shorter and thicker branched projections. Blue arrows indicate reactive astrocytes displaying thick cell bodies and processes, evident in the outer layers of the CX and throughout the HC. Photomicrographs are representative of three animals per genotype. Bar = 20 μm, magnification = 400x. (B) A1 and (D) GFAP mRNA levels measured by qPCR. Graph shows relative mRNA levels after normalization with mRNA levels of housekeeping gene βactin. Results are expressed as mean ± SEM of five to seven animals per genotype. *P < 0.05, **P < 0.01 and ***P < 0.001.
Activated microglia and reactive astrocytes are key defense mechanisms of the CNS to injury, in part through their ability to modulate immune and inflammatory responses by secreting pro-inflammatory cytokines and chemokines such as TNF, IL-6, IL-1β, and MCP-1 [41, 42]. As in all inflammatory responses, this defense system needs to be tightly modulated in order to avoid unfettered inflammation that would counterproductively cause neurotoxicity . Accordingly, we probed by qPCR for mRNA levels of TNF, IL-6, IL-1β and MCP-1 in CX and HC of A20 WT, HT and KO mice. Our results show significantly increased mRNA levels of all these pro-inflammatory mediators in the brain of KO, as compared to WT mice, further confirming glial activation (Figure 3A). HT mouse brains also showed a tendency (albeit not significant) for higher mRNA levels of all these molecules when compared to WT brains. This tendency was more prominent in the CX than in the HC. We confirmed by IHC that higher TNF, IL-6, and MCP-1 mRNA levels in the brain of A20 deficient mice correlated with higher protein levels (Figure 3B). Double immunofluorescence staining using antibodies against microglia surface marker F4/80 or astrocyte marker GFAP in combination with anti-IL-6 demonstrate that both cell types produce IL-6 and contribute to its increased levels in the brains of A20 KO mice (Figure 4). Altogether, these results indicate a heightened basal level of inflammation in the brain of A20 deficient mice, especially when A20 expression is totally knocked-out.
Levels of pro-inflammatory mediators are increased in cerebral cortex and hippocampus of A20 deficient mice. (A) TNF, IL-6, IL-1β and MCP-1 mRNA levels in cerebral cortex (CX) and hippocampus (HC) of wild type (WT), A20 heterozygous (HT) and A20 knockout (KO), measured by qPCR. Graph shows relative mRNA levels after normalization with mRNA levels of housekeeping gene βactin. Results are expressed as mean ± SEM of four to seven animals per genotype. *P < 0.05, **P < 0.01 and ***P < 0.001. (B) Representative images of TNF, IL-6 and MCP-1 immunohistochemistry (brown) in HC (TNF and IL-6) and CX (MCP-1) of A20 WT, HT and KO mice. Photomicrographs are representative of three to four animals per genotype. Top images: Bar = 50 μm, magnification = 200x. Bottom images are close-up images of the area delineated by the black box in top images.
Astrocytes and microglia contribute to higher IL-6 levels in A20 deficient brains. Representative images of double IL-6 (red) and GFAP (green), or IL-6 (red) and F4/80 (green) positive cells in the hippocampus (HC) of A20 wild type (WT), heterozygous (HT) and knockout (KO) mice, as determined by immunofluorescence staining. White arrows show IL-6 co-localization with glial fibrillary acidic protein (GFAP) (astrocytes) or F4/80 (microglia), as evidenced by the yellow overlay. Nuclei were stained with 4′,6-diamidino-2-phenylindole (DAPI, blue). Photomicrographs are representative of four animals per genotype. Top images: Bar = 20 μm, magnification = 400x. Bottom images are close-up images of the area delineated by the white box in top images.
IL-6, mostly produced by astrocytes, achieves higher concentration than other soluble pro-inflammatory mediators in the brain, and hence has been designated as a key contributor to neuroinflammation [44, 45]. To check whether enhanced IL-6 levels in the brain of A20 KO mice resulted from heightened activators, that is higher TNF levels, or also related to heightened production by A20 deficient astrocytes in response to a similar level of activator, we isolated and cultured primary astrocytes from A20 KO, HT and WT mice, exposed them for 24 hours to similar concentrations of exogenous LPS (10 μg/mL) and measured, by ELISA, TNF and IL-6 levels in cell culture supernatant. We noted a trend towards higher (albeit not significant) TNF and IL-6 levels in 24 hours culture supernatants of A20 KO as compared to WT astrocytes (2.25- and 1.5-fold, respectively), in the absence of any inflammatory stimuli. Following LPS treatment, TNF and IL-6 levels increased in response to LPS in all groups, albeit these levels were significantly higher in KO, as compared to WT astrocytes (Figure 5A and B). HT astrocytes showed an intermediate response, that is LPS treatment increased IL-6 production by two to three-fold, as compared to a ten-fold upregulation in KO astrocytes (Figure 5B). Since higher LPS-induced TNF levels is the master inducer of IL-6 in astrocytes, and hence could account for higher IL-6 levels in LPS treated A20 deficient astrocytes, we independently evaluated TNF-induced production (100 U/ml) of IL-6 in these cells. Here again, TNF-induced upregulation of IL-6 production was significantly higher in A20 KO as compared to WT and HT astrocytes (Figure 5C). We confirmed these findings in mouse primary astrocytes that had undergone siRNA mediated A20 knockdown. Transfection of astrocytes with A20 siRNA reduced by 50% LPS-induced A20 upregulation, as evidenced by mRNA levels measured 1 hour after LPS (1 μg/mL) stimulation (Additional file 2: Figure S2). Inadequate A20 upregulation following LPS (mimicking A20 knockdown in A20 HT mice) correlated with significantly higher TNF and IL-6 mRNA levels six hours after LPS, as compared to levels measured in non-transfected and All Star siRNA (C siRNA) control cells (Figure 6A and B). This was paralleled by significantly higher IL-6 protein levels in the cell culture supernatant of A20siRNA versus control cells (Figure 6C). As in astrocytes, siRNA mediated A20 knockdown in microglia cells (N13) decreased by 50% LPS induced upregulation of A20 (Additional file 2: Figure S2). Here again, this correlated with significantly higher LPS-induced upregulation of TNF and IL-6 mRNA (Figure 6D and E), and of IL-6 protein (Figure 6F) levels in these cells as compared to non-transfected or C siRNA transfected cells.
Cytokine production in response to inflammatory stimuli is enhanced in A20 deficient primary astrocytes. (A) TNF and (B) IL-6 levels, measured by ELISA, in cell culture supernatant from A20 wild type (WT), heterozygous (HT) and knockout (KO) mouse primary astrocytes following 24 hour stimulation with LPS (10 μg/mL). (C) IL-6 levels measured by ELISA, in cell culture supernatant from WT, HT and KO mouse primary astrocytes following 24 hours stimulation with TNF (100 UI/mL). NS: non-stimulated cells. Data represent mean ± SEM of primary astrocytes isolated from littermate pups (WT n = 2; HT n = 8 to 10, KO n = 3 to 4). *P < 0.05, **P < 0.01.
A20 knockdown enhances lipopolysaccharide (LPS)-mediated cytokine production in mouse primary astrocytes and microglia cell line. (A) TNF and (B) IL-6 mRNA levels in mouse primary astrocytes 6 hours after LPS (1 μg/mL) stimulation, as measured by qPCR. (D) TNF and (E) IL-6 mRNA levels in the microglia cell line N13, 1 hour and 6 hour respectively, after LPS (1 μg/mL) stimulation, as measured by qPCR. Graph shows relative mRNA levels after normalization with mRNA levels of housekeeping gene βactin. IL-6 protein levels, measured by ELISA, in cell culture supernatant of (C) mouse primary astrocytes and (F) microglia cell line N13 6 hours after LPS (1 μg/mL) stimulation. Results are expressed as mean ± SEM of three to five independent experiments. NS: non-stimulated cells. Ctrl: non-transfected control cells. A20 siRNA: cells transfected with A20 silencing RNA. C siRNA: cells transfected with All Star control silencing RNA. *P < 0.05, **P < 0.01 and ***P < 0.001.
Altogether these results establish that both heightened activators (TNF) in brains of A20 deficient mice, and hyper-responsiveness of A20 deficient glia to pro-inflammatory stimuli contribute to the amplification of the pro-inflammatory spiral, culminating in excessive amount of IL-6.
NO, when produced in physiologic levels by the low-throughput and constitutively expressed nNOS and eNOS NO synthases (NOS), mostly serves a homeostatic function through regulation of synaptic signaling and plasticity [46, 47], as well as vasoprotection, through combined anti-apoptotic, anti-inflammatory, and reactive oxygen radicals' scavenging properties . However, overproduction of NO in pathophysiological conditions is implicated in oxidative-dependent neuronal death and dysfunction. High throughput NFκB-dependent iNOS, mainly produced by activated glia, is the primary NOS involved in inflammatory neurodegenerative disorders . Accordingly, we evaluated iNOS mRNA and protein levels in CX and HC of A20-competent and A20 deficient mice. Our results show that iNOS mRNA levels significantly increase in the CX of KO mice as compared to WT, with HT demonstrating an intermediate level (Figure 7A). We confirmed this by IHC that depicted increased iNOS immunostaining in the CX of A20 deficient mice (Figure 5B). Levels of iNOS mRNA in HC were similar in all groups. Besides high NO production by iNOS, drastic increase of nNOS expression in certain pathophysiologic conditions could promote excitotoxicity causing neuronal death . Interestingly, nNOS mRNA levels were significantly decreased in CX and HC of A20 KO, as compared to WT mice, with HT showing an intermediate phenotype (Figure 7A), while brain eNOS mRNA levels were comparable in all three genotypes (Figure 7A). Increased expression of iNOS in inflammatory conditions is often associated with increased levels of NADPH oxidase, the major enzymatic complex involved in the production of superoxide anion (O2-) . Increased NO levels, in the setting of oxidative stress, favors formation of highly reactive peroxynitrite (NO/O2) species, enhancing formation of the protein adduct, nitrotyrosine . Accordingly, we evaluated, by qPCR and Western blot, the expression level of the transmembrane catalytic subunit of NADPH oxidase, gp91phox. Our results show that gp91phox mRNA and protein levels were significantly higher in CX and HC of A20 KO as compared to WT and HT mice, with HT mice showing slightly higher levels then their WT littermates (Figure 7C and D). Combined increase of gp91phox and iNOS (hence likely NO) production in brains of A20 KO mice correlated with increased immunostaining for nitrotyrosine, indicating heightened levels of protein nitration, implying nitrosative stress (Figure 7B).
Loss of A20 increases oxidative/nitrosative stress in the brain. (A) iNOS, eNOS and nNOS, (C) NADPH oxidase gp91phox subunit and (E) Nrf2 mRNA levels in cerebral cortex (CX) and hippocampus (HC) of wild type (WT), A20 heterozygous (HT) and A20 knockout (KO) mice, measured by qPCR. Graphs show the statistical analysis of relative mRNA levels after normalization with βactin. Results are expressed as mean ± SEM of five to seven animals per genotype. (B) iNOS and nitrotyrosine (NTY) immunostaining (brown) in CX of A20 WT, HT and KO mice. Top images: Bar = 50 μm, magnification = 200x. Bottom images are close-up images of the area delineated by the black box in top images. (D) NADPH oxidase gp91phox subunit expression in CX and HC protein lysates of A20 WT, HT and KO brains evaluated by Western blot (WB). Housekeeping protein GAPDH was used as loading control for semi-quantitative densitometry as shown in the graph. Graph shows semi-quantitative densitometry data using GAPDH as loading control. Results are expressed as mean ± SEM for four animals per genotype. (F) Representative images of Nrf-2 (red) and 4′,6-diamidino-2-phenylindole (DAPI, nuclear staining, blue) immunofluorescence staining in HC of WT, HT and KO mice. Photomicrographs are representative of three animals per genotype. Top images: Bar = 50 μm, magnification = 200x. Bottom images are close-up images of the area delineated by the white box in top images.*P < 0.05 and **P < 0.01.
Oxidative stress in the brain is also regulated by the down-modulating effect of the transcription factor Nrf2. Nrf2 is activated in response to oxidative stress, and initiates the transcription of several antioxidant and cytoprotective genes [53, 54]. Nrf2 also antagonizes inflammation in the brain by negatively impacting NFκB activation . Accordingly, we checked whether A20 knockdown also increases inflammation and oxidative stress in the brain through impacting Nrf2 expression or function. Interestingly, our studies show increased Nrf2 mRNA and protein levels in A20 KO brains as compared to control (Figure 7E and F), possibly an attempt to contain oxidative stress. However, increased Nrf2 levels did not translate into any significant induction of Nrf2-dependent cytoprotective and antioxidant genes such as HO-1 in A20 KO brains, suggesting that A20 knockdown likely interfered with Nrf2 activation, precluding an adequate regulatory antioxidant response in these mice (Additional file 3: Figure S3). Altogether, our results indicate that heightened inflammation in the brain of A20 deficient mice associates with enhanced oxidative and nitrosative tissue damage.
Activation of brain EC and subsequent upregulation of adhesion and other pro-inflammatory molecules is an obligate corollary of heightened cerebral inflammation and oxidative stress, as noted in A20 KO mice . Indeed, we confirmed that mRNA levels of the EC specific and prototypic activation marker, the adhesion molecule E-selectin, were significantly increased in CX and HC of A20 KO mice, as compared to WT, with HT fairing in between (Figure 8A). Similarly, vascular immunostaining for the adhesion molecules ICAM-1 and VCAM-1 was much stronger in brain sections of A20 KO mice, as compared to the faint staining observed in WT mice, with HT mice showing an intermediate staining (Figure 8B). These results demonstrate that A20 deficiency also caused spontaneous basal endothelial cell activation in the brain. Inflammation may results in disruption of the blood brain barrier (BBB), which allows for increased cytokine access to the brain. To evaluate whether permeability of the BBB was affected in A20 deficient mice, we intravenously injected a 2% Evan's blue dye solution to A20 WT, HT and KO and measured the amount of dye that extravasated into the brain parenchyma. We also evaluated the integrity of the BBB by measuring serum levels of S100 calcium-binding protein β (S100β), an astrocyte molecule usually released into the peripheral circulation upon disruption of these cells' membrane integrity, and a good indicator of enhanced BBB permeability . Our results demonstrated that the integrity of the BBB was not altered in A20 deficient brains, despite their higher basal inflammation and EC activation levels (Additional file 4: Figure S4, Additional file 5: Supplementary Experimental Procedures).
Expression of adhesion molecules is increased in A20 deficient brain vasculature. (A) ICAM-1 and VCAM-1 immunohistochemistry (brown) in cerebral cortex (CX) of A20 wild type (WT), heterozygous (HT) and knockout (KO) mice. Black arrows indicate blood vessels. Photomicrographs are representative of three animals per genotype. Bar = 20 μm, magnification = 400x. (B) E-selectin mRNA levels in CX and hippocampus (HC) of A20 WT, HT and KO mice, measured by qPCR. Graph shows the statistical analysis of relative mRNA levels after normalization with βactin. Results are expressed as mean ± SEM for four to six animals per genotype. *P < 0.05, **P < 0.01 and ***P < 0.001.
Neurofilaments (NF) are intermediate filaments of the cytoplasmic scaffold that composes the axon cytoskeleton . Expression of NF proteins decreases in physiological and pathological conditions such as aging , AD , amyotrophic lateral sclerosis and MS. Accordingly, NF protein expression levels qualify as surrogate for neuronal response to injury. Despite the fact that reduction in NF proteins is generally well tolerated , it is associated with decreased axonal transport velocity . Brains of A20 KO mice showed significantly less immunostaining for NF (Figure 9), as compared to WT mouse brain. This is suggestive of axonal damage likely induced by chronic neuronal exposure to a pro-inflammatory environment. A20 HT mice showed an intermediate phenotype.
Loss of A20 decreases the expression of neurofilaments in mice cerebral cortex and hippocampus. Immunostaining for neurofilaments (NF) (brown) in cerebral cortex (CX) and hippocampus (HC) of wild type (WT), A20 heterozygous (HT) and A20 knockout (KO) mice. Photomicrographs are representative of three animals per genotype. Top images: Bar = 50 μm, magnification = 200x. Bottom images are close-up images of the area delineated by the black box in top images.
A20 is a ubiquitously expressed NFκB negative feedback regulator that is highly and rapidly induced in response to NFκB activation in most cell types and organs, including the human brain [25, 26]. We demonstrated basal A20 mRNA expression in the mouse CX and HC, the two brain structures that were the focus of this study, though the comparative distribution of A20 in the different brain regions varies between mice and humans . We verified that basal A20 mRNA levels in CX and HC decreased by half and were totally absent in brains of A20 HT and KO, respectively. Lower A20 levels correlated with higher NFκB activation in the brains of A20 KO mice.
The inflammatory phenotype of A20 KO mice, which are cachectic and die prematurely due to uncontrolled spontaneous inflammation in the liver, kidney, joints, intestines and bone marrow, has been previously characterized . However, it lacked an account of the impact of A20's deficiency on the brain. In this study, we fill this gap by showing for the first time that loss of A20 causes spontaneous cerebral inflammation, as demonstrated by robust microglial activation, reactive astrogliosis, endothelial activation, increased oxidative/nitrosative stress and expression of NFκB regulated pro-inflammatory soluble mediators such as IL-1β, TNF, IL-6 and MCP-1 in the brain.
By immunostaining, using F4/80 as microglia cell surface marker, we noted the presence of a significant number of hypertrophied microglia in A20 KO brain. This cell morphology, characterized by enlarged soma and thick cytoplasmatic projecting processes with few ramifications, is typical of microglia undergoing activation after CNS injury. This microglial phenotype contrasts with that of WT brain, which is ramified resting microglia, depicting radially long and thin projecting processes with fine ramifications. We confirmed microglial activation by demonstrating heightened A1 mRNA expression in the brains of A20 KO mice, as compared to WT. Expression of A1, a BCL2 gene family member, in the CNS is restricted to microglia, and is uniquely upregulated when these cells undergo activation [38, 39].
A20 KO brain also display enhanced astrogliosis, as morphologically evidenced by hypertrophy of astrocyte cell body and glial processes, together with increased expression of the intermediate filament GFAP, an early and sensitive biomarker of astrogliosis .
Furthermore, we documented in vitro that A20 deficient astrocytes and microglia are hyper reactive to inflammatory stimuli. Astrocytes isolated from A20 KO brain and A20-silenced primary mouse astrocytes and N13 microglia cells produced significantly higher amounts of IL-6 in response to inflammatory stimuli than WT and control cells. This accords with A20 being a negative feedback regulator of inducible NFκB-dependent genes, such as IL-6 , and corroborates work by Wang et al. showing enhanced TNF-mediated IκBα phosphorylation/NFκB activation in A20 KO astrocytes . IL-6 plays a dual role in the CNS. IL-6 KO mice that suffer compromised inflammatory responses, increased oxidative stress, impaired neuroglial activation and decreased lymphocyte recruitment, show a slower rate of recovery and healing in several models of neuroinflammatory, degenerative and traumatic brain injury . On the other hand, excessively high intracerebral IL-6 levels aggravate brain injury and damage by causing abnormal immune activation, decreased neurogenesis and differentiation of neural stem/progenitor cells into neurons .
A20 deficient astrocytes and microglia also produced significantly higher TNF and consequently higher IL-6 levels following engagement of the Toll-like receptor (TLR) signaling by LPS treatment. Altogether, our in vivo and in vitro data ascertain the critical role of A20 in regulating glial activation. In that regard, A20 deficient glia display a similar hyper-reactive pattern to A20 KO peritoneal macrophages, that is sustained IκBα degradation and higher TNF production in response to thioglycollate or LPS treatment . As a result of microglial activation and reactive astrogliosis, A20 deficient brains bathe in a heightened pro-inflammatory milieu, as evidenced by significantly higher expression of TNF, IL-1β, IL-6 and MCP-1 in CX and HC of A20 KO mice as compared to WT.
Upregulation of the NADPH oxidase subunit gp91phox and of the high throughput NOS, iNOS, is a distinctive hallmark of glial activation . Gp91phox deficient mice do not mount a robust ROS response following traumatic brain injury, and hence are relatively protected from cerebral damage . iNOS, on the other hand, seems to have a dichotomous role in the brain. While absence of iNOS could impair neurogenesis after stroke, suggesting importance for CNS repair , excessive expression of iNOS is generally deleterious, and accordingly, genetic or pharmacologic knockdown of iNOS reduces tissue damage and neuronal death in animal models of brain injury [69, 70]. Our data demonstrate that both gp91phox and iNOS expression are increased at baseline in the brain of A20 KO mice. This would result in heightened local production of NO and of O2-, generating highly toxic peroxynitrite radicals that promote protein nitration, particularly damaging to the CNS . Indeed, we observed increased nitrotyrosine immunostaining in A20 KO when compared to WT brains. Upregulation of gp91phox and iNOS gene expression in reactive astrocytes and microglia is NFκB-dependent [72, 73], explaining their enhanced cerebral levels in the absence of A20. Importantly, NFκB activation is also a downstream target of NADPH oxidase products , hence the self-feeding inflammatory and pro-oxidant spiral observed in A20 KO brain. In addition, our data also suggest that A20 KO brains are unable to mount an appropriate antioxidant response, as they fail to significantly upregulate the expression of antioxidant genes such as HO-1 despite Nrf2 upregulation, which further amplifies oxidative stress, possibly causing heightened axonal damage, as suggested by decreased immunostaining for neurofilaments in KO brains.
Activation and loss of brain EC is another feature of inflammation driven CNS injury . Maintenance of endothelial homeostasis and of the unique phenotype of the BBB depends on tight interaction between EC, perivascular glial cells and neurons via direct cell-cell contact or through soluble factors to maintain the BBB. Having demonstrated that A20 KO mice suffer important gliosis, we checked the status of brain EC in these mice. As anticipated, astrogliosis and microglial activation corresponded with overt EC activation in A20 KO brain vasculature, as demonstrated by increased expression of the adhesion molecules VCAM-1, ICAM-1 and endothelial specific E-selectin, as well as the chemokine MCP-1, although the latter may be a product of glial cells, in addition to EC . Increased endothelial activation in brains of A20 KO mice is in keeping with the well-documented anti-inflammatory and homeostatic function of A20 in EC [15, 76], and agrees with our recent data demonstrating that mere partial loss of A20 aggravates the inflammatory phenotype of the endothelium in a vascular allograft model of transplant arteriosclerosis (Lee et al., manuscript in preparation).
Notably, A20 KO mice analyzed in this work were not exposed to exogenous toxic substances, pathogens or surgical procedure, raising questions regarding the primary signals/mediators triggering spontaneous neuroinflammation in these mice.
Data demonstrating that spontaneous multi-organ inflammation observed in A20 KO mice resolves when the TLR adapter MyD88 is simultaneously knocked out (A20/MyD88 double knockout), implicate pathogen-associated molecular patterns from commensal bacteria in driving the inflammatory process . We hypothesize that similar mechanisms might drive spontaneous neuroinflammation in these mice. Indeed, the BBB may be breached in A20 KO and as a result, greater levels of LPS may cross the BBB and directly activate TLR expressing microglia. Alternatively, heightened EC inflammation and by consequence production of cytokines, [78, 79] would engage NFκB signaling and activate microglia . Activated microglia in turn would cause reactive astrogliosis , creating a paracrine and autocrine feedback loop whereby microglia- and astrocyte-derived factors would regulate each other, promoting a self-sustained pro-inflammatory environment. We favor the latter scenario as we failed to show any significant disruption of the BBB in A20 KO mice, at least at baseline.
In contrast to our observations in whole-body A20 KO mice, astrocyte, neuronal and neuroectodermal (astrocytes, neurons and oligodendrocytes) specific A20 KO do not cause spontaneous inflammation in the CNS . This suggests that A20 knockdown on microglia and/or brain EC is required to cause spontaneous inflammation of the CNS, which would agree with our hypothesis placing these two cell types at the initiation of the neuroinflammatory process. Whether specific A20 KO in any or both of these cells is sufficient to cause neuroinflammation, or whether A20 KO in all brain cells (microglia, astrocytes, neurons, oligodendrocytes, endothelial cells) is required to have the phenotype we observe remains to be determined.
Limited survival of A20 KO animals restricts our study in terms of gauging their responses in several animal models of cerebral diseases. On the other hand, our laboratory has evidence that A20 HT mice, that do not present any apparent signs of pathology, uncover a significant phenotype upon challenge. In particular, we have strong indication that partial hepatectomy, a benign procedure in WT mice, harbors high lethality in A20 HT mice (Studer et al., manuscript submitted). High lethality in these mice stems from inadequate liver regeneration that partly results from heightened inflammation. Accordingly, we set up to check the baseline brain phenotype of A20 HT mice. Interestingly, our findings show that partial loss of A20 results in mild cerebral inflammation, as demonstrated by a moderate yet consistent increase in pro-inflammatory and oxidative/nitrosative stress markers in the CX and HC of A20 HT mice. Those findings are highly significant, given recently described SNPs in the A20/TNFAIP3 locus, imparting decreased A20 expression or function (NFκB inhibition), that were linked with auto-immune and pro-inflammatory pathologies such as systemic lupus erythematosus, rheumatoid arthritis and multiple sclerosis [82, 83]. These 'risky' TNFAIP3 SNPs, akin to those seen in A20 HT mice, may cause low-grade inflammation in the brain, predisposing patients to neuroinflammation and neurodegenerative diseases.
Neuroinflammation in brains of A20 HT mice is bound to increase with aging, and possibly metabolic diseases such as diabetes. It is well documented that microglial cells in aging brains, including those of mice, demonstrate a sensitized phenotype, that is, they release higher amounts of pro-inflammatory mediators upon activation . In addition, our group has shown that A20 protein levels decrease in the context of diabetes, as a result of increased proteasomal degradation stemming from high glucose driven post-translational modifications, namely o-glycosylation and ubiquitination .
Altogether, our data uncover the cerebral phenotype of A20 deficient mice that suffer spontaneous neuroinflammation as depicted by heightened gliosis and endothelial cell activation, feeding into a spiral of local cytokine and chemokine production together with increased oxidative/nitrosative stress, all of which culminate in neuronal damage. Future studies using A20 HT as a model for chronic spontaneous low-grade neuroinflammation may help clarify the role of A20 in brain inflammation related to aging or metabolic diseases, as well as inflammatory neurodegenerative diseases such as PD, AD, stroke or trauma.
This work was supported by NIH/NHLBI and NIH/NIDDK; Contract grant numbers: R01 HL080130, R01 DK063275 to CF. CGS is the recipient of the Eleanor and Miles Shore 50th Anniversary Fellowship Program. RPG is the recipient of a fellowship award from the National Council for Scientific and Technological Development (CNPq), Brazil. HPM was supported by the Austrian Science Fund (FWF): J3398-BW23.
RPG and CGS designed and performed experiments, participated in the critical analysis and interpretation of the data, performed statistical analysis of the data and wrote the manuscript. EC carried out the immunoassays (IHC). HPM carried out silence RNA experiments. CF participated in the critical analysis and interpretation of the results, contributed reagents/materials tools and helped write the manuscript. AM generated and provided the A20 knockout mice. All authors read and approved the final manuscript.
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This invention relates to antisense oligonucleotides that target mRNAs in cells as substrates for the cellular enzyme RNase H and thereby cause specific degradation of the targeted mRNA. The oligonucleotides have three components: a RNase H activating region, a complementarity region and 3' and 5' ends. The invention optimizes each of the components to resist intracellular nucleases, to increase hybridization to target mRNA, to specifically inactivate target mRNA in cells, and to decrease cytotoxicity.
The present application claims priority to U.S. Provisional application Ser. No. 60/026,732, filed Sep. 26, 1996 by Tod M. Woolf.
Antisense polynucleotides are useful for specifically inhibiting unwanted gene expression in mammalian cells. They can be used to hybridize to and inhibit the function of an RNA, typically a messenger RNA, by activating RNase H.
The use of antisense oligonucleotides has emerged as a powerful new approach for the treatment of certain diseases. The preponderance of the work to date has focused on the use of antisense oligonucleotides as antiviral agents or as anticancer agents (Wickstrom, E., Ed., Prospects for Antisense Nucleic Acid Therapy of Cancer and AIDS, New York: Wiley-Liss, 1991; Crooke, S. T. and Lebleu, B., Eds., Antisense Research and Applications, Boca Raton: CRC Press, 1993, pp. 154-182; Baserga, R. and Denhardt, D. T., 1992, Antisense Strategies, New York: The New York Academy of Sciences, Vol. 660; Murray, J. A. H., Ed., Antisense RNA and DNA, New York: Wiley-Liss, 1993).
There have been numerous disclosures of the use of antisense oligonucleotides as antiviral agents. For example, Agrawal et al. report phosphoramidate and phosphorothioate oligonucleotides as antisense inhibitors of HIV. Agrawal et al., Proc. Natl. Acad. Sci. USA 85, 7079-7083 (1988). Zamecnik et al. disclose antisense oligonucleotides as inhibitors of Rous sarcoma virus replication in chicken fibroblasts. Zamecnik et al., Proc. Natl. Acad. Sci. USA 83, 4143-4146 (1986).
The principal mechanism by which antisense oligonucleotides affect the level of the target RNA is by activation of RNase H, which cleaves the RNA strand of DNA/RNA hybrids. Both phosphodiester and phosphorothioate-linked DNA activates endogenous RNase H, thereby cleaving the targeted RNA (Agrawal, S., et al., Proc. Natl. Acad. Sci. USA 87, 1101-5 (1990); Woolf, T. M., et al., Nucleic Acids Res. 18, 1763-9 (1990)). However, phosphodiester-linked DNA is rapidly degraded by cellular nucleases and, with the exception of the phosphorothioate-linked DNA, nuclease resistant, non-naturally occurring DNA derivatives do not activate RNase H when hybridized to RNA. While phosphorothioate DNA has the advantage of activating RNase H, phosphorothioate-linked DNA has non-specific cytotoxic effects and also has reduced affinity for RNA (Stein, C. A., et al., Aids Res Hum Retroviruses 5, 639-46 (1989); Woolf, T. M., et al., Nucleic Acids Res. 18, 1763-9 (1990); Kawasaki, A. M., et al., J. Med. Chem. 36, 831-41 (1993)).
Chimeric antisense oligos that have a short stretch of phosphorothioate DNA (3-9 bases) have been used to obtain RNase H-mediated cleavage of the target RNA (Dagle, J. M., et al., Nucleic Acids Res. 18, 4751-7 (1990); Agrawal, S., et al., Proc. Natl. Acad. Sci. USA 87, 1401-5 (1990); Monia, B. P. et al., 1993, J. Biol. Chem. 268, 14514) A minimum of 3 DNA bases is required for activation of bacterial RNase H (Futdon, P. J., et al., Nucleic Acids Res. 17, 9193-9204; Quartin, R. S., et al., Nucleic Acids Res. 17, 7235-7262) and a minimum of 5 bases is required for mammalian bacterial RNase H activation (Monia, B. P., et al., J. Biol. Chem. 268, 14514-14522 (1993)). In these chimeric oligonucleotides there is a central region that forms a substrate for RNase H that is flanked by hybridizing "arms," comprised of modified nucleotides that do not form substrates for RNase H. Alternatively, extracellular tests using a RNase H-containing HeLa cell extract have been reported wherein the RNase H activating region was placed on the 5' or 3' side of the oligomer. Specifically these tests reported that a 5' or 3' terminal RNase H activating region composed of phosphodiester 2'-deoxynucleotides joined to a methylphosphonate-linked complementarity region was fully active, but that a 5' terminal RNase H-activating region composed of phosphorothioate 2'-deoxynucleotides joined to a methylphosphonate-linked complementarity region was only partially active. See Col 10, U.S. Pat. No. 5,220,007 to T. Pederson et al.
2'-O-Methyl or 2'-fluoro modified nucleotides have been used for the hybridizing arms of chimeric oligos. Inoue, H., et al., 1987, Nucleic Acids Res. 15, 6131-48. The 2'-O-Methyl group increases the affinity of the oligomer for the targeted RNA and increases the activity of the oligomer in cell culture. However, 2'-O-Methyl bases with phosphodiester linkages are degraded by exonucleases and so are not suitable for use in cell or therapeutic applications of antisense. Shibahara, S., et al., 1989, Nucleic Acids Res. 17, 239-52. Phosphorothioate 2'-O-Methyl nucleotides are resistant to nucleases as shown in the uniformly phosphorothioate modified oligos described by Monia B. P., et al., 1993, J. Biol. Chem. 268, 14514-14522 and terminal phosphorothioate substituted, 2'-O-Methylribo-oligonucleotides, Shibahara, S., et al., 1989, Nucleic Acid Res. 17, 239-252. However, fully phosphorothioate substituted oligomers may cause non-specific effects including cell toxicity. Stein, C. A., et al., 1989, Aids Res. Hum. Retrov. 5, 639-646; Woolf, T. M., et al., 1990, Nucleic Acids Res. 18,1763-69; Wagner, R. W., 1995, Antisense Res. Dev. 5, 113-115; Krieg, A. M., & Stein, C. A., 1995, Antisense Res. Dev. 5, 241. The effects of 2'-Fluoro-oligonucleotides on bacterial RNase H are discussed in Crooke, S. T. et al., 1995, Bioch. J. 312, 599-608 and Iwai, S. et al., 1995, FEBS Lett (Neth.) 368, 315-20.
Several other chemistries have been used to make the "arms" or regions of a chimeric oligomer that are not substrates for RNase H. The first chimeric oligomers used methylphosphonate or phosphoramidate linkages in the arms (Dagle, J. M., Walder, J. A. & Weeks, K. L., Nucleic Acids Res. 18, 1751-7 (1990); Agrawal, S., et al., Proc. Natl. Acad. Sci. USA 87, 1401-5 (1990). While these compounds functioned well in buffer systems and Xenopus oocytes, the arms decreased the hybrid affinity. This decrease in affinity dramatically reduces the activity of oligomers in mammalian cell culture.
A number of studies have been reported for the synthesis of ethylated and methylated phosphotriester oligonucleotides and their physico-chemical and biochemical evaluation. Dinucleotides with methyl and ethyl triesters were shown to possess greater affinity towards polynucleotides possessing complementary sequences (Miller, P. S., et al., J. Am. Chem. Soc. 93, 6657, (1971)). However, a few years ago, another group reported lack of, or poor binding affinity of heptaethyl ester of oligothymidine with complementary polynucleotides (Pless, R. C., and Ts'O, P. O. P., Biochemistry 16, 1239-1250 (1977)). Phosphate methylated (P-methoxy) oligonucleotides were synthesized and found to possess resistance towards endonuclease digestion (Gallo, K. L., et al. Nucl. Acid Res. 18, 7405 (1986)). A P-methoxy 18-mer oligonucleotide was shown to have high Tm value in duplexes with natural DNA and blocked to the DNA replication process at room temperature (Moody, H. M., et al., Nucl. Acid Res. 17, 4769-4782 (1989)). Moody et al. stated that phosphate ethylated (P-methoxy) oligonucleotides would have poor antisense properties. P-methoxy dimers of DNA bases were synthesized using transient protecting group of FMOC for the exocyclic amino groups (Koole, L. H., et al., J. Org. Chem. 54, 1657-1664 (1989)).
Synthesis and physico-chemical properties of partial P-methoxy oligodeoxyribonucleotides were determined. Only the thymidine and cytidine oligomers with methyl phosphotriester could be prepared satisfactorily due to difficulty in maintaining methyl triester intact. Furthermore, the methyl group was found to have destabilizing effect on the hybridization properties of the modified oligomers with its complementary sequence by comparison with unmodified parent oligodeoxynucleotide (Vinogradeov, S., Asseline, U., Thoung, N. T., Tet. Let. 34, 5899-5902 (1993)).
Other reports have suggested that P-methoxy oligonucleotides are preferable to P-ethoxy as antisense olgionucleotides because of p-methoxy oligonucleotides showed stronger hybridization than methyl phosphonate or P-ethoxy oligonucleotides (van Genderen, M. H. P., et al., Kon. Ned. Akad. van Wetensch. B90, 155-159 (1987); van Genderen, M. H. P., et al., Trav. Chim. Pays Bas 108, 28-35 (1989)). P-ethoxy oligonucleotides were reported by van Genderen et al. to hybridize poorly to DNA, for which reason they were regarded unfavorably as antisense oligonucleotides (Moody, H. M., et al., Nucl. Acid Res. 17, 4769-4782 (1989)).
P-isopropoxyphosphoramidites have been synthesized from several nucleosides (Stec, W. J., et al., Tet. Let. 26, 2191-2194 (1985)), and a few short oligonucleotides containing P-isopropoxy phosphotriesters were synthesized, and hybridization studies were carried out.
U.S. Pat. No. 5,525,719 to Srivastava, S., and Raza, S. K., Jun. 11, 1996, suggests antisense oligonucleotides consisting of 2'-O-Methyl nucleotides linked by phosphodiester and/or P-ethoxy or P-methoxy, phosphotriester moieties.
Thus, currently there are no nucleic acid chemistries nor any chimeras that have been developed that optimally achieve all the features that are needed to provide an effective antisense oligonucleotide i.e. low toxicity, high specificity, nuclease resistance, ease of synthesis, RNase H compatibility.
The invention provides a class of oligonucleotide that is optimized to target a specific RNA for RNase H degradation and to be itself resistant to degradation within in plasma and within eukaryotic, especially mammalian cells. The oligonucleotides of the invention contain no naturally occurring 5'→3'-linked nucleotides. Rather, the invention provides oligonucleotides having two types of nucleotides: 2'-deoxyphosphorothioate, which activate RNase H, and 2'-modified nucleotides, which do not. The linkages between the 2'-modified nucleotides can be phosphodiesters, phosphorothioate or P-ethoxyphosphodiester. Activation of RNase H is accomplished by a contiguous, RNase H-activating region, which contains between three and five 2'-deoxyphosphorothioate nucleotides to activate bacterial RNase H and between five and ten 2'-deoxyphosphorothioate nucleotides to activate eukaryotic and, particularly, mammalian RNase H. Protection from degradation is accomplished by making the 5' and 3' terminal bases highly nuclease resistant and, optionally, by placing a 3' terminal blocking group.
In a preferred embodiment the RNase H activating region, which is composed of highly nuclease resistant phosphorothioate nucleotides is placed at the 5' end of the oligonucleotide.
An oligonucleotide of the invention is comprised of a 3'-terminal 5'→'-linked nucleoside and from 11 to 59 5'→3' linked nucleotides, which nucleotides can be 2'-deoxynucleotides or 2'-modified nucleotides, modified to enhance the hybridization of the oligonucleotide to the target mRNA, such as 2'-fluoro, 2'-methoxy, 2'-ethoxy, 2'-methoxyethoxy, 2'allyloxy (--OCH2 CH═CH2) nucleotides (hereinafter "2'-modified nucleotides"). The 3' terminal nucleoside can, optionally, be 2'-modified nucleoside. Those skilled in the art appreciate that the 3'-OH of the 3' terminal base can but need not be esterified to a phosphate or phosphate analog. The 3' terminal residue is referred to as a nucleoside even though it may be a nucleotide.
The internucleotide linkages of an oligonucleotide of the invention can be phosphodiester, phosphorothioate or P-ethoxyphosphodiester moieties. The oligonucleotide has a 3' terminus and a 5' terminus that are protected from nuclease attack. The 3' terminus is protected by having the 3' most 5'→3' linkage or linkages be a phosphorothioate or a P-alkyloxyphosphotriester linkage and/or by having a substituted 3' terminal hydroxyl, e.g., a 3'→3' linked nucleotide, wherein the alkyloxy radical is methoxy, ethoxy or isopropoxy and, preferably, ethoxy. Preferably two or three 3' terminal internucleotide linkages are phosphorothioate or a P-alkyloxyphosphotriester linkages. To reduce nuclease degradation, the 5' most 3'→5' linkage preferrably should be a phosphorothioate linkage or P-alkyloxyphosphotriester linkage. Preferrably, the two 5' most 3'→5' linkages should be phosphorothioate linkages or P-ethoxyphosphotriester linkages. Optionally, the 5'-terminal hydroxyl moiety can be esterified with a phosphorus containing moiety, e.g., phosphate, phosphorothioate or P-ethoxyphosphate, without limitation.
The 3' terminal 5'→3'-linked nucleoside has a 3'-O that can be optionally substituted by a blocking moiety that prevents 3'-exonuclease degradation of the oligonucleotide. In one embodiment, the 3'-hydroxyl is esterified to a nucleotide through a 3'→3' internucleotide linkage. Optionally, the 3'→3' linked nucleotide at the 3' terminus can be linked by a phosphorothioate moiety.
In a preferred embodiment, the oligonucleotide contains, exclusive of an optional blocking nucleotide, between 15 and 50 bases and more preferably between 20 and 30 bases and in a most preferred embodiment the oligonucleotide is 25 bases in length. The oligonucleotide of the invention contains a single contiguous RNase H-activating region of between three to ten 2'-deoxyphosphorothioate nucleotides. The length of the RNase H activating region to activate bacterial RNase H is preferably between three and five nucleotides; to activate a eukaryotic RNase H it is between five and ten nucleotides. The preferred length of the RNase H-activating region for the activation of mammalian RNase H is nine nucleotides.
All 5'→3' linked nucleotides of the oligonucleotide that are not a part of the RNase H-activating region are 2'-modified nucleotides, which contribute to the target binding and form the complementarity determining region. The complementarity region can be a contiguous region or can be divided by the RNase H-activating region. In the preferred embodiment the complementarity region is a contiguous region, and more preferably is 3' to the RNase H-activating region.
In a preferred embodiment all bases except the from one to three 3' most nucleotides and nucleoside, the 5' terminal nucleotide and RNase H activating region nucleotides are phosphodiester linked. Large amounts of contiguous phosphorothioate linkages are detrimental to the function of the oligonucleotides of the invention. Preferably, therefore, the oligonucleotides contain not more than ten contiguous phosphorothioate linkages.
The oligonucleotides of the invention can be synthesized by solid phase or liquid phase nucleotide synthesis, however, synthesis by solid phase techniques is preferred. Phosphodiester and phosphorothioate linked oligonucleotides can be synthesized, using standard reagents and protocols, on an automated synthesizer utilizing methods that are well known in the art, such as, for example, those disclosed in Stec et al., J. Am. Chem. Soc. 106, 6077-6089 (1984); Stec et al., J. Org. Chem. 50(20), 3908-3913 (1985); Stec et al., J. Chromatog. 326, 263-280 (1985); LaPlanche et al., Nuc. Acid. Res. 14, 9081-9093 (1986); and Fasman, G. D., Practical Handbook of Biochemistry and Molecular Biology 1989, CRC Press, Boca Raton, Fla., herein incorporated by reference.
The synthesis of 2'-O-alkyl-oligoribonucleotides, where the alkyl groups are methyl, butyl, allyl or 3,3-dimethylallyl is reviewed by Lamond, Biochem. Soc. Trans. 21, 1-8 (1993). Intermediates that are useful in the synthesis of 2'-O-methyl oligoribonucleotides are described in U.S. Pat. No. 5,013,830, No. 5,525,719 and No. 5,214,135, which are hereby incorporated by reference.
The synthesis of 2'-fluorophosphodiester and 2'-fluorophosphorothioate oligonucleotides can be performed according to teaching of Kawasaki, A. M., et al., 1993, J. Med. Chem. 36, 831-41 and WO 92/03568; the synthesis of P-alkyloxyphosphotriester-linked oligonucleotides and 2'-modified oligonucleotides can be performed according to U.S. Pat. No. 5,525,719, each of which is incorporated herein by reference. The synthesis of phosphorothioate oligodeoxynucleotides is taught by U.S. Pat. No. 5,276,019 and No. 5,264,423, which is hereby incorporated by reference. Synthesis of 2'-substituted oligonucleotides can be performed by variations on the techniques disclosed therein.
The synthesis of the oligonucleotides of the invention must be conducted with great attention to quality control. It is particularly important that the phosphorothioate linkages not be contaminated with phosphodiester linkages. It is advisable to pre-test the individual reagent lots to ascertain that high coupling efficiency can be obtained therewith and to exercise all possible precautions to maintain anhydrous conditions.
The quality of the synthesis of oligonucleotides can be verified by testing the oligonucleotides by capillary electrophoresis and denaturing strong anion HPLC (SAX-HPLC). The method of Bergot & Egan, 1992, J. Chrom. 599, 35-42 is suitable. SAX-HPLC is particularly useful to verify that the phosphorothioate nucleotides are completely thiolated, i.e., are not contaminated by a small percentage of phosphodiesters.
The synthesis of oligonucleotides having both phosphodiester and phosphorothioate linkages is associated with a side reaction whereby the phosphorothioate linkages are oxidized by the standard I2 treatments that are used to oxidize the cyanoethyl phosphoramidite. This problem can be minimized but not eliminated by reducing the concentration or I2 to as low as 0.001M. Therefore, in a preferred embodiment, all phosphorothioates of the oligonucleotides of the invention are found at the 5'-end, so that no phosphorothioate bond is exposed to I2.
The oligonucleotides of the invention can be used as antisense oligonucleotides in a variety of in vitro experimental situations to specifically degrade an mRNA of unknown function and thereby determine its physiologic function.
The oligonucleotides of the invention can be also used in clinical practice for any disease and against any target RNA for which antisense therapy is now known to be suitable or which is yet to be identified. Medical conditions for which antisense therapy is reported to be suitable includes Respiratory Syncytial Virus infection, WO 95/22553 by Kilkuskie, Influenza Virus infection, WO 94/23028, and malignancies, WO 94/08003. Further examples of clinical uses of antisense oligonucleotides are reviewed, in summary form, in Glaser, V., 1996, Genetic Engineering News 16, 1. Targets of antisense oligonucleotides under that are the subjects of clinical trials include protein kinase Cα, ICAM-1, c-raf kinase, p53, c-myb and the bcr/abl fusion gene found in chronic myelogenous leukemia.
Plasmid Constructs. The plasmid used for the studies contained a portion of the ras gene sequence fused to luciferase (Monia, B. P., et al. J. Biol. Chem. 267, 19954-19962 (1992)). The control luciferase plasmids did not contain the ras target sequence.
Cell Culture Assay. HeLa cells were grown to 40-90% confluence in DMEM/10% FBS, Supplemented with glutamine, penicillin and streptomycin on gelatin coated 24 well plates. The gelatin coating was necessary for cell to remain adherent during the transfections. Prior to transfection the cells were washed twice with PBS (containing magnesium and calcium). LIPOFECTIN™ was mixed gently and 6.6 μl was added for each milliliter of reduced serum medium (OPTI-MEM™, Gibco/BRL, Gaithersberg, Md.). Oligomers were added from 50-100 μM concentrated stock to make a master mixture. The Opti-MEM/LIPOFECTIN/oligomer solution was added to the cells and incubated for 4 hours (≈0.5 mls for one well of a 24 well plate).
A target transfection mixture was prepared by first diluting 5 μl of lipofectin per ml of OPTI-MEM and mixing. Next 5 μg of luciferase target and 5 μg of CMV β-galactosidase were added per milliliter of OPTI-MEM/LIPOFECTINT™ mixture. The transfection mixture was mixed gently and allowed to complex for about 15 minutes. The master mixture reduced error by assuring that the control and experimental cells received the exact same cationic lipid/plasmid complex. The concentration of oligonucleotide in the culture medium was between 200 nM and 400 nM in all experiments. The oligonucleotide containing media was removed from the cells and replaced with growth media and incubated for an additional 9-18 hours. The cell were rinsed with calcium and magnesium free media and the media was removed. The plates were frozen at -70 for >20 minutes and 100-300 μl of reporter lysis buffer (Promega, Madison Wis.) was added.
The cells were put through 2 more freeze thaw cycles, to assure complete lysis. Luciferase assays were preformed according to the manufacture's instructions (Promega, Madison Wis.) and luminescence was detected with a 96 well luminometer (Packard, Meriden Conn.). β-galactosidase assays were preformed (Galacton Plus, Tropix) according to manufactures instructions and detected on the Packard luminometer.
The results of luciferase assay are presented in Table I below. The results are reported as the percent specific inhibition which were calculated as 100×(1- (LUCT /LUCC)OLIGO /(LUCT /LUCC)NO OLIGO); wherein LUCT and LUCC are the luciferase levels found in the cells transfected with luciferase plasmids containing and lacking the ras gene insert (SEQ ID NO: 1); and the superscripts "Oligo" and "No Oligo" refer to the presence and absence of antisense oligonucleotides.
TABLE I______________________________________ SpecificOligo Formula inhibition______________________________________Controls ("C")C1 25Mo 26%C2 25Ms 15%C3 9Ds16Mo 15%C4 9Do16MoInVT 0%C5 9Dp16MoInVT 18%C6 9Dp13Mo3Ms 14%Controls with all "S"S1 25Ds 93%S2 16Ms8DsD 100%S3 8Ms9Ds7MsM 97%S4 9Ds15MsM 95%9Ds at 3' end ("3'I")3'I1 InvTMs15Mo9DsInvT 59%3'I2 2Ms14Mo9DsInvT 57%3'I3 4Ms12Mo9DsInvT 65%9Ds in Middle ("MI")MI1 5Ms3Mo9Ds4Mo3MsM 64%MI2 2Ms6Mo9Ds7 (MsMo) InvT 71%MI3 3Ms6Mo9Ds6MoMsInvT 87%9Ds at 5' end ("5'I")5'I1 9Ds16MoInvT 83%5'I2 9Ds15MoMsInvT 85%5'I3 9Ds16MoBiotin 90%5'I4 9Ds16Mp 91%5'I5 9Ds14MoMpD 90%5'I6 9Ds13Mo2MpD 94%5'I7 9Ds12Mo3MpD 94%5'I8 9Ds14MoMsD 93%5'I9 9Ds13Mo2MsD 97% 5'I10 9Ds12Mo3MsD 95%______________________________________ Key: M and D refer to 2'Omethyl- and 2'deoxyribonucleotides, respectively The letters "o", "s" and "p" refer to phosphodiester, phosphorothioate diester, and Pethoxy-phosphotriester linked nucleotides. "InvT" referes t a 3'→3' or 5'→5' linked thymidine at the 3' or 5' end, respectively.
Table I shows the results of control oligos C1-C6, all phosphorothioate oligos S1-S4, and oligos of the invention having the RNase activating region at the 3' end (3'I1-3'I3), in the middle (MI1-MI3) and at the 5' end (5'I1-5'I10). Control oligos C1, C2, C5 and C6 showed low levels of specific inhibition because these oligos lacked an RNase H activating region. Oligos C3 and C4 were inactive because the 3' was unprotected and because native ssDNA was unstable, respectively. All phosphorothioate oligonucleotides (S1-S4) showed specific inhibitions that ranged between 93% and 100%, as did oligonucleotides 5'I6-5'I10, which have a 5'-located RNase H activating region and two or three 3' terminal 2'O-methyl modified P-ethoxy or phosphorothioate linked nucleotides (Mp and Ms, respectively). Lower levels of specific inhibition were observed when oligonucleotides with 3' and mid-located RNase H activating regions were employed or when suboptimal 3' protecting groups were present.
Although the oligonucleotides of the invention having 5' RNase activating regions achieved specific inhibitions which were comparable to that achieved by the uniform phosphorothioate oligonucleotides, the oligonucleotides of the invention were superior in that their use was associated with significantly less toxicity. Table II shows specific inhibition, the average metabolic activity as percent of no oligo control, as determined by MTS assay, and the percent viable cells, as determined by trypan blue exclusion for the conventional ("C"), all phosphorothioate ("S"), 3'I, MI and 5'I oligonucleotides, as well as for three species.
The best oligos on the chart have high percentage values in all columns.
The results demonstrated that the oligonucleotides of the invention achieve levels of specific inhibition more than four times greater than conventional oligonucleotides while showing toxicity levels that were substantially less than the phosphorothioate oligonucleotides. The optimal group, 5'I, showed specific inhibition that was comparable to the phosphorothioate oligonucleotides.
The cause of lower specific activity observed for the 3'I and MI type oligonucleotides was investigated. One possibility was that the oxidation steps using 0.02M I2 cause the oxidation of the phosphorothioate linkages to phosphodiester, when phosphodiester linked nucleotides were added 5' to the phosphorothioate linkages. This was found to be the case. Comparison of oligonucleotides 9DS 15DO D ("5'S") and 15DO 9DS D ("3'S") oligonucleotides having the sequence of the test oligonucleotide by analytical HPLC analysis showed that about 85% of the 5'S oligonucleotides were fully thiolated, by contrast only 26% of the 3'S oligonucleotides were completely thiolated (36% were S-1, 24% S-2 and 14% S-3).
Table III shows the distribution of fully thiolated and mono, di and tri-oxidized by-products as a function of the position of the phosphorothiolated region of the oligonucleotide. Four thymidyl pentadodecamers were synthesized using 0.02M I2 as the oxidant for 15 nucleotides and a thiolating agent for nine nucleotides.
The results demonstrated that 96% of the 5'S oligonucleotides are fully thiolated, which percentage steadily decreases as the phosphorothioate region is exposed to more frequent oxidation reactions. When the oxidant concentration was reduced to 0.001M, 78% fully thiolated 3'S 25-T oligonucleotides and about 60% of oligonucleotides having the sequence of the SEQ ID NO: 1 were synthesized.
the 3' terminus of said oligonucleotide is drawn from the group consisting of: an inverted deoxyribonucleotide, a contiguous stretch of one to three phosphorothioate 2'-modified ribonucleotides, a biotin group, and a P-alkyloxyphosphotriester nucleotide.
2. The oligonucleotide of claim 1, provided the 3' terminus is not blocked by a 3'→3' phosphorothioate linked nucleotide.
3. The oligonucleotide of claim 1, in which the 3' terminus is blocked by a moiety comprising a 3'→3' phosphorothioate linked nucleotide.
4. The oligonucleotide of claim 1, in which the 3' terminus is blocked by a moiety comprising a 3'→3' phosphodiester linked nucleotide.
5. The oligonucleotide of claim 4, in which the 3' most 5'→3' internucleotide linkage is a phosphorothioate linkage or a P-ethoxyphosphotriester linkage.
6. The oligonucleotide of claim 4, in which the 5' most 5'→3' internucleotide linkage is a phosphorothioate linkage or a P-ethoxyphosphotriester linkage.
7. The oligonucleotide of claim 1, in which the 3' terminal nucleoside and the 5' most nucleotide are 2'-modified nucleotides.
8. The oligonucleotide of claim 1, in which the RNase H activating region comprises the 5' most nucleotide.
9. The oligonucleotide of claim 8, in which the 3' most 5'→3' internucleotide linkage is a phosphorothioate linkage or a P-ethoxyphosphotriester linkage.
10. The oligonucleotide of claim 9, in which the two 3' most 5'→3' internucleotide linkages are independently either a phosphorothioate linkage or a P-ethoxyphosphotriester linkage.
11. The oligonucleotide of claim 9, in which all phosphorothioate linkages are contiguous with the 5' most 5'→3' internucleotide linkage.
12. The oligonucleotide of claim 11, in which the 2'-modified nucleotide is a 2'-methoxy or 2'-fluoro nucleotide.
13. The oligonucleotide of claim 11, which comprises at least thirteen 2'-methoxy phosphodiester nucleotides.
14. The oligonucleotide of claim 11, having between 15 and 50 nucleotides.
15. The oligonucleotide of claim 14, which comprises at least eight 2'-methoxy phosphodiester nucleotides.
16. The oligonucleotide of claim 14, which comprises at least thirteen 2'-methoxy phosphodiester nucleotides.
17. A chimeric antisense oligonucleotide, comprising: a 5' terminus; a 3' terminus; and from 11 to 59 5'→3'-linked nucleotides independently selected from the group consisting of 2'-modified phosphodiester nucleotides, and 2'-modified P-alkyloxyphosphotriester nucleotides; and wherein said 3' terminal nucleoside is attached to an RNase H-activating region of between three and ten contiguous phosphorothioate-linked deoxyribonucleotides, and wherein the 5' terminus of said oligonucleotide is drawn from the group consisting of: an inverted deoxyribonucleotide, a contiguous stretch of one to three phosphorothioate 2'-modified ribonucleotides, a biotin group, and a P-alkyloxyphosphodiester nucleotide.
18. The oligonucleotide of claim 1, in which the 2'-modified nucleotides are selected from the group consisting of 2'-fluoro and 2'-methoxy nucleotides.
19. The oligonucleotide of claim 1, in which there are no 2'-modified phosphorothioate nucleotides.
the 3' terminus of said oligonucleotide is drawn from the group consisting of: an inverted deoxyribonucleotide, a contiguous stretch of one to three phosphorothioate deoxyribonucleotides, phosphorothioate 2'-modified ribonucleotides, a biotin group, and a P-alkyloxyphosphodiester-linked nucleotide.
c) an exonuclease blocking group present at the 3' end of the oligonucleotide that is drawn from the group consisting of: a non-5'-3' phosphodiester-linked nucleotide, from one to three contiguous 5'-3'-linked modified nucleotides, and a non-nucleotide chemical blocking group.
22. The oligonucleotide of claim 21, wherein said non-5'-3' phosphodiester-linked nucleotide is drawn from the group consisting of: a 3'--3'-linked nucleotide, a phosphorothioate 2'-modified ribonucleotide, and a P-alkyloxyphosphodiester-linked nucleotide.
23. The oligonucleotide of claim 21, wherein said chemical non-nucleotide chemical blocking group is biotin.
De Mesmaeker et al. Current Opinion In Structural Biology 1995, 5:343-355.
Gewirtz et al. Science 93;3161-3163 (1996).
Moulds et al. Biochemistry 34:5044-5053 (1995).
EP2436784A1 (en) 2006-07-13 2012-04-04 The Ohio State University Research Foundation MIR-203 for diagnosing poor survival prognosis colon adenocarcinoma.
EP2436785A1 (en) 2006-07-13 2012-04-04 The Ohio State University Research Foundation MIR-29a for diagnosing poor survival prognosis colon adenocarcinoma.
EP2436783A1 (en) 2006-07-13 2012-04-04 The Ohio State University Research Foundation MIR-103-2 for diagnosing poor survival prognosis colon adenocarcinoma.
EP2436782A1 (en) 2006-07-13 2012-04-04 The Ohio State University Research Foundation Mir-106a for diagnosing poor survival prognosis colon adenocarcinoma.
Agrawal et al. 1990 Site-specific excision from RNA by RNase H and mixed-phosphate-backbone oligodeoxynucleotides.
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As our understanding and ability to manipulate stem cells grows, they are becoming increasingly used in clinical applications. Researchers outlined potential uses of mesenchymal stem cells in tissue regeneration and treatment of autoimmune disorders.
Stem cells represent a new, promising treatment method that may offer ways to treat previously incurable diseases. In a new paper published in Dental Clinics of America, Mao et al. outlined ways stem cells could be used in dental applications. Their main benefit is that they are undifferentiated, meaning they can turn into different cells depending on their environment or produce more stem cells depending on the needs of the body. Their ability to differentiate into different cell types, or their potency, makes them very versatile in regards to their treatment methods.
There are several types of stem cells, one of which is the mesenchymal stem cells (MSC). MSCs were first found in the bone marrow as cells that had the capacity to differentiate into a number of cell types. While they are still primarily gathered from the bone marrow, MSCs have been identified in almost all tissues, with different properties depending on tissue of origin. These differences mean that MSCs derived from different tissue origins may have different clinical applications.
Key characteristics of MSCs include their self-renewal abilities, potency, and interaction with the immune system. Adult cells are limited in their replication by the length of their telomeres, which are repeating lines of genetic code at the end of a chromosome. With each replication, bits of telomere are cut off, and below a critical level, the cell goes into apoptosis, or cell death. MSCs are able to express telomerase, which regenerates its telomeres, allowing for greater replication before cell death. They are also able to differentiate into a broad variety of tissue types, allowing for application in various parts of the body. Also, when interacting with the immune system, MSCs act in a regulatory fashion. They suppress the immune system through interaction with various cells, leading to research in applications towards treatment of autoimmune disorders.
As noted earlier, MSCs derived from different parts of the body display different characteristics. This remains true for dental pulp stem cells (DPSCs), taken from the centre of the tooth. Compared with bone marrow stem cells, they have greater proliferative properties and have a dentin-like structure formation that is particularly helpful in tooth treatments. They have also shown similar immunosuppressive properties when compared with bone marrow stem cells. These properties allow for DPSCs to be used in biotooth/bioroot engineering, periodontal defect regeneration, dentin-pulp regeneration and treatment of autoimmune diseases such as systemic lupus erythematosus, systemic sclerosis and osteonecrosis of the jaw.
While stem cells appear promising, further research needs to be conducted before they are ready for clinical application. Scientists must continue to investigate the function of MSCs in the immune system and the mechanisms behind their self-renewal and potency to be able to most efficiently manipulate these properties in cell-based treatments.
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3 unusual sources for scientific inspiration
Mazbahul G. Ahamad
Recent Journal Articles:
Relationships among college-level science course enrollment, environmental perception, and pro-environmental attitude: Evidence from the US General Social Survey, Environmental Challenges 2021; 5:100389.
Relationships among toilet sharing, water source locations, and handwashing places without observed soap: A cross-sectional study of the richest households in Bangladesh, Environmental Health Insights 2021; 15:1–6.
Mental model-based repeated multifaceted (MRM) intervention design: A conceptual framework for improving preventive health behaviors and outcomes, BMC Research Notes 2021; 14:103.
Estimation of household smoke-exposure risk using Demographic and Health Survey (DHS) data, MethodsX 2021; 101390.
Household smoke-exposure risks associated with cooking fuels and cooking places in Tanzania: A cross-sectional analysis of demographic and health survey data, International Journal of Environmental Research and Public Health 2021; 18 (5): 2534.
Officially confirmed COVID-19 and unreported COVID-19–like illness death counts: An assessment of reporting discrepancy in Bangladesh, American Journal of Tropical Medicine and Hygiene 2021; 104 (2): 546–548.
Recent Journal Abstracts:
Public search interests related to COVID-19: Insights from Google search trends in Bangladesh. International Journal of Infectious Diseases (forthcoming).
Household smoke-exposure risk from cooking fuels and cooking locations in Tanzania: A cross-sectional analysis of nationally representative survey data. Lancet Global Health, 8, S30.
Selected Under Review/Ongoing Research:
The association between social and ecological vegetation transition indicators in the US Great Plains states (with D. Uden, C. Allen, & et al.).
Immediate and long-term impacts of wildfire on woody encroachment in the US Great Plains and appropriate time to apply conservation approaches.
Public search interests related to COVID-19: Insights from Google Search Trends in Bangladesh (with M. Ahmed, & D. Uden).
The impact of health education on pastoralists' water treatment and handwashing behaviors in Tanzania (dissertation chapter).
Self-rated and social determinants of health spending attitudes in the United States (with F. Tanin).
Behavioral strategies and residential water conservation: A meta-regression analysis of field experiments (with M. Burbach).
Pastoralists' water treatment, sanitation, and hygiene (WASH)-related preventive health behaviors in Tanzania (dissertation chapter).
Beliefs, attitudes, norms, and environmental/public health intentions: Longitudinal evidence from the USA.
Selected Op-Eds:
3 unusual sources for scientific inspiration, Elsevier Connect.
Why is "controlled corruption" indispensable for Bangladesh's development? Medium.
Bad policy or wrong priority: Why public health policy fails? The Business Standard.
Facilitating strategic medical equipment production, Financial Express.
Philosophy about the Doctor of Philosophy, Behavioural and Social Sciences at Nature Research.
© 2016-2022 Mazbahul Ahamad
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Implementing a "One Stop" Consultant Led Ultrasound and Fine Needle Aspiration Service for Thyroid Lumps
John Rocke Vijay Pothula Baskaran Ranganathan Nirmal Kumar*
Department of Otolaryngology-Head & Neck Surgery, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
*Corresponding author: Nirmal Kumar, Department of Otolaryngology-Head & Neck Surgery, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK, E-mail: [email protected]
The British Thyroid Association has recently aimed to clarify the management of thyroid lumps. They released guidelines, in 2014, recommending Ultrasound (US) examination in all thyroid lesions and Fine Needle Aspiration Cytology (FNAC) if positive findings are localised. Grading systems for both US and FNA were introduced allowing the clinician to compare these results with clinical findings and determine the most appropriate next step. The current target is 62 days for potential malignant disease from urgent referral to the first definitive treatment.
We implemented a "One-Stop" Consultant led US and FNAC service for patients presenting with thyroid lesions to streamline our service and ensure this target is reached. Following this introduction we significantly increased the quality of USS grading and the number of successful FNAC investigations.
Led ultrasound; Fine needle aspiration; Thyroid lumps
Fine Needle Aspiration Cytology (FNAC) allows risk stratification of thyroid nodules according to cytological appearances. The British Association of Endocrine and Thyroid Surgeons (BAETS) 4th National Audit on Thyroid and Endocrine Surgery (2012) recommended the use of a Thy Classification for cytological staging [1]. Recent British Thyroid Association (BTA) guidelines (2014) on the management of thyroid cancer introduced an US classification based on characteristic features of thyroid nodules (Figure 1) which aimed to help clinician's grade thyroid lesions radiologically [1]. Ultrasound helps differentiate benign from malignant nodules and guides FNAC of suspicious nodules.
Figure 1: U-Classification [1]
The U Classification sets out a clear guide for radiologists and ultrasonographers to follow. It allows the classification and staging of a large variety of thyroid lesions and pathology in to five groups ranging from U1 (normal) to U5 (malignant). This combined with FNAC staging will shape the outpatient based investigation of thyroid lumps and the extrapolation of their malignant potential.
While this guidance produced a welcome standardised framework for clinicians it also posed a challenge for service provision. The guidance increased the workload for Ultrasonographers and Cytologists as all thyroid lesions now require FNAC. By adding extra diagnostic steps this also increased the challenge to formulate a management plan within the 62 day waiting time target recommended by National Health Service England [2].
Similar challenges have been faced in other specialities. Breast surgery is perhaps the most familiar example where triple assessment of a breast lump is taught at both undergraduate and postgraduate level. Its success at coalescing clinicians in different specialities to operate one clinic directed at clinical, radiographic and cytological staging in a single patient visit has been widely recognised and adopted across centres internationally as standard practice.
Despite the guidelines from the British Thyroid Association being introduced over two years ago there have been no published examples of Otolaryngologists replicating the success of our colleagues in other specialities who run multifaceted clinics. Where larger specialist units, at teaching hospitals, have a larger population base and therefore a greater number of patients with Thyroid lesions presenting to their clinics, a more economically viable scenario for a one-stop clinic is created. At smaller centres it is often more difficult to find the resources needed to implement "standard" practice once it has been released by the associations and societies.
To streamline services, in our District General Hospital, we implemented a Consultant led "one-stop" clinic for Thyroid lesions in an attempt to pair our Ultrasound and FNAC facilities to create more accurate results. While guidance recommends Ultrasound and FNAC for all thyroid lesions it does not suggest how this should be implemented in the clinical environment. In all of the BTA guidance's 136 pages there is no mention of a "one-stop" clinic.
While the one-stop clinic for thyroid lesions is now regarded as a goldstandard for clinical practice amongst Head and Neck specialists there is only one published example that has assessed its feasibility and efficiency and no studies within the United Kingdom or in smaller units [3]. This study aims to provide our experience in implementation of a one-stop patient journey for patients presenting with thyroid lesions.
Our hospital trust Wrightington, Wigan and Leigh, is made up of several district general hospitals and satellite clinic areas. The head and neck service is largely run by one Consultant ENT surgeon in a clinic supported by trainees. Before the implementation of the new clinic FNAC was undertaken by these clinicians exclusively who also assessed their adequacy. Patients were then referred for an USS scan and subsequently reviewed in clinic.
In our new clinic patients with thyroid lesions are assessed by the Ear, Nose and Throat (ENT) clinician and then are referred to a Consultant Radiologist, who undertakes FNAC. A technician is then employed to assess for cytological adequacy and a repeat can be undertaken immediately if a sample is deemed insufficient. The lump is graded using ultrasound by the Consultant radiologist immediately. Cytological specimens are sent from the clinic to a Cytologist as at present there is no personnel available to attend within the clinic setting. This means that our patients usually require a follow up appointment if FNAC is undertaken.
Data was collected from our clinical records and electronic reporting databases. We searched for data specifically relating to the clinician performing FNAC, the dates of initial consultation, FNAC and the date of diagnosis for the calendar year of 2015; during which the one-stop clinic was implemented (August).
This provided 103 patients who had attended our Head and Neck clinic and undergone FNAC. For the purpose of this investigation we specifically analysed FNAC targeted at thyroid lesions which meant 76 patients were excluded from analysis at this stage. This left 27 patients who had undergone thyroid FNAC; 16 before implementation and 11 post implementation of the one-stop clinic set up.
We used simple analysis software (Microsoft Excel and Graph Pad Prism) to compare results before and after the clinic implementation date. By recruiting a specialist radiologist to perform FNAC in the clinic, rather than an ENT clinician who sporadically performs this technique, we hypothesised that they would be able to target suspicious lesions more appropriately and accurately
We first assessed if the rate the USS images were staged pre and post clinic implementation date according the BTA guidelines U classification. We then assessed if the adequacy rate of the FNAC samples changed. Finally the time taken for diagnosis and the number of clinic visits required was investigated for significant change.
The mean age of patients examined before the one-stop set up was 61 years compared to 57 years in the after one-stop set up, 75% of patients were female and 25% male pre-implementation with 91% female and 9% male following.
In the first group of patients, before the new clinic set up, all but one of the patients underwent USS examination at some point following the initial consultation but 5 patients who underwent USS were not staged using the BTA U classification.
The staging rates are outlined in table 1. We compared results, pre and post clinic introduction, using a Chi-Squared test (p=0.02). Similarly prior to implementation of the One-Stop clinic just 44% of the initial thyroid FNAC were adequate for analysis. Following the introduction of the new service diagnostic yield increased to 100%. We again compared these results using a Chi-Squared test (p=0.002) and the results are outlined in table 2.
Staged Not staged Marginal Row Totals
Pre-Clinic 10 6 16
Post-Clinic 11 0 11
Marginal Column Totals 21 6 27
Table 1: USS Staging using U classification pre and post new clinic implementation date
Adequate Inadequate Marginal Row Totals
Pre-Clinic 7 9 16
Table 2: Adequacy of FNAC before and after new clinic implementation date
The time taken for diagnosis and management plan formulation was then assessed. This was the time taken from initial consultation in clinic to the final consultation in clinic where the results were communicated to the patient and a management plan formulated. The average time taken before the new clinic introduction date was 34 days and 28 days post but there was no statistically significant difference demonstrated using a t-test. The number of clinic visits also decreased from 3 to 2.2 but again this was not statistically significant reduction.
Introducing this clinic provided numerous advantages; a specialist service utilising the U classification has resulted in improvement in the targeting of thyroid lesions and unsurprisingly as a result increased our clinical accuracy and slickened the patient's journey. The BTA guidance does not suggest how to implement both USS and FNAC staging. Until now there has been just one published example of a one-stop Thyroid clinic being utilised and none within the United Kingdom despite it being widely regarded as "standard" practice amongst the Head and and Neck community internationally. This paper demonstrates that the guidance can be implemented successfully using this set up within a District General Hospital setting.
Prior to its implementation FNAC would be performed freehand by a Consultant ENT surgeon without the use of directed ultrasound; meaning lesions would not be radiologically targeted. Mehrota et al. [4] have already demonstrated increased accuracy and yield of USS FNAC compared to the freehand technique when targeting thyroid lesions [4]. By grading the lesions using USS the radiologist is also able to identify suspicious lesions immediately and as such direct FNAC more appropriately.
Introducing this radiologist not only increased the successful grading of lesions but also increased the diagnostic yield of our FNAC as a result significantly reduced the number of inadequate samples. This subsequently reduces the need for repeat FNAC ultimately reducing discomfort and potential morbidity for our patients.
We have demonstrated that this clinic also has the potential to reduce the time taken for a diagnosis to be made as a result of a more streamlined and productive approach. If this study was undertaken on a larger study power we believe it would reach sufficient statistical power to show a significant difference. Previous studies on similar clinic arrangements have shown a reduction in health budget expenditure as a result of this increased efficiency despite the cost of extra consultant sessions although this was not assessed in our investigation [5].
Ideally we would have a Cytologist present at the clinic, to analyse cytological specimens immediately, as this would reduce the patient journey further and increase clinic capacity as a result. However, in today's NHS, resources are often stretched and we have demonstrated that our service is working sufficiently without an onsite cytologist currently.
Whilst new guidance is often difficult to implement and creates structural challenges we have demonstrated the effectiveness of a "OneStop" thyroid clinic this framework is simple and readily adaptable for other similar units to implement.
Perros P, Boelaert K, Colley S, Evans C, Evans RM, et al. (2014)Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) 1: 1-122. [Ref.]
Williams MV (2008) The cancer reform strategy. Clin Oncol (R Coll Radiol) 20: 271-274. [Ref.]
Patel R, Skandarajah RA, Gorelik A, Shears MJ, Tasevski R, et al.(2016) One-stop thyroid nodule clinic with same-day fine-needle aspiration cytology improves efficiency of care. ANZ J Surg. [Ref.]
Mehrotra P, Hubbard JG, Johnson SJ, Richardson DL, Bliss R, et al. (2005) Ultrasound scan-guided core sampling for diagnosis versus freehand FNAC of the thyroid gland. Surgeon 3: 1-5. [Ref.]
Delaloge S, Bonastre J, Borget I, Garbay JR, Fontenay R, et al. (2016) The challenge of rapid diagnosis in oncology: Diagnostic accuracy and cost analysis of a large-scale one-stop breast clinic. Eur J Cancer 66: 131-137. [Ref.]
Citation: Rocke J, Pothula V, Ranganathan B, Kumar N (2017) Implementing a "One Stop" Consultant Led Ultrasound and Fine Needle Aspiration Service for Thyroid Lumps. J Surg Open Access 3(2): doi http://dx.doi.org/10.16966/2470-0991.142
Copyright: © 2017 Rocke J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received date: 29 Dec 2016
Accepted date: 08 Feb 2017
Published date: 15 Feb 2017
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A Simple and Validated Stability Indicating HPLC Method for Simultaneous Quantification of Brimonidine, Timolol and Benzalkonium Chloride in Anti-Glaucoma Ophthalmic Formulations
A. Krishnamanjari Pawar
[email protected]
A.U. College of Pharmaceutical Sciences, Andhra University, Visakhapatnam-530003, India
Chandana Mannepalli
Corresponding Author(s) : A. Krishnamanjari Pawar
The combined dosage form of brimonidine, timolol and benzalkonium chloride is prescribed for lowering intraocular pressure in patients with ocular hypertension. As no analytical HPLC method reported for the estimation of brimonidine, timolol and benzalkonium chloride together in ophthalmic formulations, the present study was aimed to fulfill the gap identified in literature. The separation of analytes was achieved on Cosmosil C18 (250 × 4.6 mm; 5 μ id) as stationary phase, pH 4.3 acetate buffer and methanol in 30:70 (v/v) as mobile phase at 1.0 mL/min and UV detection at 227 nm. In this condition, well resolved, retained peaks were identified at 3.11 min for brimonidine, 4.86 min for timolol and 5.57 min for benzalkonium chloride. The method reports 0.5, 1.25 and 0.0125 μg/mL, respectively for brimonidine, timolol and benzalkonium chloride as LOD, which proves that the method have enough sensitivity levels for the detection analytes in samples. The method passes all the validation parameters as per the guidelines proved that the method was valid. The method shows less % degradation in various stress studies such as acidic, base, peroxide, thermal and UV light conditions and can effectively separate various stress degradation compounds and confirms the stability indicating nature of the method. The method applicability was assessed by analyzing the drug content in Combigan® ophthalmic drops and method reports the assay of 98.92%, 99.36% and 98.46% for brimonidine, timolol and benzalkonium chloride, respectively. Based on the results, it can be concluded that the method can adequately suitable for the separation and quantification of brimonidine, timolol and benzalkonium chloride and hence can be applicable for the routine analysis of brimonidine, timolol and benzalkonium chloride in ophthalmic formulations.
Brimonidine Timolol Benzalkonium chloride HPLC analysis Stress studies Formulation assay
Krishnamanjari PawarA., & MannepalliC. (2022). A Simple and Validated Stability Indicating HPLC Method for Simultaneous Quantification of Brimonidine, Timolol and Benzalkonium Chloride in Anti-Glaucoma Ophthalmic Formulations. Asian Journal of Chemistry, 35(1), 179-186. Retrieved from https://asianpubs.org/index.php/ajchem/article/view/27532
L.B. Cantor and J. Burke, Expert Opin. Investig. Drugs, 6, 1063 (1997); https://doi.org/10.1517/13543784.6.8.1063
J.C. Adkins and J.A. Balfour, Drugs Aging, 12, 225 (1998); https://doi.org/10.2165/00002512-199812030-00005
C.B. Toris, C.B. Camras and M.E. Yablonski, Am. J. Ophthalmol., 128, 8 (1999); https://doi.org/10.1016/S0002-9394(99)00076-8
M. Volotinen, M. Turpeinen, A. Tolonen, J. Uusitalo, J. Mäenpää and O. Pelkonen, Drug Metab. Dispos., 35, 1135 (2007); https://doi.org/10.1124/dmd.106.012906
T. Atkin, S. Comai and G. Gobbi, Pharmacol. Rev., 70, 197 (2018); https://doi.org/10.1124/pr.117.014381
J.H. Liu, D.F. Kripke and R.N. Weinreb, Am. J. Ophthalmol., 138, 389 (2004); https://doi.org/10.1016/j.ajo.2004.04.022
B.M.P. Pereira and I. Tagkopoulos, Appl. Environ. Microbiol., 85, e00377 (2019); https://doi.org/10.1128/AEM.00377-19
S.M. Choi, T.H. Roh, D.S. Lim, S. Kacew, H.S. Kim and B.M. Lee, J. Toxicol. Environ. Health B Crit. Rev., 21, 8 (2018); https://doi.org/10.1080/10937404.2017.1408552
O. Condell, C. Iversen, S. Cooney, K.A. Power, C. Walsh, C. Burgess and S. Fanning, Appl. Environ. Microbiol., 78, 3087 (2012); https://doi.org/10.1128/AEM.07534-11
M.H. Goldstein, F.Q. Silva, N. Blender, T. Tran and S. Vantipalli, Eye, 36, 361 (2022); https://doi.org/10.1038/s41433-021-01668-x
H.M. Hafez, A.A. Elshanawany, L.M. Abdelaziz and M.S. Mohram, Eurasian J. Anal. Chem., 10, 46 (2015).
H.M. Hafez, A.A. Elshanawane, L.M. Abdelaziz and M.S. Mohram, J Appl. Pharm., 6, 398 (2014).
E. Büker and E. Dinç, J. Chromatogr. Sci., 55, 154 (2017); https://doi.org/10.1093/chromsci/bmw160
M.C. Damle and A. Zirange, Int. J. Res. Culture Soc., 2(7), 1 (2018).
M.A. Mukthinuthalapati, S. Malineni and S.V.S. Vellanki, J. Anal. Pharm. Res., 4, 14 (2017).
S. Kondra, B. Akula Thukaram, D. Gowrisankar, P.A. Krishnamanjari, H.S.N. Raju Dantuluri and S. Maganti, Ann. Pharm. Fr., 79, 617 (2021); https://doi.org/10.1016/j.pharma.2021.02.006
J. Venkateswaran, M. Sundarapandian and S. Venkataraman, Asian J. Pharm., 11, S588 (2017).
M. Walash and R. El-Shaheny, Yao Wu Shi Pin Fen Xi, 24, 441 (2016); https://doi.org/10.1016/j.jfda.2015.11.006
B.B. Kasimala, V.R. Anna and U.R. Mallu, Indian Drugs, 55, 41 (2018).
U.R. Mallu, V.R. Anna and B.B. Kasimala, Turk. J. Pharm. Sci., 16, 457 (2019); https://doi.org/10.4274/tjps.galenos.2018.34635
ICH Expert Working Group, ICH harmonised tripartite guideline–Validation of Analytical Procedures Text and Methodology: Q2 (R1). In Geneva: International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (2005)
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diagnostic cytopathology impact factor
The journal covers all aspects of diagnostic cytology, including fine needle aspiration cytology, gynecological and non-gynecological cytology. The Journal Impact measures the average number of citations received in a particular year (2019) by papers published in the journal during the two preceding years (2017-2018). Diagnostic Cytopathology is published by John Wiley & Sons Inc.. The Journal Impact 2019-2020 of Cytopathology is 1.540, which is just updated in 2020. Description. Compared with historical Journal Impact data, the Metric 2019 of Diagnostic Cytopathology grew by 33.33% . Cytopathology of myxoinflammatory fibroblastic sarcoma: a series of eight cases and review of the literature. The aim of the journal is to is to provide a forum for the exchange of information among cytopathologists and related oncologic disciplines concerned with the etiology and course of human cancer and its diagnosis and prevention. There are several national and international professional societies in cytopathology. is 1.52, which is computed in 2019 as per it's definition. Cytopathology is a branch of Science that focuses on the diagnosis of diseases at the cellular level. Diagnostic Cytopathology. histopathology; diagnostics; cytopathology; laboratory tests; The role of human factors (HFs) in clinical medicine is undisputed. Editor(s): Carlos W.M. ... Impact Factor ® as reported in the ... Head of Cytopathology, Department of Pathology, Faculty of Medicine, Kuwait University, Kuwait . Citescore is produced by Scopus, and can be a little higher or different compared to the impact factor produced by Journal Citation Report. precisely, called cytology. The Journal Impact 2019-2020 of Diagnostic Cytopathology is 1.520, which is just updated in 2020. Cancer Cytopathology, a journal of the American Cancer Society, publishes original research and other articles of interest to cytopathology, cytology, and pathology professionals as it relates to topics concerning the etiology of cancer, and its diagnosis and prevention.The journal maintains an international scope and is considered the elite journal in the field of cytopathology. The CytoJournal is an open-access peer-reviewed journal committed to publishing high-quality articles in the field of Diagnostic Cytopathology including Molecular aspects. Diagnostic Cytopathology - インパクトファクター The Journal Impact 2019 of Diagnostic Cytopathology is 1.520, which is just updated in 2020. The scope of Diagnostic Cytopathology covers Broadly defined it is a diagnostic discipline that requires application of distinct and discrete sets of criteria for evaluation of patient samples from diverse anatomic locations. Impact Factor: 1.161. It is impossible to get a true picture of impact using a single Metric alone, so a basket of factors is needed to support informed decisions. Springer This journal has an h-index of 61. Please refer to Web of Science data source for checking the exact journal impact factor ™ (Thomson Reuters) metric. SCImago Journal Rank is an indicator, which measures the scientific influence of journals. Diagnostic Cytopathology is published by John Wiley & Sons Inc., The Journal Impact 2019-2020 of Cancer Cytopathology is 5.000, which is just updated in 2020.Compared with historical Journal Impact data, the Metric 2019 of Cancer Cytopathology grew by 29.53 %.The Journal Impact Quartile of Cancer Cytopathology is Q1.The Journal Impact of an academic journal is a scientometric Metric that reflects the yearly average number of citations that recent … Diagnostic Cytopathology is intended to provide a forum for the exchange of information in the field of cytopathology, with special emphasis on the practical, clinical aspects of the discipline. Anyone who wants to use the articles in any way must obtain permission from the publishers. It is frequently used as a Metric for the relative importance of a journal within its field; journals with higher Journal Impact are often deemed to be more important than those with lower ones. Diagnostic Cytopathology - Subscription (non-OA) Journal. Diagnostic Cytopathology is a peer-reviewed scientific journal. Methods: The IFs of four cytopathology journals were searched from 2005 to 2009. JASC publishes regular bimonthly issues with cutting-edge original research of the highest standard. The impact factor (IF) 2018 of Diagnostic Cytopathology is 1.52, which is computed in 2019 as per it's definition. JASC publishes regular bimonthly issues with cutting-edge original research of the highest standard. Q2. Committed to bridging the gap between cytopathology and surgical pathology, Diagnostic Cytopathology stresses the value of clinical-pathological correlations, as well as the correlation between cytological and histological findings, as the gold standard for the accuracy and reliability of cytological diagnoses. Diagnostic Cytopathology is intended to provide a forum for the exchange of information in the field of cytopathology, with special emphasis on the practical, clinical aspects of the discipline. Diagnostic Cytopathology - Journal Impact Prediction System. Impact factor:1.402. Diagnostic Cytopathology is intended to provide a forum for the exchange of information in the field of cytopathology with special emphasis on the practical clinical aspects of the discipline. Cytopathology Impact Factor, IF, number of article, detailed information and journal factor. SCImago Journal Rank is an indicator, which measures the scientific influence of journals. The CytoJournal is an open-access peer-reviewed journal committed to publishing high-quality articles in the field of Diagnostic Cytopathology including Molecular aspects. The Journal Impact Quartile of Diagnostic Cytopathology is The impact factor (IF) 2018 of Diagnostic Cytopathology is 1.52, which is computed in 2019 as per it's definition.Diagnostic Cytopathology IF is increased by a factor of 0.38 and approximate percentage change is 33.33% when compared to preceding year 2017, which shows a rising trend. ISSN: 1934-662X. H-Index, Cancer Cytopathology strives to ensure that any submission from the Editor-in-Chief or a member of the journal's Editorial Board receives an objective and unbiased evaluation. To investigate the factors that might influence IF in cytopathology literature and whether IF has any impact on cytopathology practice. It is used for the recognition of journals, newspapers, periodicals, and magazines in all kind of forms, be it print-media or electronic. more. which is located in the United States. Diagnostic Pathology: Open Access Open Access Journal Emergency Medicine: Open Access Official Journal of World Federation of Pediatric Intensive and Critical Care societies Endocrinology & Diabetes Research Hybrid Open Access Journal 1.520, which is just updated in 2020. Pathologica - Journal of the Italian Society of Anatomic Pathology and Diagnostic Cytopathology, Italian Division of the International Academy of Pathology www.jmscr.igmpublication.org Impact Factor 3.79 ISSN (e)-2347-176x In addition to the 2-year Journal Impact, the 3-year Journal Impact can provide further insights and factors into the impact of Diagnostic Cytopathology. © 2019-2020 www.resurchify.com All Rights Reserved. Objective: To study the trends of impact factor (IF) in four cytopathology journals. Dear Authors, Peer Reviewers, and Readers, On behalf of the Cytopathology Foundation Inc., (CF) and the CytoJournal editorial board, we are communicating the recently announced 2012 impact factor (IF) of 1.2 for CytoJournal. Here You will find a list of all available journals concerning Pathology ranked by their current Impact Factor. [] This numerical indicator has been long awaited by authors, as many institutions use IF to determine preferences for publication metrics. ISI Journal Citation Reports © Ranking: 2018:21/29 (Medical Laboratory Technology)54/76 (Pathology) Online ISSN:1097-0339. The editors invite original scientific articles, as well as special review articles, feature articles, and … Cytopathology (C) and Diagnostic Cytopathology (DC) had a slow but steady increase in their IF. The editors invite original scientific articles, as well as special review articles, feature articles, and letters to the editor, from laboratory professionals engaged in the practice of cytopathology. NLM ID: 101641043. © Wiley Periodicals, LLC. Edited By: Zubair Baloch, MD and Lester Layfield, MD. © Wiley Periodicals, Inc. JASC is the official journal of the American Society of Cytopathology,and reflects the values and priorities of the society. ... study cytopathology review; diagnostic yield was also esti-mated over time (every 15 procedures). Diagnostic Cytopathology is intended to provide a forum for the exchange of information in the field of cytopathology, with special emphasis on the practical, clinical aspects of the discipline. Nature Reviews Drug Discovery, These tests are used to examine single cells or small clusters of cells and to assess whether they are normal or show signs of disease. ISSN stands for International Standard Serial Number. To investigate the factors that might influence IF in cytopathology literature and whether IF has any impact on cytopathology practice. LATEST ISSUE >. Publishers own the rights to the articles in their journals. In Press, Corrected Proof, Available online 8 … Whereas the early diagnosis of cancer remains at the core of our publishing philosophy, topics of interest include all subjects that impact the practice of cytopathology … Cytopathology is a discipline of medical sciences that studies and diagnoses diseases on the cellular level. In 2019, the impact factor for Cancer Cytopathology rose to an impressive 4.425, the highest for any cytology journal, while turnaround times for accepted articles published online decreased to the shortest times in the past years. Editor(s): Carlos W.M. Index Copernicus Value: 83.85 Journal of Cytology and Histology is an open access and academic journal which aspires to disseminate most comprehensive and authentic information on the innovations and current developments in all the areas of cytology and histology. Description. The ISSN of Diagnostic Cytopathology is 10970339, 87551039. Diagnostic Cytopathology is cited by a total of 792 articles during the last 3 years (Preceding 2018). Wiley Source: https://www.scimagojr.com/journalrank.php, IEEE Article The Publication History of Diagnostic Cytopathology covers 1985-ongoing. Sintawat Wangsiricharoen, ... Paul E. Wakely ... Impact of laboratory work-up of lymphoma guidelines on cytopathology practices. . Template, several advanced Journal Factors including Note that 2019 Journal Impact are reported in 2020; they cannot be calculated until all of the 2019 publications have been processed by the indexing agency. CiteScore: 0.7 ℹ CiteScore: 2019: 0.7 CiteScore measures the average citations received per peer-reviewed document published in this title. The exact Journal Impact 2019-2020 of Diagnostic Cytopathology grew by 33.33 % produced by Scopus, and submission deadlines publications. Ranked 0.562 cited by a total of 792 articles during the last years! Literature and whether IF has any Impact on Cytopathology practice the Bethesda System Reporting of Thyroid Cytopathology a... Of Science that focuses on the diagnosis of diseases at the cellular level computed in 2019 per! In United States unique code of 8 digits, targeted readers and certain types of.... 61 articles of this Journal is as following: 1985-ongoing ) 2018 of Cytopathology! 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diagnostic cytopathology impact factor 2021
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Take a personal initiative in self-education (including reading recent literature).
Review of standard texts of neurophysiological techniques and their application to care of neurological patients, including EEG, EMG/NCS, evoked potentials, and sleep studies.
Have a breadth of knowledge of neurophysiological technical aspects and application to pass the CNP board examination.
Describe the importance of EEG patterns and their implications in patient care in both routine and continuous EEG.
Describe the importance of EMG/NCS in the diagnosis and management of patients with neuromuscular disease.
Describe the diagnostic utility and application of evoked potentials including for neurological prognosis.
Determine psychosocial issues that complicate care.
Identify advocacy programs for patients with neurological disease.
Skill in practice assessment, as well as both practice- and systems improvement, to enhance quality of care and improve patient safety (Practice-Based Learning and Improvement, Systems-Based Practice).
First-hand experience at the process of data presentation and peer-review, ideally via submission of one abstract or manuscript during the course of training (Interpersonal and Communication Skills, Medical Knowledge, Professionalism).
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Praise for _The Anatomy of Addiction_
"A lucid examination of addiction and treatment from a neurobiological perspective . . . with particularly engrossing chapters dispelling the ten biggest myths of addiction."
—Kirkus Reviews
"In _The Anatomy of Addiction_ , Dr. Mohammad's look at the current addiction treatment climate is direct, unflinching, and an absolute must-read for everyone touched by addiction. The man is a true pioneer in the field of addiction and one of the few addiction experts to accurately and effectively balance science, medicine, and behavioral health. If you want a new perspective on the world of addiction, read this book."
—Darren Kavinoky, co-creator and host of Deadly Sins on Investigation Discovery; founding attorney of 1.800.NoCuffs; Certified Intervention Professional
"When I first met Dr. Mohammad, addiction had left me broken and destitute on every level. While I had spent time with countless, self-proclaimed addiction experts, Dr. Mohammad saved and changed my life in a matter of minutes. He was the only treatment professional to let me know that with the help of science, the truth about addiction, and a balanced treatment approach, I could have my life and family back. That was thirteen years ago and I've never looked back. What Dr. Mohammad shared with me that day is included in his book _The Anatomy of Addiction_ ; we are not powerless over addiction and this book tells you exactly why."
—JW, a patient of Dr. Akikur Mohammad
"This is strong medicine with no spoonful of sugar; for many, it [may be] a bitter pill to swallow. But the book is not meant to inform; it is meant to transform."
—Dr. Walter Ling, professor of psychiatry and director of Integrated Substance Abuse Programs (ISAP) at UCLA
"Dr. Akikur Mohammad is passionate about the issue of addiction, what it is and what it is not, and how it should and shouldn't be treated. Written for the layperson, this book is a helpful resource for readers struggling with addiction, and their families and friends, as well as anyone who is interested in the global problem of addiction."
—George Simpson, MD, professor of psychiatry and the behavioral sciences at Keck School of Medicine at University of Southern Califorinia and former chairman of the department of psychiatry at Keck School of Medicine at University of Southern California
** **
**PERIGEE**
**An imprint of Penguin Random House LLC**
**375 Hudson Street, New York, New York 10014**
Copyright © 2016 by Akikur Mohammad, MD
Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader.
eBook ISBN 978-1-101-98303-4
Library of Congress Cataloging-in-Publication Data
Names: Mohammad, Akikur, author.
Title: The anatomy of addiction : what science and research tell us about the
true causes, best preventive techniques, and most successful treatments /
Akikur Mohammad, MD.
Description: First edition. | New York City : Perigee, 2016. | Includes
bibliographical references and index.
Identifiers: LCCN 2015041635 | ISBN 978-1-101-98183-2
Subjects: LCSH: Substance abuse—Etiology. | Compulsive behavior—Etiology. |
Substance abuse—Treatment. | BISAC: SELF-HELP / Substance Abuse &
Addictions / General. | PSYCHOLOGY / Psychopathology / Addiction.
Classification: LCC RC564 .M634 2016 | DDC 362.29—dc23
First edition: February 2016
Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book.
While the author has made every effort to provide accurate telephone numbers and Internet addresses at the time of publication, neither the publisher nor the author assumes any responsibility for errors or for changes that occur after publication. Further, the publisher does not have any control over and does not assume any responsibility for author or third-party websites or their content.
Cover design: Eric Fuentecilla
Version_1
This book is dedicated to my mother, who inspired me in every way; to my very supportive sister; and to my loving family—my wife, Irina, and our daughters, Anastasia and Sasha.
# CONTENTS
Praise for The Anatomy of Addiction
Title Page
Copyright
Dedication
Introduction: The Invisible Epidemic That's Killing Us
Chapter 1. Addiction Is Preventable. Addiction Is Treatable.
Chapter 2. The Ten Biggest Myths of Addiction
Chapter 3. The Medical Illness of Addiction
Chapter 4. The Medical Consequences of Addiction
Chapter 5. The Process of Effective Treatment
Chapter 6. Painless Detox
Chapter 7. Maintenance and Relapse
Chapter 8. Dual Diagnosis
Chapter 9. Teens and Young Adults
Chapter 10. Fetal Alcohol Syndrome: Real and Preventable
Epilogue Overcoming the Culture of Disbelief
Bibliography
Acknowledgments
Index
About the Author
# INTRODUCTION
The Invisible Epidemic That's Killing Us
Last year, the treatment of alcoholism and drug addiction generated a staggering $34 billion in revenues. Rehab clinics dot the country and can be found in virtually every city and town in America. At 14,000 and counting, there are more addiction treatment centers in the United States than there are Starbucks stores.
Yet, the treatment of alcohol and drug addiction is failing miserably. According to the National Survey on Drug Use and Health (NSDUH), an estimated 20 million Americans, or about 8 percent of the population, aged twelve or older used an illegal drug in the past thirty days. In addition, the nonmedical use or abuse of prescription drugs—including painkillers, sedatives, and stimulants—is growing, with an estimated 48 million people, or about 20 percent of the U.S. population, aged twelve and older using prescription drugs for nonmedical reasons.
To look at it another way, 88,000 deaths were attributable last year to excessive alcohol use alone in the United States. This makes excessive alcohol use the third leading lifestyle-related cause of death for the nation (it surpassed car accidents in 2009 and never looked back). Excessive alcohol use is responsible for 2.5 million years of potential life lost (YPLL) annually, or an average of about 30 YPLL for each death. In 2006, there were more than 1.2 million emergency room visits and 2.7 million physician office visits due to excessive drinking. The economic cost of excessive alcohol consumption in 2012 was estimated at $275 billion.
The problem of addiction is seemingly everywhere, but the disease of addiction still isn't recognized. If addiction were acknowledged by society—its care providers, the policy makers, the courts and judiciary systems, and most of all, the public—as the chronic disease that it clearly is, it would be quickly brought under control.
In a landmark study of addiction in the United States published by National Center on Addiction and Substance Abuse at Columbia University, the authors found that "addiction is this nation's largest preventable and mostly health problem." They went on to say that the failure to treat addiction with scientifically sound, medically proven methods results in an "enormous array of health and social problems, including accidents, homicides, suicides, child neglect, incarceration and sexual assault."
Admittedly, the figures are so overwhelming that we in the public become desensitized to their effect, until a loved one, friend, or associate succumbs to drug or alcohol abuse. Periodically, when a high-profile figure like Philip Seymour Hoffman dies of an overdose, the country is jolted back to the reality of the dire situation, and the need for changes to addiction treatment are discussed, and then forgotten again until the next celebrity overdose.
But it doesn't have to be so. In the last decade, and, particularly in the last few years, advances have been made in the science of addiction medicine that make the disease both treatable and preventable.
As a board-certified psychiatrist with an additional certification in addiction medicine, I have been on the front line of using these advanced techniques, first, during my work in the emergency room (ER) department of Los Angeles County General Hospital, and now for the last several years at the addiction treatment center I founded in Malibu, California. Yet, I am the first to admit that evidence-based addiction treatment remains largely unknown to the public at large.
Why, then, is there such a disconnect between the problem and the solution? In this book, _The Anatomy of Addiction_ , I explain how an entrenched rehab industry has grown scandalously rich by bilking some of the most vulnerable in our society for billions of dollars each year and how it also has no intention of voluntarily changing its way.
Shockingly, an estimated 90 percent of all rehab clinics do not use any evidence-based medicine in their treatment programs. In fact, only six states in the country require any type of education for addiction treatment personnel, often self-styled as "addiction counselors." Instead of offering the kind of proven addiction medicine that has been endorsed by the American Medical Association and National Institutes of Health, these often unscrupulous and always ignorant clinics base their treatment protocols exclusively on 1930s-era concepts of the support talk group concept and enforced abstinence.
Despite decades of scientific research that have proven beyond any reasonable doubt that addiction is a brain disease, the rehab industry continues to treat addiction as a moral failing and lack of willpower. It is abetted in this falsehood by an entrenched establishment that continues to preach its 12-step dogma, despite the facts to the contrary; by policy makers and judiciary, who view the disease as the target for criminalization rather than treatment; by a medical community still largely ignorant of the disease of addiction and its proper treatment; and finally, by a public that is simultaneously supportive and scornful of addicts but mostly just confused by the whole issue.
Here are the simple, scientifically proven facts about alcohol and drug addiction:
1. Addiction is a chronic brain disease, characterized by compulsive craving for alcohol or drugs, that requires medical intervention and management over a lifetime by trained and certified professionals (just like every other chronic disease).
2. Yes, it's a chronic disease of the brain like bipolar disorder, and thus its treatment requires more than counseling and group talk therapy (no matter how good the intentions might be).
3. In fact, alcohol and drug addiction requires first and foremost, pharmacological therapy in addition to counseling and lifestyle modification.
4. As a chronic recurring illness, addiction often requires continued treatment to anticipate relapses and diminish their intensity.
5. While relapses are to be expected, addiction is a treatable condition, and people with an alcohol or drug addiction can recover and lead fulfilling lives.
These guiding principles are at the heart of this book. As you will see, I explain in layman's terms what constitutes effective, evidence-based addiction medicine and how to find it. Just as important, I detail how to avoid so-called rehab clinics that are, at best, useless and a waste of money and, at worst, dangerous and even life-threatening.
The information in this book destroys the myths that, unfortunately, continue to guide addiction treatment in this country, including
• Addiction can be cured by abstinence and willpower.
• Addiction cannot be prevented, and addicts are doomed to life of despair.
• The best form of treatment is advice from former addicts talking about how they kicked their habits.
False, false, and false. Indeed, as a physician, clinician, and professor of medicine, I know of no other medical condition of the brain—be it Alzheimer's disease, Parkinson's disease, or any other—that has amateurs diagnosing and treating it. This simple truth has been proven irrefutable by many scientifically conducted studies: Addiction is a preventable, treatable disease.
In this book you'll find actionable, _scientific_ information for addicts and their families. This is the same information that I teach to the students at the Keck School of Medicine of the University of Southern California in Los Angeles. My classes have been considered so essential that regardless of their intended specialties, all med students there are required to take them.
Now, for the first time, I am sharing this information with the public. My goal is nothing less than to once and for all end those who keep addicts and the medical treatment of their disease in the shadows of ignorance, fear, and stigma.
If there is one message you'll take away from this book, it's this: America does not have an addiction problem. It has an addiction _treatment_ problem.
# Chapter 1
# Addiction Is Preventable. Addiction Is Treatable.
Several years ago, I was a speaker at a conference about addiction medicine during which I called for change in how we think of addicts. If we accept the irrefutable science that drug addiction is a disease, then it follows that we must stop criminalizing addicts' behaviors. Imagine if we criminalized the behavior of other sufferers of leading chronic diseases? Our jails would be filled with people diagnosed with cancer, heart disease, diabetes, and asthma.
After my talk, a gentleman approached me and introduced himself as an agent with the federal Drug Enforcement Agency (DEA). He recounted the story of one of his arrests that continued to haunt him. A heroin pusher had plea-bargained his charge of possession by agreeing to finger accomplices. He identified a couple and, sure enough, a search warrant of their home turned up a couple dozen packages of heroin.
So what was the problem? Their arrest removed dangerous criminals from the streets of Los Angeles, right? In reality, the couple was anything but the stereotype of most people's idea of "heroin addicts." According to the detective, you would have never guessed by looking at the perpetrators that they were abusing drugs. They appeared to be and, in fact, were a middle-class couple living in a nice three-bedroom middle-class home, both holding steady jobs, and neither having been previously arrested for a violent crime.
They were also parents to two young children—a four-year-old girl and seven-year-old boy.
After the man's arrest and conviction (he took the blame), he went to jail, essentially, forever. The woman, depressed and no longer able to get her regular opiate fix, committed suicide. Their kids ended up in foster care.
Even after many years, clearly the detective remained distraught at the havoc his by-the-book arrest had caused to this family. "If I could do it over again, I'd make sure this time that I never found any heroin," he said with conviction. Welcome to the often heart-breaking world of addiction in America.
The Truth About Addiction
In another more just and humane world, the couple at the center of this real-life tragedy would have been diagnosed as having the chronic disease of addiction and provided medical help to end their substance abuse. After a successful evidence-based treatment program, they would have returned to normal, productive lives but without the crutch of substance abuse and the constant fear and stress of being arrested.
Indeed, decades of basic laboratory science have revealed that addiction is a bona fide medical problem involving profound brain alterations. Alcohol, opiates, cocaine, and other substances increase levels of the chemical dopamine in the reward pathway of the brain. With the advent of MRI technology in the late 1970s, we could actually see with our own eyes how addiction depleted baseline dopamine levels, with the net result being a less pleasurable high, requiring ever-larger doses.
Scientifically controlled research studies have revealed that even when people are weaned from a drug, their brains don't return to normal. So such people remain vulnerable to the drug's draw and suffer mood swings and profound urges to use again.
Such findings have been published in science journals at a prodigious rate since the early 2000s, adding weight to the position taken by National Institute on Drug Abuse chief Nora Volkow that "addiction is a chronic disorder that will require multiple rounds of therapy to reduce the risk of relapse and to lengthen drug-free intervals."
In the mid-1990s, a coalition of doctors, scientists, and leading government organizations, including the American Medical Association and the American Psychiatric Association, began pushing for broad recognition of addiction as a disease and advocating more medical approaches to therapy. Gil Kerlikowske, former director of the Office of National Drug Control Policy and President Barack Obama's former top adviser on drug policy, lent clarity to the effort by declaring that addiction "is not a moral failing on the part of the individual. It's a chronic disease of the brain that can be treated."
Despite all the progress in understanding addiction and how to treat it with evidence-based medicine, consider these sobering facts from an in-depth report released by Columbia University in 2013:
• About 21 million Americans have a substance abuse disorder for which they need, but are not receiving, evidence-based addiction treatment.
• Deaths from drug overdoses now exceed traffic fatalities.
• About 55 percent of all prisoners in federal prisons are there for drug-related offenses.
• Nine out of ten people addicted to drugs other than nicotine receive no treatment.
• Most of those who do get treatment are put through unproven programs run by people without medical training.
The Strange History of Addiction in the United States
What accounts for the discrepancy between the availability of modern-day treatment of addiction and its meager use? There are several interrelated reasons, but all have to do with the shame and ignorance surrounding addiction.
First and foremost, public opinion about addiction has not yet caught up with the science. Addicts are still stigmatized by society as moral failures who could cure themselves if they just tried hard enough or, in a variation on this theme, addicts are born losers and there's nothing that can help them.
Let's take the last point first. Judy Garland, Robert Downey Jr., Oprah Winfrey, Bob Dylan, David Bowie, Ray Charles, Keith Urban, Brian Wilson, William F. Buckley Jr., Elizabeth Taylor, James Baldwin, and even Benjamin Franklin were all alcohol and drug addicts. Clearly, these talented and financially successful people were not losers in any conventional sense.
As for the stigma of being an addict, there's no doubt that it's still a powerful force that stops most people from admitting they have an addiction problem. We only have to look at the very high profile and tragic death of actor Philip Seymour Hoffman to confirm this. Here was a celebrated and admired artist, at the top of his career, who nevertheless refused to seek the kind of professional help he needed because of the stigma surrounding a relapse after more than twenty years of sobriety. Instead, he tried curing himself by attending AA meetings. Ten weeks after he relapsed, he was found dead in his apartment with a needle stuck in his arm and seventy-five packages of heroin strewn about.
These public attitudes toward addicts are in part created by America's unique Puritanical history, which underpins our nation's belief system on a wide range of social issues. Americans also tend to think that people who behave badly while drinking or drugging are bona fide addicts. In addition, the vestiges of the late-twentieth-century federal policy known as the "war on drugs" have indelibly etched into the public mind the idea that most drug and alcohol abusers exhibit criminal behavior (when, in fact, only a small minority do).
What history tells us about addiction in America is almost the stuff of fiction. In 1914, the federal government made the fateful decision to criminalize drugs in the United States with the passage of the Harrison Act, designed to limit the distribution of opiate narcotics and to appease the great temperance movement that was sweeping the nation at the time. In 1919, the passage of the Eighteenth Amendment prohibited the sale of alcohol, and by the mid-1920s, the sale and distribution of cannabis were also regulated by federal statue, with criminal penalties attached for those who violated the new rules.
That will be the last time alcohol, narcotics, and cannabis will all be on roughly equal footing in the eyes of the law because, by wildly popular demand, the ban on alcohol became the first and only amendment to the U.S. Constitution that was ever repealed. Alcohol again became readily available, and even glamorized as a lifestyle choice. Meanwhile, marijuana, which was further criminalized, and narcotic opioids diverged onto parallel pathways and were perceived as dangerous, illicit street drugs, along with prescribed painkillers that were considered "safe when used properly." Note though that cannabis is seeing a reversal and has been legalized in some states.
From a medical viewpoint, that made no sense. Alcohol then, and now, by far continues to be the most dangerous drug in terms of the loss of human life and property—more than all other drugs combined. Six people die each day from alcohol poisoning; no one has ever died from a marijuana overdose. And while the country is currently in the midst of a heroin epidemic, it's reflective of the Alice-in-Wonderland world of drug criminalization in the United States that the reason for its resurgence is because the legal version of opiates—prescription painkillers like OxyContin, Percocet, and Demerol—became too scarce on the black market as a result of new federal regulations. Pill addicts turned to heroin, because it became cheaper than prescription painkillers.
If you're looking for any rhyme or reason to how drugs (and alcohol) have been regulated in the United States, you won't find it in history. To add but one more chapter in the surreal saga, the Narcotics Addict Rehabilitation Act of 1966, in a refreshing burst of enlightened thinking, gave judges the discretion to divert a defendant into treatment rather than jail. It was a chink in the armor of the war on drugs begun in 1914.
What the drafters of this act didn't anticipate were the unintended consequences. Suddenly, local communities were encouraged, even expected, to open their own treatment facilities. Local officials, who had virtually no experience in dealing with addicts other than putting them in jail, turned to the only group they knew in the field, Alcoholics Anonymous (AA). But here was the conundrum: co-founder Bill Wilson intended AA to be voluntary. The new law demanded that treatment be regimented with defined time frames and discipline, just like a jail. The rehab industry took off like gangbusters and never looked back.
The Science of Addiction
Here's what science tell us: Addiction is not synonymous with recreational or social use of mood-altering agents, including alcohol. On one level, we all know this intuitively. After all, not everyone who takes a prescription pill, smokes a joint, swigs a cocktail, or even shoots heroin will become an addict. Once we clear up this misunderstanding, then we can begin to realize that addiction is a true medical illness and understand why it is classified as a disease by every medical organization in the world, including the World Health Organization (WHO). Obviously, if addiction were not a medical condition meeting the clear definition of _disease_ , my board-certified area of specialization—addiction medicine—wouldn't exist.
Much of the disconnect between addiction and treatment is rooted in the recovery movement's history. Addicts, shunned by society and the medical establishment alike, received their help from those outside of it, a trend that continues to this day. Indeed, AA and other 12-step counseling programs, developed in the 1930s, have a near monopoly on addiction treatment in the United States, with only about 10 percent of rehab clinics offering any evidence-based treatment.
For decades now, the pseudo-religious AA's 12-step approach, emphasizing abstinence and submission to a "creator," has dominated the recovery industry. Historically, then, the treatment of substance or drug-use disorder developed outside mainstream medicine, and today we're still suffering from that.
To be fair to Bill Wilson, he never intended his organization to be twisted into a profitable industry, nor did he ever intend it to be antimedicine. _Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism_ (generally known as the Big Book) warns against AA members playing doctor to the detriment of other members. Wilson himself advocated for research into the medical treatment of alcoholism, going as far as beseeching the doctors who created methadone for drug addicts in the 1960s to find a comparable treatment for alcoholics.
Furthermore, until the advent of evidence-based treatment, AA was the only viable alternative for addicts in a society that certainly stigmatized and often criminalized them. AA meetings at least offered safe sanctuary to kindred spirits in a world that truly did not understand them.
The problem with AA originates in its loose structure—it keeps no records and its members are anonymous—and its oblique, often contradictory statements. AA's philosophy could be interpreted and co-opted by anyone. For example, AA's doctrinal Big Book tells us that alcoholism is a disease, yet the treatment it recommends has nothing to do with medicine or science. At best, AA is a kind of spiritually tinged psychological counseling that we call "group therapy" today.
AA also contributed to the stigmatization of the addict and alcoholic thanks to the notion that if its 12-step program doesn't work, it's the fault of the follower, not the program itself. To wit, here's an excerpt from the Big Book: "Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. They are such unfortunates. They are not at fault; they seem to have been born that way."
In one sense, AA was spot on when it said that addicts "seem to have been born that way." But by mixing that simple statement of fact with pseudo-science, AA planted the roots of today's for-profit rehab industry. AA has become the cover for the highly lucrative nontreatment of addiction in the United States.
The Big Business of Rehab
Make no mistake. Recovery is an industry—a huge business with more than $34 billion in revenue in 2013—and one in which 90 percent of the treatment centers blithely follow and promote the fact their treatment is based on AA's 12-step philosophy. Never mind that even by AA's own admission, only 5 to 8 percent of those who ever attend a single meeting stay sober for more than a year. Indeed, a comprehensive study of treatment programs in the early 2000s, later published as _The Handbook of Alcoholism Treatment Approaches_ , ranks AA thirtieth out of forty-eight methods. Just like in _Alice's Adventures in Wonderland_ , things happen that do not make any sense and are the opposite of what you would expect.
Why don't all the rehab clinics switch to a scientific treatment of addiction? After all, being profitable and providing effective treatment are not mutually exclusive.
The answer is the degree of profitability. It would greatly increase the cost of doing business and diminish profits if rehab clinics adopted a scientific approach to treating addiction. Evidence-based medicine must be administered by trained medical professionals. A 12-step program is largely self-administered, costing facilities virtually nothing in labor or, at most, the expense of a low-level addiction counselor—a job that has no mandated requirements (not even a college degree) in most states.
The other reason the vast majority of rehab clinics don't use evidence-based medicine is because they don't have to. There are no federal laws governing what constitutes an addiction treatment center and most state laws are weak and loosely defined. Truly, in most states, you can open a rehab clinic in your living room, call yourself the chief addiction counselor and openly advertise your business with impunity. And, you can shroud the whole farce in the mantle of respectability by trumpeting that you offer AA's 12-step treatment. (AA will never dispute it.)
Unfortunately, this charade is not limited to backyard operations. Two of the most respected names in addiction treatment—the Betty Ford Center, located in southern California and Hazelden Foundation in Minnesota—merged in 2014 into one business venture. In one of his first interviews on the merger with the _Los Angeles Times_ , the new CEO of the combined facilities, Mark Mishek, matter-of-factly dismissed evidence-based medicine for addiction treatment. "Nonprofits that have abstinence-based programs that are focused on the 12 Steps of Alcoholics Anonymous need to stick together. We are under attack from a competitive perspective," he said.
Hazelden has a special placeholder in the development of the rehab industry in the United States. In 1949, it was the first center to open using AA's 12 steps as its treatment modality. This in itself was a curious development, because AA founder Bill Wilson purposely created the organization with a bottom-up structure (he called it "benign anarchy"). Individual AA branches were meant to be self-governing. Hazelden turned that notion upside down by establishing a top-down structure and adding discipline to its treatment, in effect, embracing the AA 12 steps without its self-governing philosophy.
Is it any wonder that the public remains confused about addiction when no less than the name of Betty Ford—a former First Lady of the United States who became synonymous with addiction—is evoked to reject modern-day, scientifically proven treatments?
The Problem with AA in the Twenty-First Century
There is no war being fought against AA. Most clinicians, like myself, who deal every day with addicts know that 12-step programs can be a valuable tool in the management of the chronic disease of addiction. Like all chronic diseases, treatment over the long term requires, first, medications and, second, psychological therapy and counseling about lifestyle choices. For some substance abusers, a 12-step program can help them manage their chronic condition.
The problem with AA occurs when it's used instead of or to exclusion of evidence-based medicine. And, while we should point a finger at a rehab industry that preys on some of the most vulnerable in society, AA itself—or, rather, some of its hardcore members—also must share in the blame.
Self-appointed AA sponsors too often demand that those under their supervision renounce all medications, including those helping them with their addiction and, in many cases, a dual diagnosed mental disorder, notably depression. That's not only galling from the perspective of anyone in the medical profession and particularly the field of addiction medicine, it's also dangerous. I've seen too many patients who have suffered serious health consequences—even suicide—after following the advice of a 12-step sponsor to abandon all their medications. While an AA pamphlet states that "No AA members should play doctors; all medical advice and treatment should come from a qualified physician," there is absolutely no consequence if an AA sponsor thumbs her nose at the mandate and demands the new member embrace complete abstinence (meaning no drugs, even medications).
As bad as AA is, its cousin Narcotics Anonymous (NA), whose philosophy incorporates Bill Wilson's 12-step method, is worse. It publicly states it is proudly a "program of abstinence and that a member who takes medication like Suboxone violates the organization's philosophy." In a recent interview with the _Huffington Post_ , NA national office's public relations manager Jane Nickels said that if addicts "are taking a drug to treat their addiction, they are not clean in our eyes."
Plenty of Blame to Spread Around
The medical profession itself is also part of the problem. Doctors who don't fully understand the concept of addiction as a chronic disease (with medications available to treat it) are too quick to send a patient who admits to substance abuse to a 12-step program. The prime directive of a doctor is to do no harm to the patient, and such cavalier treatment of patients with a diagnosed alcohol or drug addiction violates this solemn oath. There are too few doctors who have been trained to diagnose and treat addictions. Only 2.5 percent of primary care doctors are certified to prescribe one of the most effective anti-addiction medications, Suboxone.
Like too many doctors, too many judges willfully embrace their ignorance of addiction medicine and send addicts into the hands of 12-step treatment centers, even when evidence-based treatment centers exist as alternatives. Who's to judge whether talking about your problems with other addicts or being treated by a medical professional is the better course of treatment, right?
Private insurance companies and Medicaid also contribute to the problem. In eleven states, Medicaid programs put limits of one to three years on how long addicts can be prescribed Suboxone, one of the leading medications used in addiction treatment. Imagine if we had similar limitations on inhalers for asthma sufferers and insulin for diabetics. The restriction reflects a fundamental misunderstanding that addiction can somehow be cured. Like every other chronic disease (they would not be "chronic" if they could be cured), addiction cannot be cured. But it can be treated and managed successfully so that a high quality of life is achieved.
Some managed care organizations mandate authorization of Suboxone every month. Medicaid has tried to deny payment for Suboxone if a patient fails a drug test. Um, the patient is taking Suboxone to wean himself off a narcotic, so of course it will be present in his body. Equally puzzling, Medicaid will also at times deny payment for Suboxone if the drug test is clean. In other words, you can't win.
If not covered by Medicaid, the Affordable Care Act (ACA), or private insurance, addiction medications can be prohibitively expensive, costing thousands of dollars.
The media, which should be the arbiter of truth, also sometimes gets it all wrong. In a 2013 article sensationally headlined, "Addiction Treatment with a Dark Side," the _New York Times_ , no less, asserted that Suboxone was linked to 420 deaths in the United States by the Food and Drug Administration (FDA). The FDA later repudiated the article's false assumption that Suboxone was a cause of the purported overdose deaths and rather was merely detected. The fact of the matter is that, like marijuana, it's almost impossible to overdose on Suboxone.
Finally, blame popular entertainment for creating a narrative spanning decades that the only way to treat substance abuse is through AA. Literally, dozens of films have reinforced this notion, including _Lost Weekend_ , circa 1945 with Ray Milland (who won an Oscar for his performance); _Come Back, Little Sheba_ (1952, with an Oscar-winning performance by Shirley Booth); _The Days of Wine and Roses_ (1962, another Oscar winner; are we seeing a pattern here?); _Clean and Sober_ (1988), starring Michael Keaton; _The Basketball Diaries_ (1995), starring Leonardo di Caprio; _Leaving Las Vegas_ (1995), starring Nicholas Cage (who won an Oscar for his performance) and Elisabeth Shue; _28 Days_ (2000), starring Sandra Bullock; _Half Nelson_ (2006), starring Ryan Gosling; and on and on.
Of course, many of the films about addiction were made before the advent of evidence-based medicine beginning in the 1990s. Still, having the climax of a film's plotline revolve around a dramatic scene where the protagonist overcomes his addiction through sheer willpower remains very tempting to Hollywood. Treating addiction as a chronic disease through modern science—like hypertension—isn't half as sexy.
The Story of Russell
I am an addiction medicine specialist, psychiatrist, and assistant clinical professor of psychiatry and the behavioral sciences at the University of Southern California. I treat patients, educate medical students, and conduct research.
I wanted to write this book to deliver a clear message: alcoholism and addiction are preventable, treatable medical conditions. But I was motivated to write by a young man I encountered in the ER.
In addition to diagnosing and treating patients, I also provide hands-on education to medical students and doctors in training at Los Angeles County Psychiatric Emergency Services. One evening, I met an emotional and physical wreck of a man brought in by the California Highway Patrol. He had flagged them down on the interstate and begged them to rescue him from the voices in his head and from those pursuing him.
They immediately brought him to the emergency room, and I was promptly notified. I gathered my team of doctors and interns, and we went to the ER to ascertain what was going on. I will never forget what I saw and what I heard from the lips of this most distraught and disheveled young man.
Drenched in sweat, he was a walking nightmare. His clothes were dirty, tattered and torn, and his skin had numerous scrapes and scratches. He was highly agitated, and his eyes darted back and forth as if he were expecting someone to break in at any moment.
We calmly assured him that we were there to help him and that we needed to know how he wound up on the freeway. Despite his extreme agitation, or perhaps because of it, he eagerly poured out his story.
He was a thirty-year-old from Sacramento who had come to Los Angeles for alcohol treatment. He'd been drinking a case of beer and 1.5 liters of vodka every day for the past ten years, and he finally turned to his father for help. He was sent to a free, church-sponsored rehab center in Los Angeles where there was no medical staff awaiting his arrival, no medical diagnosis of his condition, and no medical detox service. All that awaited him was a bed and spiritual counseling.
By the second day in rehab, he had the shakes, anxiety, insomnia, and paranoia—all signs of potentially life-threatening alcohol withdrawal. He asked the resident pastor for help and was given one Tylenol and told to pray.
On the third day, he became further disoriented and even more paranoid. He was hearing voices and having disturbing hallucinations that got worse by the moment. Fearing for his sanity and his life, he made a daring decision. He escaped from the rehab center under the cover of darkness, scaled the chain-link fence and threw himself over the side to the bushes below.
He tore his clothes in the process and sustained numerous scratches and abrasions. Terrified, disoriented, and believing he was being chased by the rehab staff, he struggled through bushes and brambles in almost total darkness before sighting the interstate.
He forced himself over the concrete wall onto the busy freeway, where he dodged traffic until spotted by the highway patrol. He could have been splattered on the interstate or died of seizures in his delirious and psychotic state before being rescued.
We diagnosed his condition as alcohol withdrawal and immediately started him on appropriate medications. His crisis situation was under control within three days, but a CT scan revealed significant brain damage from years of heavy drinking. His brain looked as if it belonged to a demented seventy-year-old.
I arranged a scholarship for him at one of the few medically based treatment centers in the area, and I supervised his medical care personally. He is now independent, working, attending church meetings, and in a happy personal relationship.
Had he not escaped from rehab, he would be dead. He needed far more than a Tylenol and prayer. I have no problem with prayer. Pray all you want. But I absolutely assure you that whatever benefits prayer may offer are greatly increased when you take the right medicine.
Reality Check: Addiction Treatment Today
This one young man was fortunate that he didn't die from alcohol withdrawal, but others are not so lucky. There are detox places where patients are tied down to a bed and "allowed to detox." If they survive, they are the lucky ones. If not, that's too bad. One of my patients referred to these places as "Deathbed Detox." And they're all legal in the United States.
If you are poor, that is what you can expect in the way of detox and rehab in the progressive and enlightened state of California. Even those who can afford high-priced treatment centers often find themselves in facilities that don't bother to diagnose their medical conditions. The center evaluates insurance but not the patient. It's big business with big profits. Success rates are minimal, even for the most expensive facilities.
While there are a few excellent treatment centers that have full-time medical specialists on staff, most drug and alcohol rehabs do not offer comprehensive medical diagnosis or individualized care.
Just Who Is an Addict?
I began writing this book specifically for individuals concerned about their own relationship to drugs and alcohol or that of someone they love. I wanted to dispel myths, counter outright propaganda, and give people hope where they previously had fear and despair. The more I wrote, the more I realized the importance of reaching the largest audience possible. Too many people believe that anyone who drinks often is an alcoholic and anyone who uses a recreational drug is an addict at worse, drug dependent at best. Those who are _not_ addicts are told that they are; those who _are_ addicts are being treated with two long-standing failed methods: slogans and stigma.
The probability of becoming an addict is less than the probability of becoming dependent. Your probability of becoming dependent is estimated to be 32 percent for tobacco; 23 percent for heroin; 17 percent for cocaine; 15 percent for alcohol; 11 percent for stimulants other than cocaine; 9 percent for cannabis; 9 percent for anxiolytic, sedative, and hypnotic drugs; 8 percent for analgesics; 5 percent for psychedelics; and 4 percent for inhalants.
A series of studies on the rate of addiction/behavioral dependence in chronic users of nicotine, alcohol, and opioids elegantly demonstrated that only a subpopulation of chronic substance users becomes dependent.
A majority of substance users do not develop addiction. I would venture to say that the majority of people who attend AA meetings and other 12-step programs aren't addicts, either. They may have indulged in heavy drinking or drugging and perhaps at the risk of life and limb to themselves and others (a driving under the influence, DUI, citation is a wake-up call that sends droves of individuals to seek help from AA). And perhaps this is where an AA program excels—that is, facilitating a drinker at risk to examine her bad behavior.
Addicts are different. They suffer from a chronic disease characterized by an inability to abstain from substances they know are harmful. The heavy drinker might down a bottle of vodka while partying into the night. The addict-alcoholic drinks two bottles of vodka or more until he passes out. Addicts can't stop drinking or drugging because their behavioral control—including the ability to stop craving—is impaired.
Those who develop addiction do so primarily because of genetics. The genetic model of addiction predicts that addiction is more likely to develop after initial substance use in individuals with a genetic susceptibility. The more we know about genetics and genetic testing, the more we know about predicting and treating addiction. The addiction is not in the drug; it is in the genes of the individual.
Unfortunately, AA and their allies—most of the rehab industry—don't make those kinds of distinctions. AA true believers actually deny the medical evidence that contradicts their outdated concept of addiction, including that all-or-nothing abstinence is the only hope for recovery. The rehab industry is much more cynical, taking the easy money and using AA's philosophy to rationalize and justify its dismal success rates.
The social stigma of addiction is more destructive in many cases than the disease itself, and the irresponsible continuation of false diagnoses of addiction by people with no medical credentials, combined with coerced treatment of people for a disease they may not have in the first place, especially when such treatment is devoid of comprehensive medical diagnosis, is an insult to both the patient and the entire medical profession.
Extreme Prejudice
In the all-important, life-saving profession of medicine, we must be clear and precise when discussing addictions. If the general public is wallowing in ignorance, their decisions and actions based on ancient errors and disproved assumptions, illness, and unhappiness will not only continue but increase. No person of good will and integrity would willingly promulgate ignorance.
Superstition is the child of ignorance. In a world of superstition, people believe in magical thinking, distrust new information, and cling tenaciously to outworn and even dangerous practices. A recent guest on a TV talk show insisted, with a perfectly straight face, that there was "real danger" in the practice of yoga because "Hindu demons could take up residence in your spine." Our world is full of people who believe in demons but not in germs, despite overwhelming evidence of germs and none of demons. In this Information Age, the proliferation of misinformation is unparalleled, and erroneous beliefs regarding addiction and treatment are numerous.
One fact is certain: Americans have an extreme prejudice against people suffering from the disease of addiction. This same prejudice is not shown against people with asthma, heart disease, or diabetes, despite these diseases sharing remarkable medical similarities. The reason we fear and distrust addicts is because of their behavior.
Writer and social activist Susan Sontag said it right when she observed about addiction: "Any important malady caused by something obscure and that has an inefficient treatment has the tendency to be full of meaning. At first, the objects of deepest fear (corruption, decadence, pollution, anomie, weakness) are identified with the disease. The disease itself becomes a metaphor. Then, in its name (that is, using it as a metaphor), that horror is imposed on other things. The disease begins to describe things."
Diabetics don't write bad checks to buy Snickers bars, and people with clogged arteries don't break into McDonald's to steal hamburgers. But alcoholics write bad checks to buy more alcohol. The object of addiction takes priority in the damaged decision making of someone with addiction.
Addiction Is Treatable
This is an exciting time in medicine. Astonishing technology allows us to study the actual workings of the human brain, and there are continual breakthroughs in the treatment of chronic illness, including addiction. Researchers are on the cusp of identifying the eleven genes that look to be the hereditary component of addiction.
While scientific treatment of addiction continues to be hobbled by misconceptions and prejudice, there are many glimmers of lights at the end of the tunnel. Remember how Hazelden's CEO touted the virtues of its 12-step program when it merged with the Betty Ford Center in 2014? Well, quietly behind the scenes at the same time, Hazelden's chief medical officer Marvin Seppala was introducing evidence-based medications like Suboxone into its treatment protocols. The results were dramatic. The drop-out rate at Hazelden for opiate addicts in the new medically assisted treatment decreased to just 7 percent compared to 22 percent of those patients not in the new program. In the program's first year, not one addict died from an overdose.
If the two biggest brands in the rehab industry can see the light, change engrained ways, and adopt medically assisted treatment, there's hope for the entire industry.
We must keep in mind, too, that like the privately run healthcare system of the United States, its addiction treatment industry is an anomaly in the world. In every other industrialized nation, addiction is treated like the chronic disease it is. France established evidence-based treatment of addicts in 1995 and saw the country's overdose deaths drop by 79 percent. Similar results have been reported in other Western countries, including Finland, Portugal, Switzerland, and Australia—all places where the grip of the AA philosophy never really took hold like it did in the United States.
Here in America the effectiveness of evidence-based medicine was witnessed in Baltimore with the publicly funded Baltimore Buprenorphine Initiative, which spurred a 50 percent reduction in the city overdose deaths over a fifteen-year period beginning in 1995.
The biggest change in addiction treatment will come when we stop seeing addiction as more of a crime than a disease. Until that time, the treatment of this chronic medical condition will be dominated by misguided amateurs and profiteering rehab providers—who put power and profit over patient well-being.
For the sake of saving lives, we must unite to eliminate prejudice against those born with this genetic predisposition, ensure honest and accurate public education on the subject of addiction, and protect people from fraudulent treatment.
# Chapter 2
# The Ten Biggest Myths of Addiction
After billions of dollars spent on the disinformation campaign known as the war on drugs, no wonder the American public is confused about alcohol and drug addiction. It's a crime. It's a moral failing. It's the parents' fault. It's the kids' fault.
So, why does it matter? It's important because public perception of alcohol and drugs, their use and abuse, influences public policy. From the length of sentences given to those arrested for possession of various kinds of illicit drugs to the billions of taxpayer dollars spent on addiction treatment, the truth about alcohol and drug addiction has a huge impact on society.
It's also a matter of life and death. Countless addicts are sent by courts—or seek help on their own—at treatment programs where there is no hope for recovery. It's not that real treatment doesn't exist, but rather that most Americans, doctors, judges, and addiction counselors have missed the memo.
The only thing standing between effective treatment of alcohol and drug addiction, based on real medicine, is misinformation and ignorance.
In this chapter I tell it straight—no spin, no hidden agenda, no ulterior motives. Only by telling and absorbing the real facts about alcohol and drug addiction will the American public and its elected leaders be able to come to terms with a rational strategy for dealing effectively with addiction. The truth shall, indeed, set us free.
So, take a walk with me now down the Hall of Shame of the ten biggest myths about alcohol and drug addiction.
1. Addiction Is a Problem of Willpower and Abstinence, Which Is Why Medications Don't Work
The biggest myth of all is that addiction is a problem of willpower and abstinence. The foundation for the sorry state of addiction treatment in this country was inadvertently started in the 1930s by an out-of-work investment banker named Bill Wilson. At the time Wilson had his revelation of what would become Alcoholics Anonymous, he was being treated in a hospital for alcoholism with an experimental drug whose active ingredient was belladonna, a plant known for its hallucinogenic effects (or death, if you ingest too large of a dose). Ironic, isn't it? The man who would set the standard treatment for addiction in the United States in the twenty-first century was being medicated with a psychoactive substance when he came up with it during the Great Depression.
Here's the fact of the matter: There isn't now nor was there ever any evidence that AA's 12-step group talk therapy could treat addiction effectively. Indeed, AA itself never claimed to be the end-all answer to addiction and qualified the idea by emphasizing that its particular pseudo-spiritual philosophy isn't for everyone.
That's not to say that AA 12-step programs cannot be helpful as part of an overall treatment program for addiction that includes medications, psychological counseling, and lifestyle modifications. And by the way, that formula for treatment sounds a lot like the treatment protocol for other chronic brain diseases like bipolar disorder. However, AA is part of the problem of addiction treatment in America because it's remained intransigent on the point that its philosophy of abstinence alone can work miracles.
Fortunately, modern science tells us something different. Through diagnostic tools like MRI, we can see how the brain circuitry of addicts is wired differently from nonaddicts. The advent and use of pharmaceutical drugs since the mid-1990s to stop the craving that is characteristic of substance addiction clearly show us that medications can and do work. Thanks to evidence-based treatment, thousands of addicts formerly debilitated by their disease are living happy and normal lives: holding jobs, paying taxes, and surrounding themselves with friends and family.
2. Addicts Should Be Punished for Using Drugs and Drinking Too Much Because in the End, They Know Better
It is not a crime in the United States to have the physical illness of addiction. But if the object of your addiction, such as illicit drugs, is illegal, you could be arrested and prosecuted for the mere act of possessing it. However, this places the person suffering from addiction in a situation of continually interacting with the criminal underworld rather than with medical professionals.
Imagine if we criminalized insulin or inhalers? Our jails would be filled with diabetics and asthma patients.
U.S. Supreme Court Justice Potter Stewart clearly and eloquently defined the problem in 1962 when he wrote in the case of _Robinson v. California_ that "drug addiction is an illness and not a crime" and that "punishing someone for an illness violates the 8th Amendment of the U.S. Constitution."
Let's take it from another perspective. Numerous studies have shown it's much less expensive to treat people with drug problems than to toss them into prison.
Adding to the Alice in Wonderland nature of addiction and criminal law in the United States is the fact that alcohol— _the most_ destructive of all addictive drugs in terms of the consequences to the individual and society—is legal, heavily marketed and commercialized, and even glamorized in popular culture.
3. Alcohol Is Different from Other Drugs Because It's Easier to Control and You're Less Likely to Become Addicted to It
Because of our particular culture, we are less harsh on alcoholics than we are on people addicted to other drugs. When we think of heroin addicts, for example, our mental image is _not_ one of a charming and upstanding citizen. We think of them as evil, scandalous thieves and criminals. Most people don't know that heroin was once considered a "wonder drug"; it was 100 percent legal and available over the counter.
When heroin was first introduced by Bayer (the same company that gave us aspirin), tuberculosis and pneumonia were the leading causes of death, and even routine coughs and colds could be severely incapacitating. Heroin, which both depresses respiration and gives a restorative night's sleep as a sedative, seemed a godsend. It was used in the treatment of asthma, bronchitis, and tuberculosis and even in the treatment of alcoholism.
According to an article in the _Boston Medical and Surgical Journal_ in 1900, "It [heroin] possesses many advantages over morphine. It's not hypnotic, and there's no danger of acquiring a habit." Heroin was widely used in America, and most medicines used by women for relief of menstrual pain contained heroin. Cocaine, a stimulant and anesthetic, was also legal; it was often used in combination with heroin in various medications, often in an alcohol base.
Both heroin and cocaine were inexpensive until they became illegal. Suddenly, the price went sky high, and those already addicted had no choice but to get the money by any means necessary and give that money to criminals.
Alcohol, of course, has long been associated with compulsive, uncontrolled behavior among a certain percentage of the population. The term _alcoholism_ was first used in Sweden in 1849, but the first chronicles of uncontrollable urges to drink appear in the early 1800s under the term _dipsomania_. That word actually means compulsive thirst, but it soon became used specifically to mean the compulsive, uncontrolled intake of alcohol.
The classic description of dipsomania was written by Valentin Magnan in 1893, and you will see that he did a very good job of describing what today we call alcoholism:
Preceded by a vague feeling of malaise . . . dipsomania is a sudden need to drink that is irresistible, despite a short and intense struggle. The crisis lasts from one day to two weeks and consists of a rapid and massive ingestion of alcohol or whatever other strong, excitatory liquid happens to be at hand, whether or not it is fit for consumption. It involves solitary alcohol abuse, with loss of all other interests. These crises recur at indeterminate intervals, separated by periods when the subject is generally sober and may even manifest repugnance for alcohol and intense remorse over his or her conduct. These recurring attacks may be associated with wandering tendencies (dromomania) or suicidal impulses.
Sigmund Freud saw the fevered consumption of alcohol as a complex substitute for sexual obsession and the drunken stupor as a sort of twisted victory in that it successfully desensitized the pain caused by the avoided obsession and featured an alluring mastery of total passivity. Freud considered that motor acts, with or without wandering, were central to sexual obsession, and repetitive drinking was one of those motor skills.
Whether or not Freud's analysis was psychologically accurate, he offered profound insights into the alcoholic's crises. "He never rested until he had lost everything," Freud wrote. "The irresistible nature of the temptation, the solemn resolutions, which are nevertheless invariably broken, never to do it again, the stupefying pleasure and the bad conscience which tells the subject that he is ruining himself (committing suicide)—all these elements remain unaltered in the process."
Freud postulated a hereditary component and delineated similarities between compulsive drinking and compulsive gambling. He also suggested that these compulsions have an association with an organic, toxic brain disease. Decades worth of subsequent research studies have proven him spot-on correct in that regard.
There were early attempts to link alcoholism with manic-depression, now called bipolar disorder, or with a "false manic-depressive" condition. As there were no addiction medicine specialists in those days, there were no empirical medical studies of these conditions beyond noting their characteristics.
Today we know that alcohol is the most prevalent drug abused, causes more deaths than all other drugs combined, and is the most difficult to treat because of its ability to simultaneously affect multiple brain receptors (while other drugs tend to affect only one or two).
4. Virtually Everyone Who Uses Meth or Crack Will Become Addicts and the Meth and Crack Addiction Are Increasing
Most users of meth and crack—like all drugs—never become addicts. Your probability of becoming dependent is estimated to be 32 percent for tobacco; 23 percent for heroin; 17 percent for cocaine and crack; 15 percent for alcohol; 11 percent for stimulants other than cocaine (like meth); 9 percent for cannabis; 9 percent for anxiolytic, sedative, and hypnotic drugs; 8 percent for analgesics; 5 percent for psychedelics; and 4 percent for inhalants. Bottom line: Most people simply stop using their drug of choice before it becomes a real problem.
The misinformation about crack and meth is legion. The very names of these street drugs cause politicians to foam at the mouth. Are they dangerous? Without a doubt. Do they deserve the kind of hysteria they generate? Nope.
It's worth saying again: Most people who try crack don't like it and don't use it again. Over 75 percent of people who tried crack between 2004 and 2006 were not using it at all two years later; 15 percent still smoked it occasionally, but not in a way associated with addiction.
Even though they're the same drug, but in a different form, crack and cocaine are perceived wildly differently both by the criminal justice system and the public alike.
During their lifetime, 7,840,000 (3.3 percent) of Americans have smoked crack cocaine, according to the National Survey on Drug Use and Health. However, only 467,000 (0.2 percent) of Americans reported smoking crack cocaine in the last thirty days. If crack were instantaneously addictive, the number of recent users would be much larger.
According to the same survey of Americans aged twelve and older, 5.9 percent of individuals who had tried cocaine went on to be "current users" (reported use within the past thirty days). The same statistic for crack use was also 5.9 percent. These numbers show no statistical difference in the tendency toward the future use of cocaine and crack.
Again, there is no pharmacological difference between crack cocaine and powder cocaine. Crack cocaine is simply powder cocaine that has been converted into a solid "rock" form that may be smoked. The effects of smoking crack cocaine may be more intense, but this is a result of the mode of ingestion rather than the drug's purity. Regardless, it is difficult to rationalize the extreme sentencing disparity between crack and cocaine.
Similarly, crack is perceived not only to be more addictive but more deadly. The misuse of any drug (legal or illegal) can be detrimental to your health. However, it is simply not true to claim that crack cocaine is a major cause of death. The percentage of deaths attributed to _all_ illegal drugs combined is less than 1 percent. By comparison, over 18 percent is caused by tobacco. More people die every year from legal drugs, legally prescribed, than all illegal drugs combined.
Fact: While often characterized as a drug of the black community, 60 percent of individuals who have used crack in the last month are white. White crack users also account for 66 percent of individuals who have ever used crack in their lifetime. Simply stated, the majority of crack users are white.
Despite this reality, 80 percent of people arrested for crack offenses are black. Consequently, a disproportionate number of black crack offenders face the harsh mandatory minimums associated with crack convictions.
Finally, crack is perceived as instigating violent behavior while cocaine gets a pass. Yet, research has shown that crack use does not result in violent behavior. The violence one associates with crack is not from the effects of the drug, but rather the violence between rival criminal organizations and/or law enforcement.
Like crack and cocaine, meth is perceived as a drug with no redeeming value. That's true. About a hundred years ago the same argument was used to ban and criminalize the use of alcohol. What is _not_ true is that meth is on the rise and meth users are harder to treat than, say, alcoholics.
Meth use in the United States peaked at least two decades ago and has slightly declined or stayed about the same. Addiction to methamphetamine is not much different from that of any other drug addiction except tobacco, which is the most addicting and the most difficult to quit. When it comes to successful treatment, it doesn't matter if you're talking about meth or heroin or alcohol.
Just as the vast majority of drinkers are not alcoholics, the majority of stimulant users (like meth heads) are not addicts. They stop on their own or with help from family and friends. There is that small minority of those who actually have the disease of addiction and require true medical treatment. These are the people with whom I am concerned.
"Meth is a real problem for some people, but it is an over-hyped problem. All you have to do is look at the use rates and look at sentencing," said Jason Ziedenderg, executive director of the Justice Policy Institute. "When 100,000 people a year die from alcohol, I'm still saying that's the most dangerous drug in America."
5. People Addicted to One Drug Are Addicted to All of Them
It is not true that a person who is addicted to one drug is addicted to all drugs. The drug to which someone becomes addicted corresponds to that individual's particular brain chemistry. Most alcoholics are not meth heads, most heroin junkies don't regularly use meth, and so on. Now, when the preferred drug of choice is scarce (meaning, expensive) or not available at all, addicts will turn to another drug. Read on.
6. Prescription Pills Are Safer Than Illegal Street Drugs Because They've Been Prescribed by a Doctor
The Centers for Disease Control and Prevention (CDC) recently released some startling facts about drug use and deaths in the United States.
• In 2013, of the 43,982 drug overdose deaths in the United States, 22,767 (51.8 percent) were related to pharmaceuticals, notably opioid analgesics (also called prescription painkillers), stimulants, and tranquilizers.
• In 2011, about 1.4 million emergency room (ER) visits involved the nonmedical use of pharmaceuticals. Among those ER visits, 501,207 were related to antianxiety and insomnia medications, and 420,040 were related to opioid analgesics.
• The drug overdose death rate has more than doubled from 1999—about the same time that doctors dramatically increased the prescribing of painkillers—through 2013.
• In 2013, more than 17,000 people died from prescription painkiller overdoses, with more than 400,000 going to an emergency room.
The CDC called the prescription painkiller epidemic that took hold in the late 1990s the worst of its kind in U.S. history. "The bottom line is that this is one of the few health problems in this country that's getting worse," CDC director Tom Frieden told the _Huffington Post_ in 2014.
Echoing those sentiments, the editorial board of _USA Today_ wrote in November 2013, "The deadliest drug problem in America is not heroin or cocaine or even crack cocaine. It's the abuse of perfectly legal prescription pain medications—familiar names such as Vicodin and Lortab and generic hydrocodone."
The extent of the prescription pill problem is reflected in this startling statistic: The painkiller hydrocodone is the most prescribed medication in America—136.7 million prescriptions a year at last count. To frame the problem another way, in 2010, enough prescription painkillers were prescribed to medicate every American adult every four hours for one month.
In 2014 the Food and Drug Administration (FDA) and the Drug Enforcement Agency (DEA) began a joint effort to crack down on the prescription pill epidemic by reclassifying hydrocodone, Vicodin, and other leading painkillers in the category reserved for medical substances with the highest potential for harm. The initiative also required patients to present to a pharmacist in person with a written prescription from a qualified health provider—a move to stem the practice of faxing or calling in the prescription multiple times to multiple pharmacies.
The good news is that all of that worked. The tidal wave of prescription pills available on the legal and illegal markets began to recede. The bad news is that pill addicts switched their drug of choice to an equally dangerous drug—heroin.
7. Today's Marijuana Is Extremely Powerful and a Leading Cause of Drug Overdose, thus Possession in Small Amounts Shouldn't Be Decriminalized or Legalized
I could write a book about marijuana myths alone, but I'll confine myself to two points. First, even today with some states legalizing marijuana for personal recreational use, there has not been one recorded death from marijuana overdose. While tens of thousands of people die each year from alcohol or prescription painkillers, no one has ever died or overdosed on marijuana. Why? Let me quote the National Cancer Institute: "Because cannabinoid receptors, unlike opioid receptors, are not located in the brainstem areas controlling respiration, lethal overdoses from Cannabis and cannabinoids [marijuana] do not occur."
Although painkillers can cause a person to stop breathing, you could smoke or ingest marijuana all day and all night and your respiration would still not be affected because marijuana does not affect the body's brain pathway that controls it.
Second, there is no evidence that decriminalizing, legalizing, or otherwise making marijuana more available to the public in any way increases its use. In fact, according to a recent national school-based survey among teens in grades eight through twelve, the increased availability of marijuana in the twenty-one states that legalized medical marijuana did not significantly change its use. The study was conducted by researchers at Columbia University Mailman School of Public Health and supports a growing body of evidence that making legalized marijuana more available to the public does not increase its use.
All this said, I still support the regulation of marijuana. At the moment, there are no federal standards regarding dosages. The problem of nonstandardized packaging—including the lack of clear warning labels—is particularly egregious with marijuana-infused edibles as well as drinks and pills. Unlike smoking a joint, the user can consume a relatively large quantity of THC, the high-inducing compound in marijuana, by eating a cookie, for example. This can impair the user's cognitive and motor skills, a potentially fatal scenario if it involves driving a car.
Ingesting too much THC can also increase the risk of mental illness. Too many people are ending up in the ER for THC-induced intoxication and panic attacks. Unregulated THC-infused products pose an even bigger danger for those at risk of serious mental disorders. A recent study published in the British journal _Psychiatry_ showed that large doses of THC can trigger schizophrenia in predisposed patients.
Finally, isn't it obvious to all concerned that edibles such as brownies, cookies, and candy infused with mega doses of THC pose still another danger to children? We regulate alcohol and cigarettes, which like marijuana are legalized recreational drugs intended for adult use, with standardized dosages and packaging. Why not, then, marijuana?
8. Heroin Is Mainly a Ghetto Drug
A comprehensive study called, appropriately, "The Changing Face of Heroin Use in the United States," published in 2014 by the journal _JAMA Psychiatry,_ reported that contrary to popular belief, most heroin addicts today did not start on their "silk road" to perdition with another illicit drug, such as marijuana. Instead, most first started getting high with prescription painkillers, likely obtained at home, from a friend, or illegally on the street.
As mentioned earlier, the campaign to restrict prescription painkillers simply switched the addiction problem in the United States to heroin, which, unfortunately, at the same time was becoming cheap and plentiful on the black market due to overproduction in the narcotic countries, notably Afghanistan but also Mexico and countries in South America and southeast and southwest Asia.
Quite suddenly, the new prescription painkiller epidemic transformed into the new heroin epidemic. As _The Atlantic_ magazine noted in an October 2014 article, "ten years after prescription painkiller dependence" swept America and "the government cracked down on doctors and drug companies, people went searching for a cheaper, more accessible high. Now, many areas are struggling with an unprecedented heroin crisis."
Heroin, the drug that was once exclusively associated with urban America and particularly black ghettos, was now becoming a fixture in white suburbia and in rural states. The problem became so alarming that in Vermont, everyone's ideal of pastoral beauty in America (not to mention the headquarters of Ben & Jerry's ice cream), the governor devoted his entire annual speech in 2014 to what he called "a full-blown heroin crisis" gripping his state.
In a 2014 article headlined "Heroin Overdose Deaths Quadruple over Last Decade, As Painkillers Open Fatal Gateway," the website Medical Daily reported that the death rate jumped from 0.7 deaths per 100,000 people in the year 2000 to 2.7 deaths per 100,000 in 2013. More troubling, between 2010 and 2013, the death rate made even greater leaps: from a 6 percent increase over the previous decade to 37 percent. "Beneath this trend lurks a more fundamental change in how heroin is used, and, importantly, who is using it. The demographics of fatal overdose have changed considerably in the last decade. In 2000, black adults between forty-five and sixty-four years old showed the highest rate, at two deaths per 100,000. In 2013, white adults between eighteen and forty-four earned that distinction, at seven deaths per 100,000. Some suggest heroin's vanishing stigma can explain the change," according to the report.
Fueling the epidemic was a new, more pure and potent form of heroin that could be snorted or smoked to achieve the high previously possible only through injections. So, while we're at it, let's destroy the other myth about opioids as largely a drug of choice of young people. As it turns out, prescription pill addiction skews much older than other drug epidemics. In 2012, those between the ages of forty-five and sixty-four accounted for the highest rate of inpatient hospital stays for opioid overuse. Two decades earlier, according to the federal Agency for Healthcare Research and Quality, the highest rate was for those between twenty-five and forty-four.
When the supply of prescription pills tightened because of new federal restrictions, baby boomers turned to, yes, marijuana (did they ever leave it?), but right behind it as the most common illegal drug of choice was, according to the National Institutes of Health, heroin (in its new, noninjectable form).
9. Alcoholics and Addicts Have to Hit Rock Bottom before They Can Be Treated Effectively
The need to hit rock bottom is another pseudo-science precept of AA, which, however, welcomes alcoholics to join at any stage of their addiction. Yet, if you're around anyone who is a member of AA, the idea of hitting rock bottom is thrown around like a badge of honor.
There is no medical science that supports the idea that addiction can be treated only once you've blacked out on Skid Row, driven a car into a tree, ended up in a hospital or jail cell, or any other calamities associated with hitting rock bottom. That's tantamount to saying a diabetic can be treated effectively only once he or she goes into insulin shock. It's always better with any chronic disease—be it asthma, heart disease, bipolar diseases, or substance addiction—to get help early. In short, the whole idea of rock bottom is utter nonsense.
How did we reach the point where the treatment of a chronic disease includes the notion of rock bottom? Part of the reason lies in the origins of AA. Its founder, Bill Wilson, indeed had lost everything of value to him and was hospitalized because of medical conditions related to his illness when he says that he received his epiphany to begin AA. His plight became the model for all AA followers.
Another reason is the double-speak world of AA dogma. _Rock bottom_ provides cover for when AA members fall off the wagon. AA can say that its prescribed abstinence-only treatment did not work on those who left because those quitters hadn't yet—and here it comes—hit rock bottom. In the world of AA, the program is never the problem; relapse is always the member's fault.
10. Treating Addiction with Medications Won't Work Because You're Just Substituting One Drug for Another, and Besides, Addicts Will Figure Out a Way to Abuse the New Drug
Recent scientific research shows that the process of addiction is related to overstimulation of the brain's reward pathway. A study published in _Science Daily_ states that what happens in addiction to drugs is lethally simple: "The reward pathways in the brain have been so over-stimulated that the system basically turns on itself, adapting to the new reality of addiction, whether it's cocaine or cupcakes."
From a medical perspective, then, the key to treating addiction is crystal clear: Stop the overstimulation of the brain's reward pathway. This is where AA and 12-step programs confuse correlation with cause. Abstinence can be achieved when proper medical treatment is provided, which halts the addict's craving for his favored substance. But simply talking about stopping the craving and listening to stories of other people's addiction will not achieve abstinence for most people.
Modern medical science has given us an array of pharmaceutical medications that have proven effective in stopping the craving that characterizes addiction. We'll get into that deeper in the next chapter, but suffice to say that among the most effective treatments for addiction to opioids (prescription pills, heroin, morphine) is buprenorphine, an FDA-approved, opioid-derived medication. When a patient switches from his opioid of choice to buprenorphine, the addictive behavior usually stops. That's because buprenorphine's ability to cause a high has a ceiling. Patients can snort, smoke, or inject buprenorphine all they want, but extra doses will not make them feel any differently.
Some addicts stay on buprenorphine for weeks or months, others for years. There is no one-size-fits-all cure for addiction. It's a complex disease requiring individualized treatment. Buprenorphine has allowed addicts to live a normal life by helping them regain control of their brain's reward pathways.
I'll close this chapter by acknowledging that buprenorphine is now one of the most sought-after drugs on the streets . . . but not for the reason you might think.
The medication, often dispensed under its brand name Suboxone, is tightly controlled and must be prescribed by a physician specifically trained and licensed to handle the drug. A mere 2.5 percent of all primary care doctors are certified.
As reported in the _Huffington Post_ in a 2015 groundbreaking article about the lack of evidence-based treatment ("Dying to Be Free" by Jason Cherkis), multiple states are struggling to manage the heroin epidemic in which "thousands of addicts have no access to Suboxone. There have been reports by doctors and clinics of waiting lists for the medication in Kentucky, Ohio, central New York and Vermont, among others." In one Ohio county, a clinic's waiting list ran to 500 patients.
To be clear, Suboxone has been so effective in dealing with prescription painkiller and heroin addiction that there is a great demand for it by addicts. When addicts can't get it legally, they turn to the black market. As I said before, America doesn't have so much an addiction problem as a problem with addiction treatment.
# Chapter 3
# The Medical Illness of Addiction
Joanne Campbell, forty-five, is not your idea of an addict. She is a mother with three gainfully employed and happy adult children. She is also a successful retail entrepreneur.
Born in Houston, she was a typical teenager but maybe atypical in that she rarely indulged in drinking or drugging. When she turned twenty-one, the legal drinking age in the state, she started social drinking with friends. She married and, together with her husband, began raising a family.
That's when she discovered cocaine and, by the age of twenty-eight, she was abusing it. She and her spouse split, and she was left to raise her three children on her own. "After my split with the father of my children in 2000 is when I began to abuse alcohol more often," she says.
Over the next decade she recalls that her abuse of cocaine led her to something more serious. "I think that I became addicted over a period of years with the misuse and abuse of alcohol," she says. "It kind of went up and down from the age of 35 to 43. I had some bad years and some fine years, leading up to a couple of really bad years where so many things seemed so overwhelming that I would drink more often and for longer periods of time. I believe that so many emotionally difficult things in my life built up that I had never really dealt with."
It was shortly after Christmas 2011 that Joanne came to see me. Alone at home during the holidays, her three adult children busy with their own lives, she began a familiar routine—a binge of cocaine and alcohol, except this time it didn't stop. When her concerned children finally showed up on her doorstep and gave her an ultimatum, she knew that she had to get help.
Her fear of losing everything, including her children, finally became a reality. For many years, she thought she could do it on her own. At a certain point she even began to see a therapist weekly and thought that she would be able to fix herself through counseling alone.
She had tried AA and 12-step programs but never identified with them. "I think that was also part of my problem," she said. "I didn't think anything else was available."
Realizing the gravity of Joanne's deteriorating health, her therapist recommended that she consider an evidence-based treatment under my medical supervision. After a successful detox, Joanne began a program that managed her addictive cravings through a combination of pharmaceutical intervention and cognitive behavioral therapy (CBT).
Three years later, she is flourishing, running a small business. She still regularly sees me for management of her addiction disease, but has not relapsed since.
• • •
Alcohol and drug addiction is a chronic disease with a strong genetic predisposition. Does that sound familiar? It should, because it basically describes every other leading chronic disease, including heart disease, stroke, cancer, diabetes, and asthma. It's also like mental illness because, in addition, addiction is a brain disease.
Addicts and alcoholics have structural or functional damage to the reward-motivation center of their brains. When damaged, this reward center keeps individuals doing things even when the result is pain instead of pleasure.
Whenever you do something pleasurable, it affects the amount of a substance in the brain called dopamine. If there were a pleasure impact scale based on dopamine, eating food and drinking water rates a 2, sex rates 4, cocaine rates 8, and methamphetamine scores a 12.
It's interesting to note that both methamphetamine and cocaine increase the amount of dopamine in the synapses. However, cocaine achieves this action by preventing dopamine reuptake, while methamphetamine helps the body release more dopamine. So although these drugs have similar effects, they work in entirely different ways.
Bottom line: Addiction is a medical condition, not a moral failing. The seemingly age-old debate over the treatment of alcohol and drug addiction—through willpower, spirituality, and talk therapy versus physical diagnosis and evidence-based therapy—is over. The connection between addiction and brain chemistry is indisputable. While there is a role for behavioral and cognitive counseling in addiction treatment, a program based purely on psychological therapy or the 12-step philosophy is inadequate for treating a disease with genetic and physiological roots.
The Anatomy of Addiction
Substance addictions, including alcohol and stimulant drugs like cocaine, are not caused by the drink or the drug. Addiction is primarily the result of genetics and overstimulation of the pleasure and reward pathway in the brain.
In the case of Joanne for example, it was very clear to me when I first diagnosed her that she was motivated to stop drinking. She loved her children, she wanted to pursue her dream of owning her own business, and she knew that she had the skills to turn her life around. But she couldn't stop her craving for alcohol and cocaine. "My addiction would get better for months at a time," Joanne confessed, "but I would always go back to an alcohol and drug binge when I needed to check out of my world."
We now know why the Joannes of the world cannot help themselves. Addiction is a disease characterized by anatomical and functional changes in the human brain. The anatomical changes can be clearly seen and studied with brain imaging technology, such as a standard MRI and CT scans. Functional abnormalities can be seen, studied, and evaluated by PET scans or functional MRI. These changes are in the brain's reward, motivation, memory, and related circuitry. Some of these changes are repairable, while others are not reversible—so far.
Just as heart disease causes a blatantly decreased heart metabolism, drug abuse causes a similar decrease in brain metabolism. The similarities between addiction and heart disease, diabetes, and asthma are remarkable. They each have a genetic basis and are impacted by voluntary behavior.
Because the brain controls behavior, a disease of the brain will have behavioral consequences. Because of these brain changes, people become unable to make conscious decisions in their own best interest. Individuals thus afflicted with the disease will compulsively pursue a detrimental course of action, despite continual negative medical and social consequences. In other words, despite knowing that the next bottle of vodka that he consumes will likely kill him, especially if he gets behind the wheel of car to go buy it, an alcoholic will quite literally drive himself to drink.
About 10 percent of the at-risk population becomes alcoholics or drug addicts—and the rest do not. Let's reframe that: Most people who drink alcohol, snort cocaine, or shoot heroin will not become addicts. Why? Research indicates that fully half the reason is genetic. For instance, we know that the children of alcoholics are four to five times more likely to become alcoholics themselves.
The exact mechanisms of how drugs and alcohol affect the addict's brain are still being worked out. But we know a lot right now. We know that alcohol and drugs in everyone's brains affect the delicate equilibrium in the neurological system. Pulses travel along this network of nerves, carrying information and instructions from the brain to the rest of the body. Substances called neurotransmitters keep our bodies functioning, from our most fundamental tasks, such as breathing and eating, to more intricate processes like pleasure seeking (including falling in love) and the fight-or-flight response (it's why we automatically jump away from oncoming traffic).
The neurobiology of addiction is very complex, but it appears from numerous studies that two neurotransmitters are especially important in alcohol and drug addiction: GABA and dopamine. GABA is among a group of inhibitory neurotransmitters that regulate and moderate impulses. Dopamine is on the opposite end of the spectrum and belongs to those excitatory neurotransmitters that provide the reward of pleasure. In proper balance, these neurotransmitters allow one to lead a productive and happy life, but without going overboard on the happy part.
In other words, together these two neurotransmitters achieve the moderation that philosophers have extolled through the ages. (The Greek sage Epictetus was among the first to observe, "If one oversteps the bounds of moderation, the greatest pleasures cease to please.")
Even for the normal person, drugs change the brain just like they change the brain of the addict. Psychoactive drugs artificially overstimulate dopamine flow and block the flow of the inhibitory agents in GABA. Forget the stoic advice of Epictetus. Suddenly the brain goes totally Oscar "Nothing succeeds like excess" Wilde.
But eventually, the inhibitory neurotransmitters of the normal person's brain put the brakes on the overstimulation of dopamine, and the person stops drinking or drugging. Those brakes don't work in the addict's brain. They were made defective or they've burned out. And even worse, the more they drink and drug excessively, the more they desensitize the brain's receptors.
Is There an Addiction Gene?
I was interviewed by ABC News when the Oscar-winning actor Robert Downey Jr. appeared on the cover of Vanity Fair magazine. In the accompanying magazine article, Downey talked about his concern of passing his addictive personality on to his son Indio. (You might also recall that Indio was arrested for cocaine possession in October 2014.)
I agreed that Downey was correct in believing that genes played a role in addiction, but his son's use of cocaine did not mean he was necessarily going to be an addict. Most teenagers abuse drugs—it is part of growing up in an individualistic culture like America, whether or not parents like it.
Decades of scientific research have shown that the chance of becoming an addict is at least 50 percent—and perhaps as high as 75 percent— the result of your genes. Now, that's not to say that every child of an addict will be one as well. Both clinically and statistically, we know that not to be the case. It does mean, however, that children of addicts have a higher risk, and knowing this can empower them to make lifestyle choices that can help them reduce the risk of getting the disease or controlling it.
There's no good biomarker at the moment to determine if someone is genetically programmed for addiction, so we must rely on behavior and diagnostic tools like MRI and behavioral analysis to make a predictive determination (more on this in Chapter 5). But what if a gene for addiction were identified that then could be manipulated so that the disease could be avoided altogether?
Researchers are zeroing in on the genetic basis for drug and alcohol addiction. The National Institutes of Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse all have studies under way that seek to explain the effects of alcohol and stimulant drugs by identifying specific genes that may be predictive of use as well as shed light on any underlying molecular or behavioral factors involved.
New research indicates that there isn't just one "addiction gene" but rather a panel of five to eleven genes associated with alcohol and drug abuse. Investigators at Indiana University have published results of a study that asks, if an individual is found to have the genetic predisposition across these eleven genes, is he or she predestined to be—or at least, at very high risk—of being an addict? Stay tuned.
Other research is focused on the _epigenetics_ of drug addiction, meaning how use, and particularly high volume use, over a long term actually alters the structure of DNA. Most of our DNA is locked in when we're born, but not completely. Environmental factors—ranging from exposure to radiation to everyday stress—can have lasting effects on body and brain functions.
In a study at the University of California at San Francisco, scientists found that long-term alcohol abuse changes the chemical signatures around specific genes that shield against addiction. Once changed, these protective systems never return to their full effect. As the researchers explained, this mechanism might help explain "as to why 10 percent of the population develops alcohol use disorders" and why the rest of population that indulges alcohol does not.
In other words, neuroscience is showing us that the basis of drug and alcohol abuse is found in both a pattern of genes causing risky behavior and also a pattern of risky behavior that changes the way our genes are expressed.
Why is this important? First, if a person knows definitively—beyond his familial history—that he has a genetic profile for addiction, he can take proactive steps to avoid the kind of behavior that would trigger the disease (like, for instance, avoiding alcohol and recreational drugging).
Second, knowing the genetic and epigenetic basis for addiction could be extremely helpful in the development of future medications to treat and even prevent addiction.
Finally, the emerging technique of gene therapy, which uses specific genes to treat or prevent disease, is on the cusp of entering mainstream medicine. What if in the not too distant future, doctors could treat an alcohol or drug disorder by inserting a gene into the patient's cells to correct the faulty brain circuitry that characterizes addicts? This level of understanding might even lead to the elusive cure for the chronic disease of addiction.
A New Normal
Addicts develop a "new normal" because the brain attempts to adjust to the foreign substances—the toxins—flooding its receptors. Eventually, every addict reaches a tipping point, where the brain receptors remain permanently on. The first puff of marijuana or snort of heroin can send the addict back to the level of addiction when she hit bottom.
That likely is what happened with Oscar-winning actor Philip Seymour Hoffman, who died of a heroin overdose. He admitted quite openly during his career that as a young man he tried every drug that he could get his hands on, not to mention alcohol. His official death, at age forty-six, was ruled as acute mixed-drug intoxication, including heroin, cocaine, benzodiazepines, and amphetamines. Even though he claimed twenty years of sobriety, three months before his death he purportedly snorted a line of heroin at a party, and it was like nothing had ever changed—he was back in an instant to the addiction that he had experienced as a young man.
Not only does overstimulation of the reward circuitry factor significantly in addiction but it also creates false memories of the experience. The brain regards the experience as "better than expected," even when the experience wasn't all that great. Because the memory is a permanent part of your mental makeup, anything and everything that reminds you of that memory also reminds you that the experience was better than expected and triggers an instant desire to reexperience something that perhaps wasn't anywhere as good as you remember.
Sound twisted and illogical? Well, it is! Welcome to the world of addicts and alcoholics who, no matter how bright they are, rely on a brain that is constantly giving them false signals.
However, an addict doesn't even have to ingest a substance to flip the trigger. An alcoholic can pass a bar and the mere association of the booze inside can create a cascade of anxiety that mimics the feelings of withdrawal. That's why many drug addicts and alcoholics relapse. The craving never disappears. It's always there. It's like every other chronic disease in the sense that the disease is never cured.
The difference between addiction and most other chronic diseases is that it affects the brain. That's important because, as previously mentioned, the brain controls behavior, so a disease of the brain will have behavioral consequences. Because of these brain changes, people become unable to make conscious decisions in their own best interest. The medically accepted definition of addiction clearly states that the individual thus afflicted will compulsively pursue a detrimental course of action, despite continual negative health and social consequences.
Once the brain change has taken place, medical treatment coupled with intentional behavior modification can help restore balance, and in some cases, actually repair damage to the brain's reward circuitry. To make things really clear, here is a useful, if perhaps an oversimplified, formula:
GP \+ ES = A
Genetic predisposition (GP) + Excessive stimulation of the pleasure–reward pathway (ES) = Addiction (A)
Therefore, for someone with a genetic predisposition to addiction, an effective preventive measure is a diversity of pleasures, none of them to excess. Knowing that too much pleasure repeated too often, especially from a singular source, is a major factor in addiction, the wise person practices moderation, enjoys a variety of different activities, and guards against overdoing any one thing.
Addiction is characterized by the inability to consistently abstain, by impairment in behavioral control, by cravings, by diminished recognition of significant problems with one's behaviors and interpersonal relationships, and by a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
With addiction, there is a significant impairment in executive functioning (the part of the brain that organizes and acts on information), which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors, despite mounting concerns expressed by significant others in their lives. They also display an apparent lack of appreciation of the magnitude of cumulative problems and complications.
The still developing frontal lobes of adolescents, in particular, may both compound these deficits in executive functioning and predispose youngsters to engage in high-risk behaviors, including alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors underscores the compulsive aspect of this disease. This is the connection with "powerlessness" over addiction and "unmanageability" of life, as is described in the first step of 12-step programs.
The Effects of Alcohol on the Brain
It's at this point where we must stop thinking of drug and alcohol addiction as synonymous. In terms of its physiological effect on the body and its consequences to the health of the addict, alcohol is much more insidious and its damage more serious.
Despite alcohol consumption being both socially acceptable and perfectly legal, it kills more people than any other drug in the United States. Alcohol is the third leading cause of death, because it attacks every vital organ system in the human body. Yet, the fact that it is legal—even celebrated and glamorized—makes it far more acceptable than, say, crack in modern society. Keep in mind that at the advent of the twentieth century both cocaine and heroin were sold as over-the-counter medications, and wealthy white women were more likely to be addicted to drugs, including morphine, than any other group in the country. (Celebrated early twentieth-century American playwright Eugene O'Neill made repeated references to his mother's morphine addiction in plays such as _Long Day's Journey into Night_.)
The physical effects of alcohol addiction are far more widespread than addiction to drugs. Alcohol directly or indirectly causes stomach cancer, rectum cancer, colon cancer, throat cancer, liver cancer, larynx cancer, and esophageal cancer. Alcohol doesn't cause lung cancer, but as many alcoholics also smoke, you might take that into consideration as well.
Scientists used to think of alcohol as a membrane disruptor with a generalized effect all over the brain, as the small molecule can freely diffuse across the blood–brain barrier. We now know that there are particular cells in the brain that alcohol targets by binding certain hydrophobic pockets on their surface receptors.
Unlike opioids (heroin, opium, morphine, oxycodone, and Vicodin), which tend to affect only one kind of cellular receptor, alcohol has been found to affect more than 100 unique receptors in the brain. It activates the entire neurotransmitter reward system.
The neurochemical effects of alcohol cause a range of short-term effects—from a mild buzz to slow reaction times, which make drunk driving so dangerous. In the long term, these effects are also the basis for two of the defining characteristics of alcoholism: _tolerance_ and _dependence_.
Tolerance to alcohol is one aspect of alcoholism that leads to overdrinking. Tolerance can be acute, in one bout of drinking, or long-term, requiring an ever-larger dose to get the same effect over time.
The effect of acute tolerance is a common experience for anyone who has had more than a few drinks. Initially, the first drink has a relaxing effect, but as a person continues drinking, it takes more and more alcohol to produce the same effect. Some people have more acute tolerance than others due to genetic factors. These are the people who can drink everyone else under the table, and they also may be at increased risk of developing dependence on alcohol.
Dependence on alcohol is linked to the interaction of alcohol with the brain's stress system, which alcohol activates. The major component of the brain's stress system is corticotropin-releasing factor (CRF) in the amygdala and related areas, which activates sympathetic and behavioral responses to stress. In a normal stress response, CRF recruits other parts of the brain to help adapt the mind and body to deal with the physical and mental stressors that challenge it. Alcohol interacts in such a way as to acutely reduce CRF levels in the brain; chronic alcoholism does the opposite.
Research indicates that individuals who are at increased risk of becoming alcoholics are likely to have a genetic makeup causing them to have higher CRF levels than normal. They may be drinking to tame a hyperactive CRF stress system in the brain.
Unfortunately, CRF and the stress system adjust to the alcohol. In the absence of alcohol, the alcoholic feels ill because his or her body cannot easily reverse the high levels of CRF and low reward neurotransmission. This ill feeling may contribute to the tendency of the alcoholic to overdrink—a danger because of the toxic effect on the brain and body of subjecting oneself to so much alcohol.
Sadly, the brain often does not perceive the consequences of the short-term relief that the alcohol brings. When a person overdrinks, she feels good while she is boozing. However, this short-term relief makes the whole system worse off.
Not Either/Or, but Both
During the last century, a debate raged in academic circles whether addiction was a psychological disorder or a physiological disease. Was it a behavioral problem that arises because of environmental factors in early childhood—the nurture argument? Or was addiction a hereditary disease—the nature argument?
We now know it's both. Addiction is a disease with a strong genetic component that also includes aspects of behaviors, cognitions, emotions, and interactions with others, including the addict's ability to relate to members of her family, to members of her community, to her own psychological state, and to things that transcend her daily experience.
Behavioral manifestations and complications of addiction, primarily due to impaired control, can include the following:
• Excessive use and/or engagement in addictive behaviors at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control.
• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (for example, the development of interpersonal relationship problems or the neglect of responsibilities at home, school, or work).
• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems that may have been caused or exacerbated by substance use and/or related addictive behaviors.
• A narrowing of the behavioral repertoire focusing on rewards that are part of the addiction and an apparent lack of ability and/or readiness to take consistent action toward change, despite recognition of problems.
Over time, repeated experiences with substance use or addictive behaviors damage the brain's reward circuit activity and are no longer as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, and unstable emotional experience related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs.
While tolerance develops to the high, tolerance does not develop to the emotional low associated with the cycle of intoxication and withdrawal. Thus, in addiction, people repeatedly attempt to create a high. But what they mostly experience is a deeper and deeper low. While anyone may _want_ to get high, those with addiction feel a _need_ to use the addictive substance or engage in the addictive behavior to try to resolve their uncomfortable emotional state or their physiological symptoms of withdrawal. People with addiction compulsively use even though it may not make them feel good.
It is important to appreciate that addiction is not solely—and mostly isn't—a function of choice. Addiction is not a desired condition. Remember what Joanne told us earlier in the chapter? She wanted to stop. She was aware that she should stop. She had every incentive to stop for the sake of her family and her career. But she could not stop—at least not until she was successfully treated. Simply put, people may choose to get high or drunk but no one chooses to be a junkie or an alcoholic.
Abuse vs. Addiction
The terms abuse and addiction have been defined and redefined over the years. The 1957 World Health Organization Expert Committee on Addiction-Producing Drugs defined addiction as:
A state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.
In 1964, a new World Health Organization (WHO) committee found this definition to be inadequate and suggested using the blanket term _drug dependence_ instead of drug addiction.
In 2001, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine jointly issued the following definition:
Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Their definition, went on to say, physical dependence
is a state of being that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Tolerance is the body's physical adaptation to a drug: greater amounts of the drug are required over time to achieve the initial effect as the body . . . adapts to the intake.
The _Diagnostic and Statistical Manual of Mental Disorders_ doesn't use the word _addiction_ at all. Instead it has a section about substance dependence:
When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse, are considered Substance Use Disorders.
The National Institute on Drug Abuse suggests the following definition:
Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persist even in the face of severe adverse consequences. For most people, addiction becomes chronic, with relapses possible even after long periods of abstinence. As a chronic, recurring illness, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. Through treatment tailored to individual needs, people with drug addiction can recover and lead fulfilling lives.
In 2011, the American Society of Addiction Medicine (ASAM) released a new definition of addiction highlighting that addiction is a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling, or sex. (The ASAM provides the public and medical professionals with valuable information, guidance, and research on addiction.) This was the first time the ASAM took an official position that addiction is not solely related to problematic substance use. Here is a somewhat shortened version of their most recent definition of addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
"At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas," said Michael Miller, the past president of the ASAM who oversaw the development of the new definition. "Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions."
The landmark study by Columbia University's Center on Addiction and Substance Abuse, published in 2014, refined the definition further: "Addiction is a complex disease, often chronic in nature, which affects the structure and function of the brain. It can be effectively prevented, treated and managed by medical and other health professionals."
Why do the words used to describe addiction matter? People use many words interchangeably when talking about addiction, including _experimentation, use, misuse, hazardous use, excessive use, risky behavior, abuse,_ and _dependence._ If those of us who treat addiction cannot agree on the exact wording of a definition—or even if we should use the word _addiction_ at all—it is difficult to engender confidence among the general public.
People need things well defined and perfectly clear in order to make informed decisions regarding their health and the well-being of family members. Unless we can agree on standardized terms, the ability to properly diagnose the chronic disease of addiction is jeopardized.
# Chapter 4
# The Medical Consequences of Addiction
Americans have a curious, inconsistent perspective on alcohol and drug addiction. Studies have shown that the majority of Americans now believe that genetics and biological factors play a role in the development of addiction. However, when asked about it in a different way, a recent survey revealed only 34 percent of American adults saw addiction as primarily a disease or a health problem.
It's tempting to blame an ill-informed public on this apparent contradiction, but even 43 percent of the physicians when polled said that alcoholism is primarily the result of a personal weakness or moral failing. But as a physician for five years in the ER at Los Angeles County General Hospital, treating the physical effects of lives ravaged by alcohol and drugs on a daily basis, I know that addiction is a serious disease that requires medical care.
Addiction contributes to more than seventy other conditions requiring medical attention. While each popular addictive drug differs in its effect on the body, there are overlapping medical consequences, including brain damage, psychiatric symptoms and syndromes (delusion, paranoia, anxiety, and depression), and physical symptoms from gastrointestinal (extreme stomachaches, terrible pain, and uncontrollable diarrhea and vomiting) to increased risk of hypertension, high blood pressure, heart disease, liver disease, various cancers, bone fractures, pancreatitis, pneumonia, hepatitis, kidney failure, ulcers, and urinary tract infections.
For women, addiction can result in the end of menstruation, miscarriages, and children with birth defects (more on the needless tragedy of fetal alcohol syndrome in Chapter 10). For men, addiction can result in shrunken testicles and impotency. But perhaps the most sobering statistics concerning the medical consequences of addiction is the heightened occurrence of suicide: Approximately 18 percent of alcoholics commit suicide and more than 50 percent of all suicides are associated with alcohol or drug dependence.
Neurological Impairment
All excessive behaviors have consequences. If people drink too much alcohol, they first lose coordination, and then their thinking gets screwed up. This is called _neurological impairment_. It is also called being really drunk.
Despite alcohol consumption being both socially acceptable and perfectly legal, it inflicts more damage and kills more people than any other drug in the United States. Alcohol is the third leading cause of death because it attacks every vital organ system in the human body. Simply put, the list of medical problems directly related to immoderate use of alcohol is more than all other recreational drugs combined.
Alcohol may mix harmlessly in polite social settings where moderation and decorum are the established and observed standards, but alcoholism is something else entirely. Those who overindulge in alcohol often use other drugs as well, and that's a big problem. Alcohol does not mix well with anything else. For example, there is a potentially dangerous interaction between cocaine and alcohol. This mixture is the most common two-drug combination that results in drug-related death. Also, mixing alcohol and heroin may be the true reason for overdose deaths attributed to heroin.
I previously mentioned the various types of damage alcohol can do to your body. If you want a more detailed list of alcohol-related damage, here it is: high blood pressure, damage to the heart muscle, heart failure, strokes, severe thiamine deficiency, diabetes, pancreatitis, night blindness, pneumonia, dehydration, kidney failure, vitamin D deficiency leading to bone fractures, inflammation of the digestive system, ulcers, holes in the intestines or stomach, infections of the urinary tract, and, ultimately, death from alcohol poisoning, excessive intoxication, and organ malfunction.
I haven't even mentioned sexual problems (such as erectile dysfunction and impotence), cirrhosis of the liver, and long-term brain damage. Your liver can handle only one drink per hour. Binge drinking is devastating to the liver. Between 10 and 35 percent of alcoholics have hepatitis or inflamed livers. Cirrhosis occurs when healthy liver cells become replaced by scar tissue. The damage can be so bad that the only treatment option is a liver transplant.
Alcohol slows your reactions, impairs your decision-making abilities, and makes performance of any task requiring accuracy pretty much a lost cause. Alcohol increases confidence but reduces performance. You do everything worse on alcohol, and everyone knows it except the person on alcohol.
Drinking alcohol in extreme weather conditions can be suicidal. Drinking to warm up in the freezing cold has the exact opposite effect. You think you are warmer because of increased blood flow at the surface of your skin, but you are actually losing heat quicker.
If you keep drinking when you have cirrhosis of the liver, you will most likely be dead within seven years. In the meantime, you can develop kidney failure and all kinds of disturbing brain disorders.
Brain Damage
Damage to the brain first shows up as headaches, blackouts, and numbness in the hands and feet. Keep on drinking and you can have permanent structural damage and premature aging. A thirty-five-year-old alcoholic may well have the shriveled up brain of a sick seventy-year-old.
You can tell when this brain destruction is going on. Between 45 and 70 percent of alcoholics do not perform well on tests of problem solving, abstract thinking, memory, and shifting concepts. About 10 percent have serious impairments.
As long as we're talking about brain damage, let's not ignore impairment to the entire central nervous system, which causes alcoholic blackouts, memory loss, seizures, convulsions, delusions, hallucinations, dementia, and violent behavior.
Psychiatric Problems
More than 40 percent of investigated alcoholics turn out to have one or more psychiatric conditions. Research also shows that out of the group of people with a psychiatric disorder, 28 percent suffer from alcohol dependence. So the question often asked is, What came first, the psychological problem or the alcohol problem?
Yes.
Alcohol and other drug use can _cause_ psychiatric symptoms and _mimi_ c psychiatric syndromes. Alcohol can cause delusion, auditory and visual hallucinations, anxiety, and depression. Some patients may experience auditory hallucinations for weeks or months after they stop drinking and are then misdiagnosed as schizophrenic.
According to a recent study, people with alcohol problems have psychiatric disorders almost twice as often as those who don't have alcohol problems. Drinking and drugging can initiate psychiatric disorders and make them worse. It can also _mask_ psychiatric symptoms. Withdrawal can cause psychiatric symptoms and mimic symptoms.
It is also very possible for psychiatric disorders and alcohol and drug problems to exist independently of each other.
To make it even more complicated, psychiatric behaviors can be misinterpreted as drug and alcohol problems. This is one more strong argument for diagnosis by an addiction medicine specialist before initiating treatment as well as for a psychiatric evaluation.
Suicide in a Bottle
There is a high rate of suicide in chronic alcoholics, which increases the longer a person drinks. Approximately 18 percent of alcoholics commit suicide, and more than 50 percent of all suicides are associated with alcohol or drug dependence.
Because alcohol is not digested but absorbed directly through the lining of your mouth, throat, stomach, and intestines, it irritates these organs' linings. The result: gastrointestinal disease accompanied by horrid stomachaches, terrible pain, and uncontrollable diarrhea.
If alcoholics didn't already have enough problems, add being undernourished. That doesn't sound so bad until you realize it means your pancreas isn't going to work right. That makes more work for your liver. Your glucose levels are low, and that causes more brain damage.
If you're a guy, and you want shriveled, shrunken testicles and a nice set of man boobs, keep drinking. Your testosterone levels drop with excessive alcohol use, as does your sperm count. You won't have to worry about sex issues, because you will probably be impotent and unable to have sex anyway.
Female alcoholics often quit menstruating, begin early menopause, or menstruate without ovulation. If they get pregnant, they often miscarry. The babies who survive often suffer from fetal alcohol syndrome.
Other Addictive Substances
Although alcohol is the most destructive and dangerous of all social and recreational intoxicants, there are medical dangers in the misuse of even a benign medication.
OPIOIDS
Pain is one of the most common reasons people consult a physician. The most effective pain relief is from opioid analgesics—narcotic painkillers.
Medications that fall within this class include hydrocodone (for example, Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), and codeine. Heroin, which was once prescribed as a painkiller, is the most widely used illicit opioid.
You may become physically dependent on painkillers if you take them regularly, but physical dependence is not the disease of addiction. If you stop taking them abruptly, you may develop nausea, sweating, chills, diarrhea, and shaking. When people take these medications for pleasure instead of pain reduction, there is a heightened risk of the disease of addiction.
The FDA estimates that more than 33 million Americans aged twelve and older misused extended-release and long-acting opioids during 2007—up from 29 million just five years earlier. And in 2006, nearly 50,000 emergency room visits were related to opioids.
According to former FDA commissioner Margaret A. Hamburg, "Opioid drugs have benefit when used properly and are a necessary component of pain management for certain patients, but we know that they pose serious risks when used improperly—with serious negative consequences for individuals, families, and communities."
Heroin was synonymous with rock-n-roll, and heroin overdoses were involved in the deaths of such musical luminaries as Tim Buckley, Kurt Cobain, Janis Joplin, Jim Morrison, and Sid Vicious. Like any street drug, heroin is dangerous by virtue of the fact that it is not regulated. If anything, the drug is more dangerous than at the height of the hippie drug culture of the 1960s and 1970s. Joplin likely overdosed on heroin that was 3 to 5 percent pure. Today's ultrapure smack can be 95 percent heroin. There's no evidence that actor Philip Seymour Hoffman's death by heroin overdose in 2014 was related to a suicide. It was ruled accidental in that he simply took too high of a dose of heroin.
However, contrary to public opinion, taking multiple regulated prescription painkillers in relatively low doses does not safeguard the user. Like Hoffman, Oscar-nominated actor Heath Ledger died of an opioid overdose, but the poison of his choice was a dizzying array of prescription pills. His autopsy showed that he didn't die from a large dose of any one drug (like Hoffman's overdose of heroin) but rather the cumulative effect of simultaneous and relative small doses of oxycodone, hydrocodone, alprazolam, diazepam, temazepam, and doxylamine. Taken together, they proved to be a fatal drug cocktail.
STIMULANTS
Cocaine is a stimulant, as is caffeine. Obviously, cocaine is stronger. Amphetamines are also stimulants and have proper medical uses. Methamphetamine, stronger yet, also is used medicinally. Recent studies show promise in using methamphetamine in the treatment of various conditions, including Alzheimer's disease. Amphetamines are prescribed appropriately and safely for children as young as six years of age without ill effect. As with all medicines, appropriate use for a specific condition is beneficial. Misuse and abuse, however, cause all manner of problems.
When stimulants are taken in excess for recreation, the consequences can be delusions, anxiety, hypertension, seizures, stroke, arrhythmia, chest pain, heart attack, and hyperthermia. Long-term meth misuse can cause extreme psychosis similar to schizophrenia.
There's the misguided idea that cocaine addiction is somehow easier to control than other drugs. It's not. The deaths of John Belushi, Whitney Houston, and Robin Williams are all associated directly or indirectly with the drug.
Cocaine abuse is also associated with numerous detrimental health effects. Ten cocaine-induced psychiatric disorders are described in the _Diagnostic and Statistical Manual of Mental Disorders_ , all of them the result of continued excessive indulgence.
COKE BUGS
Coke bugs, meth mites, and speed bugs are common names used for the delusion that there are bugs crawling on your skin, under your skin, or infesting your clothing, furniture, or even your pets. Amphetamines, methamphetamine, and/or cocaine can cause the physical sensation known as _formication_ , which, when combined with the seeking, searching, and exploring behavior that is symptomatic of stimulant overuse, gives rise to the false belief of infestation and parasitic insect activity. The obsession over or observation of nonexistent bugs is called _parasitosis_.
With cocaine and methamphetamine, this phenomenon occurs because the human body can't digest the hazardous additives, or "cut," that were mixed in to increase the seller's profit margin. The body forces these toxic substances out through the pores, causing sores, acne, and chronic scratching.
Stimulants also cause your body temperature to go up, and you begin to perspire heavily. When the sweat evaporates, it removes the skin's protective oils. The combined effects of sweating, lack of protective oils, and dehydration creates a sensation that feels like something irritating or crawling on or under the skin (delusional parasitosis).
This phenomenon was first noted in the 1890s and has been observed in all decades subsequently. In addition, people suffering from stimulant overuse find their attention directed to raised follicles or small irregularities in the skin, and they pick or pluck at these until they have numerous scars and lesions.
Extreme use of stimulants and the subsequent lack of sleep and nutrition may result in someone spending hours searching through his clothes or bedding with a magnifying glass for evidence of bugs. Some resort to microscopes in their quest, and it is common for those suffering from this delusion to bring evidence to doctors, pest controllers, or skin specialists. Believing they have captured one or more of these bugs, they are often upset when a doctor informs them that their evidence is nothing more than a piece of their own skin, a remnant of a scab, or a piece of lint.
In more advanced stages of this delusion, people cut their skin open to find the bugs or pluck all the hair follicles out of various areas of their body. I had one female patient who was convinced that not only she had these bugs but her dog had them too. The innocent creature was subjected to hour on hour of her plucking away at it with tweezers until the poor thing was virtually hairless.
PARANOIA
When people are paranoid, they distrust the behavior and motives of others. They view even the most innocent actions with suspicion. Among the drugs that can cause paranoia are corticosteroid medications, H2 blockers (cimetidine, ranitidine, famotidine), some muscle relaxants (baclofen), antiviral/anti-Parkinson's drugs (amantadine), some amphetamines (methylphenidate, or Ritalin), anti-HIV medications and antidepressants (Nardil). Paranoia can be prompted by the abuse of alcohol, cocaine, marijuana, ecstasy (MDMA), amphetamines (including Ritalin), LSD, and PCP (angel dust).
A common symptom of stimulant overuse is paranoia coupled with hypervigilance. This is known in the drug world as _tweaking_. Affected people actually stand at the door and peer through the peep hole, attempting to see if someone is sneaking up on them or stand and stare out the window blinds as if anticipating an attack.
While this is often described as a negative effect of cocaine or other stimulant use, research shows that some people actually enjoy hypervigilance and paranoid delusions. Stop and think about this for a moment. When you read a list of the ill effects of using stimulants for recreation, one of the bad things is paranoid delusions and fear, along with elevated heart rate. The same could be said for scary movies, and it is precisely to heighten the intensity of these fears that some people indulge in the misuse of these drugs.
"I like being paranoid," confessed one of my patients. "I know that my fear isn't really real any more than the fear from watching a horror movie. I know in the back of my head that this feeling is temporary, like the scary rides at an amusement park. Lots of folks don't like the feeling, but I do. In fact, the scary feeling is the reason I like to get high."
Most people who have paranoid delusions, however, do not find it entertaining, and these delusions can result in violence against people whom the paranoid person imagines as enemies.
MARIJUANA
When alcohol was illegal in the United States, marijuana was the only legal recreational drug available. The roles were soon reversed, and marijuana's reputation went into stark decline for several decades. Today, however, marijuana is the most commonly used drug among teenagers in the United States, and it is destined to become more popular as the legalization movement takes hold in Colorado, Washington, and other states. While alcohol is far and away the most destructive intoxicant, the combination of alcohol and marijuana is especially harmful to the developing brains of adolescents.
The human brain develops up to 400 percent more receptors for the active ingredients in marijuana if use begins in the early teenage years, and consistent use during this critical period may give rise to various neurological and psychological issues, including problems with verbal skills, sequential memory processing, motivation, and task completion.
Frequent adolescent marijuana users manifest significant impairments to important cognitive brain functions, and the negative effect of marijuana on memory and concentration is well documented. Those who begin marijuana use at the age when the brain is still developing may be more vulnerable to various neurological and psychological issues, including problems with their verbal skills.
Marijuana smokers also have a lower rate of college acceptance and a higher dropout rate, although poor academic performance often comes before the marijuana use and is one of the triggers for the onset of drug use. Once started, however, the usage combines with collateral sociological and emotional factors to further undermine the student's academic career. While it is true that there are pot smokers at Harvard and Yale, these are incredibly bright achievers who were always top academic performers, and they certainly did not spend their adolescence "wasted" instead of studying.
Another result of prolonged use of marijuana is reduced sperm count, verified by a study conducted by the American Society for Reproductive Medicine. "The bottom line is, the active ingredients in marijuana are doing something to sperm, and the numbers are in the direction toward infertility," said Lani J. Burkman, lead author on the study. "The sperm from marijuana smokers were moving too fast too early," she added. "The timing was all wrong. These sperm will experience burnout before they reach the egg and would not be capable of fertilization."
As an addiction specialist, I've treated patients with marijuana withdrawal symptoms of anxiety, agitation, insomnia, and even violent behavior. These patients struggle to stay away from marijuana with the same challenges as those who have battles with alcohol or other drugs, and their psychological pain is obviously visible and confirmed by the patients themselves.
MEDICAL MARIJUANA
In my opinion, medical marijuana continues to make a mockery of medicine. Let me begin with the fact that the approval process is outright laughable. Anyone with a checkbook can get a recommendation letter for marijuana.
Under normal standards of professional care, a doctor performs a complete physical examination and diagnosis of the patient and then prescribes appropriate medication. Once the medical treatment begins, there is continual interaction between doctor and patient to ascertain the progress and efficacy of the treatment.
In the case of medical marijuana, there is no standard medical procedure performed, no special training for the physicians, and no guidelines. There is also no prescription written, nor are there any specifics as to dose and frequency. You can get a marijuana card for as little as $35 if your complaint is "hair pain" or something equally dubious.
Anyone with any symptom can go to a marijuana doctor and can get a recommendation letter stating that the person will medically benefit from marijuana. The patient then takes this letter to a marijuana dispensary and picks out the flavor of marijuana he or she finds most appealing.
This isn't a prescription such as "take 500 milligrams 3 times a day for 30 days," and no one in the dispensary, including the patient, has any idea what it is he or she is getting.
Marijuana in a Pill
Medical marijuana in pill form, sold under the brand name Marinol, is a legal prescription medication used to treat the adverse effects of chemotherapy and to increase appetite in AIDS patients. The active ingredient is synthetic THC, and Marinol is approved by the medical community and the FDA, the nation's watchdog over unsafe and harmful food and drug products.
Why not just smoke it? Smoking is generally a poor way to deliver medicine. As a doctor, I assure you that it is almost impossible to administer safe, regulated dosages of medicines in smoked form. Morphine, for example, has proven to be a medically valuable drug, but no responsible physician endorses smoking opium or heroin.
Another reason for not smoking marijuana for its medical properties is the issue of tar. While tar is one of the most dangerous aspects of smoking tobacco, the tar level in marijuana is 400 percent higher than in tobacco. Of course, even heavy pot smokers do not smoke pot at the same level that tobacco smokers smoke cigarettes. If they did, they would have far more problems to worry about than tar.
There are profound reasons for addiction medicine specialists, as well as other physicians, to look askance at the current so-called medical marijuana programs in California as well as in other states.
Rather than further disgrace the medical profession with absurd claims of medical marijuana, it would make more sense to legalize marijuana as a recreational intoxicant, tax it, and use the revenue for public education and medical rehabilitation of those who have suffered marijuana's negative consequences.
Just as the vast majority of people who drink are neither problem drinkers nor alcoholics, the majority of adults who smoke marijuana are not problem smokers or drug addicts. My concerns are in two categories.
First, because marijuana is illegal, there are no regulatory standards of production and manufacture regarding content and potency. Hence, one cannot state that marijuana used properly is safe because there is no definition of _properly_ nor is there a standard safe dosage. Second, there is a predictable percentage of people who, due to genetics and other factors, will manifest the disease of addiction. One out of six people who smoke marijuana regularly develop problems requiring some type of medical intervention.
Like all other mind-altering drugs, marijuana is definitely dangerous in combination with any motor vehicle. It affects alertness, concentration, coordination, and reaction time. Marijuana also makes it hard to judge distances. The worst-case scenario is combining marijuana with even a small amount of alcohol. The two together are more dangerous on the road than either drug alone.
BARBITURATES AND TRANQUILIZERS
Barbiturates were first used in medicine in the early 1900s and became popular in the 1960s and 1970s for treatment of anxiety, insomnia, and seizure disorders. They evolved into recreational drugs that some people used to reduce inhibitions, decrease anxiety, and to treat unwanted side effects of other illicit drugs.
Barbiturate use and abuse has declined dramatically since the 1970s, mainly because a safer group of sedative-hypnotics called benzodiazepines is being prescribed. In the day, barbiturates abuse caused, or was significantly involved, in many of the most high-profile overdose deaths in the entertainment industry including those of Judy Garland (1969), Jimi Hendrix (1970), and Elvis Presley (1977).
Medications such as Valium and Xanax are some of the most commonly prescribed benzodiazepine medications, also known as tranquilizers, in the United States. There are numerous uses for these medications, but when people take them who don't need them, there are problems. People at risk for addiction to these substances are also at risk for alcoholism. The combination of the two is deadly.
Withdrawal from benzodiazepines is similar to alcohol withdrawal and can be a dangerous process if not done properly. One should never stop these drugs cold turkey but instead taper off the doses, as directed by a physician.
While benzodiazepine was designed as a safer alternative to barbiturates, it too was involved in some high-profile overdose deaths in Hollywood, including those of Michael Jackson (2009) and Anna Nicole Smith (2007).
Social Consequences
The idea that there are social consequences for indulging in recreational drug use has come under intense research and professional scrutiny in recent years. In the United States, the biggest social consequence risk for the nonaddict drug user is arrest and or coerced "treatment" for possession of a controlled substance.
According to the National Institute on Drug Abuse (NIDA), "Among young people in drug abuse treatment, marijuana accounts for the largest percentage of admissions: 61 percent of those under age 15 and 56 percent of those 15–19." According to the U.S. government study from which NIDA gets this figure, the majority of these teens were not in treatment because of dependence or addiction. They were given a choice of treatment or juvenile detention after being caught in possession of marijuana. There was no medical diagnosis of dependence or addiction.
The National Institute on Drug Abuse doesn't mention this fact because, as an official representative of federal drug policy, it wants the reader to infer the admissions are due to dependence and addiction. Sadly, this is exactly the type of thing that causes teens not to trust antidrug pamphlets. Once again, we see research studies used not as education but as propaganda. While the intent may be honorable, the methods undermine credibility and perpetuate harmful exaggerations.
Because of my role as a doctor who treats patients with the medical condition of addiction, you might think I would approve of any method that proposes to decrease drug use. Proposing isn't the same as accomplishing, and falsely labeling people as drug addicts when they do not have the disease of addiction diminishes the credibility of the condition itself and makes a mockery of treatment.
A 2004 conference on special designer drugs and cocaine held in Bern, Switzerland, prominently featured extensive research by Peter Cohen, author of "The Social and Health Consequences of Cocaine Use." In his final analysis, and in his words, "For all drug use and drug users, social exclusion and marginalization are the worst settings. The best harm and crime reduction money can buy is to lower marginalization and exclusion of drug users, even if this would mean that the drugs they (still) like to use have to be made available to them at acceptable costs. In my view, daily and regular use is far less of a danger to people than social exclusion."
We must deal with what is real, and the reality is that I practice addiction medicine in the United States, where the stigma against addicts is widespread, punitive legal measures are still instituted against disease sufferers, and millions of people who could avoid addiction or be treated successfully receive no help beyond a good scolding, shame, a jail sentence, and marginally helpful support group meetings.
The Criminalization of a Disease
If you thought you had cancer, you would go to a cancer specialist for medical diagnosis. You may also attend a support group for people dealing with cancer, but you would certainly pursue effective medical treatment. It is the same with heart disease, diabetes, and asthma. These are all chronic medical conditions with strong emotional and environmental components. They are all also preventable and treatable. So is addiction.
The difference, however, between addiction and every other chronic disease in the United States is that addiction is criminalized to a large degree. In federal prisons in 2014, 52.1 percent (95,079 of 182,333 prisoners) were there for drug-related crimes. Another 265,000 prisoners are in state prisons on drug charges.
More than 1.6 million people are arrested, prosecuted, and imprisoned each year for a drug law violation. The vast majority of these crimes are nonviolent, yet the violence to society because of these draconian, antiquated drug laws is immense. Nearly $33 billion each year is spent on keeping prisoners behind bars in federal and state prisons for drug-related charges. Of course, this doesn't count the incalculable costs of lives ruined and families destroyed.
I want to stress, it is not a crime in the United States to have the physical illness of addiction. But if the object of your addiction, such as illicit drugs, is illegal, you could be arrested and prosecuted for the mere act of possessing it. The situation places the person suffering from addiction in a situation of continually interacting with the criminal underworld rather than with medical professionals.
Numerous studies show it's much less expensive to treat people with drug problems than to toss them into prison. A 1994 Rand analysis concluded that for every extra dollar spent on addiction treatment, taxpayers save $7.46 in societal expenses, including the cost of incarceration.
The United States has about 5 percent of the world's population, but we have 25 percent of the world's prisoners—we incarcerate a greater percentage of our population than any country on earth. We have earned the unenviable nickname of Incarceration Nation.
An article titled "Medicine and the Epidemic of Incarceration in the United States" published in the _New England Journal of Medicine_ reviewed the deplorable plight of drug-addicted and mentally ill inmates in our nation's prisons and concluded:
Locking up millions of people for drug-related crimes has failed as a public-safety strategy and has harmed public health in the communities to which these men and women return. A new evidence-based approach is desperately needed. We believe that in addition to capitalizing on the public health opportunities that incarceration presents, the medical community and policymakers must advocate for alternatives to imprisonment, drug-policy reform, and increased public awareness of this crisis in order to reduce mass incarceration and its collateral consequence.
# Chapter 5
# The Process of Effective Treatment
I have a chronic disease called diabetes. There's no cure for my chronic disease, but I maintain a fairly normal and, some would say, highly successful life. How do I do it? I follow a strict regimen of medications formulated to address my particular disease. I also modify my lifestyle to minimize the risks associated with my disease.
Now as a diabetic, not to mention a physician, I would no more think that I could treat my disease by sitting around in a room with other diabetics and commiserating about our problems than thinking I could cure it by eating a diet of only chocolate cake. These are but ridiculous propositions—yet, that is, in effect, the expectation we have for those who suffer from the chronic disease of alcohol and drug addiction.
In western Europe, drug policies differ from country to country but focus first and foremost on providing evidence-based treatment to addicts rather than criminalization of substance abuse. Portugal has decriminalized drug possession in small amounts altogether. Germany, too, focuses on treatment, but still aggressively pursues drug trafficking. While still criminalizing possession, German prosecutors have moved away from pressing charges to emphasizing treatment. The Netherlands, famous for its legalized cannabis bars, nevertheless has taken new steps to crack down on the smuggling of so-called hard drugs, such as opium and heroin. The result of these harm-reduction programs has been a massive decrease in new drugs users, with Portugal decreasing by 38 percent, the Netherlands by 24 percent, and Germany by 17 percent.
The standard for addiction treatment in the United States—unlike all other Western nations—is a program based on a seventy-five-year-old philosophy in which sharing stories is the focus. The organization that offers this philosophy, Alcoholics Anonymous, makes no claims to having helped the majority of people with substance addiction or even the majority of people who come to it for help. By its own estimates, it is probably effective in treating addiction over the long-term for only 5 percent of those who have attended one of their group meetings.
Now, you may say that no one forces anyone to seek help for addiction treatment from AA, but that's not true. For the most part, drug courts in the United States assign mandatory treatment for those convicted of minor drug-related criminal activity (mostly possession of small amounts of illicit drugs) to so-called rehab clinics whose treatment consists mostly or exclusively of AA treatment protocols. That's a fancy way of saying that their patients sit in a room and talk about their drug problems. If they're lucky, the discussion might be led by a drug counselor, but more often than not, it's lead by someone who doesn't even have a college degree much less any medical training and whose only qualification frequently is that they, too, are recovering from an alcohol or drug addiction.
It's incredible, but that is the sorry state in this country of the treatment of alcohol and drug addiction, the third most widespread chronic disease in America.
A recent nationwide study on alcohol and drug addiction by the National Center on Addiction and Substance Abuse at Columbia University concluded, "Unlike other diseases . . . the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care." It goes on to say that the consequences of this failure are "profound," resulting in "an enormous array of health and social problems such as accidents, homicides and suicide, child neglect and abuse, family dysfunction and unplanned pregnancies."
Here's the greatest irony: This chronic disease, unlike Alzheimer's, arthritis, or asthma, for example, is largely preventable. We also know how to effectively treat it with evidence-based medicine.
Addiction Treatment in the Twenty-First Century
I mentioned earlier how the U.S. standard of addiction treatment has nothing to do with medicine. In western Europe, Japan, and most other industrialized nations, treatment of alcohol and drug dependency is grounded in science and research. Now, here in the United States, we offer that same kind of treatment, too, but the difference is that evidence-based treatment is not the standard here.
What is evidence-based treatment of addiction? Evidence-based medicine is simply the application of the scientific method into healthcare. It's the standard for the treatment of every chronic disease in America except substance addiction.
There is absolutely no denying that addiction is a chronic medical illness that must be controlled with proper treatment, including medications—just like my disease of diabetes and other complex and chronic medical conditions.
As a psychiatrist specializing in addiction medicine and who has been treating addicts for the last two decades, I can tell you the answer lies in integrating mental health and addiction treatment into a single, comprehensive program designed to meet the individual needs of each specific patient.
Effective, evidence-based treatment of addiction has three parts that work together:
• _Biomedical_ , which focuses on improved detoxification regimens, followed by the use of medicines to reduce cravings and manage addiction over a lifetime and, when appropriate, the application of psychiatric medications.
• _Psychological_ , which includes addiction counseling, cognitive behavioral treatment psychotherapy, aversion therapy, and behavioral self-control training.
• _Sociocultural_ , which uses the community reinforcement approach, family therapy, therapeutic communities, vocational rehabilitation, various motivational techniques, culturally specific interventions, and contingency management.
All three of these modalities have more than one dimension in common, such as social skills training, relapse prevention techniques, self- and mutual-help programs, support groups, and chemical aversion therapy.
Addiction is a chronic medical condition, a brain disorder. Just as hypertension and asthma have biological, psychological, and social components, so do alcoholism and drug addiction. An evidence-based addiction treatment must include all three components.
Equally important, each program must be individualized for each patient. It's not that the current AA/12-step protocol that characterizes treatment at most rehab clinics is inherently bad. It's just incomplete. Fundamentally, it lacks two of three essential components—biomedical and psychological—needed for a successful treatment of the disease of addiction over the short and long term. It also has a one-size-fits-all mentality in which any deviation from its main tenet—abstinence—is considered heresy. In a disease as complex as substance addiction, that simply does not work for most people.
Here's the good news: Just as the diabetic can live a normal life with certain adjustments (monitoring blood sugar levels, regular medicals exams, taking insulin, modifying diet, and so on), so can the recovering alcoholics or addicts can live normal lives with their own life adjustments.
Assessment
Before evidence-based addiction treatment begins, all patients need a full medical and psychiatric diagnosis and evaluation, plus evaluation of their individual psychological and social situation.
As a part of a comprehensive medical evaluation, an EKG and a complete blood chemical analysis should be performed. A blood metabolic panel is a group of chemical tests that measure the amount of vitamins, minerals, cholesterol, protein, blood sugar, electrolytes, and other bodily requirements and functions.
An EEG, CT, MRI, or PET scan may also be conducted before treatment to ascertain the severity of brain structural or functional damage, or other brain-related concerns. After all, alcoholism and substance misuse are diseases of the brain.
From this information, a physician, preferably one trained in addiction medicine, can determine the severity of the patient's addiction. The American Society of Addiction Medicine, a professional society representing more than 3,200 physicians and associated professionals dedicated to increasing access and improving the quality of addiction treatment, defines six dimensions to addiction severity: (1) potential for acute intoxication and/or withdrawal, (2) biomedical conditions and complications, (3) emotional/behavioral conditions or complications, (4) treatment acceptance/resistance, (5) relapse potential, and (6) recovery environment. The goal is to match the patient's needs to the appropriate treatment service by assessing the severity of the addiction as well as verification of the medical diagnosis.
Key to Effective Treatment
There are very few diseases that are purely biological in nature. The causes of most diseases, including alcohol and drug addiction, are multifaceted, with biomedical, psychological, and sociocultural factors. Effective treatment is achieved when all of these factors are integrated into a comprehensive program.
Let's be clear: The effective treatment of substance addiction is highly individualistic, requiring a trained physician to assess both the patient's physical and psychological condition. For some patients, no psychological treatment is required; for others, it becomes a primary focus. Sometimes counseling that includes a patient's family is absolutely necessary (and this is especially true with teen addicts), but in other cases it's not necessary and is even counterproductive. Rehab clinics that offer a standard treatment for all patients are engaging in the worst kind of breach of medical ethics. They either know better or should know better.
Despite the individualistic approach required in effective addiction treatment, this I know for certain: The successful treatment of alcohol and drug addiction _must first_ address the biological component and correct the brain's chemistry imbalance in the process.
Let's dig a little deeper into each of three parts of an evidence-based treatment.
BIOMEDICAL THERAPY
If we accept the scientifically proven theory that addiction is a medical condition, then we have to recognize that medications can compensate or even reverse the pathology of the disease. When medications work, no matter what the target illness, they have a relatively quick and dramatic effect.
Of the medications that have proven to treat the disease of addiction, Suboxone, which is the combination of buprenorphine and naloxone (the drug used by first responders to reverse the effect of an overdose), is the most successful. Suboxone mimics the effects of opioids like heroin, in effect, by occupying the receptors that opioids affect. If someone on Suboxone injects heroin, he feels little effect. And because the medication mimics an opioid, there's little craving. Unlike methadone, which has a similar if not albeit more crude effect, Suboxone doesn't have to be administered via a daily visit to a clinic. Suboxone is a pill of a sublingual (under the tongue) form that can be prescribed to the patient by an authorized doctor.
Several other drugs for treating addictions have been approved in recent years, adding to the portfolio already in use. Clonidine is used for heroin and opiate addiction and naltrexone, acamprosate, gabapentin, and topiramate for alcoholism (we will delve deeper into each of these medications further in the book).
It's important to emphasize again that each individual patient will respond differently to different medications and different dosages. That's why it is essential that biomedical therapy only be administered under the supervision of trained medical professionals.
PSYCHOLOGICAL THERAPY
Most chemically dependent people and those with mental disorders feel overwhelmed and helpless. They yearn for hope and a sense of empowerment in the face of debilitating disease. An important aspect of effective treatment includes empowering patients to see themselves in partnership with their physician, strengthening their physical, emotional, and mental health.
As the disease of addiction impacts the thought processes, another important aspect of effective treatment is individualized cognitive behavioral therapy (CBT). This therapy is a form of psychotherapy that emphasizes the important role of thinking how we feel and what we do.
There are several approaches to cognitive behavioral therapy, including rational emotive behavior therapy, rational behavior therapy, rational living therapy, cognitive therapy, and dialectic behavior therapy. All of these cognitive behavioral therapies are based on the idea that our thoughts cause our feelings and behaviors, not external things like people, situations, or events. Even if a situation remains unchanged, how we respond to that situation can change. We can choose our response, making a conscious decision to respond in ways that are in the best interest of our health and happiness.
In conjunction with CBT, there is another therapy valuable in treating addicts. Motivation enhancement therapy (MET) has been thoroughly researched in the field of substance misuse and has proven to be exceptionally effective at enhancing an individual's motivation to make positive changes in behavior. Also, with many patients, family therapy is also helpful and even essential. Depending on the patient's family dynamic, involving the family in the recovery process can mean the difference between success and failure.
An effective treatment must help patients address, identify, and describe the personal meaning of their addiction. Are they self-medicating, filling up an inner emptiness, numbing feelings related to a trauma, or all of the above? Unless clients understand what they are actually doing on a deep conscious and subconscious level, they will chronically relapse. A responsible, comprehensive treatment program takes all aspects into consideration for the ongoing health and well-being of the patient.
When it works properly, psychological therapy empowers the patient to be her own gatekeeper so she doesn't have to be told (or scolded or shamed) into avoiding behavior that can trigger relapse. Let me give an example.
Motivational Therapy at Work
Maureen was a middle-aged woman who had been referred to me by her primary-care doctor for depression (about 50 percent of all addicts have a mental disorder, and depression is the most common). While interviewing her, it quickly became clear that she had a dual disorder, both clinically depressed and an alcoholic. She drank two to three bottles of wine daily, which was not only making her more depressed but also ruining her physical health. Keep in mind that she had come to visit me only for her depression. Like many addicts, because of their impaired brain function, she didn't think she had a serious addiction.
When I suggested she think about cutting back on her wine because of the grave dangers it was posing to her health, she matter-of-factly stated, "Oh, no. I can't do that. I love my wine." It's as if she were talking about her pet dog. At that moment she could not make the connection between the enormous amounts of alcohol she was consuming and its deleterious effects on her health. Still, I went ahead and prescribed her an antidepressant that would not be dangerous to take with alcohol, nevertheless knowing that the alcohol would negate most of its effect.
Two weeks later when I saw her again, she began the conversation by saying that she had thought about what I had told her about how her large consumption of wine would eventually destroy her health. She said that she was thinking about cutting back. I reinforced her first baby step toward controlling what was obviously a full-blown alcohol addiction by saying that I wanted her to consider decreasing her daily wine consumption by two glasses. I asked if she thought she could manage that, and she affirmed that she could. She also agreed to take a pill called Topamax that helped decrease her cravings for alcohol.
When I saw her next, her depression had begun to ebb (because the medication was at last being given a real chance to work), and she had succeeded in reducing her habit to only six glasses of wine instead of the eight to twelve she had been consuming when she first saw me. I told her that she was doing a great job and that she was ready to take the next step to cut her wine back to only one bottle a day. "You think I can do that?" she asked hesitantly. "Oh, absolutely. As your doctor, I can see you're ready," I told her confidently.
Six months after she first saw me, she achieved complete abstinence from alcohol. Five years later, she is still clean and sober.
Here's what we know in the twenty-first century about the disease of alcohol and drug addiction: Willpower or the lack thereof isn't the cause of the disease. It's the symptom. Successful psychotherapy doesn't shame the patient into abstaining from alcohol or drugs, but rather cultivates that seed of ambivalence within every addict that what she is doing to herself could be very bad for her health. Together, the therapist and patient focus on creating an internally motived change rather than a step-by-step process.
SOCIOCULTURAL THERAPY
According to current brain research and developmental psychology, the risk of addictive disease is heightened by, and directly related to, life experience as much as genetics.
Human are the only species in which the majority of the brain develops after we are born, and what we experience at pivotal points in our life determines a vast amount of our neurological development. For the sake of simplicity, I'll put it this way: You are an individual, and what you experience in your life has just as much impact on your brain functioning as does heredity and genetics.
However, perhaps the most disturbing discovery, repeatedly verified by extensive international research, regarding the disease of addiction is that emotional pain and stress—especially alienation, social exclusion, and emotional distancing—create actual neurological damage that increases the risk of alcoholism and addiction and the risk of never recovering.
Stress has long been known to increase vulnerability to addiction. Research over the last decade has led to a dramatic increase in understanding the underlying mechanisms for this association. Behavioral and neurobiological correlates are being studied and evidence of molecular and cellular changes associated with chronic stress and addiction have been identified.
Effective therapy, then, must identify chronic stress factors in the patient's life and create strategies for resolving them.
Nutrition and exercise also can play important roles in treatment by mitigating the symptoms of detoxification and promoting overall treatment outcomes. Many addicts have unhealthy diets that enhance anxiety. They often turn to sugar and carb-laden junk foods to satisfy their craving because these foods increase serotonin levels. Good nutrition provides a baseline foundation for physical well-being in which all other aspects of treatment from medications to counseling are facilitated.
Exercise can also have a direct effect on maintaining proper neurotransmitter levels in the brain. Because exercise stimulates the dopamine pathways, it can mimic the reward produced by the addict's substance of choice. It also generally helps mitigate the symptoms of depression, from which many addicts suffer. Finally, patients who exercise in groups increase their social skills and create social networks in settings not related directly to their substance abuse.
A New Generation of Addiction Medications
As I mentioned earlier in the text, addiction is a chronic disease characterized by the inability to consistently abstain, by impairment in behavioral control, by cravings, by diminished recognition of significant problems with one's behaviors and interpersonal relationships, and by a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
The new generation of addiction medications, which are easy for the patient to take and easy for the physician to administer, are important for two reasons. First, recovery from addiction is hard, and patients need every tool that medicine can offer them. But there is another potential benefit: The growing availability of medical treatments will encourage doctors to treat their patients' addiction problems just as they would a patient's out-of-control blood sugar or high cholesterol.
Second, the emergence of long-acting drugs goes beyond diminishing the pain of detox and actually reduces cravings that persist, even in people who are highly committed to abstinence. Addicts no longer have to summon their willpower alone to take their medications each day. As an added benefit, long-acting drugs reduce the temptation to sell drugs on the street, easing their burden in the challenging first months of recovery.
New, even longer-lasting versions of these drugs will soon be coming to market. For example, Titan Pharmaceuticals is in the process of seeking Food and Drug Administration (FDA) approval of an implant that would provide continuous delivery of the drug buprenorphine—sold as Suboxone in its pill form—for six months to people attempting recovery from dependence on heroin or prescription painkillers. Studies at the University of California, Los Angeles found that nearly 66 percent of patients who had the implant inserted under the skin in the upper arm stuck with treatment—compared with only 31 percent of those who received a placebo implant. They had higher rates of clean urine tests and lower rates of withdrawal symptoms and cravings.
The National Institute on Drug Abuse is also putting considerable effort into developing vaccines to fight addiction to cocaine, heroin, and methamphetamine. The aim is to trigger an immune response to a drug of abuse so it can't reach the brain and elicit a high, causing cravings for the drug to erode over time.
Treating the Unique Addict or Alcoholic
All addicts and alcoholics think they are unique. In a very true medical sense, they are absolutely correct. No two are the same, and each must receive a thorough medical evaluation to receive the appropriate medical care in a compressive program incorporating all the therapeutic and/or curative methodologies available.
It is interesting that people with a history of drug misuse can take prescription medications that have great potential for abuse and not misuse them. I usually avoid prescribing mood-altering medications, because they may trigger relapse. For selected patients, however, it is both prudent and necessary to use benzodiazepines, such as for patients who are severely bipolar. I also treat patients who have uncontrolled anxiety with other psychiatric medications.
We usually avoid giving patients stimulants unless it turns out that they have undiagnosed attention deficit disorder (ADD). In the majority of those cases, once they are prescribed the most effective stimulant, their life is changed, and their drug misuse ends. For some diagnosed ADD patients who have a nonmedical stimulant dependence, even prescription stimulants trigger a relapse.
Physicians need to keep open minds and provide individualized treatment. The old belief that all addicts are the same is completely wrong. No two are exactly alike, and there is no one treatment that is appropriate for all patients.
To overlook the individuality of the patient is, quite frankly, a gross violation of both ethics and professional responsibility.
Variations in Intoxicated Behavior
ANGER
It is a fact that different people act differently when intoxicated. People often ask me why some people become rude and abusive, even violent, under the influence of alcohol.
The reasons for emotional rage, especially when under the influence, are complex. Comprehensive research regarding anger found that there are medical underpinnings to compulsive, repetitive outbursts of anger, even when not accompanied by ingestion of alcohol, and when the brain imagery of those afflicted indicates the physical disease of addiction along with other medical illnesses.
Researchers at Ohio State University found that men and women with higher levels of hostility also showed higher levels of homocysteine—a blood chemical strongly associated with coronary heart disease. It is medically correct to say that extreme and repetitive anger can cause heart attacks and strokes. There is an ongoing discussion and considerable research concerning hostility and anger because they may be three things at once: a symptom of disease, the cause of disease, or in cases of compulsive rage, a medical condition of an addictive nature.
Jill Bolte Taylor, a trained and published neuroanatomist, garnered acclaim for her specialized postmortem investigation of the human brain as it relates to schizophrenia and severe mental illnesses. According to Taylor, all emotions, including anger, have a chemical component. Once triggered, the brain releases the neurotransmitter dimethyltryptamine (DMT), and you experience the corresponding emotion. Taylor insists that the chemical associated with anger is completely dissipated from the bloodstream in ninety seconds. She asserts that if your anger lasts longer than ninety seconds, it may be that you are self-perpetuating or self-triggering the chemical for much the same reason as a heavy drinker keeps ingesting alcohol.
As a specialist in addiction medicine, I see individuals come to me with highly complex problems involving more than one diagnosis. They may have heart and liver problems, brain dysfunction, addiction, or ulcers plus psychiatric and psychological problems. They may also have any manner of ailments engendered by, aggravated by, or marginally correlated to their compulsive use of alcohol and/or drugs.
Because of both complexity and individuality, there is no simple answer to the question regarding why we have "the angry drunk." There are, however, some interesting recent insights into the phenomenon.
In an experiment at the University of Waterloo in Ontario, Canada, volunteers pressed a particular button when prompted by a computer. These same volunteers were also instructed not to press the button if there was a bright red light. Some participants, when given alcohol, would become defiant. Despite the bright red light, they would smack the button with outright aggression. This is similar to the drunk who does something despite being repeatedly told not to do it.
Furthermore, many studies in the United States have found that a percentage of people who are told they are drinking alcohol behave as if they were under the influence, even becoming aggressive, hostile, and easily sexually aroused—despite not having any alcohol whatsoever.
The reason I introduced those two studies back to back is to raise the obvious question: Is the aggressive and defiant behavior the result of alcohol (or the result of what people believe about the effects of alcohol) or does it indicate another, more subtle medical condition? There is no absolutely correct answer under all circumstances, but we do know that in cultures where alcohol consumption is not associated in any way with aggressive or hostile behavior, the behavior of those who drink is not hostile and aggressive.
The Bad Drunk
The appearance of hostility when drinking is a manifestation of a physical disorder other than alcoholism, even if alcohol addiction is also present. A person who becomes insulting, aggressive, hostile, and/or abusive when drinking, even if he or she rarely touches alcohol, is exhibiting a known symptom of one or more medical conditions other than alcoholism, all of which require comprehensive care by a trained physician. In popular culture, we know this kind of person as a "bad drunk."
The implication for successful treatment of the angry alcoholic is clear: More than the physical illness of addiction must be addressed. There will be more than one diagnosis, and personalized treatment is of paramount importance. As with the alcoholic, solemn oaths to use willpower, the use of support groups, counseling, and the best intentions are, for the most part, useless. Yet, without fail and despite repeated failure, addicts continue to do more of what doesn't work.
Symptoms indicate illness, but symptoms don't diagnose the illness any more than the existence of clues is the answer to a mystery. One symptom or characteristic of addiction is self-stimulation. If an alcoholic has one drink, it stimulates a biochemical and emotional chain reaction triggering the compulsion to keep drinking, despite any unpleasant outcomes. As alcoholism is a medical problem with a biological component of approximately 50 percent, to ignore the physical illness would be irresponsible. Hence simply not drinking is not a medical treatment, although it certainly is a beneficial change in behavior.
If someone is going to assert that anger itself is an addiction or that there are adrenaline addicts, then the people so afflicted should certainly seek the help of a specialist in addiction medicine. Much to my personal shock and dismay, I have seen so-called anger addiction treatments that encourage the "patient" to become angry, express anger, and "get it all out."
When treating alcoholics, it is unlikely that having them drink to excess would be beneficial. I doubt you would buy the alcoholic a case of beer, a large bottle of Scotch, and several wine coolers, and then have him drink to get it out of his system. No responsible person involved in the treatment of addiction would tell drug addicts or alcoholics that they need to drink or drug as much as possible as a way to achieve health and sobriety.
Telling someone with a negative and destructive behavioral addiction not only to continue but also to amplify that behavior, strikes me as both absurd and negligent. After all, with any addiction, the continuation of the behavior ignites a self-stimulating, self-perpetuating system. The more you do, the more you want, even if every indulgence in the addiction brings more pain.
COMPULSION
When compulsion replaces control, the disease of addiction has taken over. There are short episodes of abstinence as a result of coercion or feelings of guilt, shame, or remorse. Those same emotions, however, provide the stress that triggers relapse into active addiction. Once the compulsion is triggered, all efforts at control disintegrate.
When you have an addiction, you look for opportunities to feed your addiction. When the addiction is to alcohol or other drugs, seeking and procuring the drug is part of the obsession; use of the substance is the compulsion.
With an internally stimulated and self-perpetuating brain chemistry, all the addict with compulsive anger issues requires is an insult, real or imagined, to instigate rage. A medical diagnosis, however, would reveal a significant biological factor to the rage issue, in addition to medical problems engendered by the anger itself.
OBSESSION
Obsession is when you can think of only one thing at a time, and it is the same one thing _all_ the time. Obsession is an irresistible force of thought that pushes everything else aside.
Obsession is followed by consummation in an unending repetition. For example, stalkers are obsessed with their prey. Fanatics are obsessed by their passions. Active addicts are obsessed with living their addiction.
One psychological attraction of addiction for the intelligent and well informed is the delightful prospect of not being in control. These are people who, due to their important positions of responsibility in life, wish to take a vacation from being in charge and place themselves in a subservient position. Of course, as with the person who pays to visit a dominatrix, they are only pretending not to be in control. In truth, they are in charge of the entire scenario. Sadly, when true addiction manifests itself, the game of "playing a drug addict" is no longer a diversionary vacation but a tragic health crisis.
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. These are reflected in a person's pathological pursuit of reward and/or relief through substance use and other behaviors.
The transition from casual substance use to addiction can be seen in changes in the chemical substances found in the brain, known as neurotransmitters, which transmit messages within the brain's reward system.
Special Considerations for the Opiate Addict
Suboxone, a once-a-day prescription tablet that can be administered only by a physician is a partial opiate, meaning that it gives the brain something similar to what it is used to, without the dangers associated with full opiates. Suboxone contains a combination of two ingredients: buprenorphine and naloxone. Buprenorphine is an opioid medication similar to other opioids, such as morphine, codeine, and heroin.
However, Suboxone doesn't produce the high of those drugs and is therefore easier to stop taking. This has advantages over methadone, although some patients with an exceptionally high degree of addiction are often better candidates for methadone, a medication that has been used effectively and safely to treat opioid addiction for more than thirty years.
HEROIN TREATMENT AND HARM REDUCTION
The heroin that is sold on the streets today is so potent that many patients can't stay away from it, even when under treatment with Suboxone or methadone. This is why nations that adopt a true harm-reduction model of treatment, such as Switzerland, have authorized managed maintenance using actual heroin, medically supervised and dispensed. This reduces both medical harm and social harm by reducing crime and illness.
As we do not yet have this harm-reduction model in the United States, Suboxone is rapidly becoming the medication of choice for managed maintenance for the majority of heroin addicts.
Another advantage of Suboxone is that there is no tolerance developed, but there is a ceiling on the drug's effect. In other words, if you take more than your required amount, you won't get more high.
For extreme opiate-dependent patients, the managed use of Suboxone makes it possible for them to acquire the life skills and personal balance to ride out their addiction without crashing. When they have internalized and integrated the therapeutic tools given to them, these patients recognize the right time to taper off the use of Suboxone until it is completely discontinued.
Remember, we are dealing with a physical disease that can be treated in much the same manner as we treat heart disease, diabetes, or high blood pressure. Whether a patient should take medication for his or her condition, what medication would be most effective, and how long that medication should be administered are matters best determined by the treating physician in consultation with the individual patient.
The Measure of Success
In 1964, the World Health Organization noted, "There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse—that is, to excessive or persistent use beyond medical need _._ "
More than half a century later, that pronouncement rings truer than ever. The speed at which new drugs surface to join the already copious ranks of evergreen substances like alcohol, heroin, marijuana, meth, morphine, and prescription painkillers is amazing. As I write this, the latest trending street drug is something called Flakka, a synthetic drug that produces violent, hallucinatory behavior. It replaces last year's trending drug that produces violent hallucinations, bath salts.
According to _Forbes_ magazine, Flakka is imported from China or Pakistan and is either smoked, snorted, or injected. It "induces rapid body-temperature elevation, the need to disrobe and a psychotic paranoia convincing the user that he is being chased. It can raise body temperature up to 106 degrees, and like amphetamines, it creates a state of excited delirium." It's even nicknamed $5 insanity.
Why would anyone take such a drug? Of course, there is no answer to that question.
In the field of drugs, if you build it, they will try it. And that's the point I'm making. We'll never stop the ingestion of addictive substances. We as a species lost that battle when we made the first wine about 6000 B.C.E.
Our society must switch the focus from trying to stop people from drugging and drinking (remember how well forced abstinence during Prohibition turned out) to providing effective, evidence-based treatment.
Yes, but how can we possibly know when we've achieved effective treatment?
The measure of the success of the outcome of treatment is really quite simple: Does treatment improve the quality of life of the patient? Addiction treatment is successful if the patient can lead a fulfilling, productive, and relatively normal life. It's as simple as that because that is the measure for any medical condition for which there is no cure.
The Modern-Day Medicine Chest for Addiction Treatment
Like other leading chronic diseases, addiction can be controlled and managed with a combination of medication, psychological counseling, and lifestyle choices, so that the addict can experience a fulfilling life.
A number of medications work on the brain circuitry to decrease cravings and, in some instances, the physical symptoms from addiction withdrawal. A short list follows, categorized by addictive substance. Brand names of the medications appear in parentheses.
A physician trained in addiction medicine knows best how to combine these medications in a way that optimizes treatment for each individual patient.
ALCOHOL
_• Acamprosate_ (Campral): reduces cravings for alcohol, normalizes brain function affected by heavy alcohol consumption.
_• Baclofen_ (Kemstro, Lioresal, Gablofen): reduces cravings and withdrawal symptoms.
_• Disulfiram_ (Antabuse): most commonly used aversion medication for alcohol abuse.
_• Naltrexone_ (Revia): reduces the high associated with substance or alcohol use, administered as a daily pill (Revia) or monthly injection (Vivitrol), both FDA approved.
_• Ondansetron_ (Zofran): antinausea drug shown to be effective in decreasing alcohol cravings, especially effective in those with early-onset addiction.
_• Topiramate_ (Topamax): anticonvulsant that may reduce the release of dopamine, thus reducing the rewarding effects of alcohol.
MARIJUANA
_• Gabapentin_ (Fanatrex, Gabarone, Gralise, Neurontin): drug for epileptic seizures but also effective in reducing withdrawal symptoms from heavy marijuana users.
_• N-acetylcysteine_ : shown to be effective in decreasing cravings for marijuana.
_• Oral tetrahydrocannabinol_ (THC) made from psychoactive ingredient in cannabis, shown to reduce withdrawal symptoms and cravings without producing intoxicating effects.
STIMULANTS
_• Bupropion_ (Zyban, Wellbutrin): reduces cravings for meth.
_• Modafinil_ (Provigil, Alertec, Modavigil): used to treat sleeping disorders, but shown to reduce cocaine cravings and withdrawal symptoms.
OPIOIDS
_• Buprenorphine_ (Subutex): reduces cravings and eases withdrawal symptoms, must be administered by a licensed and trained physician.
_• Methadone_ : inhibits the effect of heroin and morphine, but can be administered only at a licensed clinic.
_• Naltrexone_ (Ravia): (above).
_• Buprenorphine_ \+ _naloxone_ (Suboxone): used for maintenance therapy.
# Chapter 6
# Painless Detox
The process of detoxifying from alcohol or drug addiction is seared into the public conscience through popular culture. Even in the earliest days of cinema, movie producers grasped the drama associated with alcoholism and drug addiction. The 1902 French film _The Victims of Alcoholism_ was the first feature in a string of Silent Era movies on both sides of the Atlantic to underscore the dangers of substance addiction and its withdrawal. In 1917, Charlie Chaplin jumped on the wagon with _The Cure_ (1917), a film he directed and starred in about an upper-crust fop (a departure from his trademark tramp character), who causes mayhem when he arrives at a fancy hotel/spa resort, seeking help with his alcohol addiction, with a case of booze.
Chaplin had personal experience with the subject matter; his alcoholic father died at thirty-eight years old of cirrhosis of the liver. Although tackling serious social issues with humor—abject poverty, child abandonment, racism, prostitution—was a hallmark of Chaplin's films, in reality, detoxing from alcohol and drugs, until recently, was a horrifying process resulting in extreme physical pain, anxiety, depression, and even psychosis.
Today, the advent of new pharmaceuticals has made the process virtually pain free. However, because alcohol and opiate drugs (heroin, cocaine, prescription painkillers) affect different receptors in the brain, their detoxification must be administered with different techniques.
Research studies and my own extensive clinical experiences have shown a high success rate in treating alcoholics while they go cold turkey with benzodiazepines along with gabapentin, topiramate, and clonidine. For opiate detox, the preferred pharmaceutical is clonidine, supplemented with muscle relaxers, antinausea drugs, and other medications. However, don't try this at home! Detox from a severe addiction without proper _medical_ supervision can result in brain damage and death.
Severe Intoxication and Detoxification
The American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: (1) "to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free," (2) "to provide a withdrawal that is humane and thus protects the patient's dignity," and (3) "to prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs."
Detoxification for those in severe intoxication because of alcohol, opiates (heroin and painkillers), stimulants (cocaine, meth), benzodiazepines (Xanax, Valium), and/or barbiturates can be fatal, and each patient must receive personalized medical care. Opiate withdrawal is very physically uncomfortable. Seizures, while common in the withdrawal process, are not usually fatal.
Extreme stimulant intoxication can precipitate symptoms similar to those of heart attacks and can cause strokes, seizures, arrhythmia, or life-threatening hyperthermia. The nonmedical use of methamphetamine has severe destructive potential for the brain, including microstrokes, neurotransmitter dysregulation, and death of brain cells. The long-term psychosis resulting from extreme and continued nonmedical use of methamphetamine is often misdiagnosed as schizophrenia. There are no life-threatening withdrawal considerations when someone stops using stimulants, although there is a crash period of exhaustion, lethargy, and depression.
Treating the Unique Addict or Alcoholic
As with all aspects of addiction treatment, detoxification must be individualized for each patient. No two people are the same, and each must receive a thorough medical evaluation before being given the appropriate medical care in a compressive program incorporating all the therapeutic and/or curative methodologies available.
In the previous chapter I mentioned that I usually avoid giving patients stimulants unless it turns out that they have undiagnosed attention deficit disorder (ADD). In the majority of those cases, once they are prescribed the most effective stimulant, their life is changed, and their drug misuse ends. For some diagnosed ADD patients who have a nonmedical stimulant dependence, even prescription stimulants trigger a relapse.
The point is this: Physicians need to keep an open mind and provide individualized treatment. The old belief that individual addicts are not different from each other is completely wrong. No two are exactly alike, and there is no one treatment that is appropriate for all patients. To overlook the individuality of the patient is a gross violation of both ethics and professional responsibility.
Detox vs. Treatment
Detox and treatment in the public's mind are synonymous, but in reality, that's not the case. Not every addict who seeks treatment needs to go through detoxification. It's only necessary for those patients whose dependence on a substance has reached such a critical stage that a sudden cessation—going cold turkey—could seriously endanger their health and possibly their lives.
This is the inherent problem in addiction rehab clinics that rely exclusively on nonmedical protocols and apply a one-size-fits-all abstinence model for treatment.
Detoxification is the removal of alcohol or other drugs from the body via metabolism and specifically through the liver and excretion through the kidneys. Medically assisted detoxification reduces the risk of discomfort and potential physical harm for patients in the throes of withdrawal. For those with severe substance dependency, detoxification is an often necessary step before moving on to immediate care and eventual long-term management of the disease of addiction.
Beside the fallacy that addiction treatment can be the same for everyone, another point of confusion needs to be cleared up: Detoxification is not the end of treatment but rather the precursor to it. I am reminded again of the death of actor Philip Seymour Hoffman. He reportedly checked himself into a detox center after a relapse in his drug addiction. He was released after ten days. In a few days he was back to shooting heroin and overdosed a few months later.
In my opinion, the ten-day detox, which has become a cultural ritual for the rich and famous, is more of a publicity stunt than bona fide medicine. When a celebrity gets in trouble and his career is in jeopardy, the knee-jerk response from his handlers is to exhort, "get thee to detox." That's like bandaging the wounds of a gunshot victim and then showing him the door.
The Three Steps to Detox
As outlined in the landmark addiction report known as the Columbia University CASA Report, published in 2014, there are three main components to effective detoxification. I use these in my own clinical practice.
1. EVALUATION
Examine the patient and determine if symptoms are acutely present, ideally using standardized instruments to measure the severity of withdrawal. Assess vital physical signs that manifest themselves in substance dependency. Evaluate for the presence of cooccurring medical conditions and mental health disorders. And, finally, determine by medical analysis, such as a urine test, if there are substances present in the patient's body or if substances were recently used.
2. STABILIZATION
The doctor and other trained personnel assist the patient through withdrawal to the state of physiological stability. Depending on the individual, pharmaceutical medications may be needed.
3. FACILITATION OF TREATMENT ENTRY
Guide patients with severe addiction to a bona fide addiction treatment center that uses evidence-based medicine and provides a continuation for the short-term care _and_ long-term management of the patient's disease.
Alcohol Detoxification
Alcohol withdrawal is potentially the most dangerous of any substance addiction. For the successful and safe cessation of alcohol ingestion I recommend the use of certain medications to help prevent the harmful effects that may accompany it. Withdrawal from alcohol typically takes seven to ten days, but with medical management, stabilization can be achieved sooner.
During the first six to forty-eight hours, symptoms can include anxiety, nausea, agitation, and difficulty concentrating. In more severe cases, symptoms can include hallucinations and seizures. Alcohol withdrawal delirium, also known as delirium tremens (DTs), is the most severe and dangerous withdrawal symptom, and usually appears two to four days after the last drink. Some symptoms of alcohol withdrawal, including DTs and seizures, can be life-threatening, so it is medically imperative that patients severely addicted to alcohol should undergo detox only with the supervision of trained medical personnel with ready access to hospital care if necessary.
There are a number of assessment tools that can be used to determine the severity of alcohol addiction, including Clinical Institute Withdrawal Assessment—Alcohol Revised (CIWA-Ar), the Clinical Opiate Withdrawal Scale (COWS), and the Finnegan Neonatal Abstinence Score.
The duration of detoxification varies with the severity of addiction. Withdrawal symptoms, such as sleep disturbances, can last for weeks. The severity of symptoms can increase in patients who have experienced prior alcohol detoxifications, a process known as the kindling effect.
Here's the good news: As I mentioned before, benzodiazepines, a class of psychoactive tranquilizers, have calming, sedating effects and can prevent the onset of certain alcohol withdrawal symptoms and acutely relieve such symptoms, including alcohol-induced seizures and DTs. This class of drugs includes the following drugs (brand names in parentheses):
• Diazepam (Valium)
• Clonazepam (Klonopin)
• Lorazepam (Ativan)
• Chlordiazepoxide (Librium)
Because the combined effects of benzodiazepines and alcohol can be life threatening, patients must be advised not to drink while on benzodiazepine medications. Also, benzodiazepines have their own potential for addiction and so should be used only in the relatively short-term period of detoxification and closely monitored by a medical professional.
Although DTs occur only in about 5 percent of patients undergoing alcohol detoxification, the mortality rate is more than 18 percent for those who experience them. There's no excuse for anything but expert medical care for patients experiencing DTs.
Opioid Detoxification
Withdrawal symptoms from illicitly obtained or prescription opioids, including heroin, morphine, hydrocodone, and oxycodone, are not typically life threatening, but they can be extremely uncomfortable. Among the symptoms are abdominal pain, muscle aches, agitation, diarrhea, dilated pupils, insomnia, nausea, runny nose, sweating, and vomiting.
Withdrawal symptoms generally last from seven days to several weeks. Because medical complications can develop, patients must undergo regular physical examinations and psychological evaluations.
The goal of medical detoxification is a safe, comfortable and complete withdrawal from opioids. Sudden cessation of opioids, especially for a patient who has developed physical dependence on the drug, should be avoided. Rather, the patient should be weaned off the opioid gradually.
However, this procedure is not legally permissible with illicit opioids such as heroin.
Instead, the trained medical professional uses opioid replacement therapy, which substitutes FDA-approved medications that are then gradually tapered off. Nonopioid medications, such as clonidine, can decrease the agitation and discomfort associated with withdrawal. Other medications that can relieve the symptoms of acute withdrawal can also be used, such as nonsteroidal anti-inflammatory drugs (NSAIDs) to treat muscle pain, antiemetics for nausea, nonaddicting sleeping medications like trazodone for insomnia, and buprenorphine to stop the craving.
Medically prescribed opioids formulated specifically for addiction treatment work by occupying the opioid receptors in the brain, blocking or minimizing the effects of more addicting opioid drugs. A patient using buprenorphine is protected from inadvertent overdose and prevented from getting high.
Stimulant Detoxification
Detoxification from stimulants like cocaine and meth may result in withdrawal symptoms, but normally these symptoms are less severe than with alcohol and are rarely life threatening. Symptoms include lethargy, insomnia, agitation, anxiety, increased appetite, depressed moods, and drug cravings.
As with alcohol and substance detox, the preferred method is tapering the drug off gradually. But as with illicit opioids, stimulants like cocaine are illicit and cannot be used in detoxification. Tranquilizers can be used for agitation and anxiety, and nonaddictive sedatives are helpful with insomnia.
As noted in the previous chapter, there is promising evidence supporting a medication called bupropion for curbing cravings and reducing the severity of withdrawal symptoms associated with meth addiction. Bupropion was developed to treat depression, including seasonal affective disorder, and has been proven to aid in quitting smoking. The drug appears to work by blocking the receptors of two neurotransmitters active in substance addiction: dopamine and norepinephrine. Another advantage is that it curbs the increased weight gain associated with stimulants withdrawal.
Similarly, the stimulant medication modafinil (brand names Provigil, Alertec, and Modavigil), created to treat sleeping disorders, can reduce the cravings and withdrawal symptoms associated with cocaine. Studies are inconclusive as to modafinil's effectiveness, but depending on the individual patient, it can reduce the stimulating effects of cocaine and aid in overall detoxification.
Depressant Detoxification
Benzodiazepines are commonly known as tranquilizers and are some of the most commonly prescribed medications in the United States. Brands like Valium and Xanax are household names and are found in tens of millions of medicine cabinets across the country.
Xanax, designed for anxiety, is the most commonly prescribed pill in the United States, with nearly 48 million prescriptions written in 2012. When used as prescribed, benzodiazepines can help in legitimate medical conditions, such as anxiety, insomnia, seizure control, and muscle relaxation. Indeed, earlier in this chapter we learned how benzodiazepines can be effective in alcohol withdrawal.
It's when benzos are taken recreationally for their sedative effect that they cross the line into substance abuse.
Here's the shocker: They're as popular for their illicit use as they are for their legitimate use. Nearly 15 percent of Americans aged twenty-one to thirty-four have taken tranquilizers without a prescription or recreationally according to 2012 data from the Substance Abuse and Mental Health Services Administration.
There's even a sinister side to their abuse. Benzodiazepines are the so-called date rape drug, which can impair normal brain functions to the point that a person cannot resist, or even want to resist, sexual aggression.
Withdrawal from benzos is similar to that for alcohol, with seizures and delirium being the most serious side effects. Symptoms can last between one and two weeks. Because benzos are legal, a detox program can use the drug itself to slowly wean the patient from it. Alternately, a different benzo drug from the same class can be used for detoxification.
Detoxification Venues
Where detoxification takes place depends on the severity of the patient's addiction and overall health condition. Physicians' offices, mental health treatment facilities, urgent care centers, hospitals, ER departments, and even patients' homes can be appropriate once a proper assessment has been made of the nature of the detox required and, most important, if medical assistance is needed.
On the other hand, the worst detox scenario is having an addict sent to a so-called rehab clinic without medically trained personnel or one that outright rejects evidence-based medicine for addiction treatment; these facilities are often called "12-step recovery programs" or a variation on that theme. In other words, they are making a profit on the philosophical teachings of AA, which was always meant to be free, and offering no medical safeguards in the potentially dangerous detox process.
Patients most at risk are those with a history of severe withdrawals or multiple withdrawals. It's bordering on the criminal and is certainly unethical to place one of these patients in a nonmedical setting for detoxification.
As If They Were Never Treated
If there's one message to take away from this chapter, it's this: Medications offer help in suppressing withdrawal symptoms during detoxification; however, detoxification is not in itself a full treatment program. For addicts to believe their treatment program ends at evacuating the addictive substances from their body is nothing more than wishful thinking. Rather, it is only the beginning of the treatment process.
Patients who go through withdrawal—including medically assisted withdrawal—but who do not receive any further treatment, mimic drug abuse patterns similar to those who were never treated. It's as if they were never detoxed at all.
Licensed Medical Professionals
In this book I've stressed the need for addicts with a severe substance abuse, particularly with opioids and alcohol, to have their detoxification supervised by trained medical personnel, optimally a trained physician. Unfortunately, this is a small elite group whose ranks need to be greatly expanded.
As of 2015, the American Medical Association (AMA) estimated that of the 985,375 active physicians, there were only 582 addiction physician specialists: 227 addiction medicine physicians and 355 addiction psychiatrists—the two medical subspecialties specifically trained in addiction science and its treatment—totaling 0.06 percent of all active physicians.
Although there are no recent data identifying the actual number of practicing specialists in addiction medicine or addiction psychiatry, the American Board of Addiction Medicine has certified 2,584 addiction medicine specialists and estimates that the number of full-time practicing addiction medicine specialists may be about five times the number of the AMA estimate, or approximately 1,200. This estimate still falls far short of the estimated minimum of 6,000 full-time addiction medicine specialists currently needed to meet addiction treatment demands.
All opioid maintenance therapy facilities are required by federal law to obtain certification from the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA) to demonstrate compliance with established standards for opioid maintenance therapy programs. It is a prerequisite of certification that a program be accredited by an organization approved by SAMHSA.
Becoming qualified to prescribe and distribute buprenorphine involves an approved eight-hour program in treating addiction, an agreement that the physician and medical practice will not treat more than 30 patients for addiction involving opioids with buprenorphine at any one time within the first year and up to 100 thereafter, and assurance that the trained physician will refer patients to necessary supplemental psychosocial services.
Physicians who meet the qualifications are issued a waiver by the SAMHSA and a special identification number by the Drug Enforcement Agency.
The key to finding evidence-based detoxification is to look for programs supervised by medical doctors or psychiatrists with board certification in addiction medicine by the American Board of Addiction Medicine.
# Chapter 7
# Maintenance and Relapse
Addiction is not a disease you can treat with a shot and be done with it. It's not the flu. It's a chronic disease, which, by definition, means there's no cure. Again, think heart diseases, asthma, and diabetes as reference points. Once the disease is stabilized, it must be treated over a lifetime.
As with any chronic disease, a degree of patient relapse is to be expected. The disease flares up, and you have to start the treatment again. Relapse is part of what having a chronic disease means—whether its hypertension or drug addiction. In fact, the relapse rate for addiction is typical of chronic diseases, slightly more than diabetes but less than hypertension and asthma.
A relapse is not an occasion to scold, punish, or otherwise stigmatize the person. It's not a moral failure but a symptom. Modern-day diagnostics indicate that most brains eventually return to relatively normal when the drug use stops. However, the neurological and psychological after-effects of drug use persist, and they make a relapse a significant possibility for months, years, even decades after initial treatment.
A single act can instantly reignite addiction pathways, causing the former addict to renew drug-seeking behavior. In effect, the addict's brain remembers that the substance—alcohol, cocaine, meth, Vicodin, bath salts, you name it—relieves stress, no matter how much time has passed.
The key to successful sobriety is regular, quarterly wellness checkups with a medical professional trained in addiction medicine, who can monitor brain chemistry, particularly neurotransmitter levels. Therapy and counseling can also assist in maintaining a lifestyle that avoids people and places that provide potential relapse triggers.
The Changing Face of the Addict
Knowing who suffers from the disease of addiction is essential for marshaling limited resources, both on a personal and societal level, and tailoring programs that best fit the most common profiles. A patient's demographic profile also can affect treatment. Women, for example, react differently from men to the same dosage of many drugs. Older patients absorb drugs differently from the population at large (age affects changes in body composition; the elderly typically have an increase in adipose tissue, decrease in lean body mass, decrease in total body water and lower metabolisms than the adult population at large).
Yet, the popular concept of who is an addict in America in the twenty-first century is woefully out of balance with reality.
The term _addict_ still conjures up ideas of heroin junkies shooting up in a burned-out tenement in the Bronx. In reality, the drug addict today is likely to be a grandmother living in the suburbs who's hooked on prescription pills.
There's a whole new population of addicts unthinkable a generation ago, the so-called accidental addicts. They are fifty years old or older who may have started using a prescription drug to relieve legitimate pain, perhaps from one or more chronic conditions. Unfortunately, many of these patients inadvertently have formed a severe drug dependency. They now find themselves needing to ingest more and more of the painkiller simply to navigate their daily lives. In other words, they're addicted. From a pharmacological perspective, that's not surprising. Chemically speaking, there's a fine line between an illegal opioid like heroin and a legal opioid like hydrocodone.
In 2012, adults aged forty-five to sixty-four had the highest rate of hospital stays for opioid abuse; twenty years ago, that distinction belonged to those twenty-five to forty-four years old. More than 5.7 million people over the age of fifty will need substance abuse treatment by the year 2020, according to government researchers.
Heroin vs. Prescription Drugs
Without a doubt, there has been a dangerous resurgence in the use of heroin. Between 2012 and 2013, heroin overdose deaths in the United States soared by 39 percent from 5,925 to 8,257. Add deaths related to meth, cocaine, PCP, bath salts, Flakka, and every other illicit drug, and the best data shows they were responsible for approximately 16,000 deaths in 2014.
However, the much bigger problem is the abuse of prescription pills. Overdose deaths from controlled prescription drugs have increased significantly over the last decade and now surpass the number of overdoses caused by all illicit drugs combined, accounting for more than 38,000 deaths in 2010. Enough prescription painkillers were prescribed that year "to medicate every American adult around-the-clock for a month," according to the Centers for Disease Control and Prevention (CDC).
To frame the problem another way, healthcare professionals wrote 259 million prescriptions for painkillers in 2012. Which demographic group was impacted most by this tidal wave of opioid drugs? Seniors!
More than one-third of the enrollees in Medicare Part D, which covers the cost of pharmaceutical drugs for seniors, used a prescription opioid. In 2011, 11.5 million Medicare beneficiaries, who by definition are at least sixty-five years old, filled at least one prescription for an opioid analgesic (painkiller), collectively spending more than $2.7 billion.
The rates of patients dying from prescription opiate overdose deaths for those aged fifty-five to seventy-four increased about sixfold between 1999 and 2013, according to CDC statistics, even as all other age groups saw the rate of increase slow or stabilize.
If there is a silver lining in the prescription pill epidemic, it seems that beginning in 2010, it began to peak. Most experts attribute that to new restrictions on doctors from dispensing prescription pills. Unfortunately, and it appears not coincidentally, about the same time prescription pill use, or at least abuse, was beginning to decline, heroin use started to surge. Do you see the connection? With prescription pills increasingly hard to find and expensive on the black market, users began to turn to cheap heroin.
To add to the perfect storm, the new forms of heroin that have become available since about 2000 are so pure that they no longer have to be injected. The very stigma that had once defined the heroin junkie—shooting up (or intravenous injections)—was no longer necessary. Indeed, a study published in 2014 in the prestigious _JAMA Psychiatry_ journal found that "80 percent of the people who had used heroin in 2010 had also used prescription pills," and that these users turned to heroin because it was "more readily accessible and much less expensive than prescription opioids."
Needless to say, the new users of heroin weren't kids but were older adults. Studies have shown that the face of the heroin user has changed over the last twenty years from young men in urban environments to older men and women located more in the suburbs.
The rate of death by accidental drug overdose for forty-five- to sixty-four-year-olds increased more than 10 times between 1990, when baby boomers were still outside the age group and 2010, when they were starting to fill the ranks of that age group. For the first time ever, deaths from accidental overdoses for late-middle-age adults exceeded those of the twenty- and thirty-somethings. In 2013, more late-middle-agers died from accidental overdoses than from car accidents or from the flu or pneumonia for that matter.
Dependence vs. Addiction
Emotional stress (psychological factors) can trigger the onset of a disease, including the disease of addiction, because stress may activate the genetic, biological factor. Stress may also trigger the relapse of a disease in remission.
People often confuse addiction with physical dependence in the context of clinical treatment. Drugs that we often associate with abuse, such as opiates or central nervous system stimulants, are, in the proper context, beneficial medications.
Addiction is also not synonymous with recreational or social use of mood-altering agents, including alcohol. Once we clear up this misunderstanding, everyone understands why addiction is a true clinical illness and why addiction is classified as a disease by every clinical organization in the world, including the AMA, the World Health Organization, and the American Psychiatric Association. Obviously, if addiction were not a clinical condition meeting the clear definition of disease, my area of specialization—addiction medicine—wouldn't exist.
Now, let us suppose that you use cocaine, or another stimulant, and have used it regularly for several years. Stimulants such as cocaine can contribute to, or precipitate, stroke, seizure, heat arrhythmia, heart attacks, and hyperthermia (a potentially fatal elevation of temperature). You go to the doctor for a checkup, and he tells you that because of the cumulative effect of your years of cocaine use, you must stop immediately or you will definitely have a heart attack or stroke. What do you do? Simple, you stop.
For most people, stopping heavy drinking or drugging, or other life-threatening behavior, is simply a decision they make in their own best interest. They might do so with the help of a psychologist, their primary care doctor, a family member or friend, a self-help group, or entirely on their own.
Most people who develop a substance dependency can simply end their habit. Because of all the consequences to their health and the safety of others and for the sake of their friends and families, their own financial well-being, their spiritual or philosophical beliefs, and their own sense of self and personal convictions, they choose to stop drinking or drugging excessively or altogether.
A Question of Choice
For the unlucky with the disease of addiction, it's not a question of choice. They can't simply stop taking their favorite drug (including alcohol). Likewise, they can't simply stop from relapsing.
Those scientifically proven facts about substance addiction still vex most Americans. They see addicts drinking and drugging, they know they themselves occasionally indulge in recreational drinking or drugging, and they know they can stop whenever they like. So, why can't addicts? If they just chose to stop, they wouldn't have their disease. It's so intuitive that it is hard to shake the idea that there's an alternative explanation.
Let's remove the stigma of addiction from the discussion for a moment. Many people know they have high cholesterol and high blood pressure, but make no attempt to control them. Finally, they have a heart attack or stroke. That is their choice. Many diabetics are not taking medication, cheat on their diet, and are walking around with sky-high blood sugar levels. Again, that is their choice. People choose to have unprotected sex, share needles, and possibly contract HIV/AIDS. Would you say that they chose to get HIV? No, but their choices facilitated the disease.
Can a person make a poor choice by drinking heavily knowing they have a strong family history of addiction? Yes, and that choice can lead to alcoholism, which is a form of addictive disease. The disease of addiction is, in many ways, similar to high blood pressure. People can't control their blood pressure by force of will or decision. People with the disease of addiction can't control their disease by force of thought. Patients with drug and alcohol addiction want to stop, but they need professional clinical help and true understanding from friends.
Addiction Defined by ASAM
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Let's recap: Addiction, according to the American Society of Addiction Medicine (ASAM), is characterized by the inability to consistently abstain, by impairment in behavioral control, by cravings, by diminished recognition of significant problems with one's behaviors and interpersonal relationships, and by a dysfunctional emotional response.
The ASAM Patient Placement Criteria focus on six dimensions to define severity: (1) potential for acute intoxication and/or withdrawal, (2) biomedical conditions and complications, (3) emotional/behavioral conditions or complications, (4) treatment acceptance/resistance, (5) relapse potential, and (6) recovery environment.
In the maintenance phase of treatment, the goal is to match the patient's needs to the appropriate service by assessing the severity of the addiction as well as verification of the medical diagnosis.
Managed Maintenance
Contrary to what many rehab clinics promote, there is no thirty-day fix for addiction (pardon the pun!). You can't permanently stop the progression of alcohol or drug addiction during a one-month stay any more than you could with diabetes or heart disease. Successfully treating addiction requires long-term medical intervention by trained professionals who can supervise and coordinate all treatment options.
There is no one-size-fits-all, long-term maintenance protocol for addiction treatment. Each patient's case is different, so maintenance and the recovery from inevitable relapses must be individualized.
Most addicts require additional pharmaceutical and psychological intervention after their conditions are stabilized. As discussed in the previous chapter, the measure of success for addiction treatment is not simply abstinence, which is the result of successful treatment. Rather, success is determined—as with all chronic diseases—by the quality of life. With medically supervised disease management, can the addict live a relatively normal and productive life?
I have had patients whose disease management and maintenance have lasted a few months after their initial condition has been stabilized. For other patients, I have been maintaining their health with a combination of medications and psychological counseling for years. The benchmark—the only measure of success—is their continued high quality of life.
For most patients, long-term managed care mimics in many ways the treatment provided during the acute care stage, which stabilized their condition. So, for example, a patient with an opioid addiction treated with the medication naltrexone in acute care would continue with that medication during the long-term maintenance of his treatment. Over time, the dosage of the medication would be reduced until the point when it would be no longer needed to diminish the patient's cravings for his addiction.
A new generation of extended-release naltrexone, sold under the brand name Vivitrol, is especially helpful in preventing relapse of opioid addicts. A study published in 2013 in the journal _Addiction_ confirms what I was already seeing in my clinical experience: Vivitrol blocks the effects of the opioids (heroin was the focus in the study) on brain receptors and prevents relapse by reducing "euphoria, pain relief, sedation, physical dependence and cravings." That Vivitrol is injected once a month, rather than taken as a daily pill as with standard-release naltrexone, also circumvents the need for the patient to closely and constantly manage medications.
Ongoing psychosocial therapy would provide the patient with mechanisms for coping with stress and other situations that might trigger a flare-up of the disease. An overall health regimen of good nutrition and regular exercise would further reduce stressors that might cause a relapse.
Extreme Addiction Cases
Managed maintenance is a program with proven success in restoring health, life, and hope to those unique individuals who, because of either systemic or acquired medical conditions, have become completely dependent on opiate pain relievers. These special cases are patients with addiction histories, ten-to fifteen-year medical condition such as hepatitis C, HIV, heart problems, and/or psychiatric complications. These cases are not the norm, but not being a "normal" addict is no reason to be denied effective life-saving, health-restoring treatment.
Without managed maintenance, 80 percent of these extreme cases immediately fall right back into dangerous addiction. An addiction medicine specialist knows the proper and effective way to replace dangerous and illegal substances with FDA-approved Suboxone, a prescription medication also used in detox that keeps patients from experiencing life-threatening, debilitating withdrawal and allows them to remain physically stable.
Heroin Dependence
Previously, I noted how an advantage of Suboxone, a medication used in the treatment of heroin addiction, is that no tolerance developed, but there is a ceiling on the drug's effect. In other words, if you take more than your required amount, you won't get more high. Suboxone is available only by prescription and administered only by a physician.
Other advancements include new treatments for opioids and stimulants. For opioids, this includes long-acting injectable or implanted naltrexone, and antagonists; oral or implanted buprenorphine, a partial agonist; and innovative detoxification methods using buprenorphine.
Cocaine Dependence
New developments for cocaine dependence include vaccines that provide either active or passive immunization, agonists that could decrease craving without producing euphoria, blocking agents that do not block normal pleasures, and corticotrophin-releasing factor (CRF) antagonists that could decrease both craving and relapse. In the short term, modafinil, tiagabine, topiramate, and disulfiram, medications currently marketed for other conditions, show promise for cocaine addiction.
Psychiatric Realities
Failure to address psychiatric realities dooms a person to unnecessary consequences. One of my patients had been active in Alcoholics Anonymous for many years. He would stay sober with little or no difficulty for ten months and then relapse. This pattern continued for years. Finally he sought medical help. As it turns out, he had bipolar disorder with a ten-month cycle. Every ten months, he would enter a manic phase, during which he would relapse. All it took to rectify this long-standing problem was a daily dose of a readily available prescription medicine.
If this man had been psychiatrically diagnosed in the first place, years of disappointment and feelings of failure could have been avoided.
With addiction, there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often exhibit a lower readiness to change their dysfunctional behaviors, despite mounting concerns expressed by significant others in their lives. They also display an apparent lack of appreciation of the magnitude of cumulative problems and complications.
However, addiction is more than a behavioral disorder. Features of addiction include aspects of behaviors, cognitions, emotions, and interactions with others, including:
• Excessive use and/or engagement in addictive behaviors at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for, and unsuccessful attempts at, behavioral control.
• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (for example, the development of interpersonal relationship problems or the neglect of responsibilities at home, school, or work).
• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems that may have been caused or exacerbated by substance use and/or related addictive behaviors.
• A narrowing of the behavioral repertoire focusing on rewards that are part of the addiction and an apparent lack of ability and/or readiness to take consistent action toward change, despite recognition of problems.
Over time, repeated experiences with substance use or addictive behaviors are not associated with ever-increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, and unstable emotional experience related to suboptimal reward and the recruitment of brain and hormonal stress systems. This response is associated with withdrawal from virtually all pharmacological classes of addictive drugs.
While addicts develop tolerance to the high, they do not develop tolerance to the emotional low associated with the cycle of intoxication and withdrawal. Thus addicts repeatedly attempt to create a high. But what they mostly experience is a deeper and deeper low. While anyone may _want_ to get high, those with addiction feel a _need_ to use the addictive substance or engage in the addictive behavior to try to resolve their uncomfortable emotional state or their physiological symptoms of withdrawal. People with addiction compulsively use even though it may not make them feel good.
Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in activities that promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery.
The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction from those in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to
• Decrease the frequency and intensity of relapses.
• Sustain periods of remission.
• Optimize the person's level of functioning during periods of remission.
In some cases of addiction, medication management can improve outcomes. In most cases of addiction, psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provide the best results. Chronic disease management is important for decreasing episodes of relapse and their impact.
Support Services
Because many addicts have often destroyed their lives by the time they get effective treatment, it's important to treat the whole person rather than just the disease. They may find themselves unemployed, homeless, needing childcare, facing criminal justice problems, and embroiled in family problems.
In addition to medication and psychosocial therapy, a long-term maintenance program might include support services such as family counseling, mental health care, supplementary medical care, housing and legal assistance, and vocational services.
A Late-in-Life Addict
My patient Augustus, or "Gus" as he prefers, isn't anyone's idea of a drug addict. A sixty-six-year-old family man with a loving wife, three children, and one grandchild, Gus was connected to the sea for his entire career. He joined the navy right out of high school, spending his twenties bumming around the Hawaiian Islands as deck crew on fishing charter boats. There was lots of drinking and drugging in those days, he recalled. "Doc, if you ever been on a fishing charter boat, you know they're really just an excuse for spending the day having a big party. Yeah, it's nice to catch a fish or two, but if that doesn't happen, it's just more of an excuse to get high. Now imagine doing that seven days a week," he told me when we first met.
You might surmise that Gus was a primary candidate for becoming an addict. But a remarkable thing happened when he was thirty-two-years old. He met his eventual wife, a schoolteacher, and he decided to stop his dependency on alcohol and cocaine. "OK, to be honest, my wife had a lot to do with it. She gave me an ultimatum. You can continue to pretend you're still a kid out of the navy and party every day, or you can settle down and live happily ever after with me," he said.
They soon started a family, and he went on to having a successful maritime career, first as the captain of his own sports fishing charter boat, then eventually earning his Merchant Marine credential and his tugboat license. He capped his career as the captain of one of the first-respond boats that rescued the crew from the BP oil disaster in the Gulf of Mexico.
Then, the real trouble began. He retired at age sixty-five with a good pension and, of course, the benefits of Medicare. One of the first things he did was to get some badly need orthopedic surgery. A long career involving heavy physical labor had ground away his cartilage, and so, in quick order, he got joint replacement surgery for both hips. His surgeon prescribed him Vicodin, an opioid analgesic, for the postoperative pain. A year later, after his prescription ran out, he began buying it on the black market. "I was hooked. I knew I was hooked but I couldn't stop. It was no longer so much about the pain but just being able to function as a human being. Without my Vikes, I would get very anxious during the day and couldn't sleep at night," he said.
When prescription pills became hard to find on the street, he switched to heroin. "I never thought me, a grandfather for God sakes, would ever become a heroin junkie. Even when I was a young buck, I steered away from the stuff. That was what hoods and losers took. But this new stuff was so powerful you could just snort it. I think it would have been different, harder to rationalize using it, if I had to inject myself with a needle," he said.
Gus was motivated to change. He was just beginning his retirement and, with two new hips, figured that he had at least two good decades ahead of him to enjoy traveling with his wife, visiting his kids, and even doing some sports fishing. To stop his cravings for opioid, I prescribed a regimen of Vivitrol, a kind of extended-release naltrexone, which has had years of proven results. Now that he once again was mobile, I also put him on a regular regimen of exercise (walking, alternating with biking) and a whole-food diet, all to reduce stress that could trigger a relapse.
Today, three years later, his addiction is under control. He occasionally drinks but only moderately. "Doc, the days when I would get blind drunk or fall-down high are over. I've too much to live for to let drinking or drugging get in the way," he says.
How to Find a Bona Fide Treatment Center
Where I live and work in Los Angeles, the airwaves are filled with TV commercials from addiction centers that you'd swear sound like they know what they're doing. Some of them look absolutely beautiful—with beachfront views of the Malibu coastline, hot tubs, and gourmet dining.
For the most part, however, it's all window dressing. The sad fact is that 90 percent of all addiction treatment centers, also known as rehab clinics, offer no evidence-based medicine. Among the 10 percent that do, often it's limited to detoxification.
Despite the advances made in medically assisted treatment, the days when rehab was a program driven by enforced abstinence and 12-step meetings (such as Alcoholics Anonymous and Narcotics Anonymous) are, unfortunately, still with us. Most rehab clinics are staffed with drug counselors who have little to no training and often whose only qualification is that they are in recovery from their own alcohol or drug addiction.
How is the consumer supposed to find a legitimate treatment facility? You have to do your homework. Most patients, or their families, do more research buying a car than deciding on a treatment center.
Look for a facility in which every aspect of treatment is built on a solid scientific foundation and clinically proven to be effective in overcoming addiction. It is most important that all aspects of addiction treatment be under the direction of an addiction medicine specialist. This physician or psychiatrist (not a psychologist) is qualified to coordinate, assess, and make ongoing diagnoses and medically assisted treatments. (The American Board of Addiction Medicine has a list of bona fide physicians at www.abam.net.)
The modern treatment approach identifies specific problems that require specific types of attention. This means that the patient can be placed in the least intensive, safest level of care and specifically treated with strategies selected from a wide range of effective treatments best suited to that patient's individual condition and situation. If a clinic offers only one kind of treatment, and doesn't take into account the individual needs of the patient, this should be a red flag.
An effective treatment must help clients address, identify, and describe the personal meaning of their addiction. Are they self-medicating, filling up an inner emptiness, numbing feelings related to a trauma, or all of the above? Unless clients understand what they are actually doing on a deep level, they will chronically relapse. A responsible comprehensive treatment program takes all aspects into consideration for the ongoing health and well-being of the client.
**A word of caution:** Even seemingly helpful sources of information can be misleading. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency with the federal Department of Health and Human Services, offers an online database to locate "treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems." The list is vetted, but only in the most superficial way. The facilities listed must meet local licensing requirements for rehab clinics, which vary wildly between states and, for the most part, are negligible. Also, these facilities have no oversight except that they qualify in the minimum way to charge third-party insurers. That's it. There's not even an attempt to screen for whether the services are medically sound.
In the greater Los Angeles area, for example, the SAMHSA locator database lists 700 facilities (Yes, 700!). But scanning through this overwhelming list, I can count on two hands the facilities that actually offer medically sound, evidence-based treatment programs.
Of the estimated 25 million Americans who are substance abusers, only 2 million receive any kind of treatment and only about 1 in 10 of those receive any kind of evidence-based treatment. The math is both shocking and discouraging. However, there is new hope that things are about to change for the better. The Affordable Care Act (a.k.a. Obamacare) has mandated the first-ever primary care benefit for substance-use disorders, which means the disease of addiction will be treated more like diabetes.
Also, addiction research and policy pioneer Thomas McLellan, former deputy drug czar for the Obama administration, has spearheaded the development of a program that aims to bring a rigorous, _Consumer Reports_ –style of evaluation to the nation's thousands of rehab clinics. If his plan goes to fruition, the information would be accessible via a website and is already available in the Philadelphia area. Each facility would be judged on 10 criteria points, culled from scientific literature, including whether the facility can prescribe medicine, attend to physical health and educational hurdles, and prepare patients for a long-term recovery, including monitoring and support.
A Progressive Model for Treatment
Doctors become addicts, just like every other segment of the population. But physicians who become addicted present a particularly high risk to the public. One mistake in prescribing a medication, for instance, could kill a patient.
What happens to doctors who are addicted offers a template of treatment for the public at large. The Physician Health Program (PHP), used in all fifty states and the District of Columbia by medical societies and licensing boards, is more intensive and lasts longer than the treatment programs available on average by the general public. While thirty days is the average treatment for insurance-funded public programs, PHP offers a structured therapy lasting between three and six months, followed by five years of maintenance or managed care. The program, which is funded by grants and contributions for physicians, hospitals, and others interested in physical health issues, includes pharmaceutical and psychosocial therapy, nutrition and exercise counseling, and other support services (depending on the needs of the individual).
PHP's long-term monitoring has proven to reduce relapse. When relapses do occur, the response is therapeutic, not punitive. Studies have shown that physicians in the program who relapse tend to improve quickly after a treatment adjustment.
After five years more than 80 percent of the participating physicians return to work and remain substance free.
# Chapter 8
# Dual Diagnosis
In previous chapters we discussed the biological nature of addiction, the social and political currents that have shaped the disease in the public eye, and the changing demographics of those who suffer from it. But would you know an addict if you met one?
Let's take a typical social gathering of a hundred adults, say, at a wedding or a holiday office party. About nine of those there will regularly buy drugs illegally—opioids (heroin or prescription painkillers like Vicodin and OxyContin), stimulants (cocaine, meth, or bath salts), sedatives (Sizzurp, barbiturates), hallucinogens (ecstasy, LSD), tranquilizers (Valium, Xanax), or marijuana (legal in some states).
About ten will either be at high risk of becoming or already be an alcoholic, consuming an average of seventy-four drinks per week or the equivalent of eighteen bottles of wine—by themselves—per week. These heavy drinkers make up only 10 percent of the U.S. adult population, but are responsible for 60 percent of all alcohol sales (spirits, wine, and beer).
About half those at high risk for an alcohol or drug dependency actually suffer from an addiction, probably beginning early in their lives (more on that in the next chapter), although increasingly, beginning in late middle age (as we discussed in the last chapter). And a little over half of that subset will have a substance addiction _and_ a diagnosable mental disorder (likely depression, but also possibly bipolar disease, schizophrenia, attention deficit hyperactivity disorder, autism, or psychosis).
So, if one in ten people have a substance addiction—the equivalent of the entire population of Texas—and a little more than half also have a mental disorder, could you pick those six people out among a hundred people in a room? Likely not. And that's a problem because as bad as treatment is in the United States for substance addiction in general, it's even worse for those addicted and mentally ill, a condition known as _dual diagnosis_.
Dual Diagnosis
I regularly see individuals with highly complex problems involving more than one diagnosis. They may have heart and liver problems, brain dysfunction, ulcers, plus psychological disorders, all in addition to an addiction to alcohol or drugs.
Most worrisome, however, is the correlation between mental illness and drug use that has been clearly established with about half of those with an alcohol or drug abuse problem showing signs of psychiatric disorder.
Dual diagnosis, also known as co-occurring disorder, is when a person is suffering from both the consequences of substance misuse and a simultaneous mood disorder, such as depression, bipolar disorder, panic disorder, or a more severe mental condition, such as schizophrenia.
There is a difference between induced psychosis from drugs or alcohol and psychosis as a result of mental illness. Induced psychosis is not uncommon, even with perfectly legal medications that affect brain chemistry. In that situation, the psychosis goes away as the drug's effects diminish over time. When the psychosis is the result of a mental illness, it does not diminish over time. It needs specific medical treatment.
When a patient has both drug-induced psychosis and mental illness, there are unique challenges to effective treatment. Even identifying both conditions presents problems. Drugs and alcohol can worsen the severity of mental disorders and present symptoms that look like those of mental disorders or, conversely, cover them up. Both severe intoxication and detoxification can give the appearance of mental illness, and vice versa.
It is so difficult to tell the difference that only 2 percent of mentally ill patients with substance abuse problems were detected in a university hospital emergency room. A state hospital did slightly better, detecting 15 percent.
Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse, and 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent also have problems with either alcohol or drugs. In those people diagnosed with bipolar disease, substance use problems are seven times more likely than for the nonbipolar population.
One recent study revealed that 33.7 percent of schizophrenics also meet the criteria for a diagnosis of alcohol use disorder, and 47 percent of individuals with schizophrenia are more than four times as likely as the general population to have a substance abuse disorder.
The Need for Specialized Care
A person with dual diagnosis needs specialized professional care, and most mental health services are not prepared for patients who also have severe drug and alcohol problems. As a result, the individual may be bounced back and forth between services for mental illness and those for substance abuse, or they may be refused treatment altogether. Many treatment centers will not take a person with dual diagnosis because they don't have qualified medical personnel on staff to deal with mental health issues.
A "traditional" or religious-centric nonmedical rehab is definitely not a good place for someone with a mental illness because these patients are very emotionally fragile and sensitive. Being placed in a confrontational, accusatory, and coercive environment can be the worst thing for them and for those around them.
Many patients who need medication for mental disorders have self-medicated with street drugs. They go to 12-step recovery support groups, where they are told they are not "clean and sober" if they are taking medically prescribed medication. This is not only absurd and cruel but a direct contradiction of the original 12-step philosophy, which allowed for psychiatric or psychological treatment whenever appropriate. There is even a brochure published by AA General Services, titled "A.A. Member—Medications and Other Drugs" that says members can take medications under a qualified physician's monitoring and that "no A.A. member should 'play doctor'" and offer unqualified medical advice to other members.
Unfortunately, there are few consequences for local AA groups that ignore that directive and impose a complete ban on medications, even pharmaceutical drugs prescribed by a physician for a mental disorder. This is all the more ironic since Bill W. (as he was known until after his death) conceived of AA after being treated at one of the first specialized addiction treatment hospitals in the country with a natural pain reliever that had known hallucinogenic effects, belladonna. In addition, he was exploring the use of a synthetic hallucinogen, LSD, as a possible treatment for alcohol addiction shortly before his death.
The dual-diagnosis patient is often discriminated against by nonmedical treatment professionals and emotionally abused by other recovering addicts and alcoholics who insist that all drugs are bad—often said while consuming massive amounts of caffeinated coffee and smoking cigarettes (which contain nicotine, a highly addictive stimulant drug). These unfortunate individuals find themselves as outcasts from both the drug and alcohol recovery community and from the mental health recovery community, and they are almost twice as likely to stop participating in outpatient mental health treatment than those who don't have issues with drugs and/or alcohol.
Integrating Treatment
Until recently, many mental health professionals believed that a patient with a dual disorder should be treated sequentially and that the substance addiction had to be cured before the mental disorder could be treated. There was a subtext to this approach that the addiction could be responsible for the mental disorder. To a degree, that was correct as it applied to drug- or alcohol-induced psychosis.
Today, we know that a nondrug or nonalcohol psychosis in a dual disorder is rare and that clinical depression is the most prevalent mental disorder. What, then, is the best approach to treating a dual diagnosis?
It is my opinion that the answer lies in integrating mental health and addiction treatment in a single, comprehensive program designed to meet the individual needs of the specific patient.
This approach is of proven value and is endorsed by Kathleen Sciacca, the founding executive director of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction, and Alcoholism in New York City. "There is a need for education that demonstrates that addictive disorders are illnesses," says Sciacca. "Understanding mental illness as a disease that is not caused by families was necessary to successful advocacy for the mentally ill. The same advocacy must happen for those who are dually diagnosed, through a clear understanding of the addictive disorders."
Distinguishing between Disorders
Even to the trained eye, the difference between dual pathology—addiction and mental disorder—and a mental disorder that has been substance induced can be elusive. Yet knowing the difference can have important implications for treatment. Because symptoms are similar, it's tempting to question whether all mental disorders suffered by addicts are induced by substance abuse. Yet, causative studies don't support the notion.
For example, public health surveys do not reflect a spike in the prevalence of dual disorder diagnoses when various drugs fall in and out fashion. That is, the recent rise in heroin addiction is not reflected in an increased incidence of pathological disorders among users. Simply put, exposure to addictive drugs does not increase mental illness, even though both can affect the brain similarly.
Identifying which is which remains a vexing problem for clinicians. There are diagnostic tools—tests to evaluate and assess the patient's mental health—that have been developed to help distinguish dual disorders from substance-induced disorders. These include Global Appraisal of Individual Needs—Short Screener (GAIN-SS) and Psychiatric Research Interview for Substance and Mental Disorders (PRISM) for the _Diagnostic and Statistical Manual for Mental Disorders_. However, by far the best diagnostic instrument is the _clinician's experience in treating addiction_ , which speaks to the need for more doctors and healthcare professionals trained in addiction medicine.
Substance-induced psychiatric symptoms can occur both in the intoxicated state and during the withdrawal state. For instance, severe anxiety and depression are common symptoms among alcoholics. Even binge drinking can increase anxiety and depression levels in some individuals. And, more often than not, psychiatric disorders induced by prolonged alcohol or drug abuse will eventually disappear with proper treatment and a sustained period of abstinence.
It's worth noting that abuse of hallucinogens can trigger flashbacks, delusional and other psychotic phenomena that occur months or even years after stopping the use of the drug. The condition is most associated with an acid flashback, meaning LSD induced, but there have been anecdotal reports of former ecstasy users experiencing flashbacks as well.
When Drugs Meet Mental Illness
I met my patient Samantha forty-eight hours after she had passed out from overdosing on ecstasy at an all-night rave. After an initial exam, I observed that her condition was more than substance abuse and that she likely suffered from a mental disorder.
Samantha, twenty-four years old, was a production assistant in the wardrobe department for a prime-time TV show. Pretty and fashionable, she looked the part of young professional in Hollywood. She described her work as an "investment in her future," exciting at times, but mostly stressful.
"When we're in production, I have to be on call virtually any hour. There's no down time, and my days can last eighteen hours," she said.
She used electronic dance parties as her pressure valve. "They really are a great way to escape for a while. And Molly [ecstasy] just enhances the whole experience," she said.
Lately, however, she became aware that she might be using ecstasy too much. Over the preceding eight weeks there had been times when she attended raves and used the drug that she forgot what she had been doing for several hours. Her blackout incident two days before our first visit had scared her. "If I had not been with friends—really good friends—I don't know what would have happened. Fortunately, they were there and got me to an ER," she said.
While Samantha was abusing a drug, and an illegal one at that, she was not an addict. She limited her use of the drug to weekends. While there was no way of knowing for sure, one reason she passed out the last time she used ecstasy was likely because it had been mixed with another drug, perhaps a sedative. She admitted that she bought the ecstasy tablets the evening in question from a new dealer because she couldn't find her regular pill man.
In her case, she didn't have so much a drug dependency as a behavioral problem. Psychology counseling and lifestyle medication were the best therapies for her (besides, medication was not an option because there are no known pharmacological treatments for ecstasy addiction).
However, beyond her drugging, Samantha exhibited several signs that indicated she had clinical depression. Physically, she had a flat, emotionless tone to her voice and had a difficult time holding eye contact. She also reported having recurring insomnia. While she worked long hours during the week, she said that she was tired "all the time," even on weekends. Finally, she disclosed that her family had a history of bipolar disease.
I introduced her to cognitive behavioral therapy, a short-term counseling program that helps patients see how self-destructive behaviors can play a role in depression and comes up with strategies for avoiding those problems. Her treatment also included a regimen of meditation to deal with anxiety, a healthier diet, and techniques for avoiding insomnia.
Finally, I prescribed a medication known as a selective serotonin reuptake inhibitor (SSRI). The SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). Side effects are generally mild and, if taken under the close monitoring of a trained health professional, are both safe and effective.
Over the course of six months, Samantha steadily improved. I saw her every week for the first month and then once every two weeks for next three months. Then I saw her just monthly. That time when she passed out was the last time she used ecstasy, though she confessed to continuing to smoke pot on occasion. She no longer goes to raves but still enjoys seeing live music with her friends. And she quit her job and is now pursuing a master's degree in economic anthropology. "I finally figured out what I was passionate about, and it wasn't either fashion or Hollywood," she said.
Individualized Treatment
To overlook the individuality of a patient with dual disorder is likely not only to result in ineffective treatment but also is a gross violation of medical ethics and professional conduct. Because of both the complexity of the disease and the individuality required for its treatment, there is no simple one answer fits all treatment —in spite of what many rehab clinics would have you believe.
Despite the general consensus among medical professionals that those with dual diagnoses of addiction and mental illness must be treated for both conditions if they are to stay sober, very few rehab clinics, and even very few doctors, are trained to treat the afflicted.
Theories of Dual Diagnosis
The idea that all addicts are crazy and take drugs and alcohol in order to self-medicate is a popular notion, but one with only a kernel of truth. In fact, only about 50 percent of all addicts have a mental disorder.
Not all addicts who have a dual disorder take drugs to deaden their mental anguish. Addiction is mainly a condition of the brain in which the rewards circuitry is damaged—a physical condition that can be observed with diagnostic imaging, such as MRI.
The exact relationship between substance abuse and mental disorders is unknown. Until a unifying proven theory emerges, backed by research, there are a number of competing and complementary explanations for dual disorders.
Causality: This theory suggests that casual substance abuse may lead to mental illness. Cannabis is the focus of this research that hypothesizes even limited use of marijuana can significantly increase the risk of psychotic disorders like schizophrenia. However, proponents of the theory have failed to explain why the rates of schizophrenia and other psychoses have not increased despite a sharp upward trend in marijuana use over the last four decades (in 1969, 4 percent of the general population had tried marijuana; in 2013, 38 percent had).
_Attention deficit hyperactivity disorder_ : One in four people who have a substance use disorder also have ADHD. Research has shown that ADHD is associated with an increased craving for drugs and that substance abuse results in more mental disorders than the population at large.
_Autism spectrum disorder_ : Interestingly, while ADHD and autism have a strong correlation and share many of the same symptoms, they have the opposite effect in regard to substance abuse. While ADHD seems to increase the risk of addiction, autism decreases it. Some theorize that autism's inherent personality traits of inhibition and introversion act as a barrier against drug abuse. On the other hand, studies have shown that alcohol can worsen impaired social skills associated with autism, such as the ability to perceive emotions and understand humor.
_Alleviation of dysphoria_ : Dysphoria is the opposite of euphoria (dysphoric feelings include anxiety, depression, boredom, and loneliness). This theory suggests that individuals with mental illness have a pronounced feeling of dysphoria, which prompts them to drink and drug to relieve their psychic pain. Scientific literature supports the idea that these feelings are a prime factor in substance abuse.
_Multiple risk factors_ : This theory offers that there isn't just one primary cause of dual disorder but many, including such factors as poverty, peer pressure, dysfunctional childhood, sexual abuse, social isolation, and lack of structured daily activity (like employment).
Supersensitivity: In this theory, stress during childhood triggers inherent vulnerabilities (genetic and environmental) in the individual, rendering him supersensitive to the negative effects of alcohol and drugs. Later, exposure to even comparatively small amounts of alcohol or drugs can result in disproportionate negative effects, including violent, aggressive, and even criminal behavior.
PTSD, Vets, and Addiction
Post-traumatic stress disorder (PTSD) was not recognized as a mental illness until 1980. During World War I more than 300 "hysterical" soldiers—likely suffering from PTSD—were simply shot. During World War II they were branded cowards and during the Vietnam War, as schizophrenics.
Today, it's the most common psychiatric disorder among war veterans, including those from Vietnam, Iraq, and Afghanistan. With hundreds of thousands of soldiers returning from active duty in the last decade, there is a whole new wave of PTSD patients who also are addicts.
About 9 million vets are currently under Veterans Administration care, with 27 percent diagnosed with PTSD. Studies have shown there is a strong relationship in veterans between PTSD and a substance addiction, and about one-third of vets seeking treatment for addiction are also diagnosed with PTSD. In short, there are likely hundreds of thousands of vets suffering from the dual disorder of substance addiction and PTSD.
Unfortunately, the medications that work for one condition don't seem to work for the other.
The FDA-approved medications for PTSD, sertraline and paroxetine, have shown little benefit for treatment of substance use disorders. Similarly, the FDA-approved pharmacotherapies for alcohol dependence, naltrexone and disulfiram, have been shown to reduce alcohol dependence in veterans with PTSD but have not shown any particular benefit for PTSD.
The treatment of the co-occurrence of PTSD and substance addiction among veterans, as is the case with dual disorders with the populace at large, requires an individualized approach to treatment.
# Chapter 9
# Teens and Young Adults
In 1982, when then First Lady Nancy Reagan was asked by a schoolgirl what to do if she was offered drugs, she responded saying, "Just say no!"
Thus began a forty-year public relations campaign that, incredibly, in spite of its abject failure and $50 billion price tag, continues today. There's no evidence that the campaign has had any measurable effect on alcohol or drug addiction, and if anything, addiction among young people has gotten worse. Though it's no longer actively promoted, the Just Say No campaign, an offshoot of the larger war on drugs initiative, still influences politicians, educators, police authorities, and even the judiciary.
That an entire multibillion-dollar program to stymie youth addiction evolved not from research but from a knee-jerk phrase speaks volumes about the misplaced priorities and wasted resources of a nation. If anyone truly believes that tossing a throwaway phrase at kids is sound strategy for dealing with the drug culture all around them, then they must really think kids are stupid. And they're not.
The Just Say No campaign, the war on drugs, and virtually every other effort to stop teen addiction since Congress approved the Harrison Narcotics Act in 1914, including the now hilarious 1936 documentary film _Reefer Madness_ , have failed because they don't pass the smell test: Their scare tactics and propaganda that any and all drinking and drugging lead to a straight and narrow path to addiction is false, and kids know it.
The Just Say No phrase, however, is not only useless but pernicious because it reinforces the false notion, promulgated by a well-intentioned AA community and exploited by the unscrupulous rehab industry, that addiction is simply something you can say no to. If you try hard enough, you can just stop. Addiction is like all other chronic diseases, including diabetes, heart disease, or arthritis. Just say no and you can just stop suffering from these diseases. (Oh, that's not right, is it?)
Addiction by the Numbers
Nine out of ten Americans who meet the medical criteria for addiction started smoking, drinking, or using other drugs before age eighteen, according to the national study "Adolescent Substance Use: America's #1 Public Health Problem," Columbia University's CASA study on addiction.
The CASA report finds that one in four Americans who began using any addictive substance before age eighteen are addicted, compared to one in twenty-five Americans who started using at age twenty-one or older.
Other relevant stats from the study:
_•_ 75 percent (10 million) of all high school students have used addictive substances, such as alcohol, marijuana, and cocaine; one in five of them meets the medical criteria for addiction.
_•_ 46 percent (6.1 million) of all high school students currently use addictive substances; one in three of them meets the medical criteria for addiction.
_•_ 72.5 percent have drunk alcohol.
_•_ 36.8 percent have used marijuana.
_•_ 14.8 percent have misused controlled prescription drugs.
_•_ 65.1 percent have used more than one substance.
The study found that, to a large degree, American culture drives teen substance use: "A wide range of social influences subtly condone or more overtly encourage use, including acceptance of substance use by parents, schools and communities; pervasive advertising of these products; and media portrayals of substance use as benign or glamorous, fun and relaxing."
These cultural messages and the widespread availability of alcohol, marijuana, and illicit and controlled prescription drugs normalize substance use, undermining the health and futures of our teens:
_•_ 46 percent of children under age eighteen (34.4 million) live in a household where someone eighteen or older is smoking, drinking excessively, misusing prescription drugs, or using illegal drugs.
_•_ 42.6 percent of parents list refraining from smoking cigarettes, drinking alcohol, using marijuana, misusing prescription drugs, or using other illicit drugs as one of their top three concerns for their teens.
_•_ 21 percent say that marijuana is a harmless drug.
In addition to the heightened risk of addiction, the consequences of teen substance use include accidents and injuries; unintended pregnancies; medical conditions such as asthma, depression, anxiety, psychosis, and impaired brain function; reduced academic performance and educational achievement; criminal involvement; and even death.
If you don't care about the personal well-being of teenagers, then consider the costs to society:
_•_ $14 billion in substance-related juvenile justice costs with teen substance use the origin of the largest preventable and most costly public health problem in America today.
_•_ $68 billion in immediate costs per year of teen use, which includes an estimate associated with underage drinking and drugging.
_•_ $468 billion per year in total costs to federal, state, and local governments of substance use that has its roots in adolescence.
_•_ $1,500 per year is the cost for every person in America for teen substance abuse.
"The problem is not that we don't know what to do, it's that we are failing to act," noted Susan Foster, CASA's vice president and director of policy research and analysis. "It is time to recognize teen substance use as a preventable public health problem and addiction as a treatable medical disease, and to respond to it as fiercely as we would to any other public health epidemic threatening the safety of our children."
Why Treating Teenagers and Young Adults Is Different
It's no big secret that teenagers drink alcohol and do drugs. What's not understood by the public and even most medical professionals is why. Young people begin their quests for identity, for their sense of self, in their teen years. To be clear, teenagers base their self-identity entirely on how they see themselves, not on how their parents see them. Studies have shown that one primary way teens demonstrate their struggles with identity is indulging in forbidden behavior, including drinking and drugging, behaviors associated with adulthood.
Compounding the problem of teens' natural predilections to experiment with drugs and alcohol is that physiologically they are more sensitive to brain damage from addiction because their brains are still developing. Unfortunately, most efforts at teen addiction are rooted in the early twentieth-century doom-and-gloom philosophy, which most teens correctly perceive as irrelevant to their lives.
It's important to underscore, however, that not every teen who experiments with alcohol or drugs will become an addict; in fact, most will not. Maia Szalavitz, one of the nation's leading neuroscience and addiction journalists, pointed out in a recent column for Substance.com that the average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within fifteen years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. A self-described addict who shot cocaine and heroin in her youth, she stopped when she was twenty-three years old, theorizing that, in effect, her brain finally grew up: "Although I got treatment, I quit at around the age when . . . the prefrontal cortex—the part of the brain responsible for good judgment and self-restraint—finally reaches maturity."
Truly successful teen addiction education and treatment are based on nonjudgmental harm-reduction programs, grounded in reality (not some war on drugs spin). Bottom line: The treatment for a binge-drinking teen must be entirely different from that of a middle-aged alcoholic with decades of continual consumption.
First, Do No Harm
If we are truly to reduce harm, we must give practical, short-term harm-reduction messages with which youth can identify and personalize. We have a much better chance of preventing a drunk-driving tragedy the night of the prom than we do preventing liver failure in forty years.
Writer, comic, and self-confessed screw-up Amy Dresner—known for her no-holds-barred skits that frequently incorporate references to her own personal addiction—recalls how she used to shoot meth directly into her bloodstream with a needle. As she did it more and more, she began having violent seizures. She rightly perceived the danger of possible traumatic brain injury during a meth-induced seizure. "I realized that shooting meth was an extreme contact sport requiring safety equipment," jokes Dresner. "I started wearing a football helmet when shooting up."
Silly as it sounds, Dresner was taking a positive step by considering and using the concept of harm reduction. She protected herself from a possible traumatic brain injury. The natural progression of harm-reduction thinking is to reduce harm as much as possible at all times and under all conditions. This leads to the realization of the need to stop the dangerous behavior. Dresner no longer shoots meth, and the football helmet is no longer required.
Preventing a drunk driving casualty can be accomplished by alerting teens to the real immediate danger of such behavior and by providing alternative transportation to and from parties and events. The obstacle to this life-saving strategy is that it requires dealing with reality, and harm-reduction strategies run into difficulty because they are predicated on dealing with the fact that many teens are already drinking.
As international researchers have noted, this is a major problem in the United States, where the uniform minimum legal drinking age is twenty-one, but the average age when people start drinking is thirteen or fourteen. This means that that alcohol education programs used in American schools start out with a major handicap: The erroneous assumption that a significant segment of the target audience is not already drinking or experimenting with drugs.
Peter E. Nathan, in his study "Alcohol Dependency Prevention and Early Intervention," cited research indicating that "students who are most responsive to school-based programs probably are those for whom such programs are least necessary. Programs may not be reaching those children who are at greatest risk to develop alcohol and drug problems."
In the high-risk category were teens with a family history of abuse, those with a history of antisocial behavior, and those from ethnic and racial minority groups who were "physically or psychologically beyond the reach of traditional, school-based prevention programs."
Successful programs use honest and effective educational strategies that treat drug use as just another part of a broad health curriculum that includes topics such as medical care, nutrition, exercise, hygiene, ecology, safety, and other activities that affect the students' quality of life.
In the prevention of addiction and alcoholism, addressing only drugs and alcohol overlooks other factors contributing to the onset of drug- and alcohol-related illness and addiction. An effective school program should send an honest, positive message that includes models beyond abstinence, embracing moderation, harm reduction, and personal responsibility. If possible, school-based prevention programs should be integrated into the school's academic program, because school failure is strongly associated with drug abuse. Integrated programs strengthen students' bonding to the school and reduce their likelihood of dropping out.
Any program used to prevent or reduce underage drinking and drug use must be continually evaluated. An evaluation needs to answer the following questions:
• What was accomplished in the program?
• How was the program carried out?
• How much of the program was received by participants?
• Is there a connection between the amount of program received and outcomes?
• Was the program run as intended?
• Did the program achieve what was expected in the short term?
• Did the program produce the desired long-term effects?
Repeated research and evaluation of successful methods shows that the most proven and practical approach for dealing with teen drinking and drug use is strategic harm reduction. In other words, make the world a safer place—safe _for_ the drunk teen and safe _from_ the drunk teen. Just as seat belts and airbags are harm-reduction strategies for road safety, the idea is to put a separation between the individual and harm, and society and harm.
Harm-reduction projects have aimed to minimize potential casualties and other damages associated with drinking in bars and nightclubs. Bars in the United States are now forbidden to serve alcohol to someone who is obviously intoxicated. They are also legally restrained from verbally encouraging people to get drunk. If a drunk driver kills someone and that driver was served alcohol when he was already drunk, the bartender may be criminally liable. While it can be argued that the person refused service will go elsewhere, it is hoped that his or her degree of intoxication will not increase.
Taking keys away from drunks and calling them a taxi to get them home is a major harm-reduction policy that is saving lives, as is the concept of the designated driver. "Friends don't let friends drive drunk" is a major harm-reduction campaign in the United States, and it is having a beneficial effect.
Reducing Harm
Harm reduction is a health-centered approach that seeks to reduce the health and social harms associated with alcohol and drug use, without necessarily requiring users to abstain.
Harm reduction is a nonjudgmental response that meets users where they are in regard to their substance use rather than imposing a moralistic judgment on their behaviors. This approach includes a broad range of responses, from those that promote safer substance use to those that promote abstinence.
The following features of harm reduction are clear indicators of why programs and campaigns based on this premise work:
• _Pragmatism:_ Harm reduction accepts that some use of psychoactive substances is inevitable and that some level of substance use is expected in a society.
• _Humane values:_ The substance user's decision to use alcohol and other drugs is accepted as his or her choice; no moralistic judgment is made, either to condemn or to support use of substances, regardless of level of use or mode of intake. The dignity and rights of the person who uses alcohol and other drugs are respected.
• _Focus on harms:_ The extent of a person's substance use is of secondary importance to the harms resulting from that use.
• _Hierarchy of goals:_ Most harm-reduction programs have a hierarchy of goals; the symptoms that are the most potentially harmful to the patient are addressed first.
The Harm of Social Consequences
Interaction with a punitive law-enforcement system is also harmful. Research has shown that the risks associated with drugs other than alcohol are far less than those associated with alcohol, especially for those associated with aggression and violence. The punishment handed out for illicit drug use is more harmful than the drug use itself.
Due to the relatively low harm potential of cannabis, one important aspect of harm reduction would be to limit testing for cannabis use in those jurisdictions where testing positive for cannabis would result in harmful punitive actions because of existing laws.
For example, if a foreign exchange student in America under a federal program smokes pot at a party, and his host family finds out, they are obligated to report it. Once reported, the student is never allowed to pursue a college education or career in the United States nor can he or she ever enter America again. The harm was not done by smoking marijuana. The harm was done by the punishment.
None of these long-term concerns, be they consequences of health or punishment, has any meaning to a teenager who can't imagine life twelve months down the road, let alone the impact of current behavior on advanced educational opportunities, marriage, family, and employment in some distant future.
A successful technique for reducing the risk of teen drinkers becoming alcoholics is friendly advice offered to the heavily drinking teenager by someone he or she trusts. It is important that advice to moderate consumption not be confrontational or judgmental in any way. No criticism, no drama, no threats or stress. A very brief, simple moment of advice to reduce consumption and/or moderate behavior has proven far more motivating than lectures, scolding, or threats.
Removal of secrecy has also proven a powerful method. When teens are told by their own parents or guardians that if they really want to drink or drug, they are more than welcome to do it right there at home, the mystique of substance use being a secretive or rebellious act evaporates faster than alcohol.
Treating Teenagers and Young Adults
Teenage experimentation with alcohol and drugs is normative, no matter how much we pretend otherwise. In other words, it may not be healthy behavior, or behavior parents approve of, but it is normal behavior.
There are teens who excessively use drugs and alcohol, but actual teenage alcoholism is a rarity. There are thirteen- and fourteen-year-old kids experimenting with all manners of mood-altering drugs, but they are not drug addicts. They may be at risk or have the potential for the disease of addiction, but they don't have it yet. It is as if the child has high cholesterol but not heart disease. And it is possible to prevent the onset of alcoholism or drug addiction in someone who has the telltale risk factors.
The risks of becoming an alcoholic increase with binge drinking, especially in the formative adolescent years. As biology forms up to 50 percent of one's propensity to develop drug or alcohol addiction, a family history of alcohol or drug misuse is a major red flag.
Other risk factors for teenagers developing drinking problems include low levels of parent supervision or communication, family conflicts, inconsistent or severe parental discipline, problems managing impulses, emotional instability, thrill-seeking behaviors, and perceiving the risk of using alcohol to be low.
Girls whose mothers have drinking problems are at severe risk of alcoholism, as are those who begin drinking before age fourteen. Family relationships, part of the social aspect of contributing factors, indicate that sixteen- to eighteen-year-olds are less prone to excessive drinking if they have a close relationship with their mother.
The treatment appropriate for a binge-drinking teen or a fourteen-year-old who was caught experimenting with cocaine must be entirely different from the treatment given to a middle-aged alcoholic with decades of continual consumption or a thirty-year-old heroin addict with hepatitis C and HIV or to the bipolar twenty-three-year-old who snorts ketamine on the weekend.
The most common reason teenagers end up in rehab is that they got into trouble at school or home because of their use of alcohol or drugs. Their behavior could range from normal teen experimentation and recklessness to blatantly extreme intoxication and dangerous behavior.
Although drinking does not equal alcoholism and drug use does not equal drug addiction, there is significant pressure to treat the drinking or drugging teen as an alcoholic or addict who must, for his or her own good, be sent off to rehab, even if that treatment is coerced. A current advertisement for a drug and alcohol treatment center in California states, "Even if you have to admit the teen into the facility _against their will_ , it will be best for them to be there."
A 1979 U.S. Supreme Court decision gave parents power to commit children who are under age eighteen into a facility without judicial proceedings. This has been a gold mine for private "treatment centers," private mental health facilities, and lawyers specializing in helping parents have their children involuntarily admitted to rehab centers or mental hospitals.
In the past few years, several states have revised their involuntary commitment laws, making it very easy to have loved ones treated for substance misuse, even if they don't want to be treated. According to guidelines in many states, insisting that you don't need treatment is simply proof that you don't realize that you need treatment.
This approach has been hailed by concerned parents as a blessing, because it allows them to get their kids or other family members the help they need. Yet, there is no recognized definition of "the help they need," and many doctors who treat alcoholism and addiction share serious concerns regarding the ethics and wisdom of the state being permitted to institute preventive therapeutic programs against a citizen's will.
Setting aside the ethical issue of coerced admission, there is documentation that drug and alcohol treatment may be equally effective whether admission to the program is voluntary or not. The educational and empowering experience of appropriate treatment can have significant value in helping the teenager consciously choose which behaviors to continue and which to abandon.
If the treatment experience serves only to reinforce an addict/alcoholic identity and continually places the teen in both emotional and social proximity to those with more advanced drug use, the risk of actually becoming an addict or alcoholic in his or her adult years increases.
A teen-only facility also has its challenges. Recent research cautions grouping high-risk teens in peer-group preventive interventions. Such groupings have been shown to produce negative outcomes, as participants reinforce each other's drug use. This must be taken into serious consideration when structuring the interaction of patients at an inpatient treatment center.
The most common drug and alcohol treatment for teens, and everyone else, is a twenty-eight-day program. However, there is no rational or medical reason for twenty-eight days; it is simply the number of days that most insurance companies will cover without objection. When a treatment center advises you that they offer immediate _evaluation_ , they don't mean _diagnosis_ of the patient's condition. If they meant diagnosis, they would say diagnosis. By _evaluation_ , they often mean evaluation of your insurance coverage.
Addiction: False Assumptions
Once in a drug and alcohol treatment center based on the assumption that you are an addict or alcoholic, you are regarded as such, and any protest to the contrary is deemed denial. This approach is most common at 12-step programs or facilities that have a one-size-fits-all concept of treatment.
American psychologist David Rosenhan is known for an eponymous experiment in which he assigned a group of his graduate psychology students to admit themselves into a mental institution, reporting that they were suffering from psychotic symptoms. Once on the psychiatric wards, they behaved in completely normal ways that betrayed absolutely no psychotic symptoms. The medical staff did not realize that these students were normal, diagnosed their behaviors as psychoses, and in fact, refused to let the students leave until they acknowledged and accepted their diagnoses.
Having been sent off to rehab, where they are told that they're "crazy" addicts, a hair's breadth from being failures for the rest of their lives, teenagers return home to discover that everyone else believes the negative labels about them as well. They might as well wear a giant red "A" for "Addict" on their T-shirts.
Post-rehab self-consciousness and depression, accompanied by strong bouts of shame over being such a loser, can cause extreme emotional stress. The post-rehab teen always has one group ready to accept her—those who drink and drug.
"My parents sent me to rehab when I was 13 for issues that could have easily been solved with therapy, family therapy and time," a young woman commented in an online forum. "After I got home from rehab, at age 14, I felt like a huge outcast and was suspended from a school because they found out I went to rehab."
The True First Step to Teen Treatment
Before a teenager is compelled into rehab, the parent or guardian should consult a physician specializing in addiction medicine and engage the teen in full participation with the physician. Consultation and diagnosis by a medical professional is always the best idea. If the teen isn't an alcoholic or an addict, the doctor will say so and will advise the patient regarding whatever medical issues are involved and how to decrease the risks of chronic illness. If the teen is an alcoholic or addict, an addiction medicine specialist is best qualified to recommend the treatment regimen best suited to the individual patient.
Not all teen drinkers will become alcoholics, but all teen drinkers are at risk for a wide variety of health problems and legal sanctions for dangerous behavior. The most comprehensive approach to the reality of teen drug and alcohol use is short-term harm-reduction and commonsense preventive measures to reduce the risks of alcoholism and addiction.
A Family History of Addiction
A wealthy woman had an eighteen-year-old son, Sean, who battled a severe cocaine habit. She had tried to get him into rehab for several years without success. Finally, an intervention was performed, and he was checked into a high-priced facility, where all costs were nonrefundable. Over the weekend, when family members were allowed to visit patients, the mother brought her son a reward for going to rehab—a $25,000 Rolex watch.
You can probably guess what happened. He signed out of the rehab, sold the Rolex, and went on a cocaine binge. This behavior may be immoral, but it is perfectly understandable. Addicts and alcoholics have structural or functional damage to the reward and motivation centers of their brains, located in a part of the brain known as the limbic lobe. When working properly, this reward system causes us to remember and return to pleasurable, life-affirming experiences. When the reward center is damaged, we keep doing things even when the result is pain instead of pleasure.
When I met Sean shortly after his Rolex binge, he was noticeably high. His medical exam confirmed what everyone already knew—he was a cocaine addict but also drank alcohol, popped pills, and smoked marijuana. "I don't discriminate, doc. Whatever I can get my hands on," he said with a grin.
As it turns out, Sean's family had a history of addiction. His maternal aunt died of a heroin overdose. A cousin on his father's side died in an alcohol-related car death; both of his parents were in recovery. I explained to Sean how his uncontrollable drinking and drugging were symptoms of a chronic disease and in his case, one likely with a very strong genetic basis. The fact that he couldn't stop drinking and drugging didn't make him a loser, and it wasn't his fault.
He was stunned and took a minute to absorb this. "Really? 'Cause the last rehab clinic that I went to said it was all my fault and if I really wanted to stop, I would," he said.
I explained that while his disease was not his fault, unfortunately, he was at risk of profound brain damage if he continued drinking and drugging obsessively, because of his relative youth. "You're actually on a rapid pathway to lowering your I.Q., not to mention increasing your risk for need of a liver transplant and shrinking your testicles. If you continue, soon you will be a dumber, sicker, and more impotent version of yourself."
I got his attention. With his parents' consent, I prescribed a regimen of pharmaceutical medications to stop his cravings for drink and drugs. I also arranged for him to begin motivational therapy and got him thinking about a lifestyle modification. We helped him focus on substituting an adrenaline rush through intense exercise (he favored rock climbing) for intoxication through drink and drugs.
Deep down Sean was motivated to quit. He had seen up close the damage substance addiction had caused to his family. Six months after our initial visit, he enrolled in college and is working toward a degree in criminology and forensics science. Yes, he wants to work in criminal justice.
Critical Thinking About Kids and Addiction
Families need to understand the disease of addiction and have realistic expectations of behavior change. This is accomplished when families are well-informed participants in their loved one's treatment.
Critical thinking is also an integral part of evidence-based medical practice. Obviously, we need an increase in critical-thinking abilities, in addition to factual information, to counter the prevalence of harmful ideas regarding addiction, dependence, and treatment.
Booze and the Adolescent Brain
Alcohol and drug abuse causes so much adolescent brain damage that, if we had any sense at all, we would lock up all teenagers until their brains were fully developed in their early twenties. Since that's not going to happen, the next best thing is to inform teens—and adults—of the awful, unvarnished truth.
Adolescence is a unique time in the development of the human brain. Research shows that excessive use of alcohol and drugs results in abnormalities in brain functioning, including structure and volume, white matter quality, and the ability to perform cognitive tasks.
By _abuse,_ we don't mean alcohol or drug consumption on the order of adult addiction. As little as one year of heavy drinking, meaning four to five drinks of alcohol a week, can cause the neurodevelopment damage just described. Particularly damaging were bouts of binge drinking where four to five alcoholic drinks are consumed in a short period of time.
Typical adolescent brain development marks a period of accelerated evolution between childhood and adulthood. Complex social, biological, and psychological changes are intertwined, impacting behavior. In short, both biology and environment heighten the adolescent's risk for beginning and abusing alcohol and drugs.
Scientific literature suggests that much of the damage to the brain once done in adolescence cannot be undone. One study showed that even after four weeks of monitored abstinence, youth who had indulged in heavy marijuana use performed worse on performance tests of learning, cognitive flexibility, visual scanning, and working memory than youth who did not smoke marijuana. Similar results have been found with alcohol.
Advances in neuroimaging, like MRI tests, make it easy to identify the parts of the brain affected by alcohol and drug abuse. Let's break it down:
Hippocampus: Research shows that the hippocampus, the part of the brain responsible for memory and spatial navigation, has a measurable decrease in volume among teens who drink and drug heavily, affecting both short-term and long-term memory.
_Prefrontal cortex_ : The frontal lobe is the part of the brain associated with reward, attention, planning, and motivation. As with the hippocampus, heavy teen drinkers and marijuana smokers had smaller frontal lobes than nonusers, resulting in poorer verbal memory. The difference was particularly pronounced among women.
_White matter_ : White matter matters because it regulates the speed of nerve transmission to the brain from elsewhere in the body. Again, teens who are heavy users of alcohol and marijuana have a lower volume of white matter than nonusers, resulting in increased symptoms of depression.
_Brain blood flow_ : Chronic alcoholics have been shown to have reduced blood flow to their brains. Both binge drinking and long-term heavy drinking can lead to strokes, even in people without coronary heart disease. Recent studies show that people who binge drink are about 56 percent more likely than people who never binge drink to suffer an ischemic stroke over ten years. Binge drinkers also are about 39 percent more likely to suffer any type of stroke than people who never binge drink. A recent study examining adolescent women who were heavy drinkers confirmed that their relative youth did not protect them from decreased cerebral blood flow and its potentially damaging effects.
The takeaway here is that current research clearly indicates that heavy alcohol and drug use during adolescence leads to abnormalities in the brain that are not likely to diminish over time.
# Chapter 10
# Fetal Alcohol Syndrome: Real and Preventable
If there's any underage group that deserves special consideration in any discussion of the disease of addiction, it's the unborn. You may be thinking that this statement is leading to a prolife or prochoice view on the rights of the unborn fetus and the mother. But the point that I'm about to make has nothing to do with partisan politics and everything to do with preventing a devastating condition that it is 100 percent preventable.
In 1968, Christy Ulleland, chief resident at Harborview Medical Center, University of Washington, first discovered the link between prenatal alcohol exposure and adverse outcomes in infants. In January 1968, Ulleland received funding to conduct an eighteen-month study to scientifically assess her clinical observation that infants born to alcoholic women had impaired outcomes. Her conclusion: "Chronic alcoholism can be appropriately added to the list of maternal factors that create an unhealthy intrauterine environment for the developing fetus; the consequences of which may be life long."
Fetal alcohol syndrome (FAS) is the most common preventable cause of mental retardation in the United States, as well as the most preventable cause of birth defects and developmental disabilities.
If you are pregnant or planning to become pregnant, you must absolutely not touch a drop of alcohol. There is no safe amount of alcohol at any time during pregnancy. Not a glass of pinot, a small vodka martini, a glass of hard cider, or a bottle of hand-craft beer. _There is no safe amount of alcohol while you're pregnant._
It is an established fact, beyond dispute, that even the slightest amount of alcohol, depending on the metabolism of the mother, can cause irreversible birth defects in her child, especially in the first trimester of pregnancy. A baby can emerge from a drinking mother's womb appearing perfectly normal on the outside, but damage to the baby's brain is permanent and irreversible.
There is nothing complex to preventing FAS. All you have to do is not drink alcohol while pregnant. If you can simply refrain from alcohol, you can prevent your child from alcohol-caused mental retardation, physical disabilities, and possible future behavioral problems leading to problems with the law.
Many mothers stop drinking only after they know they are pregnant, but damage to the developing fetus may already have been done. The Surgeon General's recommendation is that a woman refrains from drinking during pregnancy and even earlier if she is planning to become pregnant.
Once again, there is an enormous gap between what people believe and what is actually true. Many people mistakenly believe that mothers of children born with FAS were all heavy drinkers or full-blown alcoholics. This is a false and dangerous belief.
The degree of damage depends on the metabolism and liver functioning of the mother during pregnancy, and no two women are exactly alike. As you don't know details of your metabolism or liver functioning, there is no way to know the severity of damage to your child by having a drink. Drinking a wine cooler while pregnant is not much different from placing a handgun in front of a baby, spinning the cylinder, closing your eyes, pulling the trigger, and hoping to hear _click_ while having no idea how many chambers, if any, are empty.
Even brief exposures to small amounts of alcohol may kill brain cells in a developing fetus. A study carried out by John Olney, at the Washington University School of Medicine in St. Louis, showed that just two drinks consumed during pregnancy may be enough to kill some developing brain cells, leading to permanent brain damage.
The Canadian Paediatric Society found that "Fetal alcohol syndrome (FAS) is a common yet under-recognized condition resulting from maternal consumption of alcohol during pregnancy. While preventable, FAS is also disabling. FAS diagnostic and treatment services require a multidisciplinary approach, involving physicians, psychologists, early childhood educators, teachers, social service professionals, family therapists, nurses and community support circles."
All of those diagnostic and treatment services would be unnecessary if women would simply not drink while pregnant, if they plan on becoming pregnant, or run the possibility of becoming pregnant.
There are really only two reasons why a pregnant woman would drink despite being informed and warned about FAS and the risk of brain damage and mental retardation. The first reason would be that the woman understands the danger but is willing to put her child's brain at risk in exchange for the pleasure she derives from drinking.
The second reason would be that the mother, despite understanding the danger, has the medical illness of alcohol addiction known as alcoholism. The addict cannot stop without professional medical help. If you are pregnant and can't stop drinking, get help immediately.
Devastating Life-Long Brain Damage
Another problem that doctors face in alerting women to the very real danger of FAS is the culture of disbelief resulting from the media-driven "crack baby" scare of the 1980s. The process of medical research that disproved the crack-baby myth is the same process of professional research that has continually proven the truth of FAS and has taught us that fetal alcohol syndrome isn't a single birth defect. It's a cluster of related problems and the most severe of a group of consequences of prenatal alcohol exposure. Collectively, the range of disorders is known as fetal alcohol spectrum disorders (FASDs).
As with the illness of addiction, both the physical and functional brain damage of FAS can be seen with brain imaging technology. According to a study recently published by a team of researchers at the University of Washington, it is possible to differentiate FASD-diagnosed brains from normal brains with 80 percent accuracy using magnetic resonance imaging of the brain.
The most devastating disability caused by a mother's prenatal use of alcohol is the organic brain damage that impairs an individual's executive brain function—the ability to understand and adapt to the world. A consideration of the following incidents of disease, while more accurate in the generality than the specificity, will give you a sense of perspective.
On any given day in the United States, 10,657 babies are born. Of these, 1 is HIV positive, 2 are born with spina bifida, 3 are born with muscular dystrophy, 10 are born with Down's syndrome, and 120 are born with FAS- or alcohol-related neurodevelopment disorder. It's the number one cause of mental retardation in United States.
The Institute of Medicine's report to Congress on FAS made it clear that the incidence figures were to give a sense of perspective and "to emphasize the magnitude of a problem that has serious implications—for the individual and for society."
Life Problems End Only at Death
Individuals with FASD have problems planning and organizing information in their daily lives, have trouble comprehending the consequences of their behavior, and act on impulse with diminished control. According to expert Kay Kelly, project director of the FAS/FAE Legal Issues Resource Center at the University of Washington, "These individuals typically have an excessive desire to please others, an attitude that may lead them to take (or acquiesce in) actions that are harmful to their own interests."
The social skills of people damaged in the womb by alcohol destine them for a difficult life, despite having an average IQ. "Most individuals with average IQ lead productive and organized lives," says Kelly. "Individuals who have an average IQ but who also have brain damage caused by alcohol in uteri, often struggle unsuccessfully to deal with the usual demands of life."
Easy Prey for Predators
The behavioral disabilities make people with FAS, be they children or adults, easy prey for criminals and perverts. They are more likely to put up with abuse and not complain about it because they don't want to upset the person abusing them. They want to keep people happy and be accepted. Hence they are easily exploited. Some 7 percent of adolescents and adults with FAS or fetal alcohol effects (FAEs) have been physically or sexually abused. Sexual abuse of children with FASD by adults in their own home is a particularly serious problem.
In the court system or in law enforcement, victims or witnesses with FASD can compromise cases because they are eager to please and are very believable. They may think that the "right answer" to a question is the answer the questioner wants to hear. To the FAS person, he or she is not lying, but simply giving the proper answer.
For the millions of individuals who already have FAS, it is too late to protect them from the harm that maternal alcohol caused in their developing brains. But it is still possible to take effective measures to protect them from criminal abuse.
Adults with FAS, if left to fend for themselves, will too often end up living on the streets or, in other circumstances, where they are likely to be particularly vulnerable to crime. The social services that many of these adults need, ranging from supported community living environments to job training, are as important to preventing victimization as they are to preventing poverty.
Studies of FAS in the United States, Canada, and elsewhere portray horrific medical and social consequences for the innocent victims of their mothers' drinking. Children afflicted with full-blown FAS display both physical and mental abnormalities. Those with partial FAS may not have the obvious physical characteristics, but they suffer the same behavioral and psychological problems. These include a low IQ, difficulty in learning from experience, poor judgment, poor cause-and-effect reasoning, and an unawareness of the consequences of behavior. Obviously, these are the very attributes that can lead them to prison.
A child born with FAS will also be an adult with FAS. The condition cannot be cured; it doesn't get better. People born with FAS are very impulsive and do things without thinking about consequences. They are not malicious in their behavior. In fact, they are usually exploited by more talented criminals to do some of the running, or high-risk tasks, and are more likely to get caught.
As many as half the young offenders appearing in court may be there because their mothers drank during pregnancy, says psychologist Josephine Nanson of the Royal Hospital in British Columbia, Canada, who with four of her colleagues conducted a study of 207 cases of FAS over two years. Her assessment could have tremendous implications for how the criminal justice system handles youth in custody.
"The criminal justice system is based on the premise that people understand there are rules, why they have to be obeyed, and if they aren't obeyed then society has the right to come up with any number of options," said Canadian Legal Aid Commission lawyer Kearney Healy, in an interview with the Saskatoon _Star Phoenix_ newspaper about Nanson's study. "All of those things are irrelevant to these kids. It's got nothing to do with good or bad—they just don't see it the same way. There are an increasing number of cases reaching the courts because we've been diagnosing this for about 20 years. Those individuals are now in adolescence and adulthood, and at a prime age for when they're going to be involved in the court system."
For every full-blown case of FAS, it is estimated there are four with partial effects.
One of the ironies is that children with FAS often make model prisoners because they do very well in structured environments. "Often people are fooled in the early stages of treatment into thinking somebody is doing really well, not realizing that they're doing really well because all the opportunities for them _not_ to do well are taken care of in a structured program," Nanson told the newspaper "This is an illusion. The FAS individual will fall apart emotionally outside that system.
Ignorance Will Send Your Child to Prison
Popular misconceptions about mental illness and mental retardation are partially responsible for railroading FAS sufferers through the criminal justice system. From arrest to the determination of competency to stand trial and beyond, a person's mental health affects every stage of passage through the criminal justice system.
If you doubt that assertion, simply ask yourself whether or not mentally ill people act weird, peculiar, or suspicious. Does the behavior of people with mental problems attract attention? Of course it does, and that includes attracting police attention, even if a crime hasn't been committed.
Untrained to recognize and handle mental illness, be it caused by exposure to alcohol in the womb or any other factor, arresting officers and other staff inappropriately assume the arrestee understands such things as their Miranda rights. Children and adults with FAS are more likely to give false confessions simply to please the police.
A Public Health Issue
Even the brief review presented here should prove adequate to make my case: FAS is a devastating problem with a dreadful impact on millions of lives. All the pain, suffering, punitive measures, imprisonment, and fortunes spent on researching effective ways to treat FAS would all vanish in a generation if women simply didn't drink alcohol before or during pregnancy. Not one drop. Not one beer. No loving mother would trade her child's future for a six-pack, a wine cooler, or a bottle of single malt scotch.
Defining the Problem of Fetal Alcohol Disorders
For purposes of distinction, the term FAS is commonly used for the condition in which there are distinctive facial abnormalities that may be discerned by a trained medical expert. These facial features include small eyes, an exceptionally thin upper lip, a short, upturned nose, and a smooth skin surface between the nose and upper lip.
Doctors have used a number of terms to describe some of the signs of fetal alcohol syndrome and the spectrum of disorders caused when a pregnant woman consumes alcohol, such as fetal alcohol spectrum disorders (FASD), fetal alcohol syndrome (FAS), fetal alcohol effects (FAEs), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorders (ARNDs), static encephalopathy alcohol exposed (SEAE), and alcohol-related birth defects (ARBDs). ARND refers to mental and behavioral impairments; ARBD refers to the physical defects that occur from fetal alcohol exposure. Most of these characteristics are not characterized by the telltale facial features and require a higher level of testing and evaluation.
Signs of fetal alcohol syndrome may include the following:
_•_ Heart defects
_•_ Deformities of joints, limbs, and fingers
_•_ Slow physical growth before and after birth
_•_ Vision difficulties or hearing problems
_•_ Small head circumference and brain size (microcephaly)
_•_ Poor coordination
_•_ Sleep problems
_•_ Mental retardation and delayed development
_•_ Learning disorders
_•_ A short attention span, hyperactivity, and poor impulse control
_•_ Extreme nervousness and anxiety
The facial features seen with fetal alcohol syndrome may also occur in healthy children without FAS. Distinguishing normal facial features from those of FAS requires expertise.
Opiate Addiction during Pregnancy
Although less widespread than FAS, opiate drug use among pregnant women is a rapidly growing problem.
The number of women abusing opiates increased 500 percent between 2000 and 2009, according to the National Institute on Drug Abuse. It's estimated that 75 percent of all heroin addicts who are pregnant never receive any prenatal care.
Health risks for a baby born of a mother abusing opiates include learning disabilities, behavioral problems, and mental or physical developmental delays.
A pregnant woman addicted to opiates should go through withdrawal for her own health and that of her unborn child, and she should do it between the fourteenth and thirty-second weeks to minimize the effect on the fetus. (If she doesn't detox before birth, her newborn baby is likely to be born addicted and will have to go through a withdrawal process, which can take weeks.) The pregnant mother's detox must be done under the supervision of a physician who is trained and board-certified in addiction medicine. One other option is during pregnancy to stay on Subutex or methadone maintenance because in some individuals detox is more painful and even dangerous to the mother and fetus. Again, the objective is to do no harm; which option is better depends on the patient.
# Epilogue
# Overcoming the Culture of Disbelief
These are strange days for practitioners of addiction medicine like myself. We find ourselves living in a kind of twilight between the past and future. We're surrounded by hordes of zombie rehab clinics that offer antiquated remedies for what should be the medical treatment of addiction. Even our own medical brethren too often hear only the siren call of the 12 steps and ignore their Hippocratic Oath to do no harm by discharging their addicted patients into the hands of amateurs.
In short, we live in a culture of disbelief, where medical science about addiction is cast aside.
Dramatic? Perhaps. But I really do believe we're in the midst of an epic struggle for the treatment of addiction. I have been fighting the battle now for fifteen years. I was among the first doctors to begin treating patients with a substance addiction with controlled and scientifically verified medications like Suboxone. And it's been twenty-five years since the advent of magnetic resonance imaging proved what doctors of addiction medicine had always suspected: The brain of the alcohol and drug addict is structurally different from that of a nonaddict's.
Decades now into the struggle to make evidence-based medicine the default treatment for substance addiction, the other side still seems to be winning. Incredibly, 90 percent of all rehab clinics and treatment centers for alcohol and drug addiction offer no evidence-based medicine. The largely unregulated, $34 billion rehab industry can make more profit by refusing to recognize the science of addiction treatment. The worst of the lot have simply co-opted and commodified the simple 12-step philosophy—meant always to have been a free program as much about sanctuary and camaraderie as about treatment—into a program offered as a cure and run by drug counselors with no medical training. The more sophisticated ones offer psychological counseling staffed by degreed therapists, but most still ignore the irrefutable research that medications are an essential part of a comprehensive treatment. I know from talking to their former patients that many facilities in Los Angeles where I live won't even allow their doctors to talk about medications.
More troubling, we're drowning in new waves of substance addiction. Suburban youth are now the new poster children for the flood of cheap and powerful heroin flooding the streets. Late-middle-aged to senior adults—traditionally the last group you would think of as drug addicts—are hooked on powerful prescription painkillers with the rate of OD deaths for those ages fifty-five to sixty-four soaring 700 percent between 1993 and 2012. (In 2012, Medicare spent zero on powerful tranquilizers such as Xanax and Valium; one year later, under pressure from the pharmaceutical companies to include their products in Medicare authorized medication, it was spending $377 million on 40 million prescriptions for this class of drugs.)
Hundreds of thousands of veterans are being treated for substance addictions of all kinds. The nation's energy boom has been accompanied by a methamphetamine epidemic among gas and oil workers. One study, reported in the _Wall Street Journal_ , found nearly 25 percent of federally mandated energy workers testing positive for amphetamine in 2011, up from 17 percent just two years earlier.
As for alcohol, it now has the dubious distinction of being the third leading preventable cause of death in the United States, surpassed only by smoking and obesity and responsible for nearly 88,000 deaths in 2014. That's more than deaths from firearms, drug abuse, and sexually transmitted diseases combined (alcohol-related deaths surpassed those from car accidents in 2011 and never looked back). Heavy drinking is up more than 17 percent since 2005, with women registering the biggest increases. That is particularly saddening but not surprising since the prevalence of fetal alcohol syndrome has also risen over the last decade from approximately 3 cases per 1,000 to as high as 7 cases per 1,000 (the more broadly defined fetal alcohol spectrum disorder is as high as 50 cases per 1,000).
A complicit judiciary continues to condition people's freedom on attendance to 12-step programs rather than bona fide, evidence-based treatment centers. Quite literally, people are dying every day because of ill-informed, sometimes religiously biased and often politically cynical elected judges who kowtow to constituents who expect addicts to be demonized as criminals rather than treated as patients.
The death rate from drug overdoses more than doubled from 1999 to 2013. The nation spends nearly $468 billion annually on addiction but only 2¢ goes for prevention or long-term treatment (the rest is squandered on jails, courts, and emergency care at hospitals).
Yet, maddeningly, after all these years the public at large remains confused about addiction and its treatment. Many people do not believe that addiction is a physical disease, but that is only because they don't understand the meaning of disease and the current definition of addiction. Surveys show that the majority of Americans understand that addiction has a biological component—that it's a disease like diabetes, asthma, or bipolar disorder—yet they can't let go of the past. They cling to the notion that addicts could really stop if they wanted to and that willpower and moral fiber are the answers to substance addiction.
The destined-to-fail war on drugs and its sister campaigns DARE and Just Say No are twentieth-century relics, dismissed by anyone under thirty years old with the same derision my generation had for _Reefer Madness_. Yet, politicians continue to pay homage to these failed public health policies.
Hope on the Horizon
Still, I am hopeful about the changing landscape of addiction treatment. There is a new class of warriors who are fighting for science and medicine and the treatment of addiction as the chronic disease that it is. I know this because I teach med students and residents every semester at the University of Southern California Keck School of Medicine. The school is at the forefront of informing their soon-to-be doctors about the disease of addiction and the evidence-based treatments available. Indeed, every med student at the school, no matter what his or her intended specialty, must take the curriculum that I, along with my staff, created.
We also now have a history of how evidence-based treatment can, and has, worked. Thousands of patients who likely would have been jailed or succumbed to the ravages of substance addiction are now living normal lives. Medications such as Suboxone have been developed to stop the cravings that characterize substance addiction without the danger of a new dependency.
The concept of substance addiction as a chronic disease that must be treated over a lifetime, as is the case with every other chronic disease, has gained a toehold in popular culture. The failure of local and state authorities to use evidence-based treatment has been chronicled recently in investigative news articles in the _Huffington Post_ , _Slate_ , _The Atlantic_ magazine, and the _New York Times_ , with the cumulative effect of casting doubt on the invulnerability of the 12-step monolith.
Documentary films such as _The Business of Recovery_ directed by Adam Finberg and _Prescription Thugs_ by Chris Bell, Josh Alexander, and Craig Young question the motives behind both the rehab industry and big pharma.
Most heartening, the treatment of addiction as a medical condition is becoming institutionalized. The federal Affordable Care Act (Obamacare), for the first time in national healthcare policy, mandated what health benefits insurance plans must cover, and substance addiction treatment is included. What's more, it bars insurers from denying coverage due to preexisting conditions—including substance abuse.
But perhaps the most important changes emanating from President Obama's landmark healthcare initiative is the expansion of the so-called parity rules. _Parity_ means that insurance plans must cover mental health and substance abuse treatment at the same level as regular medical care. Once and for all, after a century of needless criminalization, the Affordable Care Act codifies in federal law that substance abuse is a medical issue—not the result of moral turpitude and not a problem meant for the criminal justice system.
Finally, under the Affordable Care Act, insurance will pay for evidence-based treatment. Already, some of the most famous and egregious proponents of the 12-step abstinence-only model for treatment are quickly changing their tune. Hazelden, the first center to, in effect, co-opt Bill Wilson's AA philosophy and charge money for it, has now incorporated naltrexone into its treatment model. Big health insurers like Cigna and United Healthcare are following the new law and simply refusing to pay for inpatient treatment claims from centers that do not use evidence-based medicine. Soon, AA will return to what its founder always meant it to be—a free service that might help heavy drinkers and even some alcoholics, rather than being enshrined as the foundation for a nationwide for-profit industry that exploits the fears and suffering of addicts and their families.
The irrationality of drug criminalization is being embraced by a younger generation of Americans. States like Colorado and Washington have decriminalized marijuana use, thus opening it to regulation and taxation (just like alcohol). Similarly, voters in California recently passed Proposition 47 that revises the calculus of drug courts. The new law changed several felonies, including drug possession, into misdemeanors, thus expanding the opportunities for potentially hundreds to receive addiction treatment whose crimes previously were deemed too serious.
Next Steps
So, where do we go from here? First, if you're reading this book because you or someone you care about is an addict, be informed! Choose a treatment center wisely. Do not be swayed by marketing campaigns that gloss over a rehab clinic's failure to provide appropriate medical care. Look for evidence-based treatment not only in the detoxification phase of treatment but also in management and maintenance. Avoid centers that promise only a 12-step model, a one-size-fits-all treatment program, and especially a cure for alcoholism or drug addiction.
As a society, we need to catch up with the rest of the Western world and incorporate commonsense healthcare reform, beyond those offered by the Affordable Care Act, including the following:
1. Require all medical schools to offer a mandatory curriculum on evidence-based addiction treatment. Remember that substance addiction is the third leading cause of preventable deaths in the United States. It's shameful that only a handful of medical schools offer training to their students, much less require it.
2. Use taxes on the legal sale of marijuana and alcohol for a public education program about the facts concerning the chronic disease that we call alcoholism and drug addiction.
3. Develop standardized terms to facilitate treatment. Too often both the public and doctors interchange terms at random, causing confusion. Not all people who drink or take drugs or who drink heavily or take lots of drugs are addicts. Most of those who consume alcohol and drugs will simply stop or moderate that behavior to a safe level. The term _addict_ must be reserved for those who have the chronic, largely genetically based brain disease, characterized by a damaged reward system and an uncontrollable, obsessive craving for a substance.
4. Regulate the alcohol and drug rehab industry. New mandates under the Affordable Care Act will go a long way, but a comprehensive federal law should be passed to require treatment centers to be under the supervision of a medical doctor with a certification in addiction medicine and staffed by trained and licensed medical professionals. The days when your only qualification for being an addiction counselor is that you used to be an addict, or still are, must end.
A Universal Problem
Addiction, as with other chronic clinical illnesses, doesn't consider your race, religion, or political affiliation. It doesn't matter if someone is Christian, Jewish, Muslim, Buddhist, Hindu, or atheist. This disease afflicts people from all walks of life, rich and poor, doctors, successful businessmen, clergy, and elected heads of state. The more people know about the disease of addiction, the less stigmatized individuals who suffer from it will be, and more will get the help they need (keep in mind that 90 percent of those who suffer from the disease are not being treated at all).
Every physician and clinical association worldwide recognizes that substance addiction is a clinical illness that is both preventable and treatable. It is to this mission of prevention and treatment that I have dedicated my life and career, and I invite you to join me as an ambassador of the truth about addiction.
# BIBLIOGRAPHY
Aalto, M., Pekuri, P., & Seppa, K. (2003). "Obstacles to carrying out brief intervention for heavy drinkers in primary health care: A focus group study." _Drug and Alcohol Review_ 22 (2): 169–73.
Abbott, P. J., Quinn, D., & Knox, L. (1995). "Ambulatory medical detoxification for alcohol." _American Journal of Drug & Alcohol Abuse _21 (4): 549–63.
Abraham, A. J., & Roman, P. M. (2010). "Early adoption of injectable naltrexone for alcohol-use disorders: Findings in the private-treatment sector." _Journal of Studies on Alcohol and Drugs_ 71 (3): 460–66.
Abraham, A. J., Knudsen, H. K., & Roman, P. M. (2011). "A longitudinal examination of alcohol pharmacotherapy adoption in substance use disorder treatment programs: Patterns of sustainability and discontinuation." _Journal of Studies on Alcohol and Drugs_ 72 (4): 669–77.
Adams, J. B., Heath, A. J., Young, S. E., Hewitt, J. K., Corley, R. P., & Stallings, M. C. (2003). "Relationships between personality and preferred substance and motivations for use among adolescent substance abusers." _American Journal of Drug and Alcohol Abuse_ 29 (3): 691–712.
Agrawal, A., & Lynskey, M. T. (2008). "Are there genetic influences on addiction: Evidence from family, adoption and twin studies." _Addiction_ 103 (7): 1069–81.
Alcoholics Anonymous World Services. (1972). _A Brief Guide to Alcoholics Anonymous_.
Alexander, J. A., Nahra, T. A., Lemak, C. H., Pollack, H., & Campbell, C. I. (2008). "Tailored treatment in the outpatient substance abuse treatment sector: 1995–2005." _Journal of Substance Abuse Treatment_ 34 (3): 282–92.
Amato, L., Davoli, M., Perucci, C. A., Ferri, M., Faggiano, F., & Mattick, R. P. (2005). "An overview of systematic reviews of the effectiveness of opiate maintenance therapies: Available evidence to inform clinical practice and research." _Journal of Substance Abuse_ 28 (4): 321–29.
American Board of Addiction Medicine Foundation. (2009). _The Need for Addiction Medicine Physicians and for Addiction Medicine Residency Training Programs: A Report of the American Board of Addiction Medicine Foundation_. Chevy Chase, MD.
American Medical Association. (2011). H-95.976. "Drug abuse in the United States: The next generation." Available at ssl3.ama-assn.org.
American Medical Association, Council on Scientific Affairs. (1979). _Guidelines for Alcoholism Diagnosis: Treatment and Referral_. Chicago.
American Psychiatric Association. (2008). "Substance use disorders: Physician performance measurement set: PCPI approved." Available at www.ama-assn.org.
American Society of Addiction Medicine. (2011). "Definition of addiction: Frequently asked questions." Available at www.asam.org.
Anderson, A. L., Reid, M. S., Li, S. H., et al. (2009). "Modafinil for the treatment of cocaine dependence." _Drug and Alcohol Dependence_ 104 (1–2): 133–39.
Anonymous. (2012, February 22). "A rewired brain: Many now see addiction as a chronic brain disease that requires new approaches to treatment." _Wall Street Journal_. Available at http://online.wsj.com/ad/cigna/cigna_article.htm.
Anthony, E. K., Taylor, S. A., & Raffo, Z. (2011). "Early intervention for substance abuse among youth and young adults with mental health conditions: An exploration of community mental health practices." _Administration and Policy in Mental Health_ 38 (3): 131–41.
Anton, R. F., Moak, D. H., Latham, P., et al. (2005). "Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence." _Journal of Clinical Psychopharmacology_ 25 (4): 349–57.
Anton, R. F., & Swift, R. M. (2003). "Current pharmacotherapies of alcoholism: A U.S. perspective." _American Journal on Addictions_ 12 (1): S53–S68.
Appel, P. W., Ellison, A. A., Jansky, H. K., & Oldak, R. (2004). "Barriers to enrollment in drug abuse treatment and suggestions for reducing them: Opinions of drug injecting street outreach clients and other system stakeholders." _American Journal of Drug and Alcohol Abuse_ 30 (1): 129–53.
Arias, A. J., & Kranzler, H. R. (2008). "Treatment of co-occurring alcohol and other drug use disorders." _Alcohol Research and Health_ 31 (2): 155–67.
Atkinson, R. M., Ganzini, L., & Bernstein, M. J. (1992). "Alcohol and substance-use disorders in the elderly." In J. E. Birren, R. B. Sloane, & G. D. Cohen, eds., _Handbook of Mental Health and Aging_ (pp. 516–55). New York: Academic Press.
Azrin, N. H., Sisson, W., Myers, R., & Godley, M. (1982). "Alcoholism treatment by disulfiram and community reinforcement therapy." _Journal of Behavior Therapy and Experimental Psychiatry_ 13 (2): 105–12.
Babor, T. F., & Hall, W. (2007). "Editorial: Standardizing terminology in addiction science: To achieve the impossible dream." _Addiction_ 102 (7): 1015–18.
Babor, T. F., & Kadden, R. M. (2005). "Screening and interventions for alcohol and drug problems in medical settings: What works?" _Journal of Trauma_ 59 (Suppl. 3): S80–S87.
Barker, M. J., Greenwood, K. M., Jackson, M., & Crowe, S. F. (2004). "Cognitive effects of long-term benzodiazepine use. A meta-analysis." _CNS Drugs_ 18 (1): 37–48.
Barnett, P. G., Zaric, G. S., & Brandeau, M. L. (2001). "The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States." _Addiction_ 96 (9): 1267–278.
Bava, S., Frank, L. R., McQueeny, T., Schweinsburg, B. C., Schweinsburg, A. D., & Tapert, S. F. (2009). "Altered white matter microstructure in adolescent substance users." _Psychiatry Research_ 173 (3): 228–37.
Bazelon Center for Mental Health Law. (2010). "Medicaid reforms in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act." Available at www.bazelon.org.
Bellack, A. S., Bennett, M. E., Gearon, J. S., Brown, C. H., & Yang, Y. (2006). "A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness." _Archives of General Psychiatry_ 63 (4): 426–32.
Biery, J. R., Williford, J. H., Jr., & McMullen, E. A. (1991). "Alcohol craving in rehabilitation: Assessment of nutrition therapy." _Journal of the American Dietetic Association_ 91 (4): 463–66.
Bina, R., Yum, J., Hall, D., Sowbel, L., et al. (2008). "Substance abuse training and perceived knowledge: Predictors of perceived preparedness to work in substance abuse." _Journal of Social Work Education_ 44 (3): 7–20.
Bishop, E. S. (1919). "Narcotic drug addiction: A public health problem." _American Journal of Public Health_ 9 (7): 481–88.
Block, M. A. (1956). "Medical treatment of alcoholism." _JAMA_ 162 (18): 1610–619.
Boden, M. T., Kimerling, R., Jacobs-Lentz, J., et al. (2011). "Seeking safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomology." _Addiction_ 107 (3): 578–86.
Boden, M. T., & Moos, R. (2009). "Dually diagnosed patients' responses to substance use disorder treatment." _Journal of Substance Abuse Treatment_ 37 (4): 335–45.
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). "Improving primary care for patients with chronic illness: The chronic care model, Part 2." _JAMA_ 288 (15): 1909–914.
Bollerud, K. (1990). "A model for the treatment of trauma-related syndromes among chemically dependent inpatient women." _Journal of Substance Abuse Treatment_ 7 (2): 83–87.
Bonnie, R. J., & O'Connell, M. E. (2004). _Reducing underage drinking: A collective responsibility_. Washington, D.C.: National Academies Press.
Boothby, L. A., & Doering, P. L. (2007). "Buprenorphine for the treatment of opioid dependence." _American Journal of Health-System Pharmacy_ 64 (3): 266–72.
Bowen, O. R., & Sammons, J. H. (1988). "The alcohol-abusing patient: A challenge to the profession." _JAMA_ 260 (15): 2267–270.
Brady, J. P., Posner, M., Lang, C., & Rosati, M. J. (1994). _Risk and reality: The implications of prenatal exposure to alcohol and other drugs_. Rockville, MD: U.S. Department of Health and Human Services and the U. S. Department of Education, Educational Development Center.
Brown, B. S., & Flynn, P. M. (2002). "The federal role in drug abuse technology transfer: A history and perspective." _Journal of Substance Abuse Treatment_ 22 (4): 245–57.
Brown, J. D., Vartivarian, S., & Alderks, C. E. (2011). "Child care in outpatient substance abuse treatment facilities for women: Findings from the 2008 National Survey of Substance Abuse Treatment Services." _Journal of Behavioral Health Services & Research _38 (4): 478–87.
Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (1998). "The prevalence and detection of substance use disorders among inpatients ages 18 to 49: An opportunity for prevention." _Preventive Medicine_ 27 (1): 101–10.
Buck, J. A. (2011). "The looming expansion and transformation of public substance abuse treatment under the affordable care act." _Health Affairs_ 30 (8): 1402–410.
Buddy, T. (2010). "Naltrexone—Treatment for alcoholism and addiction: Blocks effects of opioids, reduces alcohol craving." Available at alcoholism.about.com.
Buddy, T. (2007). "New vaccines help stop drug addiction?" Available at alcoholism.about.com.
Burge, S. K., & Schneider, F. D. (1999). "Alcohol-related problems: Recognition and intervention." _American Family Physician_ 59 (2): 361–70, 372.
Burke, B. L., Arkowitz, H., & Menchola, M. (2003). "The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials." _Journal of Consulting and Clinical Psychology_ 71 (5): 843–61.
Burrow-Sanchez, J., Call, M. E., Adolphson, S. L., & Hawken, L. S. (2009). "School psychologists' perceived competence and training needs for student substance abuse." _Journal of School Health._
Burrow-Sanchez, J. J., & Lopez, A. L. (2009). "Identifying substance abuse issues in high schools: A national survey of high school counselors." _Journal of Counseling and Development_ 87 (1): 72–79.
Burton, L. M. (1992). "Black grandparents rearing children of drug-addicted parents: Stressors, outcomes, and social service needs." _Gerontologist_ 32 (6): 744–51.
Busto, U., Sellers, E. M., Naranjo, C. A., Cappell, H., Sanchez-Craig, M., & Sykora, K. (1986). "Withdrawal reaction after long-term therapeutic use of benzodiazepines." _New England Journal of Medicine_ 315 (14): 854–59.
Calhoun, P. S., Elter, J. R., Jones, E. R. Jr., Kudler, H., & Straits-Troster, K. (2008). "Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan." _Journal of Clinical Psychiatry_ 69 (11): 1686–693.
Califano, J. A. (2007). _High society: How substance abuse ravages America and what to do about it_. New York: Public Affairs.
California Board of Behavioral Sciences. (2012). "Continuing education (CE) provider application." Available at www.bbs.ca.gov.
Callahan, D. (1999). "Remembering the goals of medicine." _Journal of Evaluation in Clinical Practice_ 5 (2): 103–106.
Carey, K. B. (2008, December 22). "Drug rehabilitation or revolving door?" _New York Times_ , p. 1D.
Carey, K. B., Bradizza, C. M., Stasiewicz, P. R., & Maisto, S. A. (1999). "The case for enhanced addictions training in graduate programs." _Behavior Therapist_ 22 (2): 27–31.
Carroll, K. M. (1996). "Relapse prevention as a psychosocial treatment: A review of controlled clinical trials." _Experimental and Clinical Psychopharmacology_ 4 (1): 46–54.
Carroll, K. M., Ball, S. A., Nich, C., et al. (2001). "Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: Efficacy of contingency management and significant other involvement." _Archives of General Psychiatry_ 58 (8): 755–61.
Carroll, K. M., Fenton, L., Ball, R. (2004). "Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: A randomized placebo-controlled trial." _Archives of General Psychiatry_ 61 (3): 264–72.
Carroll, K. M., Rounsaville, B. J., Nich, C., Gordon, L., & Gawin, F. (1995). "Integrating psychotherapy and pharmacotherapy for cocaine dependence: Results from a randomized clinical trial." _NIDA Research Monograph_ 150: 19–35.
CASAColumbia (2012). "Addiction medicine: Closing the gap between science and practice. Results from a 5-year study." Available at http://www.casacolumbia.org/addiction-research/reports/addiction-medicine.
Cassel, E. J. (1982). "The nature of suffering and the goals of medicine." _New England Journal of Medicine_ 306 (11): 639–45.
Catholic University of America. (2010). "Summary of federal laws. The Controlled Substances Act of 1970 (Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970)." Available at counsel.cua.edu.
Center for Substance Abuse Treatment. (2011). "About buprenorphine therapy." Available at buprenorphine.samhsa.gov.
Center for Substance Abuse Treatment. (2005). "Acamprosate: A new medication for alcohol use disorders (DHHS Pub. No. (SMA) 05-4114)." _Substance Abuse Treatment Advisory_ 4 (1).
Center for Substance Abuse Treatment. (2012). "Buprenorphine information center." Available at buprenorphine.samhsa.gov.
Center for Substance Abuse Treatment. (2004). _Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment improvement protocol (TIP) Series 40_ (DHHS Pub. No. (SMA) 04-3939). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Center for Substance Abuse Treatment. (1997). _A guide to substance abuse services for primary care clinicians. Treatment improvement protocol (TIP) Series 24_ (DHHS Pub. No. (SMA) 97-3139). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Center for Substance Abuse Treatment. (2000). _Improving substance abuse treatment: The national treatment plan initiative: Changing the conversation_ (DHHS Pub No. (SMA) 00-3480, NCADI Pub No. -BKD 383). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Center for Substance Abuse Treatment. (2009). _Incorporating alcohol pharmacotherapies into medical practice. Treatment Improvement Protocol (TIP) Series 49._ (DHHS Pub. No. (SMA) 09-4380). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment. (2006). "Prescription medications: Misuse, abuse, dependence, and addiction." _Substance Abuse Treatment Advisory_ 5 (2): 1–4.
Center for Substance Abuse Treatment. (1994). _Screening and assessment for alcohol and other drug abuse among adults in the criminal justice system. Treatment improvement protocol (TIP) Series 7_ (DHHS Pub. No. (SMA) 94-2076). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Center for Substance Abuse Treatment. (1998). _Substance abuse among older adults. Treatment improvement protocol (TIP) Series 26_ (DHHS Pub. No. (SMA) 98-3179). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Center for Substance Abuse Treatment. (2005). _Substance abuse treatment for persons with co-occurring disorders. Treatment improvement protocol (TIP) Series 42_ (DHHS Pub. No. (SMA) 05-3992) _._ Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2011). "Prescription painkiller overdoses in the U.S." Available at www.cdc.gov.
Chambers, R. A., Taylor, J. R., & Potenza, M. N. (2003). "Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability." _American Journal of Psychiatry_ 160(6): 1041–1052.
Cherkis, Jason. (2015, January 28) "Dying to be free—There's a treatment for heroin addiction that actually works. Why aren't we using it?" _Huffington Post_. Available at http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment.
Clark, R. E., Samnaliev, M., Baxter, J. D., & Leung, G. Y. (2011). "The evidence doesn't justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine." _Health Affairs_ 30 (8): 1425–433.
Comer, S. D., Sullivan, M. A., Yu, E., et al. (2006). "Injectable, sustained-release naltrexone for the treatment of opioid dependence: A randomized, placebo-controlled trial." _Archives of General Psychiatry_ 63 (2): 210–18.
Courtwright, D. T. (2001). _Dark Paradise: A History of Opiate Addiction in America_. Cambridge: Harvard University Press.
Crews, F. T., & Boettiger, C. A. (2009). "Impulsivity, frontal lobes and risk for addiction." _Pharmacology Biochemistry and Behavior_ 93 (3): 237–47.
Crews, F., He, J., & Hodge, C. (2007). "Adolescent cortical development: A critical period of vulnerability for addiction." _Pharmacology Biochemistry and Behavior_ 86 (2): 189–99.
Culberson, J. W., & Ziska, M. (2008). "Prescription drug misuse/abuse in the elderly." _Geriatrics_ 63 (9): 22–31.
Cunningham, J. A., Sobell, L. C., Sobell, M. B., Agrawal, S., & Toneatto, T. (1993). "Barriers to treatment: Why alcohol and drug abusers delay or never seek treatment." _Addictive Behaviors_ 18 (3): 347–53.
Cunningham, R. M., Harrison, S. R., McCay, M. P., et al. (2010). "National survey of emergency department alcohol screening and intervention practices." _Annals of Emergency Medicine_ 55 (6): 556–62.
Curtis, J. R., Geller, G., Stokes, E. J., Levine, D. M., & Moore, R. D. (1989). "Characteristics, diagnosis, and treatment of alcoholism in elderly patients." _Journal of the American Geriatrics Society_ 37 (4): 310–16.
Dackis, C. A., Lynch, K. G., Yu, E., et al. (2003). "Modafinil and cocaine: A double-blind, placebo-controlled drug interaction study." _Drug and Alcohol Dependence_ 70 (1): 29–37.
Dackis, C., & O'Brien, C. P. (2005). "Neurobiology of addiction: Treatment and public policy ramifications." _Nature Neuroscience_ 8 (11): 1431–436.
Dahl, R. E. (2004). "Adolescent brain development: A period of vulnerabilities and opportunities. Keynote address." _Annals of the New York Academy of Sciences_ 1021: 1–22.
Denizet-Lewis, B. (2006, June 25). "An anti-addiction pill?" Available at www.nytimes.com.
Devenyi, P., Mitwalli, A., & Graham, W. (1982). "Clonidine therapy for narcotic withdrawal." _Canadian Medical Association Journal_ 127 (10): 1009–1011.
DeWit, D. J., Adlaf, E. M., Offord, D. R., & Ogborne, A. C. (2000). "Age at first alcohol use: A risk factor for the development of alcohol disorders." _American Journal of Psychiatry_ 157 (5): 745–50.
Dhalla, I. A. (2011). "Facing up to the prescription opioid crisis." _British Journal of Medicine_ 343 (d5142).
Dowling, G. J., Weiss, S., & Condon, T. P. (2008). "Drugs of abuse and the aging brain." _Neuropsychopharmacology_ 33 (2): 209–18.
Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). "Review of integrated mental health and substance abuse treatment for patients with dual disorders."
Drug Policy Alliance. (2009). "Healing a broken system: Veterans battling addiction and incarceration." Available at www.phoenixhouse.org.
Druss, B. G., & Mauer, B. J. (2012). "Health care reform and care at the behavioral health–primary care interface." _Psychiatric Services_ 61 (11): 1087–1092.
Dufour, M. C., Archer, L., & Gordis, E. (1992). "Alcohol and the elderly." _Clinics in Geriatric Medicine_ 8 (1): 127–41.
Dupont, R. L., McLellan, A. T., Carr, G., Gendel, M., & Skipper, G. E. (2009). "How are addicted physicians treated? A national survey of physician health programs." _Journal of Substance Abuse Treatment_ 37 (1): 1–7.
Elisnon, Zusha. (2015, March 16). "Aging baby boomers bring drug habits into middle age." _Wall Street Journal_. Available at http://www.wsj.com/articles/aging-baby-boomers-bring-drug-habits-into-middle-age-1426469057.
Epstein, J., Barker, P., Vorburger, M., & Murtha, C. (2004). _Serious mental illness and its co-occurrence with substance use disorders, 2002_ (DHHS Publication No. SMA 04-3905, Analytic Series A-24) _._ Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
Ersche, K. D., Jones, P. S., Williams, G. B., Turton, A. J., Robbins, T. W., & Bullmore, E. T. (2012). "Abnormal brain structure implicated in stimulant drug addiction." _Science_ 335 (6068): 601–604.
Finlayson, R. E., Hurt, R. D., Davis, L. J., & Morse, R. M. (1988). "Alcoholism in elderly persons: A study of the psychiatric and psychosocial features of 216 inpatients." _Mayo Clinic Proceedings_ 63 (8): 761–68.
Finney, J. W., Wilbourne, P. L., & Moos, R. H. (2007). "Psychosocial treatments for substance use disorders." In P. E. Nathan & J. M. Gorman, eds., _A Guide to Treatments That Work_ (pp. 179–202). New York: Oxford University Press.
Fiorentine, R. (1999). "After drug treatment: Are 12-step programs effective in maintaining abstinence?" _American Journal of Drug and Alcohol Abuse_ 25 (1): 93–116.
Fournier, M. E., & Levy, S. (2006). "Recent trends in adolescent substance use, primary care screening, and updates in treatment options." _Current Opinions in Pediatrics_ 18 (4): 352–58.
Galanter, M., Dermatis, H., Glickman, L., et al. (2004). "Network therapy: Decreased secondary opioid use during buprenorphine maintenance." _Journal of Substance Abuse Treatment_ 26: 313–18.
Ganju, V. (2006). "Mental health quality and accountability: The role of evidence-based practices and performance measures." _Administration and Policy in Mental Health_ 33 (6): 659–65.
Glaser, Gabrielle. (April 2015). "The irrationality of Alcoholics Anonymous." _The Atlantic_. Available at http://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255.
Haber, P. (2012). "Pharmacotherapies for alcohol dependence." In E. Proude, O. Loptko, N. Lintzeris, & P. Haber, eds., _Guidelines for the Treatment of Alcohol Problems: A Review of Evidence_ (pp. 169–72). Sydney, Australia: University of Sydney.
Han, B., Gfroerer, J. C., & Colliver, J. D. (2010). "Associations between duration of illicit drug use and health conditions: Results from the 2005–2007 National Surveys on Drug Use and Health." _Annals of Epidemiology_ 20 (4): 289–97.
Han, B., Gfroerer, J. C., Colliver, J. D., & Penne, M. A. (2009). "Substance use disorder among older adults in the United States in 2020." _Addiction_ 104 (1): 88–96.
Hankin, J. R. (2002). "Fetal alcohol syndrome prevention research." _Alcohol Research and Health_ 26 (1): 58–65.
Holder, H. D. (1998). "Cost benefits of substance abuse treatment: An overview of results from alcohol and drug abuse." _Journal of Mental Health Policy & Economics _1 (1): 23–29.
Holloway, H. C., Hales, R. E., & Watanabe, H. K. (1984). "Recognition and treatment of acute alcohol withdrawal syndromes." _Psychiatric Clinics of North America_ 7 (4): 729–43.
Hommer, D. W., Bjork, J. M., & Gilman, J. M. (2011). "Imaging brain response to reward in addictive disorders." _Annals of the New York Academy of Sciences_ 1216: 50–61.
Hoof-Haines, K. V. (2012). "Dual diagnosis: The status of treating co-occurring disorders in the U.S." Available at www.drugfree.org.
Jerrell, J. M., & Ridgely, M. S. (1995). "Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders." _Journal of Nervous and Mental Disease_ 183 (9): 566–76.
Johnson, B. A. (2005). "Recent advances in the development of treatments for alcohol and cocaine dependence: Focus on topiramate and other modulators of GABA or glutamate function." _CNS Drugs_ 19 (10): 873–96.
Johnson, B. A. (2008). "Update on neuropharmacological treatments for alcoholism: Scientific basis and clinical findings." _Biochemical Pharmacology_ 75 (1): 34–56.
Johnson, B. A., & Ait-Daoud, N. (1999). "Medications to treat alcoholism." _Alcohol Research and Health_ 23 (2): 99–106.
Johnson, R. E., Chutuape, M. A., Strain, E. C., Walsh, S. L., Stitzer, M. L., & Bigelow, G. E. (2000). "A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence." _New England Journal of Medicine_ 343 (18): 1290–297.
Jones, H. E. (2004). "Practical considerations for the clinical use of buprenorphine." _Science and Practice Perspectives_ 2 (2): 4–20.
Kalivas, P. W., & Vokow, N. D. (2005). "The neural basis of addiction: A pathology of motivation and choice." _American Journal of Psychiatry_ 162 (8): 1403–413.
Kampman, K. M. (2008). "The search for medications to treat stimulant dependence." _Addiction Science and Clinical Practice_ 4 (2): 28–35.
Kampman, K. M., Pettinati, H., Lynch, K. G., et al. (2004). "A pilot trial of topiramate for the treatment of cocaine dependence." _Drug and Alcohol Dependence_ 75 (3): 233–40.
Karila, L., Reynaud, M., Aubin, H. J., et al. (2011). "Pharmacological treatments for cocaine dependence: Is there something new?" _Current Pharmaceutical Designs_ 17 (14): 1359–368.
Karila, L., Weinstein, A., Aubin, H. J., Benyamina, A., Reynaud, M., & Batki, S. L. (2010). "Pharmacological approaches to methamphetamine dependence: A focused review." _British Journal of Clinical Pharmacology_ 69 (6): 578–92.
Kaskutas, L. A. (2009). "Alcoholics Anonymous effectiveness: Faith meets science." _Journal of Addictive Disorders_ 28 (2): 145–57.
Kelley, A. E., & Berridge, K. C. (2002). "The neuroscience of natural rewards: Relevance to addictive drugs." _Journal of Neuroscience_ 22 (9): 3306–311.
Kelly, J. F., Magill, M., & Stout, R. L. (2009). "How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous." _Addiction Research and Theory_ 17 (3): 236–59.
Kelly, J. F., & Yeterian, J. D. (2011). "The role of mutual-help groups in extending the framework of treatment." Available at pubs.niaaa.nih.gov.
Keyes, K. M., Hatzenbuehler, M. L., McLaughlin, K. A., et al. (2010). "Stigma and treatment for alcohol disorders in the United States." _American Journal of Epidemiology_ 172 (12): 1364–372.
Khantzian, E. J. (1985). "The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence." _American Journal of Psychiatry_ 142 (11): 1259–264.
Kjome, K. L., & Moeller, F. G. (2011). "Long-acting injectable naltrexone for the management of patients with opioid dependence." _Substance Abuse: Research and Treatment_ 5: 1–9.
Kleber, H. D., Weiss, R. D., Anton, R. F., et al. (2006). "Part A: Treatment of patients with substance use disorders, second edition." American Psychiatric Association. _American Journal of Psychiatry_ 163 (Suppl. 8): 5–82.
Knudsen, H. K., Abraham, A. J., Johnson, J. A., & Roman, P. M. (2009). "Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network." _Journal of Substance Abuse Treatment._
Knudsen, H. K., Abraham, A. J., & Oser, C. B. (2011). "Barriers to the implementation of medication-assisted treatment for substance use disorders: The importance of funding policies and medical infrastructure." _Evaluation and Program Planning_ 34 (4): 375–81.
Kosten, T. R., & O'Connor, P. G. (2003). "Management of drug and alcohol withdrawal." _New England Journal of Medicine_ 348 (18): 1786–795.
Krishnan-Sarin, S., Krystal, J. H., Shi, J., Pittman, B., & O'Malley, S. S. (2007). "Family history of alcoholism influences naltrexone-induced reduction in alcohol drinking." _Biological Psychiatry_ 62 (6): 694–97.
Leshner, A. I. (1997). "Addiction is a brain disease, and it matters." _Science_ 278 (5335): 45–47.
———. (1999). "Science is revolutionizing our view of addiction—and what to do about it."
Lindborg, Kristina. (2014, March 28). "Why heroin is spreading in America's suburbs." _Christian Science Monitor_. Available at http://www.csmonitor.com/USA/Society/2014/0323/Why-heroin-is-spreading-in-America-s-suburbs-video.
Ling, W., Charuvastra, C., Collins, J. F., et al. (1998). "Buprenorphine maintenance treatment of opiate dependence: A multicenter, randomized clinical trial." _Addiction_ 93 (4): 475–86.
Mangrum, L. F., Spence, R. T., & Lopez, M. (2006). "Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders." _Journal of Substance Abuse Treatment_ 30 (1): 79–84.
Miller, W. R., Sorensen, J. L., Selzer, J. A., & Brigham, G. S. (2006). "Disseminating evidence-based practices in substance abuse treatment: A review with suggestions." _Journal of Substance Abuse._
Millery, M., Kleinman, B. P., Polissar, N. L., Millman, R. B., & Scimeca, M. (2002). "Detoxification as a gateway to long-term treatment: Assessing two interventions." _Journal of Substance Abuse Treatment_ 23 (3): 183–90.
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). "Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war." _JAMA_ 298 (18): 2141–148.
Mroziewicz, M., & Tyndale, R. F. (2010). "Pharmacogenetics: A tool for identifying genetic factors in drug dependence and response to treatment." _Addiction Science & Clinical Practice _5 (2): 17–29.
Munro, Dan. (2015, April 27). "Inside the $35 billion addiction treatment industry." _Forbes_. Available at http://www.forbes.com/sites/danmunro/2015/04/27/inside-the-35-billion-addiction-treatment-industry.
Narconon International. (2011). History of marijuana. Available at www.narconon.org.
National Center on Addiction and Substance Abuse. (2012). CASAColumbia report. _Addiction Medicine: Closing the Gap between Science and Practice._ _Results from a 5-year study_. Available at http://www.casacolumbia.org/addiction-research/reports/addiction-medicine.
National Institute on Drug Abuse. (2005). "Drug abuse and addiction: One of America's most challenging public health problems." Available at www.nida.nih.gov.
National Institute on Drug Abuse. (2011). "Preventing and recognizing prescription drug abuse." Available at www.nida.nih.gov.
National Institute on Drug Abuse. (2012). "Research report series: Heroin abuse and addiction: What are the treatments for heroin addiction?" Available at www.drugabuse.gov.
O'Brien, C. P. & McKay, J. (2007). "Psychopharmacological treatments for substance use disorders." In P. E. Nathan & J. M. Gorman, eds., _A Guide to Treatments That Work_ (3rd ed., pp. 145–177). New York: Oxford University Press.
O'Connor, P. G. (2005). "Methods of detoxification and their role in treating patients with opioid dependence." _JAMA_ 294 (8): 961–63.
O'Connor, P. G., Carroll, K. M., Shi, Ju. M., Schottenfeld, R. S., Kosten, T. R., & Rounsaville, B. J. (1997). "Three methods of opioid detoxification in a primary care setting: A randomized trial." _Annals of Internal Medicine_ 127 (7): 526–30.
O'Connor, P. G., & Fiellin, D. A. (2000). "Pharmacologic treatment of heroin-dependent patients." _Annals of Internal Medicine_ 133 (1): 40–54.
O'Connor, P. G., Nyquist, J. G., & McLellan, T. (2011). "Integrating addiction medicine into graduate medical education in primary care: The time has come." _Annals of Internal Medicine_ 154 (1): 56–59.
O'Connor, P. J., & Youngstedt, S. D. (1995). "Influence of exercise on human sleep." _Exercise and Sport Sciences Reviews_ 23 (1): 105–34.
O'Farrell, T. J., & Fals-Stewart, W. (2003). "Alcohol abuse." _Journal of Marital and Family Therapy_ 29 (1): 121–46.
Patterson, T. L., & Jeste, D. V. (1999). "The potential impact of the baby-boom generation on substance abuse among elderly persons." _Psychiatric Services_ 50(9): 1184–188.
Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence." _American Journal of Psychiatry_ 167 (11): 1321–330.
Petrakis, I. L., Leslie, D., & Rosenheck, R. (2003). "Use of naltrexone in the treatment of alcoholism nationally in the Department of Veterans Affairs." _Alcoholism: Clinical and Experimental Research_ 27 (11): 1780–784.
Petrakis, I. L., Rosenheck, R., & Desai, R. (2011). "Substance use comorbidity among veterans with posttraumatic stress disorder and other psychiatric illness." _American Journal on Addictions_ 20 (3): 185–89.
Rieckmann, T. R., Kovas, A. E., Fussell, H. E., & Stettler, N. M. (2009). "Implementation of evidence-based practices for treatment of alcohol and drug disorders: The role of the state authority." _Journal of Behavioral Health Services & Research _36 (4): 407–19.
Roan, S. (2008). "The 30-day myth." _Los Angeles Times_. Available at articles.latimes.com.
Robert Wood Johnson Foundation. (2001). _Substance Abuse: The Nation's Number One Health Problem: Key Indicators for Policy Update_. Princeton, NJ.
SAMHSA's National Registry of Evidence-based Programs and Practices. (2007). "Motivational enhancement therapy (MET)." Available at nrepp.samhsa.gov.
SAMHSA's National Registry of Evidence-based Programs and Practices. (2008). "Multidimensional family therapy (MDFT) _._ " Available at nrepp.samhsa.gov.
SAMHSA's National Registry of Evidence-based Programs and Practices. (2007). "National Registry of Evidence-Based Programs and Practices (NREPP)." Available at nrepp.samhsa.gov.
Scheinholtz, M. K. (2011). "Implementation of evidence-based practices: SAMHSA's older adults targeted capacity expansion grant program." _Journal of the American Society on Aging_ 34 (1): 26–35.
Schramm-Sapyta, N. L., Walker, Q. D., Caster, J. M., Levin, E. D., & Kuhn, C. M. (2009). "Are adolescents more vulnerable to drug addiction than adults? Evidence from animal models." _Psychopharmacology_ 206 (1): 1–21.
Seal, K. H., Cohen, G., Waldrop, A., Cohen, B. E., Maguen, S., & Ren, L. (2011). "Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment." _Drug and Alcohol Dependence_ 116 (1–3): 93–101.
Shen, X., Orson, F. M., & Kosten, T. R. (2011). "Anti-addiction vaccines." _F1000. Medicine Report_ 3: 20.
Shorter, D., & Kosten, T. R. (2011). "Vaccines in the treatment of substance abuse." _FOCUS: Journal of Lifelong Learning in Psychiatry_ 9 (1): 25–29.
Spohr, H. L., Willms, J., & Steinhausen, H. C. (1993). "Prenatal alcohol exposure and long-term developmental consequences." _Lancet_ 341 (8850): 907–10.
Squeglia, L. M., Jacobus, J., & Tapert, S. F. (2009). "The influence of substance use on adolescent brain development." _Clinical Electroencephalography and Neuroscience_ 40 (1): 31–38.
Squeglia, L. M., Spadoni, A. D., Infante, M. A., Myers, M. G., & Tapert, S. F. (2009). "Initiating moderate to heavy alcohol use predicts changes in neuropsychological functioning for adolescent girls and boys." _Psychology of Addictive Behaviors_ 23 (4): 715–22.
Substance Abuse and Mental Health Services Administration. (2012) _._ "Co-occurring disorders in veterans and military service members." Available at www.samhsa.gov.
Thomas, C. P., Reif, S., Haq, S., Wallack, S. S., Hoyt, A., & Ritter, G. A. (2008). "Use of buprenorphine for addiction treatment: Perspectives of addiction specialists and general psychiatrists."
Timko, C., Moos, R. H., Finney, J. W., & Lesar, M. D. (2000). "Long-term outcomes of alcohol use disorders: Comparing untreated individuals with those in Alcoholics Anonymous and formal treatment." _Journal of Studies on Alcohol_ 61 (4): 529–40.
Tsuang, M. T., Bar, J. L., Harley, R. M., & Lyons, M. J. (2001). "The Harvard Twin Study of Substance Abuse: What we have learned." _Harvard Review of Psychiatry_ 9 (6): 267–79.
Tsuang, M. T., Lyons, M. J., Harley, R. M., et al. (1999). "Genetic and environmental influences on transitions in drug use." _Behavior Genetics_ 29 (6): 473–79.
U.S. Department of Justice, National Drug Intelligence Center. (2010). "Impact of drugs on society." Available at www.justice.gov.
U.S. Department of Veteran Affairs, National Center for PTSD. (2011). "PTSD and problems with alcohol use." Available at www.ptsd.va.gov.
U.S. House of Representatives, Office of the Legislative Counsel. (2010). _Compilation of Patient Protection and Affordable Care Act._ 111th Cong., 2nd Sess. Print 111-111. Available at housedocs.house.gov.
University of Washington, Alcohol and Drug Abuse Institute. (2006). "Evidence-based practices for treating substance use disorders: Matrix of interventions." Available at adai.washington.edu.
van den Bree, M. B., Johnson, E. O., Neale, M. C., & Pickens, R. W. (1998). "Genetic and environmental influences on drug use and abuse/dependence in male and female twins." _Drug and Alcohol Dependency_ 52 (3), 231–41.
Van Hoof-Haines, K. (2012). "Dual diagnosis: The status of treating co-occurring disorders in the U.S." Available at www.drugfree.org.
Volkow, N. D. (2007). _Drugs, Brains, and Behavior: The Science of Addiction _[rev. August 2010] (NIH Pub. No. 10-5605). Rockville, MD: U.S. Department of Health and Human Services, National Institute on Drug Abuse.
Volkow, N. D., & Skolnick, P. (2012). "New medications for substance use disorders: Challenges and opportunities." _Neuropsychopharmacology_ 37 (1): 290–92.
Watkins, K., Pincus, H. A., Tanielian, T. L., & Lloyd, J. (2003). "Using the chronic care model to improve treatment of alcohol use disorders in primary care settings." _Journal of Studies on Alcohol,_ 64 (2), 209–18.
White, W., & Kurtz, E. (2005). _The Varieties of Recovery Experience: A Primer for Addiction Treatment Professionals and Recovery Advocates_. Chicago: Great Lakes Addiction Technology Transfer Center.
Wilk, J. E., Bliese, P. D., Kim, P. Y., Thomas, J. L., McGurk, D., & Hoge, C. W. (2010). "Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war." _Drug and Alcohol Dependence_ 108 (1–2): 115–21.
Willenbring, M. L. (2008). "New research is redefining alcohol disorders: Does the treatment field have the courage to change?" _Addiction Professional_ 6 (5): 12–19.
World Health Organization. (2011). "Management of substance abuse. Lexicon of alcohol and drug terms published by the World Health Organization." Available at www.who.int.
Yoast, R. A., Wilford, B. B., & Hayashi, S. W. (2008). "Encouraging physicians to screen for and intervene in substance use disorders: Obstacles and strategies for change." _Journal of Addictive Diseases_ 27 (3): 77–97.
Yuferov, V., Levran, O., Proudnikov, D., Nielsen, D. A., & Kreek, M. J. (2010). "Search for genetic markers and functional variants involved in the development of opiate and cocaine addiction and treatment. _Annals of the New York Academy of Sciences_ 1187: 184–207.
Zook, C. J., & Moore, F. D. (1980). "High-cost users of medical care." _New England Journal of Medicine_ 302 (18): 996–1002.
# ACKNOWLEDGMENTS
A book of this scope requires assistance from many.
First, I would like to give special thanks to the team that facilitated its publication, including Greg Ptacek for captaining the book from proposal to final manuscript; my literary agent Harvey Klinger for navigating the project through the ever-changing shoals of today's publishing world; and publisher John Duff for providing the book safe harbor at Penguin Random House.
I also to wish to thank my colleagues at University of Southern California Keck School of Medicine, who have allowed me to create and teach an addiction medicine curriculum that I hope will serve as a model for medical school nationwide. I thank, too, my students for constantly challenging convention and questioning the status quo.
Also deserving praise is the staff at my clinic and our residential facility Inspire Malibu. Their professionalism, expertise, and dedication are hallmarks of our evidence-based treatment program.
Finally, I wish to sincerely thank the patients who allowed me to share their stories here within these pages. To borrow a timeless inscription from ancient Egypt, may they _ankh wedja seneb_ : "Live long, be healthy, and prosper."
# I **NDEX**
The page numbers in this index refer to the printed version of this book. The link provided will take you to the beginning of that print page. You may need to scroll forward from that location to find the corresponding reference on your e-reader.
abstinence, xii, xiii, , , –29, –45, , , , , ,
medications and, , –29
acamprosate (Campral), ,
acid flashbacks,
addict, use of term,
addiction:
brain and, _see_ brain
as chronic disease, xii, –4, –16, , , , –67, , , , –4, , –40, , –9,
definitions of, –67, , –41,
dependence vs., –39
disorders co-occurring with, _see_ dual diagnoses
extreme cases of, –44
family history of, , , –89
films about, –16
genes and, _see_ genetics
medical consequences of, _see_ medical consequences of addiction
myths of, _see_ myths of addiction
prevention of, xiii, –79, ,
psychiatric realities in, –48
public opinion about, –5
science of, _see_ science of addiction
statistics on, , –75
treatment of, _see_ treatment
in U.S., history of, –7
_Addiction_ ,
addicts, –22, –58
accidental,
changing face of, –35,
criminalization of, _see_ criminalization
older, _see_ older addicts
physicians, –55
rock bottom and, –44
stigmatization of, –5, , , –23, , ,
teens, _see_ teenagers and young adults
adolescence:
brain in, , , –76, –92
_see also_ teenagers and young adults
Affordable Care Act (ACA), , , –10, ,
age, _see_ older addicts
Agency for Healthcare Research and Quality,
alcohol, , ,
bars and nightclubs and, –80
binge drinking and, , , , ,
brain and, , –61
danger of,
deaths from, ix–x, , , , , –71,
dependence on, , –61
detoxification from, –26
as different from other drugs, –33
driving and, , , , , –80
economic cost of, x
genetics and, ,
Joanne's experience with, –49, ,
legal age for drinking, –78
legality and social acceptability of, , , , , –71
length of average addiction to,
marijuana and, ,
mixing other drugs with,
physical damage from, , –72,
pregnancy and, _see_ pregnancy
Prohibition and, ,
psychiatric problems and, –74
tolerance to,
withdrawal from, –19
alcoholics, –58
anxiety and depression in,
Freud on, –33
rock bottom and, –44
suicide and, ,
Alcoholics Anonymous (AA), , –10, –21, , –29, –45, , , , , , ,
films and,
Hoffman and,
medications and, , –61
problems with, –13,
rock bottom and, –44
sponsors in,
structure and philosophy of, , ,
_see also_ -step programs
_Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism_ (Big Book), –10
alcoholism:
first use of term,
medications for treatment of, , –16
alcohol withdrawal delirium, –26
Alertec, ,
Alexander, Josh,
Alzheimer's disease, ,
American Academy of Pain Medicine,
American Board of Addiction Medicine, , ,
American Medical Association (AMA), xi, , ,
American Pain Society,
American Psychiatric Association, ,
American Society for Reproductive Medicine,
American Society of Addiction Medicine (ASAM), , –67, , , –41
Patient Placement Criteria of,
amphetamines, ,
analgesics, , ,
_see also_ opiates and opioids
anger, –11
Antabuse (disulfiram), , –45,
anxiety,
anxiolytic drugs, ,
_see also_ benzodiazepines
arthritis, ,
assessment for treatment, –96
asthma, , , , , , , , , , , ,
Ativan,
_Atlantic,_ ,
attention deficit disorder (ADD), –6, –22
attention deficit hyperactivity disorder (ADHD),
autism spectrum disorder,
baclofen,
Baltimore Buprenorphine Initiative,
barbiturates, –86
bars and nightclubs, –80
_Basketball Diaries, The,_
bath salts, ,
Bayer,
behavior, –63
brain and, , ,
cognitive behavioral therapy and, , , ,
modification of,
behavior, intoxicated, –12
anger, –11
compulsion, , , , –11
obsession, , –12
Bell, Chris,
belladonna, ,
benzodiazepines, –86, , , –26
detoxification from, –29
Betty Ford Center, , ,
binge drinking, , , , ,
biomedical therapy, , , –98
_see also_ medications for addiction
bipolar disorder, , , , , , –60,
birth defects, ,
_see also_ fetal alcohol syndrome, fetal alcohol spectrum disorders
_Boston Medical and Surgical Journal,_
brain, xii, –4, , –58, , , , , –12, –34, , ,
alcohol and, , –61
behavior and, , ,
blood flow to,
development of, ,
executive function in, , ,
hippocampus in,
imaging technology and, , , , , , –92, ,
limbic lobe in,
marijuana and,
neurotransmitters in, _see_ neurotransmitters
"new normal" and,
prefrontal cortex in, ,
receptors in, , , , , ,
relapse and,
reward system of, –45, , , , , , , , , , , , , ,
specific addictions and,
stress system of, –61
of teenagers, , , –76, –92
white matter in, –92
brain damage, , , –74, , , ,
from fetal alcohol syndrome, –98
breathing,
buprenorphine (Subutex), , ,
Baltimore Buprenorphine Initiative,
buprenorphine + naloxone (Suboxone), –15, , –46, –98, –5, –13, , , ,
bupropion, , –28
Burkman, Lani J.,
_Business of Recovery, The,_
caffeine,
CAMA, _see_ Columbia University Center on Addiction and Substance Abuse
Campbell, Joanne, –49, ,
Campral (acamprosate), ,
Canadian Paediatric Society,
cannabis, _see_ marijuana
celebrities, x–xi, , , ,
Philip Seymour Hoffman, x–xi, , , ,
Celexa,
Centers for Disease Control and Prevention (CDC), –38,
Chaplin, Charlie, –20
Cherkis, Jason,
chlordiazepoxide,
choices,
Cigna,
citalopram,
_Clean and Sober,_
clonazepam,
clonidine, ,
cocaine, , –34, , , , , , –39
additives in,
alcohol and,
coke bugs and, –79
crack, myths about, –36,
Joanne's experience with, –49, ,
as legal medication, ,
length of average addiction to,
medications for addiction to, –45
codeine, ,
cognitive behavioral therapy (CBT), , , ,
Cohen, Peter,
cold turkey,
Columbia University, ,
Center on Addiction and Substance Abuse (CASA) at, x, , , , –75
_Come Back, Little Sheba,_
compulsion, , , , –11
corticotropin-releasing factor (CRF), –61,
counseling, _see_ therapy and counseling
counselors, xi, , , , ,
crack, myths about, –36
crack babies,
cravings, , , , , , , , , , ,
criminalization, xii, –2, –7, , , –30, –90, –92, –8,
criminal justice system:
mental health and,
and people with fetal alcohol syndrome, –201
teens and, –82
CT scans,
culture of disbelief,
_Cure, The,_
DARE,
date rape drugs,
_Days of Wine and Roses, The,_ –16
deaths, , , –38, , , , –12
from alcohol, ix–x, , , , , –71,
from heroin, , , , –36
in late-middle-agers, –38,
mixing drugs and,
from prescription drugs,
suicide, , ,
delirium tremens (DTs), –26
Demerol,
dependence,
addiction vs., –39
on alcohol, , –61
depression, , –101, , , , –66
manic, _see_ bipolar disorder
detoxification, , –32,
from alcohol, –26
from benzodiazepines, –29
evaluation in, –24
facilitation of treatment entry and,
facilities for, , , –30
from heroin, –27
individualized programs for, –22
licensed medical professionals and, –32
from opioids, –27
rehab clinics and, , , –30
severe intoxication and, –21
stabilization in,
from stimulants, –28
ten-day,
three steps to, –24
treatment vs., –23,
diabetes, , , , , , , , , , , , , , , ,
_Diagnostic and Statistical Manual of Mental Disorders,_ ,
diazepam (Valium), , , , –7
dimethyltryptamine (DMT),
dipsomania, –32
disulfiram, , –45,
DNA,
doctors, _see_ physicians
dopamine, , , , ,
Downey, Indio,
Downey, Robert, Jr.,
Down's syndrome,
Dresner, Amy,
driving:
drinking and, , , , , –80
marijuana and, ,
Drug Enforcement Agency (DEA), ,
drugs:
addiction to one as addiction to all,
alcohol as different from, –33
criminalization of, _see_ criminalization
deaths from,
Just Say No campaign and, –72,
prescription vs. illegal, –39
war on, , , , , ,
dual diagnoses, –70
ADHD in,
autism in,
bipolar disorder, , , –60
causality in, –68
depression in, , –101, , , , –66
discrimination and,
distinguishing between disorders in, –64
dysphoria in, –69
multiple risk factors in,
PTSD in, –70
Samantha's story, –66
self-medicating and, ,
supersensitivity in,
theories of, –69
treatment for, –61, , –67
dysphoria, –69
ecstasy, ,
EEG,
Eighteenth Amendment,
Eighth Amendment,
emergency care, , ,
emotions:
anger, –11
chemical component of,
pain,
stress, _see_ stress
Epictetus,
epigenetics, ,
escitalopram,
evaluation, in detoxification procedure, –24
evidence-based addiction treatment, x, xiii, –4, , , , , –117, , ,
assessment in, –96
biomedical therapy in, , , –98
centers for,
defined, –94
effective, key to, –97
individualized programs in, , , –6
insurance and,
Joanne's experience with, –49
maintenance in, _see_ managed maintenance
measuring success of, –15,
medical schools and, –12
medications in, _see_ medications for addiction
psychological therapy in, , , , , –102
rehab clinics and, xi, , –12
sociocultural therapy in, , –3
executive brain function, , ,
exercise, ,
family history of addiction, , , –89
Fanatrex (gabapentin), , ,
fetal alcohol effects (FAEs), ,
fetal alcohol syndrome (FAS), fetal alcohol spectrum disorders (FASDs), , –204
brain damage in, –98
criminal justice system and, –201
defining, –3
degrees of damage in,
IQ and, ,
lifelong problems caused by, –98,
predators and, –99
rise in,
signs of, –3
social skills and, –99
films, –16, –20
Finberg, Adam,
Flakka, ,
fluoxetine,
Food and Drug Administration (FDA), , –76, , , , ,
_Forbes,_
Ford, Betty,
formication,
Foster, Susan,
Freud, Sigmund, –33
Frieden, Tom,
GABA,
gabapentin (Gabarone), , ,
Gablofen,
gambling,
genetics, , , , –51, –55, , –62, , , ,
alcohol and, ,
Gralise (gabapentin), , ,
group talk therapy, xii, , –29,
_see also_ -step programs
_Half Nelson,_
hallucinogens,
Hamburg, Margaret A.,
_Handbook of Alcoholism Treatment Approaches, The_ (Hester and Miller),
harm reduction, –13
Harrison Narcotics Act, ,
Hazelden Foundation, –12, ,
health care:
Affordable Care Act and, , , –10, ,
emergency, , ,
insurance in, , , , ,
Medicaid, ,
Medicare, , –7
parity rules in,
Healy, Kearney,
heart disease, , , , , –51, , , , ,
heroin, , , –31, , , , , , , , ,
alcohol and,
deaths from, , , , –36
detoxification from, –27
as ghetto drug, –43
harm reduction and, –13
as legal medication, , ,
length of average addiction to,
medications for addiction to, , –13,
prescription drugs and, , , , , –38
pure forms of, , ,
rise in use of, –36,
high blood pressure (hypertension), , , , ,
HIV/AIDS, ,
Hoffman, Philip Seymour, x–xi, , , ,
homocysteine,
_Huffington Post,_ , , ,
hydrocodone (Vicodin), , ,
hypertension (high blood pressure), , , , ,
hypervigilance,
hypnotic drugs, ,
Indiana University,
inhalants, ,
Institute of Medicine,
insurance, , , , ,
_JAMA Psychiatry,_ ,
Joplin, Janis,
Justice Policy Institute,
Just Say No campaign, –72,
Keck School of Medicine, xiv,
Kelly, Kay, –98
Kemstro,
Kerlikowske, Gil, –4
Klonopin,
law-enforcement system, _see_ criminal justice system
_Leaving Las Vegas,_
Ledger, Heath, –77
Lexapro,
Librium,
lifestyle, xii,
Lioresal,
liver, –72, , ,
_Long Day's Journey into Night_ (O'Neill),
lorazepam,
Lortab,
Los Angeles County General Hospital,
Los Angeles County Psychiatric Emergency Services,
_Los Angeles Times,_
_Lost Weekend,_
LSD, ,
Magnan, Valentin,
managed maintenance, –43,
for cocaine dependence, –45
in extreme addiction cases, –44
for heroin dependence,
medications in, _see_ medications for addiction
psychiatric realities and, –48
support services in,
manic-depression, _see_ bipolar disorder
marijuana (cannabis), , , , , , –82, –87
alcohol and, ,
brain and,
driving and, ,
in edibles,
increase in use of,
legalization of, , –40, , ,
length of average addiction to,
medical, –85
medications for addiction to,
mental disorders and, –68
myths about, –41
overdose and, ,
in pill form, –84
regulation of, –41, –85,
tar level in,
testing for,
THC in, ,
Marinol,
McLellan, Thomas,
Medicaid, ,
medical consequences of addiction, –90
from alcohol, , –72,
from barbiturates and tranquilizers, –86
brain damage, _see_ brain damage
coke bugs, –79
from marijuana, –85
for men, , ,
neurological impairment, –72
from opioids, –77
paranoia, –80
psychiatric problems, –74
from stimulants, –80
suicide, , ,
for women, ,
Medical Daily,
medical schools, –12
Medicare, , –7
medications for addiction, xii, , , –29, , , –98, –5, –17, ,
AA and,
abstinence and, , –29
to alcohol, , –16
to cocaine, –45
cost of,
at Hazelden,
to heroin, , –13,
to marijuana,
myths about, –46
to opiates, , –13, , –43,
to stimulants, –17,
Suboxone, –15, , –46, –98, –5, –13, , , ,
men, ,
sperm count in,
mental disorders, , , , , ,
cannabis and, –68
rehab clinics and,
self-medicating and, ,
12-step groups and, –61
_see also_ dual diagnoses
mental retardation, , , ,
methadone, , , , ,
methamphetamine (meth), , , , , , ,
additives in,
meth mites and, –79
myths about, –36
Miller, Michael, –67
miscarriage, ,
Mishek, Mark (Hazelden CEO), ,
modafinil (Modavigil), , , –45
morphine, , , , , , –84,
motivation enhancement therapy (MET),
movies, –16, –20
MRI (magnetic resonance imaging), , , , , , ,
muscular dystrophy,
myths of addiction, xiii, –46
addiction is a problem of willpower and abstinence, –29
addicts should be punished, –30
alcohol is different from other drugs, –33
heroin is mainly a ghetto drug, –43
about hitting rock bottom, –44
about marijuana, –41
about meth and crack, –36,
people addicted to one drug are addicted to all of them,
about prescription drugs, –39
about treating addiction with medications, –46
N-acetylcysteine,
naloxone,
naltrexone, , , ,
Revia, ,
Vivitrol, , –43
Nanson, Josephine, –200
Narcotics Addict Rehabilitation Act,
Narcotics Anonymous (NA), ,
Nathan, Peter E.,
National Cancer Institute,
National Center on Addiction and Substance Abuse at Columbia University (CASA), x, , , , –75
National Institute on Alcohol Abuse and Alcoholism,
National Institute on Drug Abuse (NIDA), , , , –87, ,
National Institutes of Health, xi, ,
National Survey on Drug Use and Health (NSDUH), ix,
nervous system,
neurological impairment, –72
Neurontin (gabapentin), , ,
neurotransmitters, –52, , , , ,
dimethyltryptamine,
dopamine, , , , ,
GABA,
norepinephrine,
_New England Journal of Medicine,_
_New York Times,_ ,
Nickels, Jane,
nicotine,
norepinephrine,
nutrition, ,
Obama, Barack,
Obamacare (Affordable Care Act), , , –10, ,
obsession, , –12
Office of National Drug Control Policy,
Ohio State University,
older addicts, , , –38,
deaths in, –38,
Gus, –50
Olney, John,
ondansetron,
O'Neill, Eugene,
opiates and opioids, , , , , –43, , , –77
detoxification from, –27
length of average addiction to,
medications for addiction to, , –13, , –43,
pregnancy and, –4
prescription, _see_ prescription painkillers
temperance movement and,
overdose:
marijuana and, ,
_see also_ deaths
oxycodone (OxyContin, Percocet), , ,
painkillers, _see_ prescription painkillers
paranoia, –80
parasitosis, –79
paroxetine (Paxil), ,
PCP,
Percocet (oxycodone), , ,
PET scans,
Physician Health Program (PHP),
physicians, , , , , , , , –32, ,
treatment of addiction in, –55
pregnancy, –96
fetal alcohol syndrome and, _see_ fetal alcohol syndrome, fetal alcohol spectrum disorders
miscarriage and, ,
opiate addiction during, –4
prescription drugs,
AA and NA attitudes toward, , –61
myths about, –39
prescription painkillers, ix, –7, –39, –43, , , ,
amount prescribed,
heroin and, , , , , –38
myths about, –39
_Prescription Thugs,_
prevention, xiii, –79, ,
Proposition ,
Provigil, ,
Prozac,
psychedelics, ,
psychiatric problems, –74
psychiatric realities, –48
_Psychiatry,_
psychological therapy, , , , , –102
psychosis, ,
Rosenhan's experiment on perception of,
PTSD, –70
punishment, –30, –82
_see also_ criminalization; criminal justice system
quality of life, , –15,
Reagan, Nancy,
_Reefer Madness,_ ,
rehab clinics, rehab industry, ix, xiii, , –13, , , , , , , , , , ,
detoxification and, , , –30
evidence-based medicine and, xi, , –12
mental illness and,
one-month stays at,
personnel in, xi, , , –30, ,
profits of, xi, –11, ,
regulation of,
Russell's experience with, –19
teenagers in, –89
treatment protocols in, xi–xii
relapse, xiii, , , , , , –6, , , –34, , ,
brain and,
Hoffman and, ,
in opioid addicts, –43
preventing, _see_ managed maintenance
stress and, ,
respiration,
Revia, ,
_see also_ naltrexone
rock bottom, –44
Rosenhan, David,
Saskatoon _Star Phoenix,_
schizophrenia, , , , ,
Sciacca, Kathleen,
_Science Daily,_
science of addiction, –10
treatment and, _see_ evidence-based addiction treatment
_see also_ brain; genetics
sedatives, ix, ,
selective serotonin reuptake inhibitors (SSRIs),
self-medication, –100, , ,
self-stimulation, ,
seniors, _see_ older addicts
Seppala, Marvin,
sertraline, ,
sex, , ,
_Slate,_
social consequences, –88
criminalization, _see_ criminalization; criminal justice system
stigmatization, _see_ stigmatization
teens and, –82
sociocultural therapy, , –3
Sontag, Susan,
speed bugs, –79
sperm count,
spina bifida,
stabilization, in detoxification procedure, –24
Stewart, Potter,
stigmatization:
of addicts, –5, , , –23, , ,
of dual-diagnosis patients,
stimulants, ix, , , , , –80, –6, –22, –39,
detoxification from, –28
medications for addiction to, –17,
stress, –61, –3, ,
relapse and, ,
Suboxone, –15, , –46, –98, –5, –13, , , ,
Substance Abuse and Mental Health Services Administration (SAMHSA), , –32
treatment facility database of, –53
Substance.com,
Subutex, _see_ buprenorphine
suicide, , ,
supersensitivity,
superstition,
support services, in maintenance program,
Supreme Court,
Szalavitz, Maia,
taxes,
Taylor, Jill Bolte,
teenagers and young adults, , –92,
brains of, , , –76, –92
critical thinking about addiction and, –90
and family history of addiction, –89
high-risk categories and,
Just Say No campaign and, –72,
prevention programs for, –79,
rehab and, –89
risk factors for,
school-based programs and, –78
secrecy and,
social consequences and, –82
treatment for, –76, –85,
temperance movement and Prohibition, ,
THC (tetrahydrocannabinol), ,
oral,
therapy and counseling, xii, , , ,
cognitive behavioral therapy, , , ,
group talk therapy, xii, , –29,
psychological therapy, , , , , –102
sociocultural therapy, , –3
tiagabine, –45
Titan Pharmaceuticals,
tobacco, , ,
topiramate (Topamax), , , , , –45
tranquilizers, , –7
_see also_ benzodiazepines
treatment:
AA, _see_ Alcoholics Anonymous
changing landscape of, –10
detoxification vs., –23,
disconnect between addiction and,
for dual diagnosis patients, –61, , –67
in Europe, –92,
evidence-based, _see_ evidence-based addiction treatment
failure of, ix, x
former addicts in, xiii
maintenance in, _see_ managed maintenance
mandatory, , –85,
measuring success of, –15,
medications in, _see_ medications for addiction
for physicians, –55
in rehab clinics, _see_ rehab clinics, rehab industry
revenues generated from, ix
scientific, _see_ evidence-based addiction treatment
standardized terms for,
for teenagers and young adults, –76, –85,
U.S. standard for, –93
treatment programs, ix, , ,
assumptions about patients in,
choosing, –54,
laws on,
mandatory admission to, , –85,
personnel in, xi, , , –30, ,
12-step, _see_ -step programs
_see also_ rehab clinics, rehab industry
tweaking,
12-step programs, xii, –14, , –29, –45, , , , , , , –7, –11
medications and, , –61
_see also_ Alcoholics Anonymous
_28 Days,_
Ulleland, Christy, –94
United Healthcare,
University of California, Los Angeles, –5
University of California at San Francisco,
University of Southern California, xiv, ,
University of Washington,
University of Waterloo, –8
_USA Today,_
vaccines, ,
Valium, , , , –7
_Vanity Fair,_
veterans, –70,
Veterans Administration,
Vicodin (hydrocodone), , ,
_Victims of Alcoholism, The,_
violent behavior, –36
Vivitrol, , –43
_see also_ naltrexone
Volkow, Nora,
_Wall Street Journal,_
war on drugs, , , , , ,
war veterans, –70,
weather,
Wellbutrin,
willpower, xii, xiii, , –29, , –2, ,
withdrawal, , , , , –47
from alcohol, –26
_see also_ detoxification
Wilson, Bill, , –9, , , , , ,
women, , , , ,
pregnancy and, _see_ pregnancy
World Health Organization (WHO), , , –14,
Xanax, , , –7
Young, Craig,
Ziedenderg, Jason,
Zofran,
Zoloft (sertraline), ,
Zyban,
# ABOUT THE AUTHOR
Akikur Mohammad, M.D., is a specialist in addiction medicine and an award-winning academic who has practiced psychiatry, addiction medicine, and general medicine since 1998, when he opened his private practice in Los Angeles. He is board-certified in addiction medicine by the American Board of Addiction Medicine and in psychiatry by the American Board of Psychiatry and Neurology. Dr. Mohammad is Adjunct Clinical Professor at LAC/USC Medical Center, where he is active in teaching medical students and residents in addiction medicine and psychiatry.
He has been honored many times for his dedication to providing superior care and support to his patients and students. He received the Outstanding Teaching Award from USC in 2003, Outstanding Teaching Award from Residents in 2012, and Outstanding Service Award in 2006 for his work as the Associate Director at LAC/USC Medical Center Psychiatric Emergency Services.
Patient's Choice Award has honored him with the Top Psychiatrists of America Award several times since 2005. In 2011, Who's Who in America named Dr. Mohammad the Top Addiction Professional of the Year. In recognition of his thorough knowledge of addiction and psychiatric medicine, Dr. Mohammad has been the guest speaker at numerous regional and national conferences.
He has also appeared on various radio and television programs, including those on ABC, A&E, and MTV.
He founded and serves as the medical director for Inspire Malibu in Los Angeles, a science and evidence-based drug and alcohol treatment facility that focuses on dual-diagnosis and treating patients with addiction and co-occurring disorders. He established the center in 2010 to create an environment where his practice of evidence-based, scientifically advanced addiction medicine could be fully realized.
**Looking for more?**
Visit Penguin.com for more about this author and a complete list of their books.
**Discover your next great read!**
1. Cover
2. Praise for The Anatomy of Addiction
3. Title Page
4. Copyright
5. Dedication
6. CONTENTS
7. INTRODUCTION
8. Chapter 1: Addiction Is Preventable. Addiction Is Treatable.
9. Chapter 2: The Ten Biggest Myths of Addiction
10. Chapter 3: The Medical Illness of Addiction
11. Chapter 4: The Medical Consequences of Addiction
12. Chapter 5: The Process of Effective Treatment
13. Chapter 6: Painless Detox
14. Chapter 7: Maintenance and Relapse
15. Chapter 8: Dual Diagnosis
16. Chapter 9: Teens and Young Adults
17. Chapter 10: Fetal Alcohol Syndrome: Real and Preventable
18. Epilogue: Overcoming the Culture of Disbelief
19. BIBLIOGRAPHY
20. ACKNOWLEDGMENTS
21. INDEX
22. ABOUT THE AUTHOR
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3. Start
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Q&A: Dr. Kathryn Edwards provides The Hustler insight on coronavirus vaccine technology and distribution timelines
Edwards, professor of Pediatrics in the Division of Infectious Diseases at Vanderbilt, talks about the progress made with coronavirus vaccines in light of her own research and political pressures for vaccine distribution.
Vanderbilt University Medical Center (VUMC), pictured above, manages more than 2 million patients each year and is one of the largest academic medical centers in the Southeast, according to its website. (Hustler Multimedia/Truman McDaniel)
Ahmad Shiraz
Professor of Pediatrics Kathryn Edwards spoke Sept. 14 about coronavirus vaccines and safety and logistical procedures relevant to their development and public distribution. Edwards leads safety initiatives for vaccines at VUMC along with the Clinical Immunization Safety Assessment Project conducted by the Centers for Disease Control (CDC). She provides consultation to doctors who have questions about adverse events that have occurred upon administration of a vaccine. She also consults for a number of pharmaceutical companies on vaccine safety and is a member of the CDC's Advisory Committee on Immunization Practices (ACIP).
The Centers for Disease Control and Prevention (CDC) has sent out guidelines to public health officials in all 50 states regarding the distribution of two coronavirus vaccines as early as late October or early November. In response to the advice, health officials are expressing potential safety concerns associated with the telescoping of distribution timelines, and the CDC cites its guidelines as a small step in what could be a large-scale deployment effort. Traditionally, vaccines are tested over a number of years on different groups of people.
Vanderbilt Hustler: What do you make of the ambitious efforts to accelerate the initial release of the vaccine? What major obstacles are in the way of distributing the vaccine given this telescoping of the timeline?
Dr. Kathryn Edwards: I think it is fair to say that the timeline regarding the availability of these vaccines is unlikely to be anytime in October and is likely to be closer to the end of the year. It is hard to know what those timelines will be; it will depend upon whether a sufficient number of people have been enrolled or infected with the virus to be able to determine whether the vaccine is effective.
It will also depend upon the safety profile of the vaccine. Last week, one study was stopped for an adverse event and an evaluation is currently being conducted. At any time, one adverse event could stop the studies and halt what is going on. So, the timeline of the availability and licensure of the vaccine is a dynamic process.
The CDC's Advisory Committee on Immunization Practices (ACIP) and state health departments are closely working on the matter of distribution. In Tennessee, most of the H1N1 vaccines were distributed through Tennessee Health Departments, a model that worked quite well. Also, the providers have to be available so the logistics of vaccine distribution takes a lot of effort, and that is what the CDC is focused on.
What vaccines are being considered for distribution and any applicable vaccine policy?
There have been a number of different vaccines in phase 3 trials. The phase 3 trials that have had the most participants are those by Moderna, Pfizer and AstraZeneca. As a group, the pharmaceutical companies have released a document stating that all of them are dedicated to making a comprehensive safety assessment before their vaccines are licensed. Additionally, the Food & Drug Administration (FDA)'s guidance document requires that the vaccine be at least 50 percent effective in order to be considered for licensure.
What will surveillance of the vaccines look like for the Nashville populace?
A couple of things will be ongoing. There will be a prioritization of the vaccine administration; there are not enough doses for everyone. The CDC and the National Academy of Medicine are working on establishing a priority list in which high-risk groups will be administered the vaccine first. Healthcare providers will be targeted first along with other high-risk groups that are coming out later, and how all of them are accessed will be important.
As for assessing the actual impact of the vaccine in Nashville, that will have to be looked at in terms of which population groups are vaccinated. Equally important is to consider whether that will be the role of occupational health, Tennessee Health groups or existing surveillance networks, but the designation of this role is not clear.
When do you anticipate college students receiving the vaccines?
At this point, they are not on the prioritization list, but there may be situations where college students are a part of the evaluation. If there are outbreaks on campuses, there may be situations that arise in which studies could be done on disease prevention, but that has not been planned.
College students, as documented in the priority list by the ACIP and the National Academy of Medicine, are not in the high-risk groups that plan to be vaccinated. However, additional studies may be done with them although they are not presently being planned.
How are coronavirus vaccines developed in relation to the SARS-CoV-2 virus and what types of potential candidates are out there?
There have been over 200 candidates proposed with most still in preclinical trials, but many vaccines are beginning phase 1 and 2 trials and even phase 3 trials. Most of the vaccines are built on the concept that the recipient needs to develop antibodies to the spike protein, which is the little red blob you see on all of the figures of the SARS-2 virus.
The protein interacts with ACE receptors on the human cell, so most of the vaccines encourage the production of antibodies that shield the protein from the receptors and prevent infection of the cell. Some vaccines directly kill the whole virus, and a study is being done in China with this type of vaccine using human participants.
For the most part, RNA and DNA vaccines are leading the pack. With RNA vaccines, the mRNA of the spike protein is injected and the body uses the mRNA to make copies of the protein. Then, the antibodies can be developed to combat the copies and prepare the body against the virus. DNA vaccines work in a similar manner, except that the DNA of the protein is injected instead. In particular, both of these vaccines are easier to produce than other candidates, which has allowed them to garner increased attention amongst providers.
About the mRNA vaccines—Do you believe companies like Moderna and Pfizer have advanced far enough in phase 3 clinical trials for an Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA) without causing dangerous side effects?
We have assurance that both the companies and the FDA would not issue an EUA unless the vaccines are efficacious and safe. The mRNA vaccines are a new concept and they are also being studied heavily for viruses other than COVID. They are not as well- developed when you compare them with inactivated vaccines made for influenza, which have been around for decades and are known to be effective.
As for the concerns about side effects, I think we've accomplished a lot in the last nine months in terms of being able to assess thousands of participants, but you have to realize that the studies are not easy to do. Adverse events can happen but they may not be causally related, and that leads to a lot of confusion in assessing safety, especially because the reasons for the event have to be ascertained and if it indeed was related to the vaccine.
On top of that, other standards have to be assessed, including the reactions to the vaccine and its ability to produce an immune response without contributing to the onslaught of the disease itself. Inactivated vaccines were found to enhance disease in animal trials with SARS-1 and MERS, and now there is much caution taken in the study of these vaccines.
As a member of the CDC's Advisory Committee on Immunization Practices (ACIP), what research have you been engaged in related to coronavirus vaccines? What standards are adhered to when evaluating the efficacy and safety of these vaccines?
In general, all vaccines have to pass through clinical trials that test their ability to evoke an immune response and provide long-lasting protection against disease. As for the coronavirus vaccines, I'll speak for those that are in phase 3. All of the phase 3 vaccines have comprehensive and standardized safety assessments.
For example, in the Moderna vaccine trial, recipients are queried by their cell phones every day after they have received their dose and are asked to report their temperature and any symptoms such as fatigue, headaches or fever that are suggestive of coronavirus. Recipients are asked to be cultured for COVID-19 if they display symptoms, so there is a close monitoring with the recipients throughout the trial, and this will probably continue for a year after administration of the vaccine.
If there are adverse events that require hospitalization, then the safety committee of the study is informed, and the adverse event is investigated in relation to the study. Worrisome adverse events usually result in suspensions of the study to evaluate the adverse event. At Vanderbilt, we have a 24/7 safety assessment hotline to address adverse events that may occur upon the administration of a vaccine. Vanderbilt works with the CDC to provide a 24/7 answering service to healthcare providers if they have safety questions and part of my role and that of subject matter experts within the medical school is responding to those inquiries.
There was an issue with the supply of vaccines with H1N1 back in 2009. Do you foresee this issue with supply happening in the deployment of coronavirus vaccines, especially if the timeline is accelerated?
There won't be enough vaccine doses for everyone to receive it on the first day. There will have to be prioritization and clear guidelines to the community about how to access vaccines, especially for the targeted groups. I would imagine that vaccine delivery within the hospital setting and the allocation of recipients to the available doses would be tasked to occupational health services and the hospitals.
The more complicated issues pertain to how high-risk groups will be targeted. Will the focus be on community house settings where there are large burdens of disease? These logistics are being worked out by the CDC and local health departments, and they will be pivotal to an efficient deployment of the available supply of vaccines that we end up having.
Content has been edited for brevity and clarity.
Dr. Kathryn Edwards
VUMC
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High awareness but low uptake of PrEP among black and Hispanic transgender women in US study
There is high awareness but low uptake of HIV PrEP (pre-exposure prophylaxis) among black and Latina transgender women in Baltimore and Washington DC, investigators report in the Journal of Acquired Immune Deficiency Syndromes. Although 87% had heard of PrEP, only 17% had taken it. However, three-quarters of HIV-negative individuals who had never taken PrEP said they would be willing to do so.
Willingness to take PrEP was associated with a history of transactional sex. But greater knowledge of HIV and legal gender affirmation were both associated with reduced willingness to consider the therapy.
"We found high PrEP awareness but low uptake," note the authors. "The most commonly reported reason for being unwilling to take PrEP was concern about drug interactions with gender affirming hormones, a concern that is also a barrier to antiretroviral therapy adherence among transgender women living with HIV. In contrast to high levels of concerns about drug interactions among Black and Latina transgender women unwilling to take PrEP, few PrEP users reported experiencing interactions with hormones."
HIV prevalence among black and Latina transgender women in the United States is high, exceeding 50% in some studies, with other research showing that transgender women are especially vulnerable to HIV with annual incidence rates close to 3%. This group therefore has an urgent need for acceptable, accessible and effective HIV prevention interventions.
Although PrEP is highly acceptable and effective in men who have sex with men (MSM), clinical trials found disappointing efficacy among transgender participants, largely due to sub-optimal adherence, which was as low as 18%, and associated with the use of feminising hormones. However, PrEP was found to be effective in transgender women who adhered to their treatment.
A three-stage continuum of PrEP care has been identified: awareness, uptake and adherence. Significant racial and gender disparities have already been identified in the latter two stages. A team of investigators led by Dr Tonia Poteat of Johns Hopkins University wanted to establish a clearer understanding of PrEP awareness and uptake among black and Latina transgender women.
They therefore designed a study with 201 participants recruited in Baltimore and Washington DC. Data were gathered during in-depth interviews and focus groups.
The most commonly reported reason for being unwilling to take PrEP was concern about drug interactions with gender affirming hormones.
The participants were aged between 19 and 82 years (median: 34 years). The majority identified as black or African American (62%), with 27% identifying as Latina/Hispanic and 10% as indigenous.
There were high levels of poverty and unemployment.
Two-thirds had documents with their desired name and gender and 78% were currently taking gender-affirming hormones.
HIV prevalence was high (56%). Participants had a good knowledge of HIV and also perceived their HIV risk as high. Almost 80% reported transactional sex and 47% said they had had unprotected anal sex in the previous 12 months.
The participants had a high sense of transgender pride.
The majority (87%) had heard of PrEP. Although 80% of these individuals knew where to obtain the treatment, only 17% had actually done so.
However, despite low uptake, 75% of HIV-negative participants said they would be willing to take PrEP if it were available to them.
After adjustment for other factors that could skew the results, increased HIV knowledge was associated with reduced willingness to use PrEP (aOR = 0.32; 95% CI 0.10-0.97). "One potential explanation for this finding is that Black and Latina transgender women who are most knowledgeable about HIV transmission, may prefer other methods to reduce their HIV risk," suggest the authors. "Ad hoc post-test counseling discussions…revealed that [women] who had received past HIV prevention education felt that condoms were a better approach given their ability to prevent sexually transmitted infections."
Legal gender affirmation was also associated with lower willingness to consider PrEP (aOR = 0.10; 95% 0.01-0.811). The investigators suggest that this may be a by-product of the MSM-focused promotion of PrEP.
However, a history of transactional sex was associated with higher PrEP willingness (aOR = 5.79; 95% CI, 1.00-33.7). The authors suggest that transgender women with a history of sex work should be prioritised for PrEP implementation.
Among those not willing to take PrEP, the most commonly cited reasons were concern about interactions with hormones (65%), side-effects (47%) and having to take pills daily (41%).
Women who had taken PrEP were asked about their experience with it. The main concerns were a perception by others that they were taking medication because they were HIV positive (52%), side-effects (44%) and feeling that they were not at risk of HIV (38%). Of the experiences asked about, the least reported was interaction with hormones (15%). The investigators highlight the findings of recent clinical trials that there are no meaningful interactions between PrEP and feminising hormones.
Interviews provided further insights into possible reasons for reluctance to use PrEP. These included distrust of the medical establishment and an excessive focus on HIV by health institutions at the expense of other needs for transgender women. Participants also emphasised the importance of incorporating PrEP and HIV services within programmes that were responsive to wider community concerns, such as violence prevention, employment and housing. It was also apparent that staff providing services for transgender individuals were not always using correct names or pronouns and that stigma was eroding trust in healthcare providers.
"Awareness of HIV risk, awareness of and willingness to take PrEP may be necessary but [are] insufficient for PrEP uptake," conclude the authors. "Future research and interventions should address not only PrEP engagement and structural barriers that limit access, but also ensure that approaches are community-led, empowering, and affirming."
Poteat T et al. A gap between willingness and uptake: findings from mixed methods research on HIV prevention among Black and Latina transgender women. Journal of Acquired Immune Deficiency Syndromes, 2019. doi: 10.1097/QAI.0000000000002112. (Abstract).
PrEP programmes and uptake
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The State Programme Management Unit monitors and evaluates the progress of different services offered under various flagship schemes of National Health Mission across state. The prime focus is on tracking service delivery, trends of various health indicators across the state which helps in evaluating the overall efficacy of the NHM schemes at ground level. The data is collected, compiled & uploaded at block and district levels. This data plays a vital role in assessing the status of different health indicators and provides valuable insights on healthcare scenario of state. This status check and performance evaluation of the health indicators is of vital importance in policy formulation and helps a great deal in effective planning.
HMIS is a web- based MIS (Management Information System) of Ministry of Health & Family Welfare, Govt. of India, used to capture both in online and offline mode. It is an integration of health related information across ongoing programmes. Key health indicators are available at national/state/district/sub-district level. The reports of HMIS are also available in Public Domain.
MCTS is a centralized web based application for improving delivery of health care services to pregnant women and children up to five years of age. It ensures name based tracking of each beneficiary and monitoring service delivery for timely service delivery.
Data is captured at state, district, and block levels. The details captured include beneficiary identification, health provider details, services delivery details for both beneficiary mothers and children including immunization.
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University of Illinois Urbana-Champaign Home
Postnatal Changes of Water and Electrolytes of Rat Tissues (39545)
Sidney Solomon, Phyllis Wise, Albert Ratner
Electrolyte and water contents of heart, liver, kidney, spleen, ovaries, and testes were analyzed in rats between 2 and 100 days of age. Tissues were dried to constant weight to measure water content. Electrolyte content was determined using emission spectrophotometry. At all times, the liver contained the least amount of water; the kidney, spleen, and heart had an intermediate water content which were approximately equal to each other; the testes and ovaries contained the highest content of water. Water contents of the liver, heart, spleen, and kidney fall from 2 to 23 days of age and then remain constant at adult levels. The water contents of testes and ovaries remain relatively constant throughout the period studied. Tissue Na content of the heart, liver, kidney, spleen, and testes is high relative to K in the early postnatal period and decreases with age, reaching a minimum at 37-44 days of age. The most unexpected result of this study is the finding that the Na content of the ovary parallels that of the kidney papilla during all the periods examined. In both these tissues, Na content is low at 16 days of age and is higher thereafter. These results demonstrate a dissociation between maturation of water and electrolyte balance. This work was supported by two grants from the National Science Foundation, BMS-72-02344-A02 (to S.S.) and PCM-71-01528 (to A.R.). We also wish to thank Ms. Carolyn Sanborn and Ms. Susan Hathaway for their expert technical assistance.
Biochemistry, Genetics and Molecular Biology(all)
Dive into the research topics of 'Postnatal Changes of Water and Electrolytes of Rat Tissues (39545)'. Together they form a unique fingerprint.
Electrolytes Medicine & Life Sciences 100%
Dissociation Chemical Compounds 73%
Water Medicine & Life Sciences 68%
Testis Medicine & Life Sciences 52%
Ovary Medicine & Life Sciences 51%
Spleen Medicine & Life Sciences 45%
Amount Chemical Compounds 43%
Heart Medicine & Life Sciences 38%
Solomon, S., Wise, P., & Ratner, A. (1976). Postnatal Changes of Water and Electrolytes of Rat Tissues (39545). Proceedings of the Society for Experimental Biology and Medicine, 153(2), 359-362. https://doi.org/10.3181/00379727-153-39545
Postnatal Changes of Water and Electrolytes of Rat Tissues (39545). / Solomon, Sidney; Wise, Phyllis; Ratner, Albert.
Solomon, S, Wise, P & Ratner, A 1976, 'Postnatal Changes of Water and Electrolytes of Rat Tissues (39545)', Proceedings of the Society for Experimental Biology and Medicine, vol. 153, no. 2, pp. 359-362. https://doi.org/10.3181/00379727-153-39545
Solomon S, Wise P, Ratner A. Postnatal Changes of Water and Electrolytes of Rat Tissues (39545). Proceedings of the Society for Experimental Biology and Medicine. 1976 Nov;153(2):359-362. https://doi.org/10.3181/00379727-153-39545
Solomon, Sidney ; Wise, Phyllis ; Ratner, Albert. / Postnatal Changes of Water and Electrolytes of Rat Tissues (39545). In: Proceedings of the Society for Experimental Biology and Medicine. 1976 ; Vol. 153, No. 2. pp. 359-362.
@article{6d60e729a8e0467390735e2b9491758f,
title = "Postnatal Changes of Water and Electrolytes of Rat Tissues (39545)",
abstract = "Electrolyte and water contents of heart, liver, kidney, spleen, ovaries, and testes were analyzed in rats between 2 and 100 days of age. Tissues were dried to constant weight to measure water content. Electrolyte content was determined using emission spectrophotometry. At all times, the liver contained the least amount of water; the kidney, spleen, and heart had an intermediate water content which were approximately equal to each other; the testes and ovaries contained the highest content of water. Water contents of the liver, heart, spleen, and kidney fall from 2 to 23 days of age and then remain constant at adult levels. The water contents of testes and ovaries remain relatively constant throughout the period studied. Tissue Na content of the heart, liver, kidney, spleen, and testes is high relative to K in the early postnatal period and decreases with age, reaching a minimum at 37-44 days of age. The most unexpected result of this study is the finding that the Na content of the ovary parallels that of the kidney papilla during all the periods examined. In both these tissues, Na content is low at 16 days of age and is higher thereafter. These results demonstrate a dissociation between maturation of water and electrolyte balance. This work was supported by two grants from the National Science Foundation, BMS-72-02344-A02 (to S.S.) and PCM-71-01528 (to A.R.). We also wish to thank Ms. Carolyn Sanborn and Ms. Susan Hathaway for their expert technical assistance.",
author = "Sidney Solomon and Phyllis Wise and Albert Ratner",
journal = "Proceedings of the Society for Experimental Biology and Medicine. Society for Experimental Biology and Medicine (New York, N. Y.)",
publisher = "Society for Experimental Biology and Medicine",
T1 - Postnatal Changes of Water and Electrolytes of Rat Tissues (39545)
AU - Solomon, Sidney
AU - Wise, Phyllis
AU - Ratner, Albert
N2 - Electrolyte and water contents of heart, liver, kidney, spleen, ovaries, and testes were analyzed in rats between 2 and 100 days of age. Tissues were dried to constant weight to measure water content. Electrolyte content was determined using emission spectrophotometry. At all times, the liver contained the least amount of water; the kidney, spleen, and heart had an intermediate water content which were approximately equal to each other; the testes and ovaries contained the highest content of water. Water contents of the liver, heart, spleen, and kidney fall from 2 to 23 days of age and then remain constant at adult levels. The water contents of testes and ovaries remain relatively constant throughout the period studied. Tissue Na content of the heart, liver, kidney, spleen, and testes is high relative to K in the early postnatal period and decreases with age, reaching a minimum at 37-44 days of age. The most unexpected result of this study is the finding that the Na content of the ovary parallels that of the kidney papilla during all the periods examined. In both these tissues, Na content is low at 16 days of age and is higher thereafter. These results demonstrate a dissociation between maturation of water and electrolyte balance. This work was supported by two grants from the National Science Foundation, BMS-72-02344-A02 (to S.S.) and PCM-71-01528 (to A.R.). We also wish to thank Ms. Carolyn Sanborn and Ms. Susan Hathaway for their expert technical assistance.
AB - Electrolyte and water contents of heart, liver, kidney, spleen, ovaries, and testes were analyzed in rats between 2 and 100 days of age. Tissues were dried to constant weight to measure water content. Electrolyte content was determined using emission spectrophotometry. At all times, the liver contained the least amount of water; the kidney, spleen, and heart had an intermediate water content which were approximately equal to each other; the testes and ovaries contained the highest content of water. Water contents of the liver, heart, spleen, and kidney fall from 2 to 23 days of age and then remain constant at adult levels. The water contents of testes and ovaries remain relatively constant throughout the period studied. Tissue Na content of the heart, liver, kidney, spleen, and testes is high relative to K in the early postnatal period and decreases with age, reaching a minimum at 37-44 days of age. The most unexpected result of this study is the finding that the Na content of the ovary parallels that of the kidney papilla during all the periods examined. In both these tissues, Na content is low at 16 days of age and is higher thereafter. These results demonstrate a dissociation between maturation of water and electrolyte balance. This work was supported by two grants from the National Science Foundation, BMS-72-02344-A02 (to S.S.) and PCM-71-01528 (to A.R.). We also wish to thank Ms. Carolyn Sanborn and Ms. Susan Hathaway for their expert technical assistance.
JO - Proceedings of the Society for Experimental Biology and Medicine. Society for Experimental Biology and Medicine (New York, N. Y.)
JF - Proceedings of the Society for Experimental Biology and Medicine. Society for Experimental Biology and Medicine (New York, N. Y.)
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A pinched nerve can occur in a variety of ways. "You can get a pinched nerve with or without a slip in the bones of the spine," explains Summit spine surgeon Dr. David Strothman. "Slippage between spinal discs was traditionally treated with fusion surgery. However, researchers wanted to compare surgical outcomes for pinched nerves with outcomes for pinched nerves combined with disc slippage. Additionally, they wanted to compare both surgical outcomes to the outcomes of patients who opted not to have surgery.
When patients with pinched nerves and spondylolisthesis were treated with decompression and fusion surgery after failing three months of conservative treatments, they did markedly better than patients who never received surgery.
These surgical patients actually returned to their age-matched control levels of function by six months.
Patients with this condition who didn't have surgery didn't get better.
Patients who have pinched nerves uncomplicated by spondylolisthesis also did better with surgery than patients who receive only conservative treatments. However they did not do quite as well as patients with both pinched nerves and spondylolisthesis.
The research further showed that the six-month benefits of surgery were maintained for four years.
Article: What Are The Risk Factors For A Pinched Nerve?
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There are two well known synthetic thyroid hormones commonly administered by bodybuilders known as T-4 and T-3. (*See "Synthroid" and "Cytomel" for more info) However, some have not yet heard of another natural thyroid hormone called T-2 or Ldiiodothyronine.
The good new is that it is highly active and naturally occurring in some foods such as beef products. It is also non-prescription in many countries…so far. The bad news is that since it works quite well and offers individuals freedom of choice, it probably will not be legal for long.
So far, T-2 seems to be slightly more effective for fat oxidation (burning) than either T-4 or T-3 alone while offering an improved protein sparing-like result. This may be true. T-2 stimulates cellular mitochondria (cellular energy producers) more so than the cell nucleus. This means, unlike T-4 and T-3, T-2 is less likely to activate other cellular functions and more likely to focus upon increased metabolic rate or energy expenditure. Personal experience had shown an excellent synergistic effect between T-2, Norephedrine, and ephedrine plus caffeine. This is due to an interesting interplay between the substances.
1.T-2 increases resting metabolic rate by stimulating mitochondria expenditure of energy from calories. T-2 also increases Adenylate Cyclase production. Adenylate Cyclase is like a master enzyme in our bodies that positively effects most other fat burning and muscle building enzymes and hormones. As example, adenylate Cyclase elevation results in an increased rate of production of cyclic AMP (cAMP) from ATP. This forces fat cells to give their stores to be used as fuel for energy production. The result is an increase in fatty acid (fat) oxidation and a protein sparing effect because fat becomes favored muscle cell food.
2. Norephedrine and ephedrine mimic and stimulate the release of the adrenal hormones norepinephrine and epinephrine. Norephinephrine raises heart rate and epinephrine stimulates carbohydrate metabolism resulting in an increased metabolic rate, fatty acids release from lipocytes (fat cells), and a protein sparing effect. Caffeine simply prolongs the effect.
There is also the drug synergy that results from a T-4, T-3, T-2 stack to consider for overall effectiveness and reduced dosage requirements. Some athletes have reported an improved rate of fat loss and better lean tissue retention with this technique.
T-2 has a half-life of 4-6 hours. Due to this brief period of activity users reportedly divided dosages into 3-4 daily administrations to maintain constant circulating T-2 levels and the resulting metabolic rate increase.
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We sell only Danazol, the generic version of Danocrine*.
*We do not sell Danocrine brand.
What is Generic for Danocrine* used for?
Generic for Danocrine* (Danazol) is an androgen used to treat endometriosis, fibrocystic breast disease, and angioedema. Danazol works by decreasing the amount of certain hormones made by the ovaries. This medicine may also be used to treat other conditions as determined by your doctor.
What is the recommended dosage of Generic for Danocrine*?
The dosage of Generic for Danocrine* prescribed to each patient will vary. Always follow your physician's instructions and/or the directions on the prescription drug label.
Generic for Danocrine* may be taken with or without food.
What if you miss a dose of Generic for Danocrine*?
If your physician has instructed or directed you to take Generic for Danocrine* medication in a regular schedule and you have missed a dose of this medicine, take it as soon as you remember. However, if it is almost time for your next dose, then skip the missed dose and go back to your regular dosing schedule. Do not double the doses unless otherwise directed.
What if you overdose on Generic for Danocrine*?
Any medication taken in excess can have serious consequences. If you suspect an overdose of Generic for Danocrine*, seek medical attention immediately.
What are the side effects of Generic for Danocrine*?
Like other medicines, Generic for Danocrine* can cause some side effects. If they do occur, the side effects of Generic for Danocrine* are most likely to be minor and temporary. However, some may be serious and may require the individual to inform the doctor or visit the nearest hospital immediately.
It is pertinent to note that side effects of Generic for Danocrine* cannot be anticipated. If any side effects of Generic for Danocrine* develop or change in intensity, the doctor should be informed as soon as possible.
Generic for Danocrine* can cause side effects such as acne, weight gain, vaginal dryness, abnormal hair growth, sweating, and nervousness. This is not a complete list of all side effects. Do concur with your doctor and follow his directions completely when you are taking Generic for Danocrine*.
What other drugs could interact with Generic for Danocrine*?
It may be noted that drugs other than those listed above may also interact with Generic for Danocrine*.
Usually drug interactions occur when it is taken with another drug or with food. Before you take a medication for a particular ailment, you should inform the health expert about intake of any other medications including non-prescription medications, over-the-counter medicines that may increase the effect of Generic for Danocrine*, and dietary supplements like vitamins, minerals and herbal, so that the doctor can warn you of any possible drug interactions.
Generic for Danocrine* can interact with blood thinners.
What are the questions to ask your doctor before taking Generic for Danocrine*?
Is it possible for me to take Generic for Danocrine* with other drugs?
Should certain beverages, foods and other products be avoided when I take Generic for Danocrine*?
What are the possible drug interactions of Generic for Danocrine*?
How will Generic for Danocrine* work in my body?
How should Generic for Danocrine* be taken?
How to reduce the risk of Generic for Danocrine* drug interactions and side effects?
The health and medical information provided here is intended to supplement and not substitute for the expertise and judgment of your physician, pharmacists or other health care professional. It should not be understood to indicate that the use of Generic for Danocrine* is safe, appropriate or effective for you. Always consult your health care professional before using this, or any other, drug.
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Following completion of implant treatment, the patient must regularly and thoroughly clean the new teeth (restorations) as instructed by their dentist. A dental hygienist may also advise on care and maintenance of the restorations and natural teeth. Regular visits to your dentist are essential so that the health of the soft tissue, bone levels and the integrity of the restoration can be reviewed.
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Impact of Angiotensin Receptor Blocker Use on Overall Survival Among Patients Undergoing Resection for Pancreatic Cancer.
Pancreatic cancer has higher concentrations of angiotensin II compared with other cancers. This study sought to assess the effect of angiotensin II receptor blockers (ARBs) on survival of patients undergoing resection using a large, nationally representative dataset.Patients undergoing pancreatic cancer resection were identified in the Truven Health MarketScan database. Multivariable Cox proportional hazards regression was used to assess the effect of ARB use on overall survival.A total of 4299 patients were identified, among whom 479 (11.1%) filled a prescription for an ARB. Mean patient age was 54.5 years (SD = 8.6 years); 2187 (51.1%) were female. Exactly 49.4% (n = 2125) of patients had a Charlson comorbidity index >2 at the time of surgery (n = 2125, 49.4%) and 59.6% (n = 2563) underwent a pancreaticoduodenectomy. Kaplan-Meier estimates of survival at 1, 2, and 4 years were 62.8% (95% CI: 61.3-64.2%), 38.2% (95% CI: 36.6-39.8%), and 19.0% (95% CI: 17.1-21.0%), respectively. On multivariable analysis, ARB use was associated with a 24% decreased risk of death over the 5-year period in which patients were under observation (HR = 0.76, 95% CI: 0.67-0.87, p < 0.001).ARB use was associated with improved survival in patients undergoing resection of pancreatic cancer. Further research is required into the differential effect of ARBs in the treatment of pancreatic cancer.
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Browse through all the pages for caring your teeth at home. Your children should be taught quite early for oral hygeine and oral health so that they do not have teeth problems and bad breath in their later life. About half of all young Australian children have cavities in their teeth, according to The Australian Institute of Health and Welfare report (year 2011). The report also says that one-fifth of adults over 65 had none of their natural teeth left, with nearly half wearing dentures.
Taking care of our teeth and gums is utmost important, because dental hygiene helps prevent artery and heart diseases, besides fighting against bad breath and yellow teeth. It is important for our overall well being.
Our teeth are very important to us, as important as our heart. Teeth are meant to last the entire life. To keep them healthy is necessary for us through out our life. Teeth cavities, erosion of tooth enamel, etc are the main problem.
Tooth decay and tooth abscess can occur anywhere on the surface of teeth, but is most common on the chewing surfaces of teeth, near the gum and in-between teeth. It is believed that filling of tooth cavities costs more than the costs involved in heart disease.
Carbohydrate foods such as sugars can cause dental decay. Sweets, biscuits, pastries, buns, cakes, sticky breakfast bars, and other similar kinds of food stick in the teeth, providing food for bacteria that live in dental plaque.
The bacteria use sugars from residues of carbohydrates to multiply. They also ferment sugary food residues around teeth, producing acids that eats into tooth enamel, causing cavities.
The longer the time that residues are in contact with bacteria in teeth, the greater the amount of acid produced.
Saliva has some ability to counteract the effect of the acid produced by bacteria as it contains some minerals that help repair tooth enamel.
Foods that do not contain sugar and need to be chewed are useful, stimulating production of saliva. When less saliva is available on very hot days, one should not consume foods containing sugars that stick in the teeth.
According a study published in the July 2006 issue of The Journal of the American Dental Association, chewing gum containing xylitol, a sweetener with antimicrobial properties, temporarily suppresses bacteria that cause tooth decomposition. Results also showed that using chewing gum with a sorbitol-aspartame-saccharin sweetening mixture or not chewing any gum was ineffective in maintaining suppression of the tooth-decaying bacteria.
The American Academy of Periodontology has identified the most common myths about oral health.
When we brush, bleeding is normal. Wrong.
Bleeding gums are one of the signs of gum disease.
We brush teeth to remove food particles. Partly correct.
Daily brushing and flossing also keep the formation of plaque to a minimum, preventing periodontal disease.
Bad breath is caused by a lack of oral hygiene. Partly correct.
There are some bacteria on the tongue and throat that produce volatile sulfur compounds. Excessive sulfur compounds result in the bad breath.
Pregnant women do not need dental checkups. Wrong.
Periodontal health can affect the health of unborn baby. The periodontal disease during pregnancy may increase the risk of delivering a premature under-weight baby.
Our overall health does not depend on our oral health. Wrong.
When the gums are infected, periodontal bacterial byproducts can enter the blood stream and may result in heart disease, stroke and under-weight baby birth.
It is the amount of time that the sugar has contact with the teeth is im portant. Foods like sodas and candies remain in the mouth for longer periods of time, increasing longer exposure time of the teeth to the acids formed by oral bacteria from the sugars.
In elders, root degeneration crumble occurs due to reduced saliva production as a result of some drugs such as antihistamines, antidepressants, diuretics and sedatives.
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Always follow doctor's orders when giving your dog medicine.
Kennel cough, a collapsing trachea, bronchitis due to old age, and a heart enlargement, can all trigger a dry, hacking cough in dogs. A veterinarian might prescribe Hycodan, also known under the generic name hydrocodone bitartrate. Because this narcotic cough suppressant isn't approved for pet use by the Federal Drug Administration, it's essential to carefully follow your veterinarian's instructions to restore your pet companion's health.
Hycodan is administered orally at a typical rate of two to four times at the veterinarian-recommended dosage. The medicine acts through the brain, and can cause side effects, such as drowsiness, sedation, constipation, vomiting, nausea, drying of oral secretions and an upset stomach. These side effects can cause discomfort to your per companion and are best reported to your veterinarian.
Hycodan should not be mixed with antihistamines or other tranquilizers. Avoid giving your dog aged cheese products, because these can interact with the medication and trigger problems with your dog's blood pressure. Pregnant dogs, and dogs with pneumonia, blood disorder, or liver, kidney, or vascular disease, should not be given this medication. Dehydrated dogs, very young and old dog, and dogs with toxic or obstructive diarrheas should also steer clear of Hycodan.
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University Radiologists are physicians that have focused training in the interpretation and evaluation of imaging procedures such as Cat Scans and MRIs. Within our diverse group, we have sub-specialized, fellowship trained physicians, meaning your doctor will have received additional training in special areas of imaging such as Neuroradiology, Chest Imaging, Cardiac PET, and Noninvasive Interventional Radiology. For you, the patient, this provides access to a team of experts no matter what imaging procedure we interpret for you or what facility you visit.
Unlike other specialists, when you arrive for a routine radiology procedure it is likely you will not see a radiologist before you leave. You will, however, work with highly trained technologists and nurses to take "pictures" that will later be reviewed and interpreted by a University Radiologist. The radiologist will then complete a full report of any findings to be sent to your doctor. Typically reports are sent to your doctor's office within 1-2 days of your exam.
If you are scheduled for a specialized or invasive radiology procedure you may be consulted by a radiologist prior to your exam. Upon completion and interpretation of your procedure, the radiologist will provide a full report to your doctor's office within 1-2 days.
Outstanding patient care is at the forefront of our values and has created a unique environment that approaches the patient experience from a different perspective. At University of Tennessee Outpatient Center in Turkey Creek, you may ask to speak directly to a radiologist if you have questions about any procedures or are concerned about your results. Our physicians are dedicated to getting your results to you faster and have committed themselves to providing a full report to your doctor's by the close of the business day.
If you are interested in having your CT, Nuclear Medicine, Digital X-Ray, completed at University of Tennessee Outpatient Center in Turkey Creek, you may bring in your doctor's referral for your imaging procedure to our office even if you are scheduled somewhere else. Please call our office at 865-777-6700 if you would like to make an appointment.
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Experimental Therapeutics, Molecular Targets, and Chemical Biology
Aurora-A Regulation of Nuclear Factor-κB Signaling by Phosphorylation of IκBα
Paraskevi Briassouli, Florence Chan, Kay Savage, Jorge S. Reis-Filho and Spiros Linardopoulos
Paraskevi Briassouli
Florence Chan
Kay Savage
Jorge S. Reis-Filho
Spiros Linardopoulos
DOI: 10.1158/0008-5472.CAN-06-2272 Published February 2007
The Aurora-A/STK15 gene encodes a kinase that is frequently amplified in cancer. Overexpression of Aurora-A in mammalian cells leads to centrosome amplification, genetic instability, and transformation. In this study, we show that Aurora-A activates nuclear factor-κB (NF-κB) via IκBα phosphorylation. Inhibition of endogenous Aurora-A reduces tumor necrosis factor α (TNFα)–induced IκBα degradation. We analyzed primary human breast cancers, and 13.6% of samples showed Aurora-A gene amplification, all of which exhibited nuclear localization of NF-κB. We propose that this subgroup of patients with breast cancer might benefit from inhibiting Aurora-A. We also show that down-regulation of NF-κB via Aurora-A depletion can enhance cisplatin-dependent apoptosis. These data define a new role for Aurora-A in regulating IκBα that is critical for the activation of NF-κB–directed gene expression and may be partially responsible for the oncogenic effect of Aurora-A when the gene is amplified and overexpressed in human tumors. [Cancer Res 2007;67(4):1689–95]
Aurora-A
IκBα
The Aurora-A gene (also known as Aurora 2, STK15, BTAK, mouse Stk6, or Iak1) encodes a centrosome-associated serine/threonine kinase ( 1). Aurora-A is the human homologue of the aurora protein kinase from Drosophila, Ipl1 kinase is from Saccharomyces cerevisiae ( 2, 3) and is a member of a family of Aurora kinases that includes Aurora-B and Aurora-C (STK13; refs. 4– 6). In somatic cells, Aurora-A mRNA, protein, and kinase activity levels are cell cycle–regulated ( 7, 8). The Aurora-A gene is located on human chromosome 20q13—a region that has been found to be amplified in a variety of human tumors ( 9), including >50% of primary colorectal cancers, 6% to 18% of primary breast cancers, as well as in breast, ovarian, colon, prostate, neuroblastoma, and cervical tumor cell lines ( 4, 5). Ectopic expression of Aurora-A in NIH3T3 and Rat1 fibroblasts results in abnormal centrosome amplification and cellular transformation ( 4, 5). However, overexpression of Aurora-A in primary mouse embryo fibroblast (MEF) cells does not induce transformation, indicating that Aurora-A alone is insufficient to induce carcinogenesis ( 10). In agreement, a transgenic mouse designed to overexpress Aurora-A in the mammary epithelium did not develop tumors ( 11).
A polymorphism in the Aurora-A gene was recently identified and showed preferential amplification associated with increased aneuploidy in colon cancers ( 12). Data from 15 case-control studies involving colon, breast, ovarian, prostate, lung, esophageal, and non–melanoma skin cancer confirmed that the Aurora-A variant Phe31Ile is a low-penetrance cancer susceptibility allele affecting multiple cancer types ( 13). We have shown that Aurora-A binds the E2 ubiquitin ligase UBE2N in vitro and in vivo ( 12). UBE2N has been previously shown to be involved in nuclear factor-κB (NF-κB) activation ( 14). The "classical" activation of NF-κB involves the IκB kinase complex [IKK-α and IKK-β and IKKγ (NEMO)] responsible for phosphorylation of IκB. Normally, IκB sequesters NF-κB in the cytoplasm ( 15), but when phosphorylated, IκB is targeted for proteolysis resulting in the nuclear translocation and activation of NF-κB complexes. A number of studies have shown that NF-κB plays a key role in the regulation of cell proliferation, inflammation, and apoptosis ( 16– 20). Aberrantly active forms of NF-κB have been described in a variety of primary tumors and transformed cell lines ( 21). The binding of Aurora-A to UBE2N and the involvement of UBE2N in NF-κB activation prompted us to investigate the role of Aurora-A in the NF-κB pathway. We found that Aurora-A mediates the phosphorylation of IκBα leading to NF-κB activation. Therefore, Aurora-A may play an important function in regulating the activation of NF-κB–directed gene expression leading to carcinogenesis and drug resistance. Our results suggest a novel approach for cancer therapy, based on combining the down-regulation of NF-κB via the inhibition of Aurora-A with the administration of chemotherapeutic agents.
Cell culture, transfections, and inhibitors. HeLa cells, MCF7 cells, and IKKβ−/− MEFs were maintained in DMEM supplemented with 10% FCS glutamine, penicillin, and streptomycin at 37°C and 5% CO2. Cell clones stably transfected with Aurora-A were selected in 400 μg/mL of G418. For transient transfections, LipofectAMINE 2000 reagent (Invitrogen, Carlsbad, CA) was used according to the instructions of the manufacturer and cells were harvested 36 h post-transfection unless otherwise indicated. For drug sensitivity assays, 8 μmol/L of cisplatin was added for 24 h unless otherwise indicated, 50 μmol/L of PD98059 (Calbiochem, San Diego, CA), 50 μmol/L of LY294002 (Calbiochem), 1.6 μmol/L of VX-680 (10× IC50; a gift from Chroma Therapeutics, Oxford, United Kingdom), and 1.5 μmol/L of IKKβ inhibitor IKKIV (Calbiochem) were incubated for 24 h, as well as 50 ng/mL of tumor necrosis factor α (TNFα; PeproTech) for 10 min prior to harvesting. Cells were treated with 10 nmol/L of Calyculin A (Sigma, St. Louis, MO) for 5 min prior to harvesting, and 10 μmol/L of MG132 (Sigma) for 1 h before harvesting.
Luciferase reporter assays. For NF-κB luciferase assays, cells were seeded at 70% confluency in six-well plates and transfected with LipofectAMINE 2000 reagent according to the instructions of the manufacturer (Invitrogen). One microgram of NF-κB–dependent luciferase reporter plasmid 3XκBL was cotransfected with 1.5 μg of corresponding plasmid as indicated in the figure legends. For luciferase assays, cells were lysed in Reporter lysis buffer (Promega, Madison, WI), and activity was measured with luciferase assay reagent (Promega) according to the instructions of the manufacturer. Normalization for transfection efficiency was done by cotransfecting 500 ng of a β-galactosidase expression plasmid (pGK-β-gal) and measuring β-galactosidase activity.
Immunoblotting and antibodies. Cells were lysed in lysis buffer [50 mmol/L Hepes (pH 7.5), 250 mmol/L NaCl, 0.5% NP40 with protein inhibitors], incubated on ice for 30 min and centrifuged at 20,000 × g for 15 min. The supernatant was collected and protein concentration was determined with Pierce BCA assay reagent. For immunoblotting, samples were separated on Novex Tris-Glycine gels (Invitrogen) followed by electrophoretic transfer onto polyvinylidene difluoride membrane (Millipore, Billerica, MA) and blocked with 5% nonfat milk. Incubation with primary antibodies was carried out at 4°C. Antibodies used were IAK1 (Aurora-A; BD Transduction Laboratories), V5 (PK; Serotec), α-tubulin and Flag (Sigma), PARP, Bcl-xL, and phospho-Ser32/Ser36 IκBα (Cell Signaling Technology), cyclin D1 and p53 (Oncogene), total IκBα, ezrin, and MYC (Santa Cruz Biotechnology, Santa Cruz, CA).
RNA-mediated interference. RNA-mediated interference for down-regulating Aurora-A expression was done by the transfection of double-stranded RNA oligonucleotides (40 mmol/mL stock) with LipofectAMINE 2000. Seventy-two hours after transfection, cells were collected. The sequences for the small interfering RNA (siRNA) against Aurora-A and the corresponding inverted siRNA were: Aurora-A forward, 5′GGCUACAGCUCCAGUUGGAdTdT; Aurora-A reverse, 5′-UCCAACUGGAGCUGUAGCCdTdT; inverted Aurora-A forward, 5′ AAAGGTTGACCTCGACATCGGdTdT; inverted Aurora-A reverse, 5′ dTdTCCGATGTCGAGGTCAACCTTT.
Electrophoretic mobility shift assay. Nuclear extracts from HeLa cells were prepared using the hypotonic lysis method. Briefly, 5 μg of nuclear extracts was incubated with 32P-radiolabeled NF-κB oligonucleotide (5′-AGTTGAGGGGACTTTCCCAGG-3′) for 30 min at room temperature and the DNA/protein complex was separated on a nondenaturing 6% polyacrylamide gel. Gels were dried and exposed to Kodak Biomax film.
Site mutagenesis. QuikChange mutagenesis was done as described in the instructions of the manufacturer. Briefly, complementary oligonucleotide primers containing the mutation were designed and used in a PCR reaction with Pfu polymerase and the wild-type plasmid DNA as a template (IκBα S32A, 5′-CCGCCACGACGCCGGCCTGGAC-3′; IκBα S36A, 5′-CGGCCTGGACGCCATGAAAGA-3′). The reaction mixture was then digested with the restriction endonuclease DpnI for 1 h at 37°C to remove the template DNA and transformed into competent JM109 bacteria. DNA prepared from the resulting colonies was sequenced to detect the presence and integrity of the mutation.
Immunohistochemistry. p65 immunostaining on the tissue microarray was done using a rabbit polyclonal anti–NF-κB p65 antibody (Zymed). Slides were dewaxed in xylene (twice for 5 min) and cleared through a series of graded alcohols. Antigen retrieval was done by microwaving for 18 min in 0.01 mol/L citrate buffer (pH 6.0). Endogenous peroxidase activity was blocked using Envision + peroxidase blocking solution (Dako, Glostrup, Denmark). Sections were rinsed in 0.05% TBS/Tween 20 buffer (pH 7.4) and Dako serum-free protein block was added for 5 min. Sections were drained and the primary antibody (1:100 in TBS) was applied for 30 min. Sections were rinsed in TBS/Tween for 5 min. The antibody binding was detected using the Dako Envision/HRP system.
Chromogenic in situ hybridization. Chromogenic in situ hybridization (CISH) was used to allow a direct evaluation of copy number changes in the neoplastic cells of 57 invasive breast carcinomas. The probes used were generated in-house and made-up of two contiguous, fluorescence in situ hybridization–mapped and sequence-verified bacterial artificial chromosomes (RP11-158O17 and RP11-120E08), which map to 20q13.31 (∼54.3 and ∼54.5 Mb) according to the Ensembl v37 of the human genome. 3 The in-house probe was generated, biotin-labeled, and used in hybridizations according to the protocol described ( 22). Heat pretreatment of deparaffinized sections were incubated for 15 min at 98°C in CISH pretreatment buffer (SPOT-light tissue pretreatment kit; Zymed) and digested with pepsin for 6 min at room temperature according to the instructions of the manufacturer. An appropriate gene-amplified breast tumor control was included in the slide run. Signals were evaluated at ×400 and ×630, and 60 morphologically unequivocal neoplastic cells were counted for the presence of the gene probe signals. Amplification was defined as more than five signals per nucleus in >50% of cancer cells, or when large gene copy clusters were seen ( 22). Signals were interpretable in 44 cores. Immunohistochemistry and CISH were done in duplicate on serial sections of the MaxArray Human Breast Carcinoma Tissue MicroArray (Zymed).
Cell viability assay. The effects of cisplatin on cell viability was analyzed with the colorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay (Sigma) according to the instructions of the manufacturer. HeLa cells were plated in 96-well plates at 7,500 cells per well in triplicate 24 h before transfection with the appropriate siRNA primer. Twenty-four hours after transfection, the cells were treated with a range of 0 to 200 μmol/L of cisplatin for 55 h. The absorbance was measured at 570 nm using the Wallac VICTOR2 1420 Multilabel Counter (Perkin-Elmer).
Aurora-A regulates NF-κB via IκBα phosphorylation. To gain insight into the involvement of Aurora-A in the regulation of NF-κB, we did a series of experiments using HeLa cells. We selected this cell system for two reasons. First, in HeLa cells, the cell cycle kinetics and oncogenic activity of Aurora-A have been extensively characterized. Induction of Aurora-A leads to centrosome amplification and aneuploidy ( 23, 24). Second, these cells are TNFα-responsive and the IκBα degradation pathway is intact ( 25, 26). HeLa cells were cotransfected with a NF-κB–dependent luciferase reporter plasmid together with plasmids expressing Aurora-A, UBE2N, or the catalytically inactive mutant of UBE2N (C87A; ref. 14). Assays of luciferase activity in lysates showed that overexpression of Aurora-A or UBE2N alone, or in combination, had a dramatic effect in increasing NF-κB activity in comparison to the vector control ( Fig. 1A ). The UBE2N (C87A) mutant alone or in combination with Aurora-A did not activate NF-κB.
Regulation of NF-κB activity by Aurora-A. A, reporter gene analysis with the 3XκBL and the pGK-β-galactosidase reporter plasmids. Transient transfection assays in HeLa cells with empty vector or plasmids expressing Aurora-A, UBE2N dominant-negative mutant (C87A), UBE2N, Aurora-A with UBE2N (C87A) mutant, or Aurora-A with UBE2N and assayed for NF-κB–dependent luciferase and β-galactosidase activation. B, HeLa cells were cotransfected with plasmids expressing Aurora-A kinase inactive (KI), Aurora-A alone or in combination with the Aurora kinase inhibitor VX-680, Aurora-A COOH-terminal catalytic domain, or empty vector control together with NF-κB luciferase reporter plasmid. Luciferase activity in the extracts was measured as in (A). C, NF-κB DNA binding activity was examined by electrophoretic mobility shift assay in lysates from HeLa cells transfected with empty vector or plasmids expressing Aurora-A (2 and 4 μg), Aurora-A COOH-terminal, and kinase inactive (KI). p65 was used as positive control.
We next investigated whether Aurora-A kinase activity was necessary for NF-κB activation. A kinase-inactive form of the enzyme (Aurora-A KI, K162M; ref. 27) or HeLa cells treated with the Aurora kinase inhibitor VX-680 ( 28) were unable to activate NF-κB, indicating that the kinase activity of Aurora-A was required for NF-κB regulation ( Fig. 1B). The use of the Aurora-A KI rules out also the possibility that this result was due to a mitotic failure rather than specific activation of NF-κB by Aurora-A because the inactive form of Aurora-A also causes mitotic defects ( 23). In electrophoretic mobility shift assays, a clear dose-response elevation of NF-κB DNA-binding activity was observed after transfection of plasmid expressing Aurora-A in HeLa cells ( Fig. 1C). By contrast, use of plasmids expressing the Aurora-A COOH-terminal catalytic domain or kinase-inactive Aurora-A, showed no effect on NF-κB DNA-binding activity ( Fig. 1C). To exclude the possibility that Aurora-A regulates other transcription factors, we examined its effect on activator protein 1 (AP-1) transcriptional activation. Reporter assays were conducted using AP-1 luciferase reporter plasmid cotransfected with a plasmid construct expressing Aurora-A or siRNA against Aurora-A in HeLa cells. Only c-Jun showed a dramatic effect on AP-1 activation (Supplementary Fig. S1).
To determine whether Aurora-A regulates NF-κB via phosphorylation of IκBα, HeLa cells and HeLa cells overexpressing Aurora-A were used. Figure 2A shows a significant increase in the phosphorylation of IκBα in cells overexpressing Aurora-A compared with the control cells. A dramatic reduction of phosphorylation of IκBα was observed when the Aurora kinase inhibitor VX-680 ( 28) was used alone or in combination with the IKKβ-specific inhibitor IKKIV ( 29) in the Aurora-A–overexpressing cells. These results indicated that IKKβ may be important in Aurora-A–mediated IκBα phosphorylation. To investigate these observations, we used MEFs derived from IKKβ-deficient mice. No phosphorylation of IκBα was observed when Aurora-A was overexpressed in these cells ( Fig. 2B). In contrast, increased levels of IκBα phosphorylation were observed when Aurora-A was cotransfected with IKKβ, compared with IKKβ transfected alone ( Fig. 2B). To confirm these results, the proteasome inhibitor MG132 was used to inhibit IκBα degradation.
Aurora-A phosphorylation of IκBα. A, HeLa cells transfected with plasmids expressing Aurora-A and IKKβ, and treated with Aurora (VX-680) and IKKβ (IKKIV) inhibitors alone or in combination. Cell lysates were analyzed for phosphorylated IκBα (S32/36) levels by immunoblotting. Aurora-A, IKKβ, and ezrin antibodies were used as controls. B, IKKβ-deficient MEFs were transfected with empty vector or plasmids expressing Aurora-A, IKKβ, or in combination in the presence or absence of proteasomal inhibitor MG132. Cell lysates were analyzed for phosphorylated IκBα (S32/36) levels by immunoblotting. Aurora-A, IKKβ, and ezrin antibodies were used as controls.
Aurora-A mediates phosphorylation of IκBα at Ser32 and Ser36. To assess if Aurora-A–mediated phosphorylation of IκBα affects Ser32 and Ser36, single (S32A or S36A) and double (S32/36A) phosphorylation site mutants of IκBα were used. HeLa cells were transiently cotransfected with MYC-tagged Aurora-A and PK-tagged wild-type IκBα, S32A-IκBα, S36A-IκBα, or S32/36A-IκBα. IκBα phosphorylation was detected with anti–phospho-S32/36-IκBα antibody ( Fig. 3A, top ). The lower band seen in all the lanes represents the endogenous phosphorylated IκBα, whereas the upper band, present only in the PK-IκBα lane, is the exogenous IκBα phosphorylated on both Ser32 and Ser36. Neither of the upper two bands were observed with the S32A/36A mutant. This implies that Aurora-A induces the phosphorylation of IκBα at both the Ser32 and Ser36 residues. To test these observations in a different cell system, we transfected Aurora-A into MCF7 breast cancer cells. We showed that overexpression of Aurora-A results in increased levels of phosphorylated IκBα ( Fig. 3B).
Aurora-A–induced phosphorylation of IκBα at Ser32/Ser36 and its inhibition rescues TNFα-induced IκBα degradation. A, HeLa cells cotransfected with plasmids expressing Aurora-A and empty vector, PK-IκBα, PK-IκBα-S32A, PK-IκBα-S36A, or PK-IκBα-S32/36A, respectively. Cell lysates were analyzed for phosphorylated IκBα (S32/36) levels by immunoblotting (top). Anti-IκBα antibody shows the endogenous and exogenous IκBα (middle). Tubulin and MYC-Aurora-A used as controls (bottom). B, in MCF7 and MCF7 overexpressing MYC–Aurora-A cells, the levels of S32/S36-phosphorylated IκBα were assessed by immunoblotting. Bottom, levels of IκBα and Aurora-A, respectively. C, HeLa cells with or without TNFα were treated with VX-680 and IKKIV inhibitors towards Aurora-A and IKKβ, respectively, and total IκBα levels were assessed by immunoblotting. The relative levels of IκBα in Aurora-A and IKKβ-inhibited and control cell lysates were quantified by densitometry (bottom). Tubulin provides a loading control. D, HeLa cells cotransfected with plasmids expressing Aurora-A or empty vector and treated with MEK1 (PD98059), PI3K (LY294002), Aurora (VX-680), and IKKβ (IKKIV) inhibitors, respectively. Cell lysates were analyzed for phosphorylated IκBα (S32/36) and Aurora-A levels by immunoblotting. Ezrin used as a loading control.
Next, we examined the possible signaling pathways linking Aurora-A to NF-κB activation. Activation of NF-κB in response to TNFα is mediated through phosphorylation and activation of the IKK complex, which in turn, phosphorylates and inactivates IκBα ( 29). Dominant-negative forms of NF-κB–inducing kinase have been shown to inhibit this pathway by preventing degradation of IκBα ( 30). The inhibition of Aurora-A in HeLa cells using the small molecule inhibitor VX-680 partially rescued TNFα-induced IκBα degradation, indicating that Aurora-A may be one of the TNFα-induced pathways regulating NF-κB ( Fig. 3C). Similar results were obtained when specific siRNA towards Aurora-A and IKKβ were used, simultaneous depletion of the proteins had an additive effect on inhibiting TNFα-stimulated NF-κB activation (Supplementary Fig. S2). An additional pathway implicated in NF-κB activation by TNFα involves activation of the PI3K/AKT cascade. In HeLa cells, treatment with the well-characterized PI3K inhibitor, LY294002 ( 31), did not prevent phosphorylation of IκBα in response to Aurora-A ( Fig. 3D). MEK1 has also been shown to activate NF-κB via IκBα phosphorylation. Similar negative results were obtained when using the MEK1 inhibitor PD98059 ( 32). These results indicate that Aurora-A was not involved in the regulation of the PI3K or MEK1 signaling pathways that lead to IκBα phosphorylation. In contrast, the IKKβ inhibitor IKKIV and the Aurora kinase inhibitor VX-680 considerably reduced the hyperphosphorylated IκBα form ( Fig. 3D).
Invasive breast carcinomas with Aurora-A gene amplification show NF-κB nuclear expression. Numerous studies have documented elevated NF-κB DNA-binding activity, in a hormone-independent manner, in tumor formations in human mammary carcinoma and primary breast cancer cell lines ( 33). The mechanisms that underlie the elevated expression of NF-κB are not clear. Therefore, to assess the association between Aurora-A and NF-κB, we investigated the presence of Aurora-A gene amplification by means of chromogenic in situ hybridization ( 22) and p65 nuclear localization in 44 invasive breast carcinomas. Aurora-A amplification was found in six (13.6%) cases (5 of 38 invasive ductal carcinomas, 1 of 5 medullary carcinomas, and 0 of 1 invasive mucinous carcinoma), all of which showed NF-κB nuclear expression ( Fig. 4A–D ). Aurora-A amplification significantly correlated with p65 expression (P = 0.0289, Fisher's exact test). p65 nuclear expression was more pervasive, being found in 19 of 38 (50%) cases without Aurora-A amplification. The cases exhibiting p65 nuclear localization without Aurora-A amplification may be due to other factors such as ER or ErbB2 status.
Aurora-A amplification was associated with NF-κB nuclear localization. A, invasive ductal carcinoma with Aurora-A gene amplification. Presence of more than five signals and signal clusters in the nuclei of neoplastic cells (original magnification, ×630). B, invasive ductal carcinoma without Aurora-A gene amplification. Presence of two to three copies of Aurora-A gene in the nuclei of the neoplastic cells (original magnification, ×630). C, p65 strong nuclear and cytoplasmic expression in samples with Aurora-A gene amplification (original magnification, ×200). D, p65 expression was restricted to the cytoplasmic compartment of neoplastic cells (original magnification, ×200).
Aurora-A–mediated regulation of NF-κB affects chemotherapeutic efficacy. Cisplatin is a DNA-damaging agent widely used in cancer therapy and its clinical efficacy relies on its ability to trigger apoptosis ( 34). In response to chemotherapeutic reagents such as cisplatin, NF-κB is up-regulated, leading to the expression of antiapoptotic genes such as Bcl-xL ( 35). Furthermore, NF-κB inhibition has been reported to increase the efficacy of chemotherapeutic drugs ( 36– 38). HeLa cells were chosen for the following experiments because they are sensitive to drugs such as cisplatin ( 39). Indeed, in HeLa cells, NF-κB was induced in a dose-dependent manner following cisplatin treatment ( Fig. 5A ). Despite NF-κB activation, however, cells die indicating that this survival signal was not strong enough to abrogate apoptotic pathways. To examine whether the down-regulation of NF-κB via Aurora-A inhibition sensitizes HeLa cells to cisplatin, we transiently transfected HeLa cells with a reporter NF-κB expression plasmid and siRNA towards Aurora-A. Aurora-A–depleted cells treated with cisplatin severely suppressed NF-κB activation ( Fig. 5B). In a cell viability assay, we sought to determine whether Aurora-A depletion in HeLa cells potentiates the effect of cisplatin. HeLa cells transfected with control siRNA or siRNA towards Aurora-A were incubated with various concentrations of cisplatin. The cellular EC50 was determined by MTT assay. Aurora-A depletion in HeLa cells was able to enhance the cell-killing activity of cisplatin (siRNA Aurora-A, EC50 = 2.55; siRNA control, EC50 = 19.75; Fig. 5C). Aurora-A overexpression induces a striking increase in resistance to cisplatin-induced cell killing (EC50 = 56.78; data not shown). To further confirm these results, inhibition of Aurora-A by VX-680 was also examined in combination with cisplatin. VX-680 was able to enhance the cell-killing activity of cisplatin in HeLa cells (VX-680–treated HeLa cells, EC50 = 17.6; HeLa cells, EC50 = 31; Aurora-A–overexpressed HeLa cells, EC50 = 83.7; Supplementary Fig. S3). The down-regulation of NF-κB led to the acceleration of the apoptotic program, as PARP cleavage was markedly increased in Aurora-A–depleted cells ( Fig. 5D). To examine how Aurora-A depletion enhances cisplatin-induced cell death, we analyzed the expression of NF-κB target genes known to be involved in cell proliferation and apoptosis such as cyclin D1 and Bcl-xL ( 39). The expressions of both Bcl-xL and cyclin D1 were down-regulated in Aurora-A–depleted cells ( Fig. 5D). The severe down-regulation of cyclin D1 expression is likely due to the down-regulation of NF-κB and to changes in cell proliferation. Cisplatin treatment led to a p53 induction in control cells but had a weaker effect in Aurora-A–depleted cells. This is in contrast to previous studies which showed that Aurora-A depletion stabilizes p53 ( 40, 41). One possible explanation is that this was due to the activity of p53 in the cell lines used; in HeLa cells, p53 is disrupted by the E6 oncogene of human papilloma virus. Despite the lower levels of p53 induced in Aurora-A–depleted HeLa cells, these were more sensitive to cisplatin-induced apoptosis, possibly due to concomitant down-regulation of antiapoptotic proteins such as Bcl-xL. To confirm that increased cisplatin sensitivity in Aurora-A–depleted cells was due to NF-κB inhibition, we examined early events occurring after cisplatin treatment such as IκBα phosphorylation. After only 30 min of cisplatin addition, there was an increase in IκBα phosphorylated at residues Ser32/Ser36 in control cells but not in Aurora-A–depleted cells ( Fig. 5E).
Aurora-A depletion enhances cisplatin-induced apoptosis in HeLa cells. A, HeLa cells were transfected with the 3XκBL and the pGK-β-galactosidase reporter plasmid together with empty vector. Twenty-four hours after transfection, cells were left untreated or treated with cisplatin (8–25 μmol/L) and luciferase activity was estimated. B, HeLa cells were transfected with the 3XκBL and the pGK-β-galactosidase reporter plasmid together with empty vector, or Aurora-A siRNA. Twenty-four hours after transfection, cells were treated with cisplatin (8 μmol/L) for 24 h and the luciferase activity was assessed as in (A). C, HeLa cells transfected with control siRNA or Aurora-A siRNA were incubated with a range of 0 to 200 μmol/L of cisplatin for 55 h and analyzed with MTT assay. D, HeLa cells were transfected with control or Aurora-A siRNA. Twenty-four hours after transfection, cells were treated with cisplatin for 24 h. PARP cleavage, Bcl-xL, cyclin D1, and p53 were assessed via immunoblotting. Tubulin provides a loading control. E, HeLa cells were transfected with control or Aurora-A siRNA. Twenty-four hours after transfection, cells were treated with cisplatin (8 μmol/L) for 30 min. Levels of Aurora-A and phosphorylated IκBα at Ser32/Ser36 were assessed by immunoblotting. CP, cisplatin.
We have identified a novel role for Aurora-A kinase as a regulator of NF-κB signaling. Overexpression of Aurora-A occurs during the early events of carcinogenesis ( 42) and coincides with the aberrant activation of NF-κB ( 43). Our data provide new insight into the role of Aurora-A in tumor promotion via induction of the NF-κB survival pathway. Aurora-A is a cell cycle–regulated protein, the protein levels and activity of which oscillate during mitosis ( 44). Overexpression of both active and kinase-inactive Aurora-A gives rise to multinucleated HeLa cells ( 24). Overexpression of inactive Aurora-A induces abnormal spindles, leading to prolonged mitosis and cell death ( 7). In contrast, overexpression of active Aurora-A also induces an abnormal spindle that leads to prolonged mitosis but is accompanied by cell survival. This can be caused by both inactivation of p53 and the induction of antiapoptotic proteins such as Bcl-xL, a transcriptional target of NF-κB. Although the role of NF-κB during mitosis has not been thoroughly investigated, it has been shown to promote survival during mitotic exit ( 45).
We have shown that the mechanism by which Aurora-A regulates NF-κB is through the IκBα phosphorylation and this is required for full activation of NF-κB. It remains to be determined whether Aurora-A contributes to the activation of the IKK complex by an additional activation of an upstream kinase or by altering IKK complex conformation to cause autoactivation. The possibility that the PI3K/AKT or RAF/mitogen-activated protein kinase pathways were involved in the Aurora-A–dependent NF-κB activation was excluded.
We examined the association between Aurora-A amplification and NF-κB nuclear localization in 44 invasive breast carcinomas. Aurora-A gene amplification was found in 13.6% of the cases, which is in agreement with the prevalence of Aurora-A amplification and 20q copy number gains in medullary carcinomas and invasive ductal cancer ( 46). Most importantly, in all cases with Aurora-A amplification, neoplastic cells consistently showed NF-κB nuclear expression. p65 nuclear expression was seen in 25 out of 44 cases (56%) analyzed in this series. High levels of NF-κB activation have been previously reported in primary breast tumor specimens, especially in ER-negative/ErbB2-positive (86%) as well as in ER-negative/ErbB2-negative (33%) cases ( 47). Although elevated levels of this transcription factor in breast tumors have been reported ( 47, 48), the results herein are the first to show the association between Aurora-A amplification and nuclear NF-κB.
We also validated the potential therapeutic importance of Aurora-A–dependent inhibition of NF-κB. Several chemotherapeutic agents induce NF-κB, leading to the survival of tumor cells. Furthermore, constitutively active NF-κB is found in a variety of tumors that exhibit increased resistance to chemotherapy and this is achieved at least in part by the induction of the multidrug P-glycoproteins which are NF-κB–regulated gene products ( 49, 50). Aurora-A depletion sensitized HeLa cells to cisplatin-induced apoptosis through suppression of NF-κB antiapoptotic target gene expression. This is consistent with our recent data which showed that Aurora-A inhibition enhanced the efficacy of chemotherapeutic agents and reversed acquired resistance resulting from the activation of NF-κB ( 51). Our studies not only provide insight into Aurora-A function, but may also be important in the design of therapeutic protocols that involve targeting of either Aurora-A or NF-κB. In NF-κB constitutively active tumors, down-regulation of NF-κB via inhibition of Aurora-A might be useful, leading to the potentiation of standard chemotherapeutic agents.
Grant support: Programme Grants from Breakthrough Breast Cancer and Cancer Research UK (C309/A2187).
We thank R. Hay for plasmids of PK-IκBα constructs; A. Pintzas for AP-1 and c-Jun constructs; Z.J. Chen for the UBE2N (C87A) construct; M. Karin and T. Lawrence for IKKβ−/− MEFs; A. Ashworth, C. Isacke, P. Workman, and all the members of the Cancer Drug Target Discovery Team for critically reading and discussing the manuscript.
Note: Supplementary data for this article are available at Cancer Research Online (http://cancerres.aacrjournals.org/).
P. Briassouli and F. Chan contributed equally to this work.
Current address for P. Briassouli: UCSF Comprehensive Cancer Center, Box 0875, 2340 Sutter Street, San Francisco, CA 94143.
↵3 http://www.ensembl.org
Received June 21, 2006.
Revision received November 24, 2006.
Accepted December 16, 2006.
Giet R, Prigent C. Aurora/Ipl1p-related kinases, a new oncogenic family of mitotic serine-threonine kinases. J Cell Sci 1999; 112: 3591–601.
Francisco L, Wang W, Chan CS. Type 1 protein phosphatase acts in opposition to IpL1 protein kinase in regulating yeast chromosome segregation. Mol Cell Biol 1994; 14: 4731–40.
Glover DM, Leibowitz MH, McLean DA, Parry H. Mutations in aurora prevent centrosome separation leading to the formation of monopolar spindles. Cell 1995; 81: 95–105.
Bischoff JR, Anderson L, Zhu Y, et al. A homologue of Drosophila aurora kinase is oncogenic and amplified in human colorectal cancers. EMBO J 1998; 17: 3052–65.
Zhou H, Kuang J, Zhong L, et al. Tumour amplified kinase STK15/BTAK induces centrosome amplification, aneuploidy and transformation. Nat Genet 1998; 20: 189–93.
Bernard M, Sanseau P, Henry C, Couturier A, Prigent C. Cloning of STK13, a third human protein kinase related to Drosophila aurora and budding yeast Ipl1 that maps on chromosome 19q13.3-ter. Genomics 1998; 53: 406–9.
Dutertre S, Descamps S, Prigent C. On the role of aurora-A in centrosome function. Oncogene 2002; 21: 6175–83.
Honda K, Mihara H, Kato Y, et al. Degradation of human Aurora2 protein kinase by the anaphase-promoting complex-ubiquitin-proteasome pathway. Oncogene 2000; 19: 2812–9.
Kallioniemi A, Kallioniemi OP, Piper J, et al. Detection and mapping of amplified DNA sequences in breast cancer by comparative genomic hybridization. Proc Natl Acad Sci U S A 1994; 91: 2156–60.
Anand S, Penrhyn-Lowe S, Venkitaraman AR. AURORA-A amplification overrides the mitotic spindle assembly checkpoint, inducing resistance to Taxol. Cancer Cell 2003; 3: 51–62.
Zhang D, Hirota T, Marumoto T, et al. Cre-loxP-controlled periodic Aurora-A overexpression induces mitotic abnormalities and hyperplasia in mammary glands of mouse models. Oncogene 2004; 23: 8720–30.
Ewart-Toland A, Briassouli P, de Koning JP, et al. Identification of Stk6/STK15 as a candidate low-penetrance tumor-susceptibility gene in mouse and human. Nat Genet 2003; 34: 403–12.
Ewart-Toland A, Gao YT, Nagase H, et al. Aurora-A/STK15 T+91A is a general low penetrance cancer susceptibility gene: a meta-analysis of multiple cancer types. Carcinogenesis 2005; 26: 1368–73.
Deng L, Wang C, Spencer E, et al. Activation of the IκB kinase complex by TRAF6 requires a dimeric ubiquitin-conjugating enzyme complex and a unique polyubiquitin chain. Cell 2000; 103: 351–61.
DiDonato JA, Hayakawa M, Rothwarf DM, Zandi E, Karin MA. Cytokine-responsive IκB kinase that activates the transcription factor NF-κB. Nature 1997; 388: 548–54.
Kaltschmidt B, Kaltschmidt C, Hehner SP, Droge W, Schmitz ML. Repression of NF-κB impairs HeLa cell proliferation by functional interference with cell cycle checkpoint regulators. Oncogene 1999; 18: 3213–25.
Hinz M, Krappmann D, Eichten A, Heder A, Scheidereit C, Strauss M. NF-κB function in growth control: regulation of cyclin D1 expression and G0/G1-to-S-phase transition. Mol Cell Biol 1999; 19: 2690–8.
Nagata D, Suzuki E, Nishimatsu H, et al. Transcriptional activation of the cyclin D1 gene is mediated by multiple cis-elements, including SP1 sites and a cAMP-responsive element in vascular endothelial cells. J Biol Chem 2001; 276: 662–9.
Joyce D, Albanese C, Steer J, Fu M, Bouzahzah B, Pestell RG. NF-κB and cell-cycle regulation: the cyclin connection. Cytokine Growth Factor Rev 2001; 12: 73–90.
Foo SY, Nolan GP. NF-κB to the rescue: RELs, apoptosis and cellular transformation. Trends Genet 1999; 15: 229–35.
Rayet B, Gelinas C. Aberrant rel/nfkb genes and activity in human cancer. Oncogene 1999; 18: 6938–47.
Lambros MB, Jones C, Natrajan R, et al. Unlocking pathology archives for molecular genetic studies: a reliable method to generate probes for chromogenic and fluorescent in situ hybridization. Lab Invest 2006; 86: 398–408.
Meraldi P, Honda R, Nigg EA. Aurora-A overexpression reveals tetraploidization as a major route to centrosome amplification in p53−/− cells. EMBO J 2002; 21: 483–92.
Marumoto T, Honda S, Hara T, et al. H. Aurora-A kinase maintains the fidelity of early and late mitotic events in HeLa cells. J Biol Chem 2003; 278: 51786–95.
Smith RA, Baglioni C. Multimeric structure of the tumor necrosis factor receptor of HeLa cells. J Biol Chem 1989; 264: 14646–52.
Ito CY, Kazantsev AG, Baldwin AS, Jr. Three NF-κB sites in the IκB-α promoter are required for induction of gene expression by TNFα. Nucleic Acids Res 1994; 22: 3787–92.
Littlepage LE, Wu H, Andresson T, Deanehan JK, Amundadottir LT, Ruderman JV. Identification of phosphorylated residues that affect the activity of the mitotic kinase Aurora-A. Proc Natl Acad Sci U S A 2002; 99: 15440–5.
Harrington EA, Bebbington D, Moore J, et al. VX-680, a potent and selective small-molecule inhibitor of the Aurora kinases, suppresses tumor growth in vivo. Nat Med 2004; 10: 262–7.
Stevenson CS, Roshak AK, Marquez B, et al. Scytonemin—a marine natural product inhibitor of kinases key in hyperproliferative inflammatory diseases. Inflamm Res 2002; 51: 112–4.
Malinin NL, Kovalenko AV, Wallach D. MAP3K-related kinase involved in NF-κB induction by TNF, CD95 and IL-1. Nature 1997; 385: 540–4.
Grumont RJ, Gerondakis SB. Cell growth is controlled by phosphatidylinosotol 3-kinase-dependent induction of Rel/NF-κB regulated c-myc transcription. Mol Cell 2002; 10: 1283–94.
Dudley DT, Decker SJ, Bridges AJ, Saltiel AR. A synthetic inhibitor of the mitogen-activated protein kinase cascade. Proc Natl Acad Sci U S A 1995; 92: 686–9.
Nakshatri H, Bhat-Nakshatri P, Martin DA, Goulet RJ, Jr., Sledge GW, Jr. Constitutive activation of NF-κB during progression of breast cancer to hormone-independent growth. Mol Cell Biol 1997; 17: 3629–39.
Siddik ZH. Cisplatin: mode of cytotoxic action and molecular basis of resistance. Oncogene 2003; 22: 7265–79.
Perego P, Righetti SC, Supino R, et al. Role of apoptosis and apoptosis-related proteins in the cisplatin-resistant phenotype of human tumor cell lines. Apoptosis 1997; 2: 540–8.
Nie Z, Mei Y, Ford M, et al. Oxidative stress increases A1 adenosine receptor expression by activating nuclear factor κB. Mol Pharmacol 1998; 53: 663–9.
Pahl HL. Activators and target genes of Rel/NF-κB transcription factors. Oncogene 1999; 18: 6853–66.
Pommier Y, Sordet O, Antony S, Hayward RL, Kohn KW. Apoptosis defects and chemotherapy resistance: molecular interaction maps and networks. Oncogene 2004; 23: 2934–49.
Funaoka K, Shindoh M, Yamashita T, Fujinaga K, Amemiya A, Totsuka Y. High-risk HPV-positive human cancer cell lines show different sensitivity to cisplatin-induced apoptosis correlated with the p21Waf1/Cip1 level. Cancer Lett 1996; 108: 15–23.
Katayama H, Sasai K, Kawai H, et al. Phosphorylation by aurora kinase A induces Mdm2-mediated destabilization and inhibition of p53. Nat Genet 2004; 36: 55–62.
Liu Q, Kaneko S, Yang L, et al. Aurora-A abrogation of p53 DNA binding and transactivation activity by phosphorylation of serine-215. J Biol Chem 2004; 279: 52175–82.
Goepfert TM, Adigun YE, Zhong L, Gay J, Medina D, Brinkley WR. Centrosome amplification and overexpression of aurora A are early events in rat mammary carcinogenesis. Cancer Res 2002; 62: 4115–22.
Sovak MA, Bellas RE, Kim DW, et al. Aberrant nuclear factor-κB/Rel expression and the pathogenesis of breast cancer. J Clin Invest 1997; 100: 2952–60.
Eyers PA, Maller JL. Regulating the regulators: Aurora A activation and mitosis. Cell Cycle 2003; 2: 287–9.
Mistry P, Deacon K, Mistry S, Blank J, Patel R. NF-κB promotes survival during mitotic cell cycle arrest. J Biol Chem 2004; 279: 1482–90.
Rennstam KM, Baldetorp B, Bendahl PO, et al. Patterns of chromosomal imbalances defines subgroups of breast cancer with distinct clinical features and prognosis. A study of 305 tumors by comparative genomic hybridization. Cancer Res 2003; 63: 8861–8.
Biswas DK, Baily S, Strickland I, Ghosh S, Pardee AB, Iglehart JD. NF-κB activation in human breast cancer specimens and its role in cell proliferation and apoptosis. Proc Natl Acad Sci U S A 2004; 101: 10137–42.
Cogswell PC, Funkhouser WK, Baldwin AS, Jr. Selective activation of NF-κB subunits in human breast cancer: potential roles for NF-κB2/p52 and for Bcl-3. Oncogene 2000; 19: 1123–31.
Greten FR, Karin M. The IKK/NF-κB activation pathway—a target for prevention and treatment of cancer. Cancer Lett 2004; 206: 193–9.
Bentires-Alj M, Barbu V, Fillet M, et al. NF-κB transcription factor induces drug resistance through MDR1 expression in cancer cells. Oncogene 2003; 22: 90–7.
Sun C, Chan F, Briassouli P, Linardopoulos S. Aurora kinase inhibition downregulates NF-κB and sensitises tumour cells to chemotherapeutic agents. Biochem Biophys Res Commun 2007; 352: 219–24.
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Cancer Res February 15 2007 (67) (4) 1689-1695; DOI: 10.1158/0008-5472.CAN-06-2272
Decitabine Sensitivity in Testicular Cancer
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Skin ageing caused by sun exposure, facial blemishes due to excessive pigmentation and, in general, imperfections caused by melanin, are more and more common problems today… "Dark blemishes", especially on hands and face, are one of the greatest skin concerns of modern men and women… It will only be possible to remove the skin pigmentation and recover the smoothness of the skin, bringing back its luminosity, with a treatment that has a direct effect on the intimate formation process of the pigment (melanin).
Cosmelan treatment guarantees the improvement of the skin blemishes with a very high safety margin. Cosmelan Depigmentation treatment's principal action is the elimination of melanin patches on the face – Melasma .Also called cholasma if the pigmentation occurs with pregnancy Cosmelan Depigmentation treatment involves a very versatile, dynamic process which is easily adapted to the needs of each individual patient.
WHAT RESULTS CAN BE EXPECTED FROM COSMELAN DEPIGMENTATION?
In 99% of the cases, the appearance of the blemishes improves by 95%.
ONE WEEK after starting the Cosmelan Depigmentation treatment, a noticeable significant improvement of the skin is observed. The reduction of the treated blemish is detected and the appearance of new luminous and rejuvenated skin is present.
At the end of the Cosmelan Depigmentation treatment, the blemishes start to disappear altogether, so that, although the patient may be able to "locate" the place where the spot was, the truth is that the pigmentation will have disappeared and nobody will be able to see it just by looking at it.
WHAT CONDITIONS CAN BE TREATED WITH COSMELAN DEPIGMENTATION TREATMENT?
Cosmelan works by blocking the process that causes hyper pigmentation.
WHAT PRECAUTIONS MUST BE UNDERTAKEN BEFORE PROCEEDING WITH COSMELAN?
Stop all applications especially glycolic acid two weeks before treatment.
The treatment must not be interrupted under any circumstances, during the entire time prescribed.
It is completely forbidden to combine the Cosmelan Depigmentation treatment with other Depigmentation treatments, as the appearance of undesired effects cannot be guaranteed.
Treatment control visits are recommended 8 days after treatment, 15 days after, and a follow up visit every month thereafter.
WHAT CAN BE EXPECTED AFTER A COSMELAN TREATMENT MASK?
During the first two days of the treatment, the skin may turn red. If the skin is very sensitive, the patient may experience an itching feeling. Slight burning and tightening of the skin is also absolutely normal, especially during the first 24 to 48 hours after starting the treatment. To relieve these problems, it is advisable to apply the creams advised.
The reddening that occurs on the face after applying the Cosmelan mask treatment is similar to the effects of day-long exposure to the sun in the snow without protection.
Flaking may occur on all skin types between the second and third day. In this case it is advisable to apply cream advised, repeating this every two hours on the day when the flaking is most intense until it improves. Do not pull on the flakes. Do not rub or scratch the skin. Do not use exfoliants, scrubs or peels. Avoid steam baths, saunas and swimming in a hot spring for 2 weeks following treatment. It is advisable to wait until the initial flaking period is over before starting to apply make-up again.
After the third or fourth day, the skin appears healthy and luminous and the marks begin to fade.
WHAT CAN BE EXPECTED AFTER THE HOME APPLICATION OF COSMELAN 2?
The second phase of the Cosmelan consists of a home maintenance cream Cosmelan with the intention of securing the Depigmentation by association of agents such as Kojic Acid, Phytic Acid, and Vitamin C. We have added a physical agent to block the sun and guarantee that the UV rays do not keep on aggravating unwanted damage to skin though the sunscreen advised has to be used three times a day.
WHAT DOES THE STABILIZATION PERIOD OF A COSMELAN DEPIGMENTATION TREATMENT MEAN?
The period following the initial 6 month treatment process, is called the STABILISATION period, and this can ideally be extended up to one year. Every effort should be made to continue treatment throughout the first summer. Even if the treatment is a great success, long term success depends on how well the protocol is followed, during both the treatment and stabilization phases. VERY GOOD sun block is essential at all times which protect against both uva and uvb radiations.
WHAT ARE IMPORTANT INSTRUCTIONS BEFORE USING COSMELAN?
IMPORTANT NOTE: The treatment results are largely dependent on your cooperation and adherence to the post treatment skin care. The first 4 months constitute the treatment period. The period following is called the stabilisation period, and this is ideally extended up to one year, or longer. Every effort should be made to continue treatment throughout the first summer. Even if the Depigmentation treatment was a great success, you need to understand that long term success depends on how well the protocol is followed, during both the treatment and stabilization phases. Avoid sun exposure for 2 weeks prior to treatment.
IS COSMELAN COMBINED WITH OTHER TREATMENTS?
No peels can be done 2 weeks prior to treatment No Laser treatment can be done on area to be treated 2 days prior to peel ,Avoid Dermal Filler in area to be treated 2 weeks prior to peel.
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Healthgrades is an independent source of hospital quality outcomes, providing objective, comprehensive information about health care quality in approximately 4,500 US hospitals. Healthgrades uses more than 45 million Medicare medical claims records for the most recent three-year reporting period available to help consumers understand, compare and evaluate hospital performance.
Each spring Healthgrades evaluates patient survey results about doctor and nurse communication, hospital cleanliness and noise levels, and medication and post-discharge care instructions to recognize the top 15% of hospitals with Outstanding Patient Experience Awards. It also analyzes standard patient safety indicators like preventing infections and other complications to recognize the top 10% of hospitals in the nation with Patient Safety Excellence Awards.
Each fall Healthgrades analyzes common diagnoses and procedures--from appendectomies to sepsis treatment--for its Clinical Quality Awards. It rates hospitals' performance as "better than expected" (5-Star), "as expected" (3-Star), and "worse than expected" (1-Star) and also recognizes hospitals with specialty excellence awards.
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The clinical stage of the products developed by the R&D area is carried out by the Research Clinic, which operates in conjunction with renowned doctors in their specialties, in addition to a multidisciplinary team in the design of their clinical protocols.
Eurofarma constantly invests in research and development (R&D) in order to expand in Brazil and abroad, through the expansion of its portfolio and by offering innovative products. The production of quality medicines makes up one of the company's mission pillars. With investments above 130 million reais in research and development in 2015, Eurofarma has fulfilled its role among the largest companies in the Brazilian market, with strength in Latin America. By the year 2020, the area of R&D will receive investments of about 20% of the company revenues.
The clinical stage of the products developed by R&D is performed by the Eurofarma Clinical Research Area, which works together with renowned physicians in their specialties, and a multidisciplinary team in the design of their clinical protocols, with studies in the therapeutic areas of: rheumatology, endocrinology, infectious diseases, oncology, neurology, pulmonology and cardiology. The research of biotechnological products such as biosimilars, is also part of the scope of the Company's Research and Development. Over the past 10 years, this sector conducted more than 40 clinical studies in phases I, II and III, generating 13 products, 8 of them already registered in Brazil. Among the most recent records obtained are: FIPRIMA® (filgrastim), LUGANO® (Formoterol + Fluticasone) and PERLATTE® (Lactase).
Radical products are in the Company's crosshairs, with investment from the earliest stages of discovery of a new compound, so that after all the pre-clinical _ (in vitro and in vivo) and clinical (human beings) tests are performed, new medications can reach the population.
The Clinical Research area also includes the development of generic and similar medications (brand) which hold much of the product portfolio. For the registration of generic similar drugs, studies of Relative Bioequivalence / Bioavailability in healthy volunteers are conducted. This type of study comprises the checking of the absence of a significant difference between the bioavailability of the same active principle of two pharmaceutical equivalent products (or pharmaceutical alternatives) when both are administered at the same dosage and under similar conditions in an appropriate design study. In addition to the human health, the large-size animal segment _ products (mainly cattle) and swine are also the responsibility of the Clinical Research area. _ For proof of effectiveness and safety of these medications, several studies are conducted in target species, and only after approval by the Ministry of Agriculture and Livestock, products are marketed.
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A1 vs A2 Cows Milk: What's the Difference, Benefits, & Nutrition
There is an ongoing debate about the nutritional value of both A1 and A2 milk.
Growing number of studies from top milk-producing countries Australia, New Zealand, and some European nations enumerate the benefits of A2 milk and the health risks associated with continuous consumption of A1 milk.
This article will look at the differences between A1 and A2 milk, as well as available evidence that support the A1 vs A2 debate.
What Is Wrong with A1 Milk?
The Difference Between A1 and A2 Milk
When Did the A1 Mutation Start?
What is BCM7?
Risk of Type 1 Diabetes Mellitus
Does A1 Milk Harm Your Heart?
Does A1 Milk Cause SIDS?
Is There a Direct Relationship Between A1 Milk and Autism?
Is A1 Milk the Major Cause of Lactose Intolerance?
At present, there are two types of cow's milk available in the market, A1 and A2 milk.
The majority of cows that are being raised in the United States and other parts of the globe are A1 variety.
Milk produced by A1 cows supposedly produces opiate-like effects resulting in the development of mild to serious medical conditions (2).
Prominent professor Bob Elliot from the University of Auckland claims that a switch to A2 milk can ultimately solve all problems that 1 in every 4 Americans have in relation to dairy consumption (4).
KEY POINT: It is claimed A1 milk consumption produces harmful health effects, yet these harmful effects are not present when drinking A2 milk.
The protein component in milk is made up of up to 80% casein (1).
Milk has several types of casein and beta casein is the second most common type casein in cow's milk. Beta-casein comes in 13 different forms (5).
Source: Medifit Bilogicals
A1 beta-casein comes from the most common cow breed that originated in Australia, United States, and Northern Europe. Holstein, Friesian, Ayrshire, and British Shorthorn features A1 beta-casein genetic material. A1 beta-casein can be found on all commercially-prepared milk.
A2 beta-casein is protein found in milk produced by 'old-fashioned' cows like the Jersey, Charolais, Guernsey, and Limousin. Milk produced by other mammals such as those from human, goat, and sheep is similar to A2 dairy milk mainly due to the presence of proline (6 ,7).
A1 is considered a genetic mutation that results in the production of the compound BCM7 assumed to be causing the development of unwanted health conditions and illnesses among consumers.
The A1 gene mutation began hundreds of years ago from Holstein cow breed that was then passed onto other breeds (8).
This mutation of the A1 beta-casein proved to be highly beneficial to dairy farmers who wanted to increase milk production without the added costs.
A2 milk is found in milk and dairy products produced by older cow breeds, have not been manipulated in any way.
Thus many regard it as the better type of casein protein. It is found in milk we consume along with A1 milk.
A2 milk is produced by A2 Milk Company, and contains no A1 beta-casein.
KEY POINT: The difference between A1 and A2 is in the amino acid chain number 67.
At this position, A2 features proline whilst A1 is linked with histidine.
This mutation in the amino acid chain link of A1 milk is supposed to cause adverse effects in humans, whilst making A2 milk the healthier option.
BCM7 (Beta-casomorphin-7), an opioid peptide in A1 beta-casein is produced as a result of the breaking off of histidine in the number 67 amino acid chain during digestion (9, 10).
BCM7 is the reason why regular cow's milk is considered to be a less healthy option than milk containing A2 beta-casein.
BCM7 found in A1 milk is known to have opioid or narcotic side effects and is identified to be the culprit of lactose intolerance in 1 out 4 Americans.
The absorption of BCM7 into the bloodstream leads to the high incidence of autism, schizophrenia, and other neurological disorders (11, 12, 13, 14).
Despite extensive and ongoing research, the extent of BCM-7 absorption into the bloodstream still remains unknown.
Studies reveal that BCM-7 is absent in the blood of healthy adults, whilst presence of BCM-7 in infants is a possibility (15, 16, 17).
KEY POINT: The presence of BCM7 in A1 milk makes it a less attractive dairy option due to the problems that are assumed to develop as a result of consumption of A1 milk.
Type 1 Diabetes Mellitus is an autoimmune disease that typically develops in children. The illness is characterized by the inability of the body to produce insulin.
Based on epidemiological evidence, the consumption of A1 milk is a contributing factor in the increased risk of development diabetes type 1 among children (12, 15, 18, 19).
Human breast milk contains A2 beta-casein only whereas pasteurized milk formulations may either contain A1/A1 beta-casein or A1/A2 beta casein.
According to a 1992 observational study by Elliot RB, there was low incidence of diabetes mellitus type 1 among infants who were breastfed in the Polynesian Islands as opposed to Polynesian infants in Auckland that were supplied with commercial milk formulations containing A1 beta-casein (20).
Observational studies were insufficient to prove that A1 milk may cause type 1 Diabetes, but only showed that those who consumed more A1 beta-casein are likely to develop insulin-dependent diabetes.
There are also reports that show no difference in the effects of A1 and A2 milk in children.
Lastly, a few studies claim that milk containing A1 beta-casein has no effect on prevalence of diabetes type 1 altogether (18, 21, 22, 23).
KEY POINT: A1 beta-casein is assumed to stimulate the development of type-1 diabetes in children.
Observational studies reveal mixed evidence, thus requiring more research in order to confirm or deny claims.
According to New Zealand research conducted by CNS McLachlan, the regular intake of common milk containing A1 beta-casein inspires the development of coronary heart disease (24).
The findings of McLachlan are supported by ecological data produced after extensive testing on rabbits.
The test rabbits that were supplied with A1 beta-casein featured larger areas of fatty streaks in the aorta while those that received A2 milk came up normal.
Apart from fatty streaks, rabbits nourished with A1 milk had higher levels of LDL cholesterol as opposed to those that received A2 milk for 6 weeks (12, 19).
The experiment on rabbits clearly showed that the accumulation of fats may potentially clog and block blood vessels that may result in heart disease.
Unfortunately, the relevance of these findings for humans is still up for debate (6, 25).
To date, there are only two human studies that have tested the effects of A1 beta-casein as a predisposing factor of heart disease.
One study included 15 male and female test subjects with known high risk of heart disease.
The crossover design of the study meant that participants consumed both A1 and A2 beta-casein at different periods of time (26, 27).
The results derived from the study tell us that there are no serious adverse effects on heart disease risk factors.
When compared alongside A2 beta-casein, A1 showcased similar effects on blood pressure levels, blood vessel function, blood fats concentration, and inflammatory markers (27).
Based on the results derived from the other study, there are no significant differences in the effects of A1 and A2 beta-casein on blood cholesterol levels (26).
KEY POINT: Despite numerous studies that point to the increased risk of coronary heart disease in animals, there are no solid evidence that can confirm the negative effects of A1 beta-casein in humans.
The most common cause of death in infants less than one year of age is identified to be Sudden Infant Death Syndrome or SIDS.
It is unexpected infant death without clear or visible cause (28).
Some researchers hypothesized that BCM-7 from A1 beta-casein may be the culprit in some cases of SIDs.
As some mothers may opt to breastfeed their babies up to 2 years of age, there are also those who prefer to provide their newborns with instant milk formulations instead (29).
In one study, high levels of BCM-7 in the bloodstream were found among infants suffering from sleep apnea or temporary breathing patterns during sleep.
Sleep apnea has been linked to an increased incidence of SIDS (15).
BCM-7 penetration into a newborn's central nervous system may potentially inhibit normal respiratory system functioning as evidenced by abnormal respiratory breathing, hypoxia, and excessive levels of carbon dioxide resulting in sudden death (30).
Results obtained from these studies also tell us that some children may be suffering from hypersensitivity issues to A1 beta-casein in cow's milk.
More studies should be implemented before any solid conclusions can be made to connect A1 milk consumption with SIDS.
KEY POINT: Due to limited studies, there are no concrete evidence that can link SIDS to the death of infants that exclusively consumed A1 milk formulations.
More research is needed to prove the hypothesis that A1 milk is a contributing factor to increased risk of sudden death in infants.
Autism is a developmental disorder characterized by disabilities including problems with social interaction, communication, and repetitive behaviors.
It was theorized that BCM-7 plays a crucial role in the development of autism in children.
Although there have been numerous studies trying to link A1 milk to autism, there are still no solid proof that can verify this hypothesis (31, 32, 33).
In a study conducted by Russian researchers, high amounts of BCM-7 were found in the urine of infants with autism that were fed with milk formula.
Over time, there were infants that showed the ability to metabolize BCM-7 at a fast rate, whilst there are those who showcased inability to process and excrete BCM-7 and other peptides altogether.
The study also reveals that those who were fed with formula milk exemplified delayed psychomotor development as well as high levels of BCM-7 in their bloodstream.
On the other hand, infants with autism that were breastfed or those under Gluten-free, Casein-free or GFCF diet displayed more developmental improvements with no traces of BCM-7 in their bloodstream (14).
Due to some observation from these studies, there are some nutritionists who have started recommending parents of children with autism to start supplementing their diets with A2 milk.
Making the switch from common A1 milk to A2 milk is supposed to be beneficial for child afflicted with autism.
Major improvements have been observed among children who regularly consume A2 milk sourced from Guernsey cows due to its high A2 beta casein at 95%.
Those who opted to provide their children with A2 milk also reported improvement in digestive function, communication skills, and eye contact.
Another study reveals that drinking cow's milk over time may potentially exacerbate the symptoms among children with autism.
There are also studies that showed that drinking A1 or A2 milk has no effect on overall behavior (34).
With autism, there are more than one cause to its development.
There is not enough human trials that can prove the hypothesis that A1 and A2 milk have significant impact on the incidence and severity of autism symptoms (35, 36).
KEY POINT: Despite numerous studies that link autism symptoms to A1 milk consumption, researchers still need to find out more solid connections for the negative effects of A1 milk among children with autism.
Based on studies, 1 in 4 Americans suffer from lactose intolerance - the inability if the digestive system to process milk resulting in the development of unpleasant symptoms such as stomach upsets, diarrhea, flatulence, and bloating to name a few.
A1 and A2 milk feature the same lactose concentrations.
The makers of A2 milk contend that lactose is not the real suspect for the development of lactose intolerance, but a mutation caused by A1 beta-casein, a compound found in store-brought milk and dairy products.
Some researchers say drinking A2 milk causes less digestive issues than milk containing A1 beta-casein (37, 38).
Studies that support these claims reveal that apart from lactose, there are other milk components that bring about unwanted digestive problems.
It was also suggested by scientists that certain proteins present in milk may be the major suspects in some cases of milk intolerance.
In one study involving 41 men and women, results revealed that drinking A1 milk may result in softer stools than A2 milk consumption in some test subjects.
Additional students in rodents implicate that A1 milk may be a predisposing factor to increased inflammation in the digestive system (39, 40, 41).
KEY POINT: Although there are reports that show positive benefits of drinking A2 milk, there is not enough data to support the hypothesis that A1 beta-casein can trigger or worsen the symptoms of lactose intolerance.
The shortage of proof that switching to A2 milk intake can make a huge impact on health and wellness has made it impossible to boycott the sales, use, and continuous production of milk and dairy products from A1 cow breeds.
Even if there is solid evidence on the benefits of A2 milk and the detrimental effects of A1 milk intake, it will take years, even decades, to adapt to the raising of pure A2 cow breeds and the manufacturing of A2 milk.
Good stuff regarding the A1 vs A2 milk.
Naren Sharma
VERY EDUCATING ARTICLE THANKS FOR THE INFORMATION DISPENSED
So correct me if I'm wrong, histadine is an essential amino acid (we must consume it) but we are better to eliminate it from milk (A1 milk) and replace it with A2 that contains proline a non-essential amino acid instead? This makes no sense! Also lactose intolerance is to do with the carbohydrates in dairy not the protein! My understanding is cows do not only produce one protein or the other, rather a different proportion of each eg 80℅ A2 20% A1, therefore the milk is going through yet another stage of processing to meet their marketing claims.
The problem is not histidine in itself. The issue comes when histidine breaks off from the chain, BCM-7 is produced. BCM-7 can potentially lead to a range of health issues.
The inflammatory nature of BCM-7 can affect lactase activity/production and possibly worsen existing hypolactasia and consequently lactose malabsorption symptoms in susceptible people.
The colonic inflammation affects the processing of malabsorbed lactose, possibly via changes in the gut microbiota that occur with gut inflammation:
Grant Richardson
For calcium, milk has 120mg/100ml. Almonds have 264mg/100g calcium (more than twice as much as milk). Chia seeds and sesame seeds have between twice to four times the amount as almonds. Broccoli has 93g/100mg. Even plain old lettuce has around 30-40mg/100g. It's a myth you need milk for calcium (and protein for that matter). Wouldn't the best way to avoid the ills of milk be to just not drink it (regardless of the root cause of those ills or the superior A2 to A1 ratio of certain cow breeds)? Milk is a dying industry for many reasons – health (links… Read more »
Your picture diagram of the 5 cows is inaccurate. Cow 1 which has a lable of "a1" is a Jersey cow, yet you have described below that Jersey cows are "a2". Please can you amend please by removing the incorrect "a1" label from the Jersey cow. We need accurate information so people can be properly informed.
Thanks for catching this Hayley. I shall be amending this, probably changing the picture even.
I would respectfully want to tell you that A2 milk is not given by Jersey, A1 is
Thanks for the feedback. According to the California Research Foundation (http://cdrf.org/2017/02/09/a2-milk-facts/) Jersey contain the A2 beta casein.
Larry & Mimi
Haley, we have enjoyed your book so much. It figures you'd spot a club like that with your background. Do you give lectures anywhere near Burbank or NOHO?
*flub not club
Bitty vachani
M using milk from A 2 cow…. I m happy having it n even happier after knowing the results…
The article clearly states the lack of connections made to health problems vs. A1. The little questionnaire, 'are you going to switch?' with 67% YES suggests not enough people read carefully or thoroughly. I appreciated the reporting, found it interesting, but am amused at the bias in the comment section and questionnaire response.
Total: 1.7K
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An application of magnetic resonance imaging to the study of the diffusion of water in gelatin and other materials is described. Gelatin was studied in great detail while plaster, balsa wood, and cement were studied to a lesser degree. Images of the materials at various stages of the diffusion process were recorded and analyzed. In order to properly interpret the imaging signal, the relationships between two intrinsic system parameters, Ti and T2, with the experimental parameters of the study need to be established. In the case of gelatin studies, Ti and T2 times were measured for gelatin samples varying in gelatin concentration and degree of D20 dilution. Tx and T2 were found to decrease with increasing gelatin concentration and increase with increasing D 20 dilution. T 1 relationships were modeled successfully with the crossrelaxation theory while T2 relationships were established empirically. Two gelatin studies were performed, one involving the counterdiffusion of H20 and D20 in a crosslinked gelatin matrix of a given gelatin concentration, and one involving the drying of a water containing gelatin matrix. In the counter-diffusion study, the selfdiffusion coefficient for H20 was found to be 2.0 x 10~5 cm2/s. The diffusion coefficients of H20 in gelatin matricies of 1.5, 5, and 11% wt. gelatin were found to be 2.0, 1.8, and 1.5 x 10-5 cm2/s, respectfully. In the drying study, it was found that a good first approximation for the modeling of the drying process is provided by Fick's second equation solved with a diffusion coefficient depending linearly with gelatin concentration. The shrinking character of the drying gelatin sample needs to be included in a more precise model.
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Mesothelioma / Mesothelioma Stages / Stage 1
Stage 1 is typically the most treatable form of mesothelioma. There are many symptoms and treatment options for those affected.
What Is Stage 1 Mesothelioma?
As with other forms of cancer, stage 1 mesothelioma is the least advanced stage and often carries the best prognosis. At this stage, the tumors are localized, meaning they haven't spread to other parts of the body.
When caught early, this type of cancer can be treated with a multimodal plan of surgery, chemotherapy, radiation, or immunotherapy. Although there's no cure, doctors can remove the majority of cancerous cells through resection (surgery to remove the tumors), as well as prevent the growth of new ones. Life expectancy, when treated, can span from 21–40 months.
Unfortunately, mesothelioma is seldom diagnosed in stage 1. This is mainly due to the fact that symptoms do not present themselves until the disease has already begun to spread throughout the body. Even when symptoms are present, they can mirror those of less severe conditions like pneumonia. In the secluded instances when it's caught early, it's usually by accident and the patient is being examined for another reason.
Details surrounding stages can differ depending on their location in the body.
Stage 1 Pleural Mesothelioma
This cancer is staged like many other cancers on a 1 through 4 scale. For pleural mesothelioma cases, doctors use one of three staging systems — the Butchart system, the Brigham system, or the TNM system.
The TNM system is recommended when staging pleural mesothelioma. T refers to the size of the primary tumor, N refers to the number of affected nearby lymph nodes, and M refers to the extent of metastasis (spread).
Found in the inner lining of the chest wall (the pleura)
Localized on one side of the chest
Cancer cells found in the tissue covering the lungs, the area between the lungs (the mediastinum), and the top of the diaphragm
Found in the inner lining of the chest wall and in the tissues covering the lung, the mediastinum, and the top of the diaphragm on a single side of the chest
Cancer has begun spreading into the diaphragm, lung tissue, tissues between the ribs, soft tissues in the chest wall, and the sac around the heart
Stage 1 Peritoneal Mesothelioma
Of the approximately 3,300 cases of this disease diagnosed per year, only about 660 cases occur in the peritoneum. Due to the rarity of this form of the disease, there is not an established staging system for peritoneal mesothelioma. Doctors typically use the American Joint Committee on Cancer (AJCC) 1 through 4 staging scale or the Peritoneal Cancer Index (PCI) when diagnosing this type of disease.
PCI has become the preferred method for staging peritoneal mesothelioma. It scores the extent and spread of the cancer on a 0 through 39 range. A patient's PCI can help doctors assess whether or not they are eligible for treatment. Lower scores typically exhibited in stage 1 mesothelioma indicate less aggressive cancer, smaller tumors, and an overall better prognosis. Patients with low PCI scores tend to be candidates for invasive treatments. At stage 1, the PCI ranges between 1 and 10.
Stage 1 Pericardial Mesothelioma
When tumors develop on the lining of the heart sac, it's called pericardial mesothelioma. This is extremely rare, accounting for less than 5 percent of all cases. As a result, there is not a formal staging system for this form of the disease. Doctors can use the AJCC staging scale; however, because the pericardial form is so aggressive, it is often diagnosed in advanced stages or after the patient has passed away.
As with other aggressive cancers, patients with stage 1 mesothelioma typically exhibit few or no symptoms. It is for this reason that most patients go undiagnosed at this stage. When symptoms do manifest, they may be mistaken for other conditions, such as pneumonia or the flu.
Stage 1 symptoms can include:
A persistent cough
Shortness of breath (dyspnea)
Survival rates for any form of cancer are calculated using statistics from other patients with the same or similar conditions. The rate demonstrates how long other patients have typically survived after their diagnosis.
Patients with stage 1 mesothelioma who receive treatment generally have a survival rate between 21 and 40 months. However, because this is illness is scarce, research is scarce and every case is unique. Survival rates also vary by histologic subtypes. Some genetic factors may alter the overall prognosis of the patients. Improved treatment options have also correlated to improved survival rates.
Doctors typically treat stage 1 with a multimodal treatment plan that includes a combination of surgery, chemotherapy, radiation, and immunotherapy. While stage 1 patients generally have the greatest range of treatment options, they must be healthy enough to undergo a radical treatment plan.
Patients may also be eligible for clinical trials. Researchers hold clinical trials as a means to test new treatments and emerging drugs. Talk to your doctor about whether clinical trials are a good solution for you.
Author Brittany Nelson Content Writer
Brittany Nelson holds a BSBA in Marketing from the Daniels College of Business at the University of Denver. As someone whose life has been touched by cancer, she strives to connect those affected by mesothelioma with the support and resources they need to overcome a life-changing cancer diagnosis. Brittany is a proud Denver native. When she isn't sipping coffee, researching, and writing for the site, you can catch her noshing at a new restaurant or trying to hold a handstand in the yoga studio. Note: Brittany is not a medical professional.
Reviewer Muaiad Kittaneh Last Reviewed:
Muaiad Kittaneh, MD, FACP, MBA, is a hematology and oncology professor at Loyola University Medical Center on the Palos Health South Campus in Illinois. He specializes in treating patients with mesothelioma, as well as lung, breast, kidney, and gastrointestinal cancers. Dr. Kittaneh plays the role of both clinician and researcher, focusing on cancer genomics and immunotherapy. He is currently studying the BAP1 gene mutation, which is found in nearly 70% of patients who develop mesothelioma, and could play a role in the prevention and treatment of this rare cancer.
American Cancer Society. (2018). About Malignant Mesothelioma. Retrieved on July 19, 2018, from https://www.cancer.org/content/dam/CRC/PDF/Public/8733.00.pdf
Bonomi, Maria; et al. (2017). Clinical Staging of Malignant Mesothelioma: Current Perspectives. Retrieved on July, 25th, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571821/
Faig, Jennifer. (2015). Changing Pattern in Malignant Mesothelioma Survival. Retrieved on July, 25th, 2018, from https://www.sciencedirect.com/science/article/pii/S1936523314001363
Mayo Clinic. (2019). Mesothelioma. Retrieved on September 30th, 2019, from https://www.mayoclinic.org/diseases-conditions/mesothelioma/symptoms-causes/syc-20375022
National Cancer Institute. (2019). Malignant MEsothelioma Symptoms, Tests, Prognosis,. and Stages (PDQ®)—Patient Version. Retrieved on July, 25th, 2018, from https://www.cancer.gov/types/mesothelioma/patient/about-mesothelioma-pdq#section/_26
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Maternal Egg Hormones In The Mating Context: The Effect Of Pair Personality
S. Ruuskanen
T. G. G. Groothuis
Alexander T. Baugh, Swarthmore CollegeFollow
S. V. Schaper
B. de Vries
K. van Oers
Functional Ecology
1. Animal personality traits emerge developmentally from the interaction of genetic and early environmental factors. Maternal hormones, such as androgens (testosterone, T and androstenedione, A4), transferred to embryos and egg yolks may simultaneously organize multiple behavioural and physiological traits. Although previous studies demonstrated an association between the mother's personality and yolk androgen levels, the independent effects of the male partner's personality and pair combination remains unknown. 2. We test this association using an ecological model species for personality research, the great tit (Parus major) using multiple approaches: (1) a wild population, (2) a randomly mated captive population and (3) an experimental study with (dis)assortatively mated pairs from lines selected for fast exploration/boldness or slow exploration/shyness. 3. Egg androgen concentrations were associated with variation in female personality traits, and the experimental data suggested that this is independent of male personality: Experimental females from the slow-shy line tended to have higher egg T concentrations than females from the fast-bold line, with no effect of male personality. Shy females from the wild population had higher egg A4 concentration than bold females. However, in the correlative data yolk hormones were linked with male personality, as well as the interaction between female and male traits: Male handling responsiveness correlated negatively with egg A4 concentration in wild birds. In randomly mated birds, pairs that were mated assortatively for personality had lower egg T concentrations than disassortatively mated pairs. 4. Given that egg androgens are known mediators of avian personality, our results suggest that maternal hormones might contribute to the heritability of personality, may be sensitive to the social context of mating, and act as key drivers of individual differences.
This work is freely available under a Creative Commons license.
S. Ruuskanen, T. G. G. Groothuis, Alexander T. Baugh, S. V. Schaper, B. de Vries, and K. van Oers. (2018). "Maternal Egg Hormones In The Mating Context: The Effect Of Pair Personality". Functional Ecology. Volume 32, Issue 2. 439-449. DOI: 10.1111/1365-2435.12987
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Because of socio - economic factors, adverse drug reactions, complexity of regimens and prolonged ( or life - long ) therapy, over half of asthma patients fail to take their medication regularly. Compliance with 'anti-inflammatory' or ' preventive' therapy is particularly important, as its early initiation helps in preventing disease progression. Likelihood of improved compliance is strong with once daily dose schedules.
Inhaled steroids have traditionally been administered twice daily. Several recent studies suggest that once-daily dosing ( of the same cumulative daily dose ) may be equally effective, in both adults and children, particularly in patients with mild to moderate asthma.
Most of the data in published reports relate to dry-powder formulations of budesonide. In children upto 12 years of age with mild to moderate asthma, once daily doses of 200-400 micrograms, can be used. Upto 800 micrograms once daily can be used by adults. There is no evidence of local or systemic side-effects with once-daily dosing. Some data in support of once-daily dosing of other inhaled steroids, such as beclomethasone, fluticasone, flunisolide and momentasone is also available now.
Once daily inhaled corticosteroids should be prescribed in the evening since there is increasing evidence that mechanisms of inflammation are under circadian control. Many patients experience particularly troublesome symptoms at night and in the early morning. Bronchial smooth muscle hyper-responsiveness varies in a circadian fashion and is enhanced at night. The clinical relevance is that better asthma control might be achieved by evening dosing, so that rising drug levels coincide with the natural peak in airways inflammation.
Oral steroids are not a safe first-line option for most patients in view of the large number of side - effects associated with their use.
Low-dose oral theophyllines, sometimes used once daily in the evening, may have some weak anti-inflammatory effects.
LTRAs, a relatively new class of asthma therapy, work by antagonizing the effect of endogenous leukotrienes. Leukotrienes are potent broncho-constrictors, cause recruitment of inflammatory cells and increase vascular permeability (thus causing tissue oedema and promoting mucus formation). LTRAs, effective orally, have dual antiinflammatory and bronchodilatory properties.
Montelukast is the only LTRA available for once -daily oral use (10 mg in evening) as add- on therapy and as mono-therapy (in patients with exercise-induced bronchoconstriction). Rapidity of effect (in days) and ease of administration may be relevant in terms of compliance, but cost is prohibitive and efficacy is seen in only 50% cases.
To conclude, simplifying treatment regimens by switching to once-daily dosing is one pratical way of improving compliance. Inhaled corticosteroids are current 'gold-standard' antiinflammatory therapy and other agents should only be reserved for second line add-on therapy.
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When You Take Too Much Aspirin, This Is What Happens To You
Ariadne Barroso/Shutterstock
By Zrinka Peters/Sept. 2, 2021 2:09 pm EST
Aspirin has been around for so long and is so common that practically everyone has a bottle of it somewhere at home. And most of us wouldn't think twice about popping a pill or two if we have a fever or headache. But as harmless as it might seem, it is definitely possible to overdose on aspirin, and the results can be fatal.
Aspirin is a medicine synthesized from salicylic acid, which is a compound found in willow bark, per Healthline. It's a non-steroidal anti-inflammatory drug (NSAID) which is usually used to help reduce fever and pain. It's also commonly prescribed by doctors as a blood thinner. Aspirin comes in three "strengths:" 81 mg (sometimes called "baby" aspirin, though it should not be given to infants), 325 mg (regular), and 500 mg (extra strength).
Aspirin overdose can be acute if too much is taken at one time, or it can be chronic, gradually building up in the body over a longer period, according to MedLinePlus. In either case, per Healthline, an overdose occurs when your kidneys and liver can't filter the aspirin out properly, and so it accumulates in toxic levels. While mild toxicity can happen in healthy people with a dose of as little as 300 milligram per kilogram of body weight, for those with preexisting conditions — especially those involving the kidneys or liver — it can take much less.
This is what happens during an aspirin overdose
fizkes/Shutterstock
When an overdose of aspirin happens, symptoms can include respiratory problems like wheezing and difficulty breathing, blurred vision, skin rash, nervous system problems like confusion, headache, or seizures, and gastro-intestinal (GI) problems like diarrhea, vomiting, and stomach pain or bleeding, as noted by MedLinePlus.
Although doctors have routinely prescribed a daily aspirin to help prevent heart attacks, this approach is changing, according to AARP. One study of 19,000 people over age 70 found that taking an aspirin daily actually did nothing to prevent heart attacks and strokes. It did, however, increase the risk of GI bleeding by a shocking 38%. Leslie Cho, section head for preventive cardiology and cardiac rehabilitation at the Cleveland Clinic, told AARP, "The trials that established aspirin for primary prevention were done way before we had high-potent medications to help lower cholesterol, like statins. Now, newer research shows that the risks for most people probably outweigh the benefits."
With these facts in mind, it's best to consult a doctor if you're ever concerned about how much aspirin you're taking.
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The search for alternative therapies for oral candidiasis is a necessity and the use of medicinal plants seems to be one of the promising solutions. The objective of this study was to evaluate the in vitro and in vivo effects of the essential oil of Melaleuca alternifolia on Candida albicans.
The minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) of M. alternifolia were determined by the broth microdilution assay. For the in vivo study, twelve immunosuppressed mice with buccal candidiasis received topical applications of M. alternifolia with MBEC. After treatment, yeasts were recovered from the mice and quantified (CFU/mL). Mice were killed for morphologic analysis of the tongue dorsum by optical and scanning electron microscopy. Data were analyzed using Student's t test or Mann-Whitney test.
The MIC of M. alternifolia was 0.195% and the MBEC was 12.5%. Treatment with M. alternifolia achieved a 5.33 log reduction in C. albicans and reduced the microscopic lesions of candidiasis.
M. alternifolia oil at a 12.5% was effective to eradicate a C. albicans biofilm formed in vitro and to reduce yeasts of C. albicans in an immunosuppressed mouse model.
Recent decades have seen a significant increase in the incidence of all forms of candidiasis. This increase reflects changes in medical practice with more frequent use of invasive surgical procedures, and more widespread use of immunosuppressive therapies and broad-spectrum antibiotics . However, key to the increase in oral candidiasis has been the expansion of acquired immunodeficiency syndrome (AIDS) worldwide . Oral candidiasis is the most common fungal infection in patients with AIDS and it usually indicates the progression of HIV infection [2–4]. Treatment of oral candidiasis in HIV-positive patients is difficult because of recurring episodes, intermittent exposure and continual selection of antifungal therapy-resistant strains. Studies have shown that C. albicans and non-albicans strains are developing resistance to the antifungals widely used for treatment of oral candidiasis, such as fluconazole and amphotericin B [5, 6].
Another aspect related to antifungal resistance and the recurrence of infection is the ability of Candida spp. to form biofilms on various surfaces in the oral cavity. A biofilm has been defined as a community of microorganisms organized at interfaces, enclosed in a self-produced polymeric matrix and adhered to an inert or living tissue. The presence of an exopolymeric matrix couple with the organization of layers of cells may confer protection of organisms in the inner layers, thereby contributing to antifungal resistance [7–9]. For example, biofilms formed in vitro by C. albicans on silicone catheters were sensitive to micafungin only at a concentration 100 to 500 times higher than the minimum inhibitory concentration (MIC) in planktonic cells .
The search for alternative therapies for oral candidiasis is a necessity and the use of medicinal plants seems to be one of the promising solutions [11, 12]. The plant Melaleuca alternifolia has been used as an antiseptic remedy for decades. Although there is no published documentation of specific medicinal applications for M. alternifolia by Aboriginals prior to the colonization of Australia, the Bundjalung Aboriginals of New South Wales used the plant for medicinal purposes and spoke of the wound healing properties of the water from a lake into which M. alternifolia leaves had fallen . The essential oil of M. alternifolia, termed tea tree oil, contains almost hundreds components, the majority of which are monoterpenes and related alcohols. It has a minimum content of 30% of terpinen-4-ol and a maximum content of 15% of 1,8-cineole. Terpinen-4-ol is a major M. alternifolia component and exhibits strong antimicrobial and anti-inflammatory properties, whereas 1,8-cineole is probably an undesirable allergen in M. alternifolia products . Preliminary trials suggest that M. alternifolia formulations may be effective in the treatment of acne and fungal infections, and in bacterial pathogen decolonization protocols . The antimicrobial activity of M. alternifolia is attributed to its ability to denature proteins and alter the properties and function of the cell wall membrane, leading to the loss of intracellular components and eventually cell death [15–17].
Several in vitro studies described the antifungal activity of M. alternifolia against Candida isolates in planktonic growth, with MICs typically between 0.5-2% (v/v) and showed inhibition of germ tube formation by C. albicans. Few studies were performed in vivo to confirm and strengthen the in vitro results [19, 20]. Because M. alternifolia shows promise as a topical anti-candidal therapy and its antimicrobial effects depend on the concentration used , the aim of this study was to determine the minimal concentration of M. alternifolia required to eradicate C. albicans biofilms formed in vitro and to study the effects of this concentration in treating oral candidiasis induced in an immunosuppressed mouse model.
C. albicans strain ATCC 18804 was used for all experimental assays in this study. This strain was stored as frozen stocks in 30% glycerol at -80°C, subcultured on Sabouraud Dextrose agar plates and routinely grown in Sabouraud liquid medium at 37°C.
M. alternifolia was purchased at the Federal University of Viçosa/UFV. The UFV has the botanical identification of the plant studied, as well as its own deposit in a herbarium voucher specimen of the University, with registration number 30839 corresponding to M. alternifolia. The oil was obtained by the steam distillation technique. The oil sample contained the following major components: terpinen-4-ol (42.8%), γ-terpinene (20.4%), p-cymene (9.6%), α-terpinene (7.9%), 1,8-cineole (3%), α-terpineol (2,8%) and α-pinene (2.4%) as determined by gas chromatography mass spectrometry .
The MIC of M. alternifolia was determined by the broth microdilution method according to the Clinical and Laboratory Standards Institute (CLSI) document M27-A2. Initially, C. albicans were grown in Sabouraud dextrose agar for 48 h at 37°C. Then, the yeast suspension was prepared in 5 mL sterile saline (0.85%) and the cellular density was adjusted to 0.284 using a spectrophotometer (B582, Micronal, São Paulo, Brazil) at wavelength = 530 nm, resulting in a standard solution with 1 × 106 cells/mL. The standard solution was diluted 1:50 in RPMI 1640 medium with L-glutamine without sodium bicarbonate and buffered with 0.165 M morpholinepropanesulfonic acid (MOPS; Sigma-Aldrich, Steinheim, Germany), followed by a 1:20 dilution to obtain a final concentration of 1-5 × 103 cells/mL.
Eleven serial 1:2 dilutions were made from the M. alternifolia into a 96-well plate (25 to 0.01% (v/v)) from 100 μL of M. alternifolia in 100 μL of culture medium RPMI 1640 at pH 7.0 ± 0.1. Subsequently, 100 μL of the standardized suspension of C. albicans were added to each well of 96-well plate. A well for positive control (medium with inoculum) and another well for negative control (medium alone) were included.
Tween-80 (final concentration 0.001% v/v) was included to facilitate oil solubility . The plates were incubated at 37°C for 24 h. Minimal inhibitory concentration (MIC) was determined in the well of lowest concentration, in which turbidity was not observed when compared to oil-free growth control. This experiment was performed independently in triplicate.
C. albicans biofilms were formed in vitro using the methodology described by Seneviratne et al. with some modifications. Cultures of C. albicans grown on Sabouraud dextrose agar (Himedia) at 37°C for 18h were harvested in yeast nitrogen base (YNB, Himedia) supplemented with 50 mM glucose (Vetec, Duque de Caxias, RJ, Brazil). After an 18 h incubation at 37°C , yeasts were centrifuged at 358 × g for 10 minutes, washed twice with PBS, resuspended with YNB supplemented with 100 mM glucose and adjusted to an optical density of 0.381 at 530 nm (107 cells/mL) using a spectrophotometer (B582, Micronal). A 250 μL aliquot of C. albicans suspension was pipetted into each well of a 96-well flat-bottom microtiter plate (Costa Corning). The plate was incubated for 90 min at 37°C in a shaker at 75 rpm (Quimis, Diadema, Brazil) for the initial adhesion phase. After this period, the wells were washed with 250 μL of PBS to removed loosely adherent cells. A 250 μL aliquot of YNB supplemented with 100 mM glucose was then pipetted into each washed well, and the plates were incubated at 37°C in a shaker at 75 rpm for 48 h. The broth was changed every 24 h. Plates with biofilms formed by C. albicans were washed with 250 μL of PBS to remove loosely adherent cells.
The biofilm formed in each well was immersed in 250 μL of M. alternifolia suspended in 1% Tween 80 for 5 min in an orbital shaker (Solab, Piracibaca, Brazil). The concentration of M. alternifolia tested ranged from the MIC to 25%. The biofilm of the control group was pipetted with phosphate buffered saline (PBS) for the same period of time. All tests were performed in triplicate.
After treatments with M. alternifolia, biofilm cells were scraped off the well wall using a sterile toothpick and transferred to Falcon tubes containing 10 mL PBS. To disrupt the biofilms, the contents of the tubes were homogenized for 30 s using an ultrasonic homogenizer (Sonoplus HD 2200, Badelin Electronic, Berlim, Germany) with an output power of 50 W. The solution in the Falcon tubes was considered to be diluted by a factor of 10-1. Serial dilutions were then made using each original 10-1 dilution, and aliquots of 0.1mL were seeded onto Sabouraud dextrose agar (Himedia) plates that were incubated at 37°C for 48 h. After the incubation period, CFU/mL values were determined for each plate. Minimal biofilm eradication concentration was defined as the lowest concentration of oil that resulted in complete inhibition of CFU/mL.
Biofilms of C. albicans treated with the minimal biofilm eradication concentration of TTO (n = 2) and treated with PBS as a control group (n = 2) were subjected to SEM analysis.
Biofilms were formed and treated by M. alternifolia as described above with a minor modification: biofilms were formed on polystyrene discs approximately 8 mm in diameter that had been previously sterilized in a 20 -kGy gamma radiation chamber (cobalt 60) for 6 h (Embrarad, São Paulo, Brazil). The discs were placed into 24-well plates (Costa Corning, New York, USA) in which the total volume of suspension, PBS, broth culture and essential oil was 1 mL. The discs were transferred after biofilm formation to 24-well plates fixed in 2.5% glutaraldehyde for 1 h and dehydrated in several ethanol washes (10, 25, 50, 75 and 90% for 20 min each and 100% for 60 min). The plates were then incubated at 37°C for 24 h to dry the discs. The discs were transferred to aluminium stubs and covered with gold for 120 s at 40 mA (BAL-TEC 50D 050 Sputter Coater, Liechtenstein). After metallization, the biofilms were examined and photographed by SEM (Jeol JSM 5600, Tokyo, Japan) operating at 15 kV in increments of 1000 and 5000 times.
All animal experiments were conducted in accordance with the policies for animal care, welfare, and use of the Institute of Science and Technology/UNESP and to the Declaration of Helsinki. This study was approved by the Research Ethics Committee of the Institute of Science and Technology/UNESP (protocol number 024/2009-PA/CEP). Twenty-four adult male mice (Mus musculus, Albinus, Swiss) with twelve-week-old that tested negative for the Candida genus in the oral cavity, weighing approximately 30 to 60 g, were included in the study. Animals were divided into 2 groups: treated with TTO (n = 12) and treated with physiological solution (n =12). In each group, 10 mice were used for analysis by optical microscopy and 2 mice were used for scanning electron microscopy. The design of the experiments is shown in Table 1.
Euthanasia of the mice: macroscopic analysis, optical microscopy, and Scanning Electron Microscopy (SEM) of the tongue dorsum of mice.
The methodology described by Takakura et al. was used to induce experimental candidiasis with some modifications. Briefly, animals were immunosuppressed with 2 subcutaneous injections of prednisolone (Depo-Medrol, laboratórios Pfizer Ltda., Guarulhos, SP, Brazil) at a dose of 100 mg/kg of body weight 1 day before and 3 days after infection with Candida. Tetracycline chloride (Terramicina, Laboratórios Pfizer Ltda., Guarulhos, SP, Brazil) was administered in the drinking water at a concentration of 0.83 mg/mL beginning 1 day before infection and was maintained throughout the experiment. A 50 μL intramuscular injection of chlorpromazine chloride (10 mg/kg of body weight; Amplictil, Sanofi Aventis, Suzano, SP, Brazil) in each thigh was used to sedate the animals.
C. albicans grown for 24 h at 37°C on Sabouraud dextrose agar (Himedia, Mumbai, Maharashtra, India) was resuspended in 10 mL PBS and centrifuged at 358xg for 10 minutes. The pellet was resuspended in 10 mL PBS and adjusted to 108 cells/mL after counting in a Neubauer chamber (Laboroptik GMBH, Bad Homburg, Germany). A sterile swab (Absorve, Cral, São Paulo, SP, Brazil) soaked in the C. albicans suspension was used to inoculate the sedated mice by rubbing the swab for 1 minute on the tongue dorsum.
At 4 days post C. albicans inoculation, animals were anesthetized by intramuscular injection of ketamine (União Química, São Paulo, Brazil) at a concentration of 100 mg/kg of body weight and Xylazine (Produtos Veterinários J. A. Ltda., Patrocínio Paulista, SP, Brazil) at a dose of 10 mg/kg body weight. The minimal biofilm eradication concentration of M. alternifolia determined by the in vitro assay (12.5%) was used to treat oral candidiasis. M. alternifolia was suspended in 1% Tween 80 and pipetted onto the dorsum of the tongue in 50 μL for 3 times in intervals of 10 minutes. The control group received physiological solution in the same volume and with the same frequency.
Samples from the tongue dorsum were collected with a mini-swab before and immediately after each experimental treatment, the swab was placed in a test tube containing 0.99 mL PBS and shaken for 1 minute. This solution was estimated to be diluted by a factor of 10-2 Candida from the soaked swab. Serial dilutions were subsequently made, and 0.1 mL of each dilution was plated onto the surface of Sabouraud dextrose agar (Himedia) containing chloramphenicol (Viximicina, São Paulo, SP, Brazil). Dilutions were plated in duplicate and incubated at 37°C for 48 hours. Candida colonies were counted on plates exhibiting 30 to 300 colonies to determine colony-forming units (CFU)/mL. Plates with fewer than 30 colonies from the initial 10-2 dilution were estimated to contain 10-1 Candida cells.
One day after the experimental treatment, an excessive dose of anesthetic, 100 mg/kg body weight ketamine (União Química Farmacêutica Nacional S/A., Embu-Guaçu, SP, Brazil) and 10 mg/kg body weight xylazine (Produtos Veterinários J. A. Ltda., Patrocínio Paulista, SP, Brazil) was administered to kill the mice, corresponding to 5 days after experimental candidiasis induction. Tongues were removed for macroscopic and microscopic analyses (optical and scanning electron microscopy, respectively).
Characteristic lesions of candidiasis on the tongue dorsum were observed using a stereomicroscope (Zeiss, Göttingen, Germany). For quantification of lesions on the tongue dorsum, scores were assigned from 0 to 4: 0, normal; 1, white patches on less than 20% of the surface; 2, white patches covering between 21% and 90% of the surface; 3, white patches on more than 91% of the surface; and 4, thick white patchy pseudomembranes covering more than 91% of the surface .
For microscopic analysis of the lesions, the tongues were fixed in 10% formalin for 24 h. After embedding in paraffin, 5 μm-thick tissue slices were cut and stained with hematoxylin-eosin (H&E) and periodic acid-Schiff (PAS). The presence of candidiasis was analyzed using optical microscopy (Olympus, CX41, Toquio, Japan) at X400 magnification.
Candidiasis lesions were quantified by counting the number of hyphae and epithelial lesions in histological sections stained with PAS and H&E, respectively. For each stain, two histological sections were selected randomly and analyzed from each animal. In each histological section, 21 histologic fields were analyzed in the anteroposterior direction in 42 histologic fields.
The presence of yeasts and hyphae was quantified according to the methodology of Junqueira et al., attributing the following scores to histologic fields: 1, 1 to 5 yeasts/hyphae; 2, 6 to 15 yeasts/hyphae; 3, 16 to 50 yeasts/hyphae; and 4, more than 50 yeasts/hyphae. For statistical analysis, a median of the scores obtained from the 42 histologic fields was determined per animal.
The intensity of the tissue lesions was evaluated by counting the number of histologic fields with the presence of epithelial lesions, such as epithelial hyperplasia, disorganization of the basal cell layer, exocytosis, spongiosis, loss of filiform papillae, hyperkeratosis and development of intraepithelial microabscesses. The mean of the number of histologic sections with epithelial lesions was determined per animal for statistical analysis.
For SEM analysis, tongues were fixed in 2.5% glutaraldehyde in phosphate buffer (0.1 mol/L and pH 7.3) for 24 h at 4°C. The tongues were washed with a physiological salt solution (0.85% NaCl) for 30 minutes. Specimens were subsequently dehydrated in a series of ethanol solutions (50%, 70%, and 90% for 20 minutes each and 100% for 20 minutes 3 times). After dehydration, tongues were dried to the critical point using CO2 (Denton Vacuum DCP 1, Moorestown, NJ). The tongues were then fixed on aluminum stubs and coated with gold for 120 seconds at 40 mA (BAL-TEC 50 D 050 Sputter Coater, Liechtenstein) and evaluated using SEM (JEOL JSM 5600, Tóquio, Japan) at 15 kV. The images obtained from SEM analyses were evaluated only to identify yeasts, hyphae and tissue damage that characterize the experimental candidiasis induced in immunosuppressed mouse model. No quantification of Candida or epithelial lesions was performed.
The data obtained from the recovered CFU/mL and quantification of epithelial lesions using optical microscopy were analyzed by Student's t test. The scores from the macroscopic analysis and the quantification of yeasts and hyphae in optical microscopy were evaluated using the non-parametric Mann-Whitney test. A P value less than 0.05 was considered statistically significant.
The effects of M. alternifolia on the in vitro growth of C. albicans were first examined following the CLSI. Among the tested concentrations of M. alternifolia (0.01 to 25%), the MIC value was determined to be 0.195% (1.95 mg/mL). After determination of the MIC, concentrations of M. alternifolia ranging from 0.195 to 25% were tested on C. albicans biofilms, and 12.5% was determined to be the minimal biofilm erradication concentration. To confirm complete inhibition of C. albicans biofilms after treatment with 12.5% M. alternifolia, the biofilms were analyzed by scanning electron microscopy (SEM). In SEM analysis, no formation of hyphae or blastoconidia was observed in the biofilms treated with M. alternifolia. However, a heterogeneous biofilm composed of blastoconidia, pseudohyphae and hyphae was observed on the polystyrene discs in the control group without M. alternifolia treatment (Figure 1).
Scanning electron microscopy (SEM) of C. albicans biofilms formed in vitro on the polystyrene discs. The biofilm formed after 48 h was composed of blastoconidia, pseudohyphae and hyphae (Control group).
The numbers of C. albicans recovered from the oral cavity of mice before and immediately after experimental treatments with M. alternifolia or physiological solution (control group) are shown in Figure 2. The group treated with M. alternifolia showed a 5.33 Log10 reduction in the number of C. albicans cells after treatment, while the control group had a 0.24 Log10 reduction after application of physiological solution, indicating that the essential oil of M. alternifolia significantly reduced the colonization by C. albicans in the oral cavity of mice.
Number of fungal cells before and after with M. alternifolia treatment. Means and standard deviations of the CFU/mL of C. albicans recovered from the oral cavity of the mice before and after experimental treatment (n = 10 per group). The recovery of C. albicans was performed immediately after treatment with M. alternifolia. *Significant difference between the number of CFU/mL recovered before and after treatment with TTO (Student's t-test, P = 0.001).
After 24 h of experimental treatments, macroscopic analysis of the tongue dorsum showed the presence of candidiasis lesions characterized by pseudomembranous white plaques (Figure 3) in both experimental groups (treated with M. alternifolia and control) with a median score of 2, representing white patches covering between 21% and 90% of the tongue surface. In all mice studied, only scores 1 and 2 were identified. Although the number of animals receiving score 2 in the group treated with M. alternifolia was lower when compared to the control group, this difference was not significant (Figure 4). These data demonstrated that candidiasis lesions persisted for 24 h after treatment with essential oil of M. alternifolia.In optical microscopy analysis, candidiasis lesions were represented by the presence of yeasts and hyphae limited to the keratinized layer on the tongue dorsum (Figure 5). In these regions, the epithelial tissue showed loss of filiform papillae, microabscesses, exocytosis, spongiosis, basal layer disorganization, epithelial hyperplasia, and an increased number of mitoses in the basal layer. Muscle inflammation, inflammatory infiltrate and some congested blood vessels in the lamina propria were also observed.
Macroscopic lesions of candidiasis on the tongue dorsum characterized by pseudomembranous white plaques.
Macroscopic analysis of candidiasis on the tongue dorsum of mice. Scores obtained from the macroscopic analysis of candidiasis on the tongue dorsum of mice after 24 h of the treatment with essential oil of M. alternifolia or physiological solution for the control group (n = 10 per group). The scores were attributed according to Takakura el al. 2003 as follows: Score 0 (normal), Score 1 (white patches on less than 20% of the surface), Score 2 (white patches covering between 21% and 90% of the surface), Score 3 (white patches on more than 91% of the surface) and Score 4 (thick white patchy pseudomembranes covering more than 91% of the surface). There were no significant differences between the groups treated with M. alternifolia oil and control (Mann-Whitney test, P = 0.3662).
Sagittal section of the dorsum of the tongue of mice. A) Control group - Hyphae of C. albicans in the keratin layer (arrows) and areas of exocytosis (arrow head). B) M. alternifolia group - Yeasts of C. albicans in the keratin layer (arrows) and intraepithelial microabscesses (*).PAS staining, 400X magnification.
The hyphae and yeasts were quantified in histological sections stained by PAS (Figure 6). Although the median scores obtained for the M. alternifolia and control groups were scored 1 and 2, respectively, no statistically significant difference was observed between groups treated with M. alternifolia and control (P = 0.2596). The epithelial lesions were also quantified using histological sections stained by H&E (Figure 7), and it was observed that the group treated with M. alternifolia showed fewer candidiasis lesions when compared to the control group, this difference was statistically significant (P = 0.005).SEM analysis on the tongue dorsum showed a large quantity of bacteria, yeasts and hyphae. Yeasts appeared in less quantity than hyphae and some hyphae were penetrating the epithelial tissue (Figure 8). In some regions, the filiform papillae were damaged, while papillae were lost in others, showing that the animals developed well-established candidiasis lesions on the tongue dorsum.
Microscopic analysis of candidiasis on the tongue dorsum of mice. Scores obtained from optical microscopy of histological sections stained by PAS after 24 h of the treatment with essential oil of M. alternifolia or physiological solution for the control group (n = 10 per group). Scores were attributed according to Junqueira et al. 2005: Score 1 (1 to 5 yeasts/hyphae), Score 2 (6 to 15 yeasts/hyphae), Score 3 (16 to 50 yeasts/hyphae), and Score 4 (more than 50 yeasts/hyphae). There were no significant differences between the groups treated with M. alternifolia oil and control (Mann-Whitney test, P = 0.2596).
Means and standard deviations of epithelial lesions obtained from optical microscopy. Means and standard deviations obtained from optical microscopy of histological sections stained by H&E after 24 h of the treatment with essential oil of M. alternifolia or physiological solution for the control group. The number of histological fields with the presence of epithelial lesions was determined for each animal studied (n = 10 per group). *A significant difference between the groups was observed (Student's t-test, P = 0.005).
Scanning electron microscopy of the tongue dorsum. A) Control group - Hyphae of C. albicans (arrows) penetrating the tissue of the tongue dorsum after 24 h of the treatment with physiological solution. B) M. alternifolia group -Yeasts of C. albicans (arrows) on the tissue of the tongue dorsum after 24 h of the treatment with M. alternifolia oil.
Numerous essential oils such as M. alternifolia oil have been tested for both their in vitro and in vivo antifungal activity. M. alternifolia has been traditionally used by Australian natives and more recently, it has become a popular essential oil used as a non-ethnic remedy worldwide [12, 20]. In this study, we demonstrated that the essential oil of M. alternifolia at a 12.5% concentration completely inhibited the C. albicans biofilms formed in vitro and had a protective effect against oral C. albicans infections in mice.
M. alternifolia has demonstrated activity against C. albicans[17–20]. New studies that can identify and evaluate the clinical effectiveness of M. alternifolia need be developed, such as assays with different experimental models and cell lines by evaluating the cytotoxicity, various concentrations and combinations with conventional antifungal agents to verify the possible synergism. Our findings can contribute in the future to prove M. alternifolia as an adjuvant clinical therapy, especially in cases of Candida lesions that is the most frequent fungal condition among humans living with HIV.
First, the in vitro effects of M. alternifolia on C. albicans were examined by the broth microdilution method (CLSI), and the MIC obtained was 0.195% (1.95 mg/mL). According to Carson et al., the MICs of M. alternifolia for yeasts generally range between 0.03 and 0.5%, while fungicidal concentrations generally range from 0.12 to 2%. In addition to inhibiting the growth of Candida, some studies have shown that M. alternifolia inhibits the formation of germ tubes and decreased the cell surface hydrophobicity of C. albicans[13, 17, 18]. Hammer et al. verified that germ tube formation was affected by the presence of sub-inhibitory concentrations of M. alternifolia oil, and it was completely inhibited by the presence of 0.25% TTO. Sudjana et al. investigated the effects of the oil from M. alternifolia on C. albicans cell adhesion to both abiotic and biotic surfaces. Adhesion of C. albicans to polystyrene was significantly reduced for 3 isolates at 0.031%, 6 isolates at 0.062% and 0.125% and for all 7 isolates studied at 0.25% M. alternifolia. Similarly, adhesion to buccal epithelial was also significantly reduced in the presence of 0.016-0.062% M. alternifolia.
Essential oil mouthwashes containing a range of natural plant extracts, including thymol, eucalyptol, bioflavanoids and M. alternifolia oil derivatives, demonstrated direct bactericidal and anticandidal activity in vitro. It is thought that essential oil mouthwashes kill microorganisms by cell membrane disruption and enzyme inhibition. However, the effectiveness of natural antimicrobials on established biofilms in the oral cavity is unknown, with incomplete penetration by the agents being reported. The clinical efficacy of essential oil mouthwashes has been studied, but largely against plaque bacteria. Therefore, the clinical benefits of these agents in treating oral candidiasis remain to be established .
In this study, we determined the minimal concentration of M. alternifolia oil necessary to eradicate C. albicans biofilms formed in vitro. The minimal biofilm eradication concentration (MBEC) was 12.5%, equivalent to 64 times the MIC. Budzynska et al. also evaluated the minimal inhibitory concentration (MIC) and the minimal biofilm eradication concentration (MBEC) of M. alternifolia in biofilms formed by Staphylococcus aureus. The MIC value was 0.38%, and the authors achieved an MBEC concentration of 173 times the MIC for 1 h of treatment, whereas 8 times the MIC was sufficient to obtain a 90% reduction in biomass metabolic activity after 4 h of treatment.
After establishing the MBEC, we tested the in vivo effects of M. alternifolia at a 12.5% concentration on oral candidiasis. For this, we used an experimental model of oral candidiasis in immunosuppressed mice developed by Takakura et al.; this model is an established methodology that is widely used by several authors for the study of this infection [20, 26–29]. In the control group of this study, a large number of viable Candida cells (5-6 Log10) were recovered from the oral cavity of mice. This finding is in agreement with studies by Costa et al. and Ninomiya et al. that recovered 5-6 Log10 Candida cells from the oral cavity of animals.
In contrast, a relatively low number of C. albicans cells was recovered from the oral cavity of mice treated with M. alternifolia. The treatment with this essential oil resulted in a 5.33 Log10 reduction of C. albicans, indicating clinical efficacy of M. alternifolia for the treatment of oral candidiasis. Ninomiya et al. also studied the effects of M. alternifolia on oral candidiasis in an immunosuppressed mouse model and found an approximate 1 Log10 reduction of C. albicans after treatment with M. alternifolia at concentrations of 1 and 4%. Probably, the highest Candida reduction observed in our study was achieved by the concentration of M. alternifolia tested (12.5%).
According to Hammer et al. , while the antimicrobial properties of M. alternifolia oil are increasingly well-characterized, relatively limited data are available on the safety and toxicity of this oil. Greay et al. showed that topical treatments of 10% M. alternifolia had significant activity against subcutaneous tumours in immunocompetent mice. The antitumor effect of topical M. alternifolia was accompanied by skin irritation similar to other topical chemotherapeutic agents, but unlike other approved topical agents, this irritation was quickly resolved. Furthermore, topical M. alternifolia caused an influx of neutrophils in the treated area, with no evidence of systemic toxicity. The lack of systemic activity within the treatment period was verified by normal body weigth, no changes in serum alkaline phosphatase or aspartate aminotransferase and normal liver histology of the animals studied.
Clinical evidence suggests that topical use of the oil is relatively safe and that adverse events are minor, self-limiting and occasional . In a study conducted by Veien et al., 217 patients consecutively sampled in a dermatology clinic were patch-tested with 10% M. alternifolia with no irritant reactions recorded. Catalán et al. tested 20% M. alternifolia to identify the in vitro and in vivo activity of this oil mixed with different tissue conditioners on the C. albicans strain. In the in vitro study, these authors verified that Coe-Comfort or Fitt conditioners mixed with M. alternifolia exhibited total inhibition of C. albicans. Patients treated with M. alternifolia mixed with Coe-Comfort in an in vivo study showed a significant decrease in palatal inflammation when compared to those treated with Coe-Comfort alone. However, M. alternifolia can be toxic if ingested, as evidenced by studies with experimental animals and from cases of human poisoning [34, 35]. The 50% lethal dose for M. alternifolia in a rat model is 1.9 to 2.6 mL/Kg. Incidences of oral poisoning in children and adults have been reported, and in all cases, patients responded to supportive care and recovered without apparent sequelae .
In this study, M. alternifolia was suspended in 1% Tween 80 to be applied on the dorsum of the tongue. Tween 80, a nonionic surfactant and an emulsifier, is frequently used as a carrier for M. alternifolia. Considering the biological effects of Tween 80 in experimental oral candidiasis treated by M. alternifolia, Ninomiya et al. [20, 36] used 1% Tween 80 as control group and found similar results of C. albicans CFU/mL compared to other studies of oral candidiasis in immunosuppressed mice that used physiological solution as control group. Several studies showed that Tween 80 has low toxicity for human cells and experimental animals [37, 38]. In addition, its application is permitted for intradermal and intravenous injection in human beings .
After verifying that M. alternifolia at concentration of 12.5% significantly reduced the C. albicans colonization in the oral cavity of mice, we tested the effects of M. alternifolia treatment on the candidiasis lesions and tissue repair. Therefore, mice were killed 24 hours after the treatment and the tongues were removed for macroscopic and microscopic analyses. In these analyses, we verified that the animals treated with M. alternifolia showed fewer candidiasis lesions when compared to untreated animals (control group). Despite this, no statistically significant difference was observed for the macroscopic analysis and quantification of hyphae (histological sections stained by PAS) between M. alternifolia and control-treated groups. Only the quantification of epithelial lesions (histological sections stained by H&E) showed a statistically significant difference between groups.
However, Ninomiya et al. found a significant reduction in the macroscopic lesions of the dorsum tongue for groups treated with M. alternifolia. This difference might be attributed to the time of M. alternifolia application in relation to the stage of candidiasis infection. Ninomiya et al. applied M. alternifolia on the dorsum tongue at 3 and 24 h after infection by C. albicans. Because it is known that C. albicans form germ tubes and hyphae 3 hours after inoculation in experimental oral candidiasis , Ninomiya et al. may have found a significant reduction in macroscopic lesions because M. alternifolia prevented Candida invasion of the epithelium by hyphae. These data suggest that early administration of M. alternifolia is highly effective. In the present study, M. alternifolia was applied 4 days after infection by C. albicans. Therefore, oral candidiasis lesions were already well-established, and consequently impaired the action of M. alternifolia. Furthermore, we evaluated candidiasis lesions on the dorsum tongue 24 h after application of M. alternifolia, and this time period may not have been long enough for improvement of the lesions and tissue repair to occur.
In this study, we concluded that M. alternifolia oil at a 12.5% concentration was effective to eradicate a C. albicans biofilm formed in vitro and to reduce yeasts of C. albicans in an immunosuppressed mouse model.
The authors thank Prof. Antônio Lelis Pinheiro for his assistance with the preparation of M. alternifolia essential oil and Prof. Oslei Paes de Almeida and Adriano Luis Martins for their assistance with scanning electron microscopy of the dorsum tongue. We acknowledge the São Paulo Council of Research - FAPESP, Brazil (Grants 2010/19117-7, 2010/06602-4 and 2012/02184-9) for supporting this research.
Conceived and designed the experiments: RDR, VMCR, ACBPC, CFA, PPB, ALA. Performed the experiments: JCJ, RDR, ACBPC, VMCR. Analyzed the data: JCJ, ACBPC, VMCR, AOCJ, ALA. Contributed reagents/materials/analysis tools: JCJ, AOCJ. Wrote the paper: RDR, JCJ, ALA, AOCJ. All authors read and approved the final manuscript.
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Primary care cancer control interventions including Latinos: a review.
BACKGROUND: Even though 86% of adult Latinos have a usual source of care, there is a paucity of literature on primary care-based interventions to promote cancer prevention and control in this population. This systematic review examines published primary care-based cancer control interventions that included Latinos. METHODS: MEDLINE, the Cochrane Registry, and EMBASE were searched from January 1985 to January 2003. Any primary care-based intervention using a controlled trial, quasi-experimental, or pre-post design that targeted breast, cervical, or colorectal cancer was included if at least 5% of the sample was Latino. RESULTS: A total of 14 intervention studies met inclusion criteria. Seven of the 14 studies described patient or provider reminder interventions. Other interventions incorporated into the primary care setting one of the following: community health educators, culturally sensitive videos, audit with feedback, materials from the "Put Prevention Into Practice" campaign, and vouchers for free screenings. The heterogeneity of designs and outcome variables and the low number of Latinos presented obstacles to combining data to estimate the overall effectiveness of primary care interventions for this population. Qualitatively, patient and physician reminders and management systems strategies including audit with feedback for providers appear to result in improved screening utilization. CONCLUSIONS: There is a paucity of data on the effectiveness of primary care cancer control interventions directed at Latinos. Primary care-based interventions that have been effective in non-Latinos could incorporate culturally appropriate elements and lessons from community-based research and could be applied to Latinos so that their effectiveness can be assessed in this group.
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Urine sample analysis is irreplaceable as a non-invasive method for disease diagnosis and follow-up. However, in urine samples, non-degraded protein and RNA may be only found in urinary extracellular vesicles (uEVs). In recent years, various methods of uEV enrichment using low volumes of urine and unsophisticated equipment have been developed, with variable success.
Scientists at CIC bioGUNE compared the results of the differential ultracentrifugation procedure with 4 of these methods. The methods tested were a lectin-based purification, Exoquick (System Biosciences), Total Exosome Isolation from Invitrogen and an in-house modified procedure employing the Exosomal RNA Kit from Norgen Biotek Corp. The analysis of selected gene transcripts and protein markers of extracellular vesicles (EVs) revealed that each method isolates a different mixture of uEV protein markers. In their conditions, the extraction with Norgen's reagent achieved the best performance in terms of gene transcript and protein detection and reproducibility. By using this method, they were able to detect alterations of EVs protein markers in urine samples from prostate cancer adenoma patients. Taken together, these results show that the isolation of uEVs is feasible from small volumes of urine and avoiding ultracentrifugation, making easier the analysis in a clinical facility. However, caution should be taken in the selection of the enrichment method since they have a differential affinity for protein uEVs markers and by extension for different subpopulation of EVs.
Two 10-ml aliquots of urine from 10 healthy individuals were used to test each of the 5 methods (overall, 100 samples were processed). The final pellet obtained in each case was suspended in 100 µl of Exosome Resuspension Buffer (ERB, Life Technologies) and then divided for RNA, protein and EM analysis at the ratio of 70:20:10. The same ratio was used for NOR extraction, before proceeding to the first centrifugation.
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COVID-19: The Dynamics of Quality of Life (QOL) and Artificial Intelligence (AI)
Bongs Lainjo Cybermatic International, Canada
Covid-19, quality of life, strategies, lessons learned, artificial intelligence
The objective of the study is to conduct an exploratory review of the COVID-19 pandemic by focusing on the theme of COVID-19 pandemic morbidity and mortality considering the dynamics of Artificial Intelligence and Quality of life (QOL). The methods used in this research paper include a review of literature, anecdotal evidence, and reports on the morbidity of COVID-19, including the scope of its devastating effects in different countries such as the US, Africa, UK, China, and Brazil, among others. The findings of this study suggested that the devastating effects of the Coronavirus are felt across different vulnerable populations. These include the elderly, front-line workers, marginalised communities, visible minorities, and more. The challenge in Africa is especially daunting because of inadequate infrastructure, financial, and human resources, among others. Besides, AI technology is being successfully used by scientists to enhance the development process of vaccines and drugs. However, its usage in other stages of the pandemic has not been adequately explored. Ultimately, it has been concluded that the effects of the COVID-19 are producing unprecedented and catastrophic outcomes in many countries. With a few exceptions, the common and current intervention approach is driven by many factors, including the compilation of relevant reliable and compelling data sets. On a positive note, the compelling trailblazing and catalytic contributions of AI towards the rapid discovery of COVID-19 vaccines are a good indication of future technological innovations and their effectiveness.
Lainjo, B. (2021) "COVID-19: The Dynamics of Quality of Life (QOL) and Artificial Intelligence (AI)", African Journal of Inter/Multidisciplinary Studies, 3(1), pp. 161–177. doi: 10.51415/ajims.v3i1.908.
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A Point Mutation in DNA Polymerase β (POLB) Gene Is Associated with Increased Progesterone Receptor (PR) Expression and Intraperitoneal Metastasis in Gastric Cancer
Xiaohui Tan1, 6*, Xiaoling Wu2, 6*, Shuyang Ren1, Hongyi Wang3, Zhongwu Li4, Weaam Alshenawy6, Wenmei Li1, Jiantao Cui1, Guangbin Luo5, Robert S. Siegel6, Sidney W. Fu6✉, Youyong Lu1✉
1. Laboratory of Molecular Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital & Institute, 52# Fu-Cheng-Lu, Hai-Dian District, Beijing, 100142, China;
2. Department of Gastroenterology, The Chengdu Military General Hospital, Chengdu, China;
3. Department of Sugary, Peking University School of Oncology, Beijing Cancer Hospital & Institute, 52# Fu-Cheng-Lu, Hai-Dian District, Beijing, 100142, China;
4. Department of Pathology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, 52# Fu-Cheng-Lu, Hai-Dian District, Beijing, 100142, China;
5. Department of Genetics, Case Western Reserve University, Cleveland, OH 44106, USA;
6. Department of Medicine, The George Washington University School of Medicine and Health Sciences, 2300 Eye Street, N.W. Ross Hall 402C, Washington, DC 20037, USA.
*These authors contributed equally to this work.
✉ Corresponding authors: Sidney W. Fu, sfuedu or Youyong Lu , youyonglucom.
Tan X, Wu X, Ren S, Wang H, Li Z, Alshenawy W, Li W, Cui J, Luo G, Siegel RS, Fu SW, Lu Y. A Point Mutation in DNA Polymerase β (POLB) Gene Is Associated with Increased Progesterone Receptor (PR) Expression and Intraperitoneal Metastasis in Gastric Cancer. J Cancer 2016; 7(11):1472-1480. doi:10.7150/jca.14844. https://www.jcancer.org/v07p1472.htm
Increased expression of progesterone receptor (PR) has been reported in gastric cancer (GC). We have previously identified a functional T889C point mutation in DNA polymerase beta (POLB), a DNA repair gene in GC. To provide a detailed analysis of molecular changes associated with the mutation, human cDNA microarrays focusing on 18 signal transduction pathways were used to analyze differential gene expression profiles between GC tissues with T889C mutant in POLB gene and those with wild type. Among the differentially expressed genes, notably, PR was one of the significantly up-regulated genes in T889C mutant POLB tissues, which were subsequently confirmed in POLB gene transfected AGS cell line. Interestingly, patients with T889C mutation and PR positivity were associated with higher incidence of intraperitoneal metastasis (IM). In vitro studies indicate that PR expression was upregulated in AGS cell line when transfected with T889C mutant expression vector. Cotransfection of T889C mutant allele and PR gene induced cell migration in the cell line. These data demonstrated that T889C mutation-associated PR overexpression results in increased IM. Therefore, T889C mutation-associated PR overexpression may serve as a biomarker for an adverse prognosis for human GC.
Keywords: Gastric cancer, DNA polymerase beta, progesterone receptor, metastasis.
Tan, X., Wu, X., Ren, S., Wang, H., Li, Z., Alshenawy, W., Li, W., Cui, J., Luo, G., Siegel, R.S., Fu, S.W., Lu, Y. (2016). A Point Mutation in DNA Polymerase β (POLB) Gene Is Associated with Increased Progesterone Receptor (PR) Expression and Intraperitoneal Metastasis in Gastric Cancer. Journal of Cancer, 7(11), 1472-1480. https://doi.org/10.7150/jca.14844.
Tan, X.; Wu, X.; Ren, S.; Wang, H.; Li, Z.; Alshenawy, W.; Li, W.; Cui, J.; Luo, G.; Siegel, R.S.; Fu, S.W.; Lu, Y. A Point Mutation in DNA Polymerase β (POLB) Gene Is Associated with Increased Progesterone Receptor (PR) Expression and Intraperitoneal Metastasis in Gastric Cancer. J. Cancer 2016, 7 (11), 1472-1480. DOI: 10.7150/jca.14844.
Tan X, Wu X, Ren S, Wang H, Li Z, Alshenawy W, Li W, Cui J, Luo G, Siegel RS, Fu SW, Lu Y. 2016. A Point Mutation in DNA Polymerase β (POLB) Gene Is Associated with Increased Progesterone Receptor (PR) Expression and Intraperitoneal Metastasis in Gastric Cancer. J Cancer. 7(11):1472-1480.
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Swine flu (swine influenza) is a disease of pigs that can, rarely, be passed to humans. It is a highly contagious respiratory disease caused by one of many Influenza A viruses.
How does a human catch swine flu?
Contact with infected pigs – this is the most common way of catching swine flu. Any contact with infected pigs makes transmission more likely.
Contact with infected humans – this is a much less common way of catching swine flu, but is a risk, especially for those in close contact with an infected person.
Like the regular flu, swine flu can lead to more serious problems including pneumonia, a lung infection, and other breathing problems. And it can make an illness like diabetes or asthma worse. If you have symptoms like shortness of breath, severe vomiting, pain in your belly or sides, dizziness, or confusion, call your doctor.
Washing hands regularly with soap.
Refraining from touching surfaces that may have the virus.
Do not get close to people who are sick.
Stay away from crowds if there is a swine flu outbreak in your area.
This remedy corresponds to the commencement of the trouble, when the patient is weak, tired and aches throughout the body. It removes speedily the intense aching and muscular soreness.
This remedy covers more phases of flu than perhaps any other remedy. when there is a copious flow, prostration and paroxysmal coryza. Its periodicity makes it suitable to epidemics, and it suits the early symptoms when the affection is in the upper portion of the respiratory tract. The burning dryness and copious watery excoriating secretion and the involvement of the conjunctiva are unmistakable indications. Langour and prostration are prominent symptoms.
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Have you considered seeing a counselor for depression therapy?
Therapy for anxiety and depression can help individuals understand the symptoms associated to depression or anxiety while creating healthy coping skills. At Santos Counseling PLLC we offer counseling in Greensboro and Winston Salem, focused on talk therapy for depression that is considered one of the best therapy for depression.
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Depression therapy can help by providing coping skills.
Therapy is a treatment for depression aimed at increasing awareness and providing appropriate coping skills.
If you feel that depression therapy is something you would like more information on please feel welcome to complete the form below. Therapy is available with Santos Counseling PLLC in Greensboro and Winston Salem, NC.
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bioskinrevive.com
Category Archives: LTA4H
Background Sepsis is a high-mortality disease without effective therapeutic choices
Background Sepsis is a high-mortality disease without effective therapeutic choices. between 17 grams to 19 grams) were randomly divided into an LPS group (n=10) and a GENT group (n=10). After intraperitoneal (i.p.) injection of GENT (50 mg/kg, Peimine 2 mg/mL) for GENT group or the same volume of physiological saline for the LPS group for 30 minutes, mice of both organizations were treated with lethal LPS (40 mg/kg, 2 mg/mL, i.p.) to induce LPS shock. Both LPS and GENT were dissolved in physiological saline. The mice were injected 8 instances with GENT or saline every 2 hours after the 1st injection. All mice were closely observed, the time and quantity of deaths were recorded every hour and the survival rates were determined. The experiment was replicated 3 times. For serum and cells investigation, a total of fifty 7C8-week-old woman C57BL6 mice (excess weight between 17 grams to 19 grams) were randomly divided into three organizations, an LPS group (n=20), a GENT group (n=20) and a mock group (n=10). Firstly, the GENT group mice were injected with GENT (50 mg/kg, 2 mg/mL), and the LPS and mock organizations were injected with the same volume of physiological saline. Thirty minutes later, both LPS and GENT group mice received an injection of LPS at the same dose mentioned above, while the mock group mice were injected with the same volume of saline as a negative control. Serum and lung cells were Peimine collected in the indicated time points (2 hours and 4 hours after LPS injection) for cytokine measurements and morphological evaluation. GENT was bought from Chemfaces (kitty. # "type":"entrez-protein","attrs":"text":"CFN98047″,"term_id":"801938547″,"term_text":"CFN98047″CFN98047, CAS: 0831-76-9), and LPS from O55:B5 was bought from Sigma (kitty. # L2880) and dissolved in physiological saline. Cell planning Primary bone tissue marrow-derived macrophages (BMMs) had been extracted from the bone tissue marrow of 8C12-week-old C57BL6 mice. Quickly, bone tissue marrow cells were collected from femur and tibias bone fragments. Following red bloodstream cell lysis, discarding and centrifugation of supernatant, bone tissue marrow cells had been seeded at 2 million/well in 12-well plates in comprehensive 1640 moderate (Invitrogen, Grand Isle, CA, USA) filled with 10% (vol/vol) fetal bovine serum (FBS), penicillin and streptomycin (100 U/mL) and 20 ng/mL murine M-CSF (Peprotech, kitty. # 315-02). Fifty percent from the moderate was replaced with fresh moderate on the fifth and third times. At the 6th day, the moderate was fully transformed with comprehensive 1640 moderate (without M-CSF), as well as the adherent cells had been mature BMMs completely, which were employed for following experiments. Principal mouse peritoneal elucidated macrophages (PEMs) from C57BL6 mice had been prepared as defined previously (5). Quickly, mice had been injected intraperitoneally with 3 mL of 3% BBLTM Thioglycollate Moderate Brewer Modified moderate (BD Pharmingen, MD, USA; kitty. # 211716). Peimine Four times later, we attained PEMs by frequently cleaning the peritoneal cavity with Dulbeccos Modified Eagles moderate (DMEM). The PEMs had been cultured in comprehensive DMEM supplemented with 10% (vol/vol) FBS, penicillin and streptomycin (100 U/mL). Organic 264.7 cells (good gifts from Dr. B. Sun, SIBCB, CAS, Shanghai, China) were used to test cell viability. LATH antibody siRNA transfection Lipofectamine? RNAiMAX Transfection Reagent was used to transfect 40 nM synthesized siRNA or nonspecific siRNA (GenePharma) into PEMs according to the manufacturers instructions. The sequences of two P65 siRNAs were AGAAGACAUUGAGGUGUAUTT (5′-3′) (p65#1) and GAAGAAGAGUCCUUUCAAUTT (5′-3′) (p65#2). RNA extraction and qPCR Total RNA was extracted from cells or cells by TRIzol reagent (Invitrogen, Carlsbad, CA, USA), and cDNAs were generated with Reverse Transcriptase M-MLV (Takara, cat. # 2641A), dNTP blend (Thermo Scientific, Lot 00314428), and Random Primer OligodN6 (Sangon Biotech Co., Peimine Ltd., Shanghai, China). The relative mRNA manifestation of IL-1, IL-6, iNOS, CCL5, CXCL10 and p65 was measured in duplicate on a BIO-RAD CFX96 machine (Bio-Rad Laboratories) with SYBR Premix Ex lover Taq Peimine (Takara, cat. # RR420). All mRNA manifestation listed above was normalized to the housekeeping gene -actin. The qPCR.
Lichen planopilaris (LPP) is considered as a follicular version of lichen planus
Lichen planopilaris (LPP) is considered as a follicular version of lichen planus. 1a]. Follicular keratotic locks and papules reduction had been on the higher hands as well as the trunk, respectively. Light microscopy evaluation for mind lice was harmful. Dermoscopy from the head demonstrated perifollicular erythema, tubular perifollicular scales, fibrotic white dots, and locks casts distributed along Rabbit Polyclonal to OR1A1 the locks shafts [Body ?[Body1b1b and ?andc],c], as the lesions in the trunk revealed focus on design of blue-gray dots and reduced follicular ostia [Body 1d]. Histopathology from the vertex head uncovered perifollicular mucinous fibrosis from the higher AG-024322 part of the hair roots [Body 1e]. Schedule blood urinalysis and ensure that you antinuclear antibody were regular. The final medical diagnosis was GLPLS. Her scratching, hair loss, and erythema from the head got relieved after 2-month treatment with systemic isotretinoin and corticosteroids;[1] however, the hair thinning progressed again after discontinuation of therapy slowly. Open in another window Body 1 (a) Clinical picture: A great deal of dandruff-like locks casts over the top (reddish colored arrows). (b) Trichoscopy: Perifollicular erythema, fibrotic white dots, and silver-white peripilar keratin casts across the rising locks shafts. (c) Trichoscopy: A firm, silver-white, 6-mm long hair cast along the scalp hair. (d) Dermoscopy: Perifollicular diffuse blue-gray peppering pattern and AG-024322 disappearance of follicular ostia in the stomach. (e) Histopathologic examination: Perifollicular mucinous fibrosis with lymphocytic infiltration of the higher portions from the hair roots (H and E, 40) GLPLS, a subtype of LPP, affects middle-aged females predominantly, from the postmenopausal generation particularly.[2] Because the initial description of GLPLS in 1913,[3] equivalent reports are implemented lately, regarding Caucasians in Europe and America mainly. To the very best of our understanding, this is actually the initial case survey of GLPLS in Chinese AG-024322 language population. Locks casts (peripilar keratin casts) are company, white, openly movable tubular public that encircle the locks shaft totally, which could be considered a feature for energetic LPP and visualized greatest on dried out trichoscopy.[4] Differential diagnoses for a great deal of white hair casts in the head include pili annulati, pediculosis capitis, pityriasis capitis (dandruff), tinea capitis, and trichorrhexis nodosa. In pili annulati, alternating light-dark rings could be observed in the locks shafts on trichoscopy, as well as the white rings are almost the width of the locks and their edges aren't clear-cut. In pediculosis capitis, the nits set towards the relative side from AG-024322 the hair shaft however, not warp it. Our case is certainly characterized by regular LPP with a lot of locks casts; the comprehensive noncicatricial hair thinning from the trunk, the axillary and pubic locks also, was spared, that was uncommon in GLPLS. Symptoms regarding the triad of results in GLPLS do not need to be present concurrently;[5] thus, the incidence from the syndrome may be underestimated by clinicians. Declaration of affected individual consent The writers certify they have attained all appropriate affected individual consent forms. In the proper execution the individual(s) provides/have provided his/her/their consent for his/her/their pictures and other scientific information to become reported in the journal. The sufferers recognize that their brands and initials will never be published and credited efforts will be produced to conceal their identification, but anonymity can't be assured. Financial support and sponsorship Nil. Issues of interest A couple of no conflicts appealing. Sources 1. Spano F, Donovan JC. Efficiency of dental retinoids in treatment-resistant lichen planopilaris. J Am Acad Dermatol. 2014;71:1016C8. [PubMed] [Google Scholar] 2. Yorulmaz A, Artuz F, Er O, Guresci S. A complete case of Graham-Little-Piccardi-Lasseur symptoms. Dermatol Online J. 2015;21:pii: 13030/qt7gj157xg. [Google Scholar] 3. Small EG. Folliculitis decalvans et atrophicans. Proc R Soc Med. 1915;8:139C41. [PMC free of charge content] [PubMed] [Google Scholar] 4. Mathur M, Acharya P, Karki A, Shah J, Kc N. Tubular hair casts in trichoscopy of scalp and hair disorders. Int J Trichology. 2019;11:14C9. [PMC free of charge content] [PubMed] [Google Scholar] 5. Bolognia JL, Schaffer JV, Cerroni L, editors. Dermatology. 4th ed. Singapore: Elsevier (Singapore) Pte Ltd; 2017. [Google Scholar].
Supplementary Materialsmmc1
Supplementary Materialsmmc1. control and prevention, Wuhan had a substantial drop in the amount of newly confirmed situations and announced the finishing lockdown JAK3 covalent inhibitor-1 on Apr 8, 2020. Nearly all city hospitals began to continue outpatient clinical function, to meet up the raising demand for regular endoscopic activities. Nevertheless, because of the features of endoscopy procedures, the chance of mix disease could be high between your endoscopist still, staff as well as the patients. Furthermore, the slow-growing emerging cases of asymptomatic carriers sounded an alarm to us. Here we share our experience and policies, provide recommendations for gastrointestinal endoscopy units on infection control during post-Covid-19 endemic outbreak. The endoscopy labs needs to focus on these 5 directions: 1) patient triage and pre-screening before endoscopy; 2) reconstruction of endoscopy center;3) regular JAK3 covalent inhibitor-1 monitoring of personal protective equipment; 4) protective device training; and 5) implementation of a strategy for stepwise resumption of endoscopic services in post endemic period. Clinical manifestations and diagnosis of Covid-19 Robust evidence coming from Wuhan and other regions across China confirms that about 80% of Covid-19 patients were asymptomatic or only had mild disease. The median age of infected patients was below 60 years [1, 2]. Of confirmed cases, about 20% were seriously or critically ill. Fever, cough, and fatigue were the dominant symptoms while some patients also presented other atypical symptoms, such as headache, sore throat, shortness of breath, and muscle soreness [3, 4]. Additionally, gastrointestinal (GI) symptoms including diarrhea, nausea and vomiting were not uncommon [5]. The most common laboratory abnormalities in patients with COVID-19 were elevated C-reactive protein, decreased lymphocyte count and increased lactate dehydrogenase [6]. Among patients who underwent chest computerized tomography (CT), ground-glass opacities and bilateral pneumonia were the most frequently reported findings [7]. Children were less likely to become infected or, if infected, showed mild symptoms [8]. On Rabbit Polyclonal to PDK1 (phospho-Tyr9) the other hand, the elderly and those with comorbidities including hypertension, diabetes, cardiovascular disease, liver diseases, malignancy were more likely to develop serious complications, such as acute respiratory distress syndrome, arrhythmia, and shock critical illness [9]. According to either WHO diagnostic standards [10] or the National Health Commission of China standards [11], the diagnosis of COVID-19 can be made based on a combination of epidemiologic information (e.g., a history of residence in or travel to affected region 14 days prior to symptomatic onset), clinical symptoms, laboratory tests (e.g., reverse transcriptase polymerase chain reaction [RT-PCR] tests on respiratory tract specimens) and upper body CT scan results. Of note, an individual negative RT-PCR test from suspected patients for COVID-19 does not exclude infection. All health care providers should be alert of patients with an epidemiologic history, COVID-19 related symptoms, abnormal laboratory tests, and/or positive CT scan results. Asymptomatic carriers pose infection risk during routine endoscopic procedures It is now thought that COVID-19 infects human being by transmitting respiratory droplets and through get in touch with transmitting [12]. Raising proof shows that fecal-oral pass on and airborne transmitting may be additional resources of transmitting [13, 14]. Latest observation shows JAK3 covalent inhibitor-1 that asymptomatic individuals and individuals within their incubation period are companies of SARS-CoV-2 and extremely contagious [15, 16]. Furthermore, high viral lots were within asymptomatic individuals during incubation period [17], and it had been reported that viral contaminants was recognized from both feces and urine in individuals with COVID-19 in JAK3 covalent inhibitor-1 some instances [18, 19]. Remarkably, the viral fill in feces was greater than that in respiratory samples in some instances [18] significantly. This epidemiologic features of COVID-19 offers produced its control demanding incredibly, as it can be difficult to recognize and quarantine these individuals during pre-symptomatic stage as well as for asymptomatic companies [12]. Furthermore, it remains to become proved whether individuals in the recovering stage are potential resources of transmitting [20]. Since there's a huge accumulated level of postponed endoscopy instances during Wuhan lock down, a substantial number of individuals needing regular endoscopy methods may fall in the group of asymptomatic companies or those within their recovering period. They are potential.
Parkinsons disease is a neurodegenerative disorder, the engine symptoms of which are associated classically with Lewy body formation and nigrostriatal degeneration
Parkinsons disease is a neurodegenerative disorder, the engine symptoms of which are associated classically with Lewy body formation and nigrostriatal degeneration. mutation also has been associated with a shift towards a CD4+ pro-inflammatory T cell response, suggesting that T cells are involved in PD [150]. Since the discovery of this SNP by this research team in 2010 2010, several purchase Obatoclax mesylate other common genetic variants associated with an increased risk of PD have been identified in the and plants, allows researchers to better investigate the physiological functions of the cannabinoid system, and thus advance potential therapies for neurological disorders. For the structures and pharmacological profiles of the cannabinoids mentioned throughout the review, see the comprehensive review by Pertwee and colleagues [212]. 3.2. The Cannabinoid System in Inflammation and Immune Modulation Mounting evidence indicates that the cannabinoid system has a major function in the modulation of the immune response and inflammation, both and peripherally centrally. Therefore, this technique gets the potential to become purchase Obatoclax mesylate manipulated to be able to offer therapeutic results in illnesses with an inflammatory element. The current presence of both CB1 receptor as well as the CB2 receptor on immune system cells was among the first bits of evidence to point how the endocannabinoid program might are likely involved in the immune system response [192]. Outcomes from following in vitro and in vivo APH-1B research claim that cannabinoids execute their immunomodulatory effects in numerous ways: by induction of apoptosis, by suppression of cell proliferation, by modulation of immune system cell migration, by elevated anti-inflammatory cytokine creation and inhibited creation of pro-inflammatory cytokines and chemokines, and by modulation purchase Obatoclax mesylate of the growth of regulatory T cells [218,219]. Cannabinoid compounds have been seen to cause alterations in immune function from as early as the 1980s, a decade before the cannabinoid receptors were even characterized. Tindall et al. [220] detected a more rapid progression from HIV contamination to AIDS in marijuana smokers compared to those who did not use the drug. HIV-positive individuals who use marijuana also had an increased risk of bacterial pneumonia, opportunistic infections, and Kaposis sarcoma [221,222]. Alveolar macrophages obtained from the lungs of habitual marijuana smokers who were otherwise healthy individuals showed a decreased phagocytic ability, decreased cytotoxicity, and decreased cytokine production [223]. Clearly, exogenous cannabinoids affect the immune system and if this effect could be manipulated, it could be beneficial in purchase Obatoclax mesylate the treatment of a vast number of conditions. As stated in the previous section, in the brain, CB1 receptors are predominantly found on the terminals of neurons, where they play a role in neurotransmitter release. However, as they are also present on immune cells, albeit in relatively low quantities, ergo they can have an effect on immune modulation. mRNA analysis showed that with regards to human peripheral immune cells, the highest levels of CB1 expression were seen in B cells, followed by natural killer cells, and with varying expression in several other blood cell types including monocytes and lymphocytes [192]. Multiple sources of evidence suggest that the CB1 receptor on immune cells could be a potential target for the regulation of inflammation. Much evidence exists for a job from the CB1 receptor in the chronic demyelinating disease multiple sclerosis (MS), which can be an immune-mediated disease relating to the demyelination of neurons by Compact disc4+ T cells. In post-mortem human brain tissues from MS sufferers, CB1 staining co-localized with Compact disc68+ macrophages and Compact disc3+ T cells in regions of energetic lesions (i.e., areas with turned on microglia) [224]. Needlessly to say, this study reported CB1 staining in purchase Obatoclax mesylate MAP2+ neurons and MBP+ oligodendrocyte cells also. Animal types of MS like the experimental autoimmune encephalomyelitis (EAE) model discovered immune system modulation or disease amelioration through CB1 receptor.
Supplementary Materials Additional file 1
Supplementary Materials Supplementary Data supp_37_2_206__index
Phenylbutyrate (PBA) is a histone deacetylase inhibitor known for inducing differentiation, cell routine arrest, and apoptosis in various malignancy cells
Supplementary MaterialsSupplemental data jci-129-123726-s166
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Prurigo nodularis (PN) is a chronic skin disease that affects an estimated 72 out of 100,000 people in the U.S. The disease disproportionately affects Black patients and other minority groups. Patients with PN have intensely itchy nodules on their arms and legs, which greatly impact their quality of life. Johns Hopkins researchers identified two distinct clusters of patients with PN: those who had increased inflammation in the blood, and those who did not but were more likely to have a history of spinal disease, which may sensitize the nerves. Identifying those with unique types of inflammation may help doctors provide more precise and personalized treatment for the disorder.
In a study published Oct. 27 in the Journal of Investigative Dermatology, Shawn Kwatra, M.D., an assistant professor of dermatology at the Johns Hopkins University School of Medicine, and his colleagues determined there are patients who have differences in their bodies' inflammation profiles.
"In Black patients with PN, we have noticed thicker, more fibrotic nodules, so we hypothesized that there would be a unique inflammatory signature in the blood," Kwatra says. "We also have noticed that some patients respond very well to immune modulating therapies while some patients do not, so this study shows there are patients who have varying degrees of immune and neural dysregulation that have implications for personalized treatment."
Using algorithms on a broad panel of patients' bloodwork, Kwatra and his colleagues were able to characterize different patterns of cytokines—small proteins in the blood that regulate inflammation in the body and help control the immune system.
They found two distinct clusters: noninflammatory plasma profiles, in which patients had a greater likelihood of spinal disease (Cluster 1), and inflammatory plasma profiles (Cluster 2). Cluster 1 included fewer minority patients who had a higher rate of myelopathy (an injury to the spinal cord due to severe compression). Cluster 2 included more Black patients who had a higher severity of itch.
By identifying these clusters, doctors gain better insight into selecting appropriate treatments that are personalized for PN patients with medications that primarily treat inflammation versus medications that treat those with myelopathy.
"We've known that therapy cannot be a one-size-fits-all approach," says Kwatra. "The goal is to understand what is unique to every patient so we can use precision medicine to tailor treatment, and this data reinforces why this is so important."
Kwatra hopes to next study a larger cohort of patients to gather more information and build on this research.
U.S. extends ban on securities investments in companies linked to China military
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MONISTAT® 1, 3, & 7 should only be used for the treatment of vaginal yeast make sure to read the safety information provided below, or in the product insert. Be aware that a mild increase in vaginal burning, itching or irritation may occur. Find patient medical information for Monistat 7 Vaginal on WebMD including its Miconazole reduces vaginal burning, itching, and discharge that may occur. Mar 24, This is my first night using monistat for a yeast infection, never had one before. My doc told me to use this stuff but I literally starting burning and.
The concentrations of bisphenol A and miconazole in raw sewage were similar to that The sludge filling period of the reactors is expected to be years. . As the fuel burns up, the excess reactivity decreases and the neutron absorber is .. The system is capable of initiating scram insertion by a signal from the plant. bds iv past paper questions medical science oral medicine diabetes mellitus hypertension thyroid disease alcoholism liver disease 11 kidney diseases 19 sle. Dec 27, 7, , discloses bioadhesive compositions comprising collagen miconazole, clotrimazole, oxiconazole, butocontazole, tioconazole, econazole, and ketoconazole. melanoma vaccine (CTL Immuno), β-alethine (Dovetail) for the temporary relief of pain and itching due to minor burns, sunburn.
Jan 1, 7. The role of advertising in branding pharmaceuticals. MICHAEL PALING Paling Monistat (J&J)* .. consumers for most everyday pain relief indications, as supported by most strategy should be embedded in the overall clinical development and commer- They dovetail on the established. A death from destruction of skin, as in a burn, or in toxic epidermal necrolysis (p. . The corneocyte cytoplasm is packed with keratin filaments, embedded in a matrix . Melanogenesis is described at the beginning of Chapter 1 7 on disorders of a bacterial, fungal or yeast infection, worm infestation, drug sensitivity and. Seven completely edentulous male patients with on history of denture Before dismissing the patients and one month after denture insertion, .. They also had significantly lower OHRQoL for the domain of Pain (median LO: 4, FBBA: 5, p= ). Patient was treated with topical (nystatin oral suspension and miconazole.
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Home Books Fitzpatrick's Dermatology in General Medicine, 8e
Chapter 20. Reactive Arthritis
John D. Carter
Carter JD. Carter J.D. Carter, John D.Chapter 20. Reactive Arthritis. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Goldsmith L.A., & Katz S.I., & Gilchrest B.A., & Paller A.S., & Leffell D.J., & Wolff K(Eds.),Eds. Lowell A. Goldsmith, et al.eds. Fitzpatrick's Dermatology in General Medicine, 8e. McGraw Hill; 2012. Accessed January 31, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=392§ionid=41138715
Carter JD. Carter J.D. Carter, John D. (2012). Chapter 20. reactive arthritis. Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Goldsmith L.A., & Katz S.I., & Gilchrest B.A., & Paller A.S., & Leffell D.J., & Wolff K(Eds.),Eds. Lowell A. Goldsmith, et al. Fitzpatrick's Dermatology in General Medicine, 8e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=392§ionid=41138715
Carter JD. Carter J.D. Carter, John D. "Chapter 20. Reactive Arthritis." Fitzpatrick's Dermatology in General Medicine, 8e Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Goldsmith L.A., & Katz S.I., & Gilchrest B.A., & Paller A.S., & Leffell D.J., & Wolff K(Eds.),Eds. Lowell A. Goldsmith, et al. McGraw Hill, 2012, https://accessmedicine.mhmedical.com/content.aspx?bookid=392§ionid=41138715.
Reactive Arthritis: Introduction
Etiology and Pathogenesis
Bacterial Triggers of ReA
Clinical Manifestations
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Reactive Arthritis at a Glance
Reactive arthritis is one of the spondyloarthritides. It is an inflammatory syndrome that typically begins 1–4 weeks after certain genitourinary or gastrointestinal infections.
Most patients do not have the "classic triad" of symptoms (synovitis, urethritis, and conjunctivitis) and other organs are often involved (namely the skin).
Key clinical features are asymmetric arthritis of a few joints, most often large joints of the lower extremities, often accompanied by axial arthritis and enthesitis typically at the Achilles tendon or plantar fascia and sacroiliac joints.
Psoriasiform lesions on the soles—keratoderma blenorrhagicum—or penis—circinate balanitis—occur in one-third of patients and inflammatory eye disease is present in a similar proportion. Urethritis may occur with or without urogenital infection.
HLA-B27 appears to increase disease susceptibility and chronicity of reactive arthritis, but recent data suggest it might portend more fulminate symptoms thereby serving as a diagnostic bias.
Chlamydia, Salmonella, Campylobacter, Shigella, and Yersinia are definitive triggers of reactive arthritis, but other infections may also act as initiators.
Although reactive arthritis often is self-limited in weeks to months, as many as 30%–50% of patients will develop chronic disease that often waxes and wanes.
Reactive arthritis (ReA) is an inflammatory syndrome that results after certain genitourinary or gastrointestinal symptoms. The most common inciting infections include Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. The term reactive arthritis was introduced in 1973 to describe this type of arthritis that occurs after a triggering infection.1 There is considerable ambiguity in the literature in terms of the nomenclature of this condition for many terms and eponyms have been utilized. In 1942 two Harvard researchers, Bauer and Engelmann, recognized a case of ReA and upon their review of the literature they discovered that Hans Reiter had described this same syndrome in 1916.2 Reiter had described a German officer who developed the clinical triad of arthritis, nongonococcal urethritis, and conjunctivitis after an episode of acute dysentery. It was at that point that Bauer and Engelmann coined the term Reiter syndrome and this eponym was often used to describe the condition.
In recent years, the eponym Reiter syndrome became problematic for several reasons. First, most clinicians often demanded that a patient have the classic triad of symptoms involving the synovium, urethra, and conjunctiva before the diagnosis would be made. It is now known that most patients with ReA do not have the complete triad of symptoms.3 Further, many common features of ReA are not included in this "classic triad" including involvement of the skin and mucous membranes as well as other parts of the eye, namely the anterior uveal tract. More troubling is the acts of the man from which the eponym was coined. Although Hans Reiter was an erudite intellectual and a brilliant investigator who performed many useful studies early in his career including the discovery of the spirochete that causes leptospirosis and a nonpathogenic strain of Treponema, some of his later experimentation during World War II was deplorable. Reiter played an active role in the design of a study that inoculated concentration camp victims at Buchenwald with an experimental typhus vaccine, which directly resulted in hundreds of deaths.4 Reiter was arrested after World War II; he was tried and convicted at Nuremberg for these war crimes. Because of this, some have correctly argued that the term Reiter syndrome should be abandoned and should only be used in historical context.5
It turns out that Reiter was not the first to describe ReA. In reality, it had been described by many physicians in different parts of the world many years before Reiter's case in 1916. Several others have described similar cases in the literature including Pierre van Forest's description of a case of "secondary arthritis and urethritis" in 1507,6 Thomas Sydenham's association of arthritis with diarrhea in 1686,7 Stoll's documentation of arthritis following dysentery in 1776,8 and Yvan's description of a French captain who developed "ophthalmia" and inflammatory arthritis primarily of the lower extremities 15 days after a venereal infection.9 Sir Benjamin Brodie was an English physiologist and surgeon who pioneered research in joint disease. He described five patients with rather classic ReA in his treatise Pathological and Surgical Observations on the Diseases of the Joints.10 Importantly, he recognized the similar "train of symptoms" that all five patients experienced, and clearly noted the relapsing course in the few who developed chronic disease. Interestingly, in 1897 Launois clearly made the distinction of septic from aseptic arthritis and demonstrated that patients with the latter occasionally develop cutaneous lesions on the plantar surface of the feet (keratoderma blenorrhagicum).11 Finally, two French physicians, Fiessinger and Leroy, described this same syndrome in the exact same year as Reiter, i.e., 1916.12 Therefore, the term Fiessinger Leroy syndrome has occasionally been used in the past, especially in the French literature.
In light of the above issues, the more recent literature has made a concerted effort to standardize the disease terminology for this condition. Because Hans Reiter was not the first to describe the syndrome, and the fact that many clinicians are reluctant to diagnose this condition in those who do not display the complete triad of symptoms thereby missing the majority of cases, and ReA is a more descriptive term, the term ReA has become the appropriate terminology for this disease process regardless of whether their symptoms involve the three classic organ systems.
In a similar fashion to the ambiguity that previously involved the proper disease terminology, so too there has been no definitive set of diagnostic criteria. This can result in nonhomogenous patient populations in various studies. This coupled with the fact that the disease can often be mild, there has been a traditional overreliance on the complete clinical triad of symptoms, and the incidence of the trigger infections can vary over time, makes epidemiological studies problematic. There is a link between ReA and the human leukocyte antigen (HLA)-B27, but the role this antigen plays in ReA disease susceptibility might be overstated although this HLA antigen plays a role in those individuals who develop chronic disease.13 Nevertheless, the prevalence of HLA-B27 varies between populations and, as might be expected, the incidence and prevalence of ReA varies widely in studies. Because ReA has a definitive trigger as an etiologic agent, but not all patients exposed to these causative organisms develop ReA, the concept of attack rate is extremely important in ReA. The attack rate represents the percentage of patients who develop ReA after exposure to one of the causative organisms. Finally, many cases diagnosed as seronegative oligoarthritis or undifferentiated oligoarthritis may actually be ReA, thereby resulting in an underestimate of disease prevalence or incidence.
The postdysentery form of ReA affects males and females with the same frequency, whereas the postvenereal form occurs at a male to female ratio of 9:1.14 Adults are more likely to develop ReA than children.15 In Finland, the annual incidence of ReA has been estimated to be 30/100,000 individuals,16 whereas in Norway the annual incidence is approximately 10/100,000.17 In this latter study, the incidences of postenteric and postchlamydial ReA were essentially equal at 5/100,000 and 4.6/100,000, respectively. In the United States, one study estimated the age-adjusted annual incidence of ReA in males younger than age 50 as 3.5/100,000.18 However, in this same study no female cases were identified, suggesting this represents an overall underestimate. In terms of overall prevalence of ReA, a German study suggested a prevalence of 10/100,000.19 Yet, in this study undifferentiated spondyloarthritis (uSpA) was the second most common type of spondyloarthritis diagnosed (after ankylosing spondylitis) and this same diagnosis was more than twice as common as psoriatic arthritis. Data described below suggests that many cases of uSpA are actually ReA. If true, the prevalence of ReA in this German study would be much greater.
An analysis of the expected number of cases of ReA and those actually diagnosed rather strongly argues that ReA is underdiagnosed. Perhaps this is most true with postchlamydial ReA. Because many of the organisms responsible for causing ReA are reportable diseases, the annual incidence of these infections is well described. The expected number of cases of ReA that results from these infections should result in an annual incidence of ReA that greatly exceeds the annual incidence of rheumatoid arthritis.20 However, the number of patients diagnosed with rheumatoid arthritis greatly exceeds that diagnosed with ReA. One study demonstrated that 36% of ReA subjects went undiagnosed in the community clinic in spite of a clear antecedent gastrointestinal infection.21 These data suggest that awareness of this condition needs to improve and the burden of ReA on society might be significantly underrecognized.
Triggering Organisms
Bacteria that commonly cause ReA are Salmonella, Shigella, Campylobacter, Yersinia, and Chlamydia trachomatis. Indeed, these organisms represent the definitive triggers of ReA; however many other infectious agents have been implicated as potential causes (Box 20-1). Chlamydia trachomatis (Ct) is the most common etiologic agent causing ReA in the United States.14,22 Despite the obvious difference of initial route of infection (i.e., gastrointestinal vs. genitourinary), another distinction exists. The postdysentery form of ReA is always preceded by a symptomatic infection, and recent data suggest the more severe the initial gastrointestinal infection, the more likely ReA develops.23–25 However, an initial Ct infection is often asymptomatic.26–28 Recent data suggest that an initial asymptomatic Ct infection is a common cause of ReA.29 In this study, the majority of patients diagnosed with uSpA, because of no known preceding infection prior to the onset of their arthritis, were found to be polymerase chain reaction (PCR) positive for Chlamydiae on synovial tissue analysis. This is in keeping with previous data suggesting that 78% of subjects who develop ReA after a venereal infection had an asymptomatic infection.30 A number of published studies also indicate that Chlamydophila (Chlamydia) pneumonaie (Cpn), a related respiratory pathogen, is another causative agent in ReA, albeit at a lower frequency.31–33
Box 20-1 Triggering Microbes of Reactive Arthritis
DEFINITE CAUSES
Postvenereal
Postenteric
Salmonella (S. enteritidis, S. typhimurium, S. bovismorbificans, S. blockley)
Shigella (S. flexneri, S. dysenteriae, S. sonnei, S. boydii)
Campylobacter (C. jejuni, C. coli)
Yersinia (Y. enterocolitica, Y. pseudotuberculosis)
PROBABLE CAUSES
Chlamydophila (Chlamydia) pneumoniae
Bacille Calmette-Guérin (intravesicular)
Brucella abortus
Hafnia alvei
Neisseria meningitidis serogroup B
Pseudomona
Intestinal parasites (Strongyloides stercolis, Taenia saginata, Giardia lamblia, Ascaris lumbricoides, Filariasis, and Cryptosporidium)
OTHER TYPES OF INFLAMMATORY ARTHRITIS IN WHICH BACTERIA MAY PLAY A CAUSATIVE ROLE
Borrelia burgdorferi (Lyme disease)
Propionbacterium acnes (SAPHO)
Streptococcus sp. (poststreptococcal reactive arthritis)
Trophyrema whippelii (Whipple's disease)
Reprinted with permission from Carter JD: Reactive arthritis: Defined etiologies, emerging pathophysiology, and unresolved treatment. Infect Dis Clin North Am 20:827, 2006.
Chlamydiae are Gram-negative, obligate intracellular organisms. The attack rate of ReA after a Ct infection is approximately 5%.30 Synovial tissue analyses from patients affected with postchlamydial ReA have shown that these organisms traffic from the initial site of infection to the synovium. These synovium-based Chlamydiae exist in a morphologically aberrant but metabolically active viable state termed chlamydial persistence.34,35 The pattern of gene expression is attenuated and significantly different than that seen during normal active infection. For example, during persistence of Ct expression of the major outer membrane protein (omp1) gene and several genes required for the cell division process are severely downregulated. This is coupled with differential regulations of the three paralog genes specifying Chlamydia trachomatis heat shock proteins (HSP)-60 [(1) Ct110, (2) Ct604, and (3) Ct755].36 The exact role that these synovium-based persistent Chlamydiae play in terms of disease pathogenesis or disease propagation is not completely understood. Of note, it has been demonstrated that these same persistent Chlamydiae traffic to other end organs, specifically the skin in patients with suspect keratoderma blenorrhagicum.37
Other recent data relating to Chlamydia-induced ReA force us to reconsider our traditional paradigms. Because these pathogens are responsible for genital infections, it was logical to assume that the genital strains of C. trachomatis were responsible for triggering ReA. However, there are several serovars of C. trachomatis, specifically serovars A through K. Serovars A, B, and C are ocular (trachoma) serovars and the remainders (serovars D through K) are genital. Remarkably, a recent study analyzing the chlamydial serovars of 36 subjects with known C. trachomatis-induced ReA demonstrated that all 36 synovial tissue samples were positive for the ocular serovars, not the genital serovars.38 It is known that genital infection with the ocular strains do occur, but are rare.39,40 The infrequent rate of genital infections with the ocular strain might explain the low attack rate of ReA in patients with acute chlamydial infections.
Host Factors
Reactive arthritis represents the classic interplay of host and environment. The environmental triggers outlined above play and undeniable role in disease genesis; the concept of bacterial persistence lends speculative support that these pathogens might also play a role in disease propagation. Certain bacterial serovars or species might be particularly arthritogenic or more prone to dissemination. However, genetic susceptibility also clearly plays a role. Because ReA is one of the spondyloarthritides, much of the focus on host genetics has centered on HLA-B27. There are also data indicating that patients with HIV are at increased risk for ReA and the symptoms can improve with antiretroviral HIV therapy.57
The prevalence of HLA-B27 and reactive arthritis varies around the world.58 In Caucasian populations, HLAB27 is present in 7%–9% of individuals. Older literature suggested that as many as 70%–80% of patients with ReA were HLA-B27 positive.59,60 However, several large epidemiological studies of ReA now dictate that, in reality, about 30%–50% of ReA patients are positive for this antigen.45,61–67 More recent data even suggest there might be no association with HLA-B27 and ReA.25,47,64 The vast majority of data regarding the prevalence of HLA-B27 in ReA comes from epidemiological studies of postenteric ReA after outbreaks with certain enteric pathogens. Therefore, the true prevalence of HLA-B27 in postchlamydial ReA is less well defined.
The possibility exists that HLA-B27 plays more of a role with phenotypic disease expression rather than a true genetic susceptibility locus. Several large ReA studies demonstrate that HLA-B27 positive patients have more severe symptoms, thereby making the condition more clinically apparent.23 This haplotype might also increase one's risk for developing the complete triad of symptoms.68 It should also be noted that the variation in the prevalence of HLA-B27 in various studies described above could, at least in part, be explained by the potential role that HLA-B27 plays on phenotypic expression. The studies cited above suggesting that HLA-B27 has little to no role in disease susceptibility include patients with milder symptoms, whereas the previous studies demonstrating a higher HLA-B27 prevalence only include patients with more fulminate symptoms sometimes requiring the complete triad of symptoms.
Whether HLA-B27 is more important in disease susceptibility or clinical expression, it clearly plays a role in ReA. Many theories exist regarding its pathophysiologic role, but none are proven. Since HLA-B27 is a Class I histocompatability antigen, it has been postulated that HLA-B27 presents arthritogenic microbial peptides to T cells stimulating an autoimmune response, so called molecular mimicry.69 Conversely, B27 itself may serve as the autoantigen that is targeted by the immune system.70 It is also possible that exposure to the triggering bacteria may subvert self-tolerance to the B27 antigen.71 Another theory suggests that the role of HLA-B27 may be to enhance invasion of the causative organisms into human intestinal epithelial cells in patients with postenteric ReA.72 Vast data demonstrate that misfolding of HLA-B27 can lead to the unfolded protein response enhancing the production of interleukin-23;73 however this unfolded protein response has not been definitively linked to ReA. HLA-B27 has multiple alleles that could influence host response and disease susceptibility. One study suggests that although HLA-B*2705 is the most common allele observed in B27-positive ReA patients, this allele is seen less frequently than in the other SpA's and in B27 healthy controls.74
While HLA-B27 is important to pathogenesis in ReA, it is not the sole determinant. Clearly patients who are HLA-B27 negative can develop ReA. It has been suggested that HLA-B*5703 increases the risk for the classic triad of symptoms in patients who develop ReA.75 Gene expression analyses suggest that proangiogenic factors account for genetic susceptibility of ReA.76 Much remains to be learned about other HLA loci or even non-HLA genes that might be important in the pathophysiology of ReA.
These recent data regarding the apparent causality of the ocular serovars raise intriguing questions about other features of ReA, namely the eye involvement with uveitis and/or conjunctivitis and the propensity of uveitis to recur in these subjects. As it turns out, we might have had clues to the apparent arthritogenicity of the ocular serovar years ago. In the 1960s and early 1970s, Bedsonia (Chlamydia) recovered from patients with ReA caused arthritis 100% of the time when injected into rabbits; in addition, intra-articular injection of these same organisms often caused ocular involvement.41,42 This suggests these particular organisms were not only arthritogenic, but had the ability to disseminate with particular affinity for the eye.
The four enteric organisms known to cause ReA represent the largest bulk of the cases of ReA as a group. Salmonella is a Gram-negative, rod-shaped, motile bacterium widespread in animals and environmental sources. It is the most frequently studied enteric bacterium associated with ReA. The attack rate of Salmonella-induced ReA has ranged between 6% and 30% in different studies.43,44 All four of the species of Shigella (S. flexneri, S. dysenteriae, S. sonnei, and S. boydii) can cause ReA. The attack rate of Shigella-induced ReA was reported to be 7%–9% in one study.45 Campylobacter is another Gram-negative motile bacterium; it is a very common cause of enteric infections. C. jejuni is the main cause of bacterial food-borne disease in many developed countries.46 It spite of its frequency it appears to be somewhat less arthritogenic with an attack rate of 1%–5%.47 Although Yersinia infections are not as common as some of the other enteric pathogens, some data suggest that Yersinia is particularly arthritogenic. A study in Denmark suggests that it was the most likely organism to cause ReA with an attack rate of 23%.23 Other studies have suggested an attack rate of 12%.48,49 As with Chlamydiae, efforts have been made to detect these enteric pathogens in synovial tissue or fluid of patients with ReA. Bacterial DNA or bacterial degradation products have been detected, but, unlike Chlamydiae, no viable organisms have been demonstrated.50–52 However, one study did suggest viable Yersinia were present in synovial samples of these patients,53 yet other data contradict this finding.54 As is the case with Chlamydiae, the role these bacterial products play in the pathophysiology of ReA remains uncertain. However, the fact that these enteric bacteria do not appear to be viable, their role is likely different than that of the persistently viable Chlamydiae. It is also likely that different species from the same genus of the triggering enteric bacteria vary in their arthritogenic propensity.
Many other organisms have been implicated as potential causes of ReA. These include Ureaplasma urealyticum, H. pylori, and various intestinal parasites. The majority of these reports exist in the form of single cases or small series. Reports of ReA secondary to E. coli,23–25 C. difficile,55 and intravesicular Bacillus Calmette-Guérin (BCG)56 have garnered recent recognition. A recent study in Denmark suggested that a gastrointestinal infection with E. coli was just as likely to cause ReA as Shigella.23
It is apparent that the causative bacteria of ReA are incorporated intracellularly, either in-part or in-whole, then taken from the site of initial infection and trafficked to the synovium. However, what governs this process is not yet evident. It is also not clear if their presence in the affected organs represents a trigger for an autoimmune response, or if these organisms are the source for the inflammatory process. It appears that this phenomenon of cellular uptake, trafficking, and host tolerance is multifactorial in nature.
Although the causative organisms are intracellular pathogens, the process of cellular uptake is not entirely apparent. Indeed the specific mechanisms for cellular uptake of these microbes are probably different for each organism. In the case of Chlamydiae, the quest to find a specific extracellular ligand has been unsuccessful. Intriguing recent data suggest that there might not be a specific chlamydial ligand, rather these pathogens might utilize a different ligand entirely. Apolipoprotein E (ApoE4) that is adherent to the surface of chlamydial elementary bodies (EB) attaches to the host cell low-density lipoprotein (LDL) receptor family carrying the EB with it.77 However, this only appears to be true of C. pneumoniae, not C. trachomatis. In the case of Salmonella, type 1 fimbriae mediate the attachment of this organism to the cell leading to internalization.78
Toll-like receptors (TLR) are a key component of the innate immune system. Because they are among the first line of defense against microbes and they recognize extracellular pathogens, they could play a role in ReA. All of the definitive triggering organisms are Gram-negative with a lipopolysaccharide (LPS) component to their cell wall, and TLR-4 recognizes LPS. TLR-4 deficient mice exposed to Salmonella demonstrate dramatically increased bacterial growth and demise.79 Other animal data have shown that effective host clearance of Ct depends on appropriate TLR-4 expression by neutrophils.80 However, recent human data suggest that TLR-2, not TLR-4, is important in determining ReA disease susceptibility after a Salmonella infection.81
In terms of cytokine response in ReA, it appears that both Th1 and Th2 are important, but the Th2 pathway predominates. Although ReA patients have higher serum TNF-α (Th1) than normal controls,82 lower levels of TNF-α have been demonstrated in ReA compared to other types of inflammatory arthritis.83–85 Synovial fluid analyses from patients with ReA demonstrate higher levels of IL-10 and lower levels of TNF-α and IFN-γ (favoring a Th2 profile).84,85 Interestingly, in terms of postchlamydial ReA, lower levels of these same two cytokines (TNF-α and IFN-γ) have been associated with increased chlamydial replication and overall bacterial burden in vitro.86–88 The suppression of Th1 cytokines is likely mediated through suppression of IL-12 synthesis.
Data also exist suggesting that these cytokine levels can change over time. ReA patients with a disease duration of greater than 6 months secreted significantly less TNF-α.83 Temporal relationships of these different Th1 and Th2 cytokines might also be important in disease manifestations. Slight changes in the Th1/Th2 balance may explain the relapsing course that is frequently seen chronic ReA. Animal data also suggest that blunting of the initial cytokine response of TNF-α, IFN-γ, and Interleukin-4 (IL-4) to an acute chlamydial infection leads to decreased bacterial clearance.89 Therefore, lower initial responses of these Th1 cytokines may increase the likelihood of developing ReA. These animal data provide an interesting potential correlate to the fact that asymptomatic chlamydial infections in humans can often lead to ReA.
In spite of the fact that ReA has several distinct etiologic agents and the apparent differences in the pathophysiology depending on the triggering microbe, the clinical features of ReA are congruent regardless of the initiating infection. The clinical syndrome that encompasses ReA can involve many different organ systems, although it has a predilection for the synovium, urethra, eye, and the skin (Box 20-2). The symptoms start within 1–4 weeks of the initial infection. However, as stated with Chlamydiae, the inciting infection could be asymptomatic obfuscating the diagnosis. It has traditionally been felt that the vast majority of cases of ReA resolve spontaneously within weeks to months, but more recent data suggest that 30%–50% of cases can become chronic.45,61–67 One series suggested that 63% of patients develop chronic symptoms.18 In general, if a patient experiences symptoms of longer than 6 months duration, then they are felt to have chronic disease (Box 20-3). Typically, patients have more significant symptoms during the acute phase; these can include constitutional symptoms (malaise, fatigue) and fever. If the symptoms persist, then the long-term manifestations tend to be milder. In these chronic cases, it is not unusual for the symptoms to wax and wane.
Box 20-2 Clinical Manifestations of ReA
ACUTE SYMPTOMS
Articular
Most commonly present with oligoarthritis, but can also present with polyarthritis or monoarthritis
Frequently involved
Sacroiliac joints
Lumbar spine
Occasionally involved
Thoracic spine (usually seen in chronic ReA)
Cervical spine (usually seen in chronic ReA)
Cartilaginous joints (symphysis pubis; sternoclavicular and costosternal joints)
Large joints of the lower extremities (especially knees)
Dactylitis (sausage digit)
Very specific for a spondyloarthropathy
Enthesitis
Hallmark feature: inflammation at the transitional zone where collagenous structures such as tendons and ligaments insert into bone.
Common sites: plantar fasciitis, Achilles tendonitis; but any enthesis can be involved.
Mucosal
Oral ulcers (generally painless)
Sterile dysuria (occurs with both postvenereal and postdysentery forms)
Keratoderma blenorrhagicum
Pustular or plaque-like rash on the soles and/or palms
Grossly and histologically indistinguishable from pustular psoriasis
Can also involve nails (onycholysis, subungal keratosis, nail pits), scalp, extremities
Circinate balanitis
Erythema or plaque-like lesions on the shaft and/or glans of penis
Anterior uveitis (iritis)
Rarely described
Typically during acute stages only
Often recurrent
Scleritis, pars planitis, iridocyclitis, and others
Pericarditis (uncommon)
CHRONIC SYMPTOMS (≥6 MONTHS)
Cervical spine
Cartilaginous joints (symphysis pubis; sternoclavicular joints)
Chronic inflammation can cause collagen fibers to undergo metaplasia forming fibrous bone
Chronic enthesitis leads to radiographic findings:
Plantar/Achilles spurs
Nonmarginal syndesmophytes
Syndesmoses of the sacroiliac joints
Sterile dysuria
Keratoderma blennorrhagicum
Aortic regurgitation
Valvular pathologies
Reprinted with permission from Carter JD, Hudson AP: Reactive arthritis: Clinical aspects and medical management. Rheum Dis Clin North Am 35:21, 2009.
ReA is often misdiagnosed or underdiagnosed. The reasons are varied, but an overreliance on the "classic" clinical triad of symptoms lends to this underdiagnosis. Some of the earliest descriptions of ReA included patients with this triad of symptoms. For many years, clinicians felt this triad was necessary for the diagnosis. In 1976, the concept of "Incomplete Reiter syndrome" was introduced describing a case series of 13 patients, who were predominately HLA-B27 positive, and presented with oligoarthritis, heel pain, periostitis, dactylitis, and mucocutaneous lesions, but no urethritis or conjunctivitis.90 It is now apparent that the majority of cases do not involve the three classic organ systems.
ReA nearly always involves an inflammatory arthritis. It is unclear if some patients with other symptoms of ReA, such as recurrent uveitis or enthesitis without arthritis, might represent cases of ReA as well. Patients with ReA can develop an inflammatory arthritis that involves the axial skeleton and/or the peripheral joints.
The axial arthritis of ReA (Box 20-2) presents as pain and stiffness in the low back and/or buttocks. A classic feature is prolonged pain and stiffness in the morning or after periods of rest or inactivity. These symptoms tend to improve with activity or exercise. The cause of the pain includes inflammation in the synovial portion of the sacroiliac joints and enthesitis of these same joints, pelvis, and lumbar spine. The combination of synovitis and enthesitis of the sacroiliac joints results in one of the classic features of ReA, i.e., sacroiliitis. These symptoms might be more pronounced during the acute phase of the illness. It is important to note that sacroiliitis can often be documented on plain radiographs, but these imaging studies might be of lesser utility in patients with acute symptoms since radiographic evidence of sacroiliitis can take weeks to months to develop. In patients with a high index of suspicion of acute disease and normal plain radiographs, advanced imaging with magnetic resonance imaging (MRI) might prove useful (Fig. 20-1). Such advanced imaging can show evidence of early inflammatory sacroiliitis that might be otherwise missed by conventional radiographs.91 Plain radiographs remain the imaging investigation of choice for patients with chronic disease. ReA patients with radiographic sacroiliitis typically have unilateral or bilateral asymmetric findings.
Magnetic resonance image showing unilateral sacroiliitis.
The axial inflammatory arthritis of ReA involves the thoracic and cervical spine less often than the lumbar spine. If present, symptoms are similar including prolonged pain and stiffness in the morning and improvement with activity. In addition to sacroiliitis, patients can also develop spinal changes on plain radiographs. The most typical finding is nonmarginal syndesmophytes (eFig. 20-1.1). These are thick, bridging, comma-shaped bony growths between vertebral bodies. These are most often seen in patients with chronic disease. Finally, the axial symptoms can include inflammation in cartilaginous joints, such as the symphysis pubis or sternoclavicular joints, with resultant radiographic changes.
eFigure 20-1.1
Anterioposterior view of spine showing nonmarginal syndesmophytes that bridge from one vertebral body to the next. (Reproduced with permission from Bruce M. Rothschild, MD.)
The peripheral arthritis of ReA most often is an inflammatory oligoarthritis; there is a predilection for the large joints of the lower extremities. However, patients can also present with a polyarthritis or even monoarthritis. This clinical picture involving one or a few joints, particularly of the lower extremities contrasts with other types of inflammatory arthritis, such as rheumatoid arthritis, that typically present with a symmetrical polyarthritis. As with the axial symptoms, these tend to be more pronounced during the acute stage and can relapse and remit. In patients with more chronic or severe cases the small joints of the hands and feet can be involved. Radiographic features of peripheral joints in patients with chronic disease can include erosive changes, periostitis, and possibly even "pencil-in-cup" deformities most often associated with psoriatic arthritis.
Dactylitis (sausage digit) is a valuable diagnostic clue for potential ReA (Fig. 20-2). Dactylitis represents diffuse inflammation of an entire finger or toe. While not specific to ReA, if present, it is strongly suggestive of a spondyloarthropathy. Besides the spondyloarthropathies, only a few conditions, namely sarcoidosis and gout, cause dactylitis. One series suggested that ReA was the most common diagnosis in patients presenting with dactylitis; 28% of ReA patients had this finding as part of their constellation of symptoms.92
Dactylitis of second toe (sausage toe).
Enthesitis, or fibrocatilagenous enthesitis, is inflammation at the transitional zone where collagenous structures such as tendons, ligaments, and joint capsules insert into bone. This is a hallmark feature of ReA (as well as for other types of spondyloarthritis). There are two main phases of enthesitis: (1) subchondral osteitis and (2) reparative ossification. The inflammation starts in the intraosseous portion of the enthesis, eventually destroying the bone and cartilage plate. The defect is rapidly filled with newly formed bone that extends to the terminal part of the tendon producing an enthesophyte (eFig. 20-2.1). Common types of enthesitis in ReA are Achilles tendonitis and plantar fasciitis, but inflammation can occur at any enthesis. Sacroiliitis represents a combination of synovitis and enthesitis.93 A recent report of >6,000 cases of culture-confirmed infections with bacterial enteric pathogens revealed that enthesitis was the most common finding in those individuals who developed ReA.25
Lateral plain radiograph of a calcaneus demonstrating a plantar "spur" that results from chronic plantar fasciitis. (Reproduced with permission from Carter JD, Hudson AP: Reactive arthritis: Clinical aspects and medical management. Rheum Dis Clin N Am 35:1, 2009.)
Dermatologic manifestations of ReA are several. The two most common are keratoderma blenorrhagicum and circinate balanitis. Keratoderma blenorrhagicum is a pustular or plaque-like rash that most often occurs in a palmoplantar distribution (Fig. 20-3). These typically begin as erythematous macules or vesicles. These vesicles are often pustular in nature, but they can also be hemorrhagic; over time they can become thickened or papular forming a horny excrescence. These chronic lesions can become hyperpigmented and may coalesce. Rarely these lesions can occur in a more general distribution involving the entire body94; this is felt to be more likely in the setting of HIV. Interestingly, keratoderma blenorrhagicum is clinically and histologically indistinct from pustular psoriasis.95 Histologic findings include hyperkeratosis and parakeratosis, elongation and hypertrophy of the rete ridges, general epidermal hyperplasia, and extensive neutrophilic infiltration with formation of microabscesses and spongiform pustules. Recently it has been demonstrated that these lesions are PCR positive for Chlamydia trachomatis in patients with suspected Chlamydia-induced ReA.37
Keratoderma blennorrhagicum.
Circinate balanitis is a cutaneous manifestation of ReA involving the penis. These are erythematous, pustular, or plaque-like lesions that most often involve the glans of the penis, but they can include the shaft and rarely the scrotum (Fig. 20-4). It has been suggested that these lesions on the glans can exhibit different characteristics depending on whether the patient is circumcised or not. In circumcised males, hyperkeratotic plaques are most typical and in uncircumcised patients they often begin as vesicles or pustules that may coalesce into a circinate pattern (Fig. 20-4).96 Females with ReA can rarely get ulcerative vulvitis that has similar appearance to circinate balanitis.
Circinate balanitis.
Patients with ReA may also have nail involvement, which is similar to psoriasis and presents as onycholysis, subungal keratotic debris, transverse ridges, periungual scaly lesions, and nail pitting. These changes occur in about 20%–30% of ReA patients.96 The relationship between distal interphalangeal arthritis and nail involvement is well recognized in psoriatic arthritis,97 the same is also likely to be true for ReA, but there are no definitive data in this regard.
The true prevalence of keratoderma blenorrhagicum and circinate balanitis in patients ReA remains somewhat uncertain. Previous data have suggested that they occur in about 10%98 and 50%99 of patients, respectively and it was felt that they are more common in patients who are HLA-B27 positive.100 However, as is the case with ReA in general, it is not clear if this genetic marker truly increases the occurrence of these cutaneous manifestations or if it has served as a diagnostic bias. More recent data demonstrate that circinate balanitis more strongly correlates with a previous chlamydial infection than previously thought.101 In this same study, there was no apparent association with HLA-B27 and the majority of patients had no other signs or symptoms of ReA. The fact that these lesions are also clinically and histological indistinct from pustular psoriasis can also obfuscate the diagnosis.
(Boxes 20-2 and 20-3)
Although the original "classic triad" of symptoms of ReA included eye involvement, conjunctivitis was specifically mentioned. Not only do patients with ReA develop conjunctivitis, they often develop iritis/anterior uveitis. Although both conditions can occur at any time during the condition, it has traditionally been felt that conjunctivitis most often occurs during the early stage and less frequently becomes chronic whereas iritis/anterior uveitis occurs both as an acute and chronic (intermittent) problem. However, a long-term study of 25 ReA subjects with eye involvement at the time of diagnosis demonstrated that long-term ocular complications included conjunctivitis and anterior uveitis in 96% and 92% of patients, respectively.102 Other long-term complications were seen in this study including posterior uveitis (64%), keratitis (64%), cataract (56%), intermediate uveitis (40%), scleritis (28%), cystoid macular edema (28%), papillitis (16%), and glaucoma (16%). These data suggest that patients with ocular involvement at the time of diagnosis are at increased risk for many long-term ocular complications; perhaps this risk is higher than previously appreciated.
Mucosal involvement of the mouth, oral pharynx, and tongue can occur in patients with ReA, but these are infrequent. If they occur, typical lesions on the oropharnyx include diffuse erythema, macules, and plaques. They are often painless and might go unnoticed by the patient. Such lesions will sometimes present with bleeding. Lesions involving the tongue are most often circinate or annular in appearance. More common mucosal manifestations include intestinal inflammatory lesions that resemble those of inflammatory bowel disease. One study found that 67% of subjects with ReA had histologic evidence of ileocolitis, even in the absence of gastrointestinal symptoms.103 This finding might be higher in patients with postenteric ReA. Finally, it is well described that patients with ReA develop sterile dysuria. Interestingly this occurs with equal frequency in both postvenereal and postenteric ReA. This sterile dysuria can become a chronic intermittent problem for some patients. Prostatitis, cystitis, and pelvic inflammatory disease have also been described.104,105
Cardiac involvement from ReA is rare. There are sparse reports of ReA patients developing pericarditis, aortic regurgitation, or valvular pathologies. When they occur, they are more likely in chronic disease. These manifestations are rare enough in the acute setting that routine echocardiography is not recommended.106 Electrocardiographic abnormalities can occur in the acute setting with significant arrhythmias occurring in approximately 5% of patients.107
Diagnostic criteria are broad and rely on clinical symptoms.100,108 Difficulties with these diagnostic criteria have been raised.109 The traditional disease definition also suggests that ReA represents a sterile inflammatory arthritis, but data presented above, specifically pertaining to Chlamydiae, challenge this paradigm. Although not pathognomonic for the condition, the documentation of the DNA presence of one of the causative organisms by PCR in synovial tissue or fluid of patients who fulfill the clinical criteria for ReA represents the most accurate means of diagnosing the condition.110 Unfortunately, such synovial tissue analysis is not readily available for the majority of clinicians. Stool and urogenital sampling for the causative organisms in patients with chronic disease have been analyzed, but many patients test negative limiting the utility of this approach.111,112 Serologic testing for antibodies to the causative organisms is unreliable. Because more than half of affected patients are HLA-B27 negative, this genetic antigen should not be utilized as a diagnostic tool. Therefore, at the current time we are left without a practical diagnostic test. Recognition of an underlying spondyloarthritis and identifying one of the triggering infections remains the most practical means of diagnosis ReA until better diagnostic tests are widely available. A diagnostic algorithm is shown in Figure 20-5.
Diagnostic algorithm "making the diagnosis." Anti-DNAse B = antideoxyribonuclease B; ASOT = antistreptolysin O titer; IBD = inflammatory bowel disease; MRI = magnetic resonance imaging; PCR = polymerase chain reaction.
In the setting of acute or mild ReA, treatment is most often symptomatic and conservative. It is important to remember that many of the symptoms of acute ReA are self-limiting. The initial treatment of choice for the arthritis is nonsteroidal anti-inflammatory (NSAIDs). Not only is there a breadth of clinical experience with NSAIDs demonstrating their efficacy, there are also two randomized trials that have formally evaluated their use in ReA. The first was a double-blind crossover study comparing azapropazone to indomethacin in patients with both psoriatic arthritis and ReA.113 Both medications were efficacious with a trend favoring indomethacin. Neither medication helped with the skin manifestations of either condition. The second was another double-blind crossover study comparing ketoprofen to indomethacin in 50 patients with ReA.114 Both drugs were efficacious in treating the articular symptoms with no significant difference between the two. There were slightly more adverse events with indomethacin in both studies. Corticosteroids are quite helpful in patients with more severe articular symptoms. It has been suggested that systemic corticosteroids might be more efficacious in the treatment of peripheral articular symptoms rather than the axial symptoms.115 Because ReA often involves one or few joints, intra-articular corticosteroids are often a useful treatment strategy.
Initial treatment of many of the extra-articular features of ReA includes topical corticosteroids. These have been utilized to treat iritis/uveitis, keratoderma blenorrhagicum, and circinate balanitis.115 Given the similarities between the cutaneous manifestations of ReA and psoriasis, it is not surprising that other medications used to treat psoriasis have been advocated as potential treatments for keratoderma blenorrhagicum and/or circinate balanitis. Data suggest that topical calcipotriene is a useful treatment modality for keratoderma.116 Emollients, keratolytics, coal tar, and phototherapy have also been advocated for keratoderma blenorrhagicum. In severe cases of keratoderma blenorrhagicum and circinate balanitis methotrexate (low-dose regimen as for psoriasis) and etretinate (0.5 mg/kg body weight) have been found to be beneficial but no formal clinical trials have been performed!
In spite of the fact that ReA often remits, as many as 30%–50% of patients will develop chronic disease. Both the articular and extra-articular features can persist. Because ReA can lead to pathologic sequelae (e.g., joint damage, visual impairment, skin disfigurement) resulting in decreased health-related quality of life, more definitive treatments have been sought. Paralleling the opposing schools of thought regarding the true role bacterial persistence plays in the pathophysiology of the disease, both traditional disease modifying antirheumatic drugs (DMARDs) and antibiotics have been assessed as potential therapeutic options. The latter have been studied in both acute and chronic disease, whereas the former are most often reserved for patients with chronic symptoms.
Several DMARDs have been advocated as treatments for ReA. These include sulfasalazine, methotrexate, azathioprine, and cyclosporine. Surprisingly, only one of these, sulfasalazine, has been formally evaluated in prospective clinical trials. Sulfasalazine has been studied as a potential treatment for both acute and chronic ReA. In the acute ReA study, there was no significant difference between sulfasalazine and placebo in terms of pain, number of swollen joints, and erythrocyte sedimentation rate (ESR) after 6 months of therapy.117 In addition, there was no apparent efficacy difference in patients regarding the initial triggering infection, HLA-B27 status, or presence/absence of axial arthritis. However, it is important to remember that acute ReA often remits spontaneously, so this potentially confounds these data. Sulfasalazine has also been studied in the setting of chronic ReA.118 In this study, all patients had failed NSAIDs and were followed for 36 weeks' duration. There was a trend favoring sulfasalazine over placebo in terms of overall response. Sulfasalazine fared significantly better than placebo in some of the secondary endpoints including a longitudinal analysis and ESR.
The tumor necrosis factor (TNF)-α antagonists have demonstrated remarkable success treating several types of inflammatory arthritis including other types of spondyloarthritides, namely ankylosing spondylitis and psoriatic arthritis. Therefore it might seem logical that they would be useful therapeutic agents for ReA. However, several studies suggest that ReA is more of a Th2 driven disease.83–85 Conversely, ReA patients have higher serum TNF-α levels than normal controls.82 Adding to this complexity, it has been suggested that the Th1 versus Th2 predominance depends on the cell analyzed (synovial fluid derived T-cell clones vs. synovial fluid mononuclear cells).82 It should also be noted that, in the case of chlamydial persistence, chlamydial replication is inversely proportional to TNF-α levels.86–88 There are no randomized trials in ReA to accurately assess the efficacy of anti-TNF therapy, but several case reports and a small open label study suggest clinical benefit with these drugs in the treatment of ReA.119–122 It might also be noteworthy that a rare, but defined, adverse event of anti-TNF therapy, in general, includes the onset of de novo psoriasis.123 The similarities of keratoderma blenorrhagicum and pustular psoriasis are well described. The majority of these cases of anti-TNF therapy induced psoriasis occurs on the palms and/or soles and is pustular in nature. Three reported cases have been shown to be PCR positive for Chlamydia trachomatis on lesional skin biopsies.37 The exact pathophysiology of these de novo cases of psoriasiform lesions remains unknown.
The fact that certain bacterial organisms are responsible for the genesis of ReA makes the notion of using antibiotics plausible. Data have demonstrated that the causative bacterial organisms traffic to the synovium and in the case of persistent synovium-based Chlamydiae, specifically, these organisms exist in a viable, albeit aberrant, state. This important difference in postchlamydial and postenteric ReA suggests a potential difference in antimicrobial response.
The first prospective, double-blind trial assessed antibiotics in the setting of acute ReA.124 In this trial, 3 months of therapy with lymecycline significantly decreased the duration of illness in those subjects with postchlamydial ReA, but not those with the postenteric variety. This led to several studies assessing the utility of long-term treatment with various antibiotics, including ciprofloxacin, azithromycin, and doxycycline, in the ensuing years that produced negative results.67,125–128 However, the initial concept that postchlamydial and postenteric ReA might behave differently in terms of therapeutic response was somewhat lost in these follow-up studies. More recently, data have suggested that a prolonged course of combination antibiotics is an efficacious treatment specifically for chronic postchlamydial ReA. Initially, an open-label comparison of doxycycline with rifampin versus doxycycline monotherapy suggested superiority with the former.65 A double-blind, placebo-controlled follow-up study demonstrated that 6-month courses of doxycycline with rifampin and azithromycin with rifampin were significantly better than placebo.129 In this study, all patients had to be PCR positive for Chlamydiae in order to be randomized to treatment. Significantly more patients on combination antimicrobial therapy converted to PCR negative compared to those treated with placebo after 6 months of therapy.
In terms of chronic diseases, ReA is unique in that the etiologic agents are known. This insight into disease initiation has led to significant advances in the understanding of this condition but much remains to be learned regarding its pathophysiology. In an almost ironic fashion, the definitive nature of disease genesis is juxtaposed with convoluted evolution regarding disease terminology and the original overreliance on the "classic triad" of symptoms; these issues have now been clarified. However, there remains ambiguity regarding a definitive therapeutic approach. Ongoing studies will hopefully answer the latter.
1. Aho K et al: HLA antigen 27 and reactive arthritis. Lancet 2:157, 1973
2. Reiter H: Uber eine bisher unerkannte Spirochateninfektion (Spirochetosis arthritica). Dtsch Med Wochensohr 42:1535, 1916
3. Parker CT, Thomas, D: Reiter's syndrome and reactive arthritis. J Am Osteopath Assoc 100:101, 2000
4. Wallace DJ, Weisman MH: The physician Hans Reiter as prisoner of war in Nuremberg: A contextual review of his interrogations (1945–1947). Semin Arthritis Rheum 32:208, 2003
5. Panush RS et al: Retraction of the suggestion to use the term "Reiter's syndrome" sixty-five years later: The legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum 56:693, 2007
6. Sharp JT: Reiter's syndrome. In: Arthritis and Allied Conditions, 8th edition, edited by JH Hollander, DJ McCarthy. Philadelphia, Lea and Febiger, 1979, p. 1223
7. Sydenham T: The Works of Thomas Sydenham, M.D, vol. 198. Translated by RG Latham. London, Sydenham Society, II, 1848, p. 257
8. Stoll M: De l'arthrite dysenterique. Arch Gen Med 14:29, 1869
9. Yvan AU: Observation sur une metastase de gonorrhee. Ann Soc Med Prat de Montpellier 119-125, 1806
10. Brodie BC: Pathological and Surgical Observations on Diseases of the Joints. London, Longman, 1818, p. 54
11. Launois M PE: Arthropaties recidivantes amythrophie generalize troubles trophiques multiples. D'origine blennofthalmique. Bull Mem Soc Med Hosp Paris 14:93, 1897
12. Fiessinger M, Leroy E: Contribution a l'etude d'une epidemie de dysenterie dans le somme. Bull Soc Med Hop Paris 40:2030, 1916
13. Leirisalo-Repo M: Prognosis, course of disease and treatment of the spondyloarthropathies. Rheum Dis Clin Am 24:737, 1998
14. Carter JD: Reactive arthritis: Defined etiologies, emerging pathophysiology, and unresolved treatment. Infect Dis Clin North Am 20:827, 2006
15. Rudwaleit M et al: Low incidence of reactive arthritis in children following a salmonella outbreak. Ann Rheum Dis 60:1055, 2001
16. Isomäki H et al: Incidence of inflammatory rheumatic diseases in Finland. Scand J Rheumatol 7:188, 1978
17. Kvien TK et al: Reactive arthritis: Incidence-triggering agents and clinical presentation. J Rheumatol 21:115, 1994
18. Michet CJ et al: Epidemiology of Reiter's syndrome in Rochester, Minnesota: 1950–1980. Arthritis Rheum 31:428, 1988
19. Braun J et al: Prevalence of spondyloarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum 41:58, 1998
20. Carter JD, Hudson AP: Reactive arthritis: Clinical aspects and medical management. Rheum Dis Clin North Am 35:21, 2009
21. Boyer GS et al: A comparison of patients with spondyloarthropathy seen in specialty clinics with those identified in a communitywide epidemiologic study. Has the classic case misled us? Arch Intern Med 157:2111, 1997
22. Barth WF, Segal K: Reactive arthritis (Reiter's syndrome). Am Fam Physician 60:499, 1999
23. Schiellerup P, Krogfelt KA, Locht H: A comparison of self-reported joint symptoms following infection with different enteric pathogens: Effect of HLA-B27. J Rheumatol 35:480, 2008
24. Garg AX et al; Walkerton Health Study Investigators: A gradient of acute gastroenteritis was characterized, to assess risk of long-term health sequelae after drinking bacterial-contaminated water. J Clin Epidemiol 59:421, 2006
25. Townes JM et al: Reactive arthritis following culture-confirmed infections with bacterial enteric pathogens in Minnesota and Oregon: A population-based study. Ann Rheum Dis 67:1689, 2008
26. Nelson HD, Helfand M: Screening for chlamydial infection. Am J Prev Med 20:95, 2001
27. Manavi K: A review on infection with Chlamydia trachomatis. Best Pract Res Clin Obstet Gynaecol 20:941, 2006
28. Stamm WE: Chlamydia trachomatis infections: progress and problems. J Infect Dis 179(Suppl. 2):380, 1999
29. Carter JD et al: Chlamydiae as etiologic agents in chronic undifferentiated spondylarthritis. Arthritis Rheum 60:1311, 2009
30. Rich E et al: Reactive arthritis in patients attending and urban sexually transmitted disease clinic. Arthritis Rheum 39:1172, 1996
31. Saario R, Toivanen A: Chlamydia pneumonia as a cause of reactive arthritis. Br J Rheumatol 32:1112, 1993
32. Braun J et al: Chlamydia pneumoniae – A new causitive agent of reactive arthritis and undifferentiated oligoarthritis. Ann Rheum Dis 53:100, 1994
33. Hannu T, Puolakkainen M, Leirisalo-Repo M: Chlamydia pneumoniae as a triggering infection in reactive arthritis. Rheumatology (Oxford) 38:411, 1999
34. Gerard HC et al: Synovial chlamydia trachomatis in patients with reactive arthritis/Reiter's syndrome are viable but show aberrant gene expression. J Rheumatol 25:734, 1998
35. Gerard HC et al: Chlamydia pneumoniae present in the human synovium are viable and metabolically active. Microb Pathog 29:17, 2000
36. Gerard HC et al: Differential expression of three Chlamydia trachomatis hsp60-encoding genes in active vs. persistent infections. Microb Pathog 36:35, 2004
37. Carter JD, Gerard HC, Hudson AP: Psoriasiform lesions induced by tumour necrosis factor antagonists: A skin-deep medical conundrum. Ann Rheum Dis 67:1181, 2008
38. Gerard HC et al: Patients with Chlamydia-associated arthritis have ocular (trachoma), not genital, serovars of C. trachomatis in synovial tissue. Microb Pathog 48:62, 2010
39. Mittal A: Serovar distribution of Chlamydia trachomatis isolates collected from the cervix: Use of the polymerase chain reaction and restriction endonuclease digestion. Br J Biomed Sci 55:179, 1998
40. Workowski KA et al: Clinical manifestations of genital infection due to Chlamydia trachomatis in women: Differences related to serovar. Clin Infect Dis 19:756, 1994
41. Schachter J et al: Isolation of bedsoniae from the joints of patients with Reiter's syndrome. Proc Soc Exp Biol Med 122:283, 1966
42. Gilbert RJ et al: Antibiotic therapy in experimental bedsonial arthritis. Arthritis Rheum 16:30, 1973
43. Dworkin MS et al: Reactive arthritis and Reiter's syndrome following and outbreak of gastroenteritis caused by Salmonella enteritidis. Clin Infect Dis 33:1010, 2001
44. Buxton JA et al: Reactive arthritis and other sequelae following sporadic Salmonella typhimurium infection in British Columbia, Canada: A case control study. J Rheumatol 29:2154, 2002
45. Hannu T et al: Reactive arthritis attributable to Shigella infection: A clinical and epidemiological nationwide study. Ann Rheum Dis 64:594, 2005
46. Altekruse SF et al: Campylobacter jejuni–An emerging foodborne pathogen. Emerg Infect Dis 5:28, 1999
47. Pope JE et al: Campylobacter reactive arthritis: A systematic review. Semin Arthritis Rheum 37:48, 2007
48. Hannu T et al: Reactive arthritis after an outbreak of Yersinia pseudotuberculosis serotype O:3 infection. Ann Rheum Dis 62:866, 2003
49. Press N et al: Clinical and microbiological follow-up of an outbreak of Yersinia pseudotuberculosis serotype Ib. Scand J Infect Dis 33:523, 2001
50. Braun J et al: Nested polymerase chain reaction strategy simultaneously targeting DNA sequences of multiple bacterial species in inflammatory joint diseases. I. Screening of synovial fluid samples of patients with spondyloarthropathies and other arthritides. J Rheumatol 24:1092, 1997
51. Granfors K et al: Bacterial lipopolysaccharide in synovial fluid cells in Shigella triggered reactive arthritis. J Rheumatol 19:500, 1992
52. Nikkari S et al: Salmonella-triggered reactive arthritis: Use of polymerase chain reaction, immunocytochemical staining, and gas-chromatography-mass spectrometry in the detection of bacterial components from synovial fluid. Arthritis Rheum 42:84, 1999
53. Gaston JS, Cox C, Granfors K: Clinical and experimental evidence for persistent Yersinia infection in reactive arthritis. Arthritis Rheum 42:2239, 1999
54. Nikkari S et al: Yersinia-triggered reactive arthritis. Use of polymerase chain reaction and immunocytochemical in the detection of bacterial components from synovial specimens. Arthritis Rheum 35:682, 1992
55. Birnbaum J, Bartlett JG, Gelber AC: Clostridium difficile: An under-recognized cause of reactive arthritis? Clin Rheumatol 27:253, 2008
56. Tinazzi E et al: Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: A systematic review. Rheumatol Int 26:481, 2006
57. Calabrese LH, Kirchner E, Shrestha R: Rheumatic complications of human immunodeficiency virus infection in the era of highly active anti-retroviral therapy: Emergence of a new syndrome of a new reconstitution and changing patterns of disease. Semin Arthritis Rheum 35:166, 2005
58. Reveille JD, Ball EJ, Khan MA: HLA-B27 and genetic predisposing factors in spondyloarthropathies. Curr Opin Rheumatol 13:265, 2001
59. Morris R et al: HL-A W27–a clue to the diagnosis and pathogenesis of Reiter's syndrome. N Engl J Med 290:554, 1974
60. Khan MA: Clinical application of the HLA-B27 Test in rheumatic diseases. A current perspective. Arch Intern Med 140:1097, 1980
61. Inman RD et al: Postdysenteric reactive arthritis. A clinical and immunogenetic study following an outbreak of salmonellosis. Arthritis Rheum 31:1377, 1988
62. Mattila L et al: Reactive arthritis following an outbreak of Salmonella infection in Finland. Br J Rheumatol 33:1136, 1994
63. Mattila L et al: Reactive arthritis following an outbreak of Salmonella Bovismorbificans infection. J Infect 36:289, 1998
64. Hannu T et al: Campylobacter-triggered reactive arthritis: A population-based study. Rheumatology 41:312, 2002
65. Carter JD, Valeriano J, Vasey FB: A prospective, randomized 9-month comparison of doxycycline vs. doxycycline and rifampin in undifferentiated spondyloarthritis – with special reference to Chlamydia-induced arthritis. J Rheumatol 31:1973, 2004
66. Hannu T et al: Reactive arthritis following an outbreak of Campylobacter jejuni infection. J Rheumatol 31:528, 2004
67. Kvien TK et al: Three-month treatment of reactive arthritis with azithromycin: A EULAR double-blind, placebo-controlled study. Ann Rheum Dis 63:1113, 2004
68. Girschick HJ et al: Bacterial triggers and autoimmune rheumatic diseases. Clin Exp Rheumatol 26:S12, 2008
69. Dulphy N et al: Common intra-articular T cell expansions in patients with reactive arthritis: Identical beta-chain junctional sequences and cytotoxicity toward HLA-B27. J Immunol 162:3830, 1999
70. Kuon W et al: Identification of novel human aggrecan T cell epitopes in HLA-B27 transgenic mice associated with spondyloarthropathy. J Immunol 173:4859, 2004
71. Popov I et al: Breakdown of CTL tolerance to self HLA-B*2705 induced by exposure to Chlamydia trachomatis. J Immunol 169:4033, 2002
72. Saarinen M et al: Invasion of Salmonella into human intestinal epithelial cells is modulated by HLA-B27. Rheumatology (Oxford) 41:651, 2002
73. Colbert RA et al: From HLA-B27 to spondyloarthritis: A journey through the ER. Immunol Rev 233:181, 2010
74. Sampaio-Barros PD et al: Frequency of HLA-B27 and its alleles in patients with Reiter syndrome: Comparison with the frequency in other spondyloarthropathies and a healthy control population. Rheumatol Int 28:483, 2008
75. Díaz-Peña R et al: Influence of HLA-B*5703 and HLA-B*1403 on susceptibility to spondyloarthropathies in the Zambian population. J Rheumatol 35:2236, 2008
76. Rihl M et al: Identification of candidate genes for susceptibility to reactive arthritis. Rheumatol Int 29:1519, 2009
77. Gérard HC et al: Apolipoprotein E4 enhances attachment of Chlamydophila (Chlamydia) pneumoniae elementary bodies to host cells. Microb Pathog 44:279, 2008
78. Guo A et al: Adhesin-dependent binding and uptake of Salmonella enterica serovar Typhimurium by dendritic cells. Microbiology 153:1059, 2007
79. Vazquez-Torres A et al: Toll-like receptor 4 dependence of innate and adaptive immunity to Salmonella: Importance of the Kupffer cell network. J Immunol 172:6202, 2004
80. Zhang X et al: Innate immunity and arthritis: Neutrophil Rac and toll-like receptor 4 expression define outcomes in infection-triggered arthritis. Arthritis Rheum 52:1297, 2005
81. Tsui FW et al: Toll-like receptor 2 variants are associated with acute reactive arthritis. Arthritis Rheum 58:3436, 2008
82. Rihl M et al: Alpha beta but not gamma delta T cell clones in synovial fluids of patients with reactive arthritis show active transcription of tumour necrosis factor alpha and interferon gamma. Ann Rheum Dis 63:1673, 2004
83. Braun J et al: Low secretion of tumor necrosis factor alpha, but no other Th1 or Th2 cytokines, by peripheral blood mononuclear cells correlates with chronicity in reactive arthritis. Arthritis Rheum 42:2039, 1999
84. Thiel A et al: Analysis of the antigen-specific T cell response in reactive arthritis by flow cytometry. Arthritis Rheum 43:2834, 2000
85. Yin Z et al: Crucial role of interleukin-10/interleukin-12 balance in the regulation of the type 2 T helper cytokine response in reactive arthritis. Arthritis Rheum 40:1788, 1997
86. Ishihara T et al: Inhibition of chlamydia trachomatis growth by human interferon-alpha: Mechanisms and synergistic effect with interferon-gamma and tumor necrosis factor-alpha. Biomed Res 26:179, 2005
87. Perry LL, Feilzer K, Caldwell HD: Immunity to Chlamydia trachomatis is mediated by T helper 1 cells through IFN-gamma-dependent and–Independent pathways. J Immunol 158:3344, 1997
88. Takano R et al: Cytokine response of lymphocytes persistent infected with Chlamydia pneumoniae. Curr Microbiol 50:160, 2005
89. Inman RD, Chiu B: Early cytokine profiles in the joint define pathogen clearance and severity of arthritis in Chlamydia-induced arthritis in rats. Arthritis Rheum 54:499, 2006
90. Arnett FC et al: Incomplete Reiter's Syndrome: Discriminating features and HL-A W27 in diagnosis. Ann Intern Med 84:8, 1976
91. Grigoryan M et al: Imaging in spondyloarthropathies. Curr Rheumatol Rep 6:102, 2004
92. Rothschild BM, Pingitore C, Eaton M: Dactylitis: Implications for clinical practice. Semin Arthritis Rheum 28:41, 1998
93. François RJ et al: Histopathologic evidence that sacroiliitis in ankylosing spondylitis is not merely enthesitis. Arthritis Rheum 43:2011, 2000
94. Hancock JAH: Surface manifestations of Reiter's disease in the male. Br J Venereal Dis 36:36, 1960
95. Schneider JM, Matthews JH, Graham BS: Reiter's syndrome. Cutis 71:198, 2003
96. Wu BI, Schwartz RA: Reiter's syndrome: The classic triad and more. J Am Acad Dermatol 59:113, 2008
97. Cohen MR, Reda DJ, Clegg DO: Baseline relationships between psoriasis and psoriatic arthritis: Analysis of 221 patients with active psoriatic arthritis. Department of Veterans Affairs Cooperative Study Group on Seronegative Spondyloarthropathies. J Rheumatol 26:1752, 1999
98. Chogle AR et al: Reiter's syndrome with keratoderma blennorrhagica. J Assoc Physicians India 47:416, 1999
99. Callen JP, Mahl CF: Oculocutaneous manifestations observed in multisystem disorders. Dermatol Clin 10:709, 1992
100. Willkens RF et al: Reiter's syndrome: Evaluation of preliminary criteria for definite disease. Arthritis Rheum 24:844, 1981
101. Brook MG, Kell PD, Atia WA: Lone circinate balanitis and genital keratoderma: Underdiagnosed presentations of chlamydial infection in men? J Eur Acad Dermatol Venereol 8:34, 1997
102. Kiss S et al: Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology 110:1764, 2003
103. Cuvelier C et al: Histopathology of intestinal inflammation related to reactive arthritis. Gut 28:394, 1987
104. Olhagen B: Urogenital syndromes and spondarthritis. Br J Rheumatol 22:33, 1983
105. Yli-Kerttula UI, Kataja MJ, Vilppula AH: Urinary genital involvements in rheumatic disorders in females. An interview study. Clin Rheumatol 4:170, 1985
106. Hannu T et al: Cardiac findings of reactive arthritis: An observational echocardiographic study. Rheumatol Int 21:169, 2002
107. Bergfeldt L: HLA-B27-associated cardiac disease. Ann Intern Med 127:621, 1997
108. Kingsley G, Sieper J: Third International Workshop on Reactive Arthritis. 23–26 September 1995, Berlin, Germany. Ann Rheum Dis 55:564, 1996
109. Braun J et al: On the difficulties of establishing a consensus on the definition of and diagnostic investigations of reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3–6, 1999. J Rheumatol 27:2185, 2000
110. Siala M et al: Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis. FEMS Immunol Med Microbiol 55:178, 2009
111. Schnarr S et al: Chlamydia and Borrelia DNA in synovial fluid of patients with early undifferentiated oligoarthritis: Results of a prospective study. Arthritis Rheum 44:2679, 2001
112. Wollenhaupt J, Schnarr S, Kuipers JG: Bacterial antigens in reactive arthritis and spondarthritis. Rational use of laboratory testing in diagnosis and follow-up. Baillieres Clin Rheumatol 12:627, 1998
113. Lassus A: A comparative pilot study of azapropazone and indomethacin in the treatment of psoriatic arthritis and Reiter's disease. Curr Med Res Opin 4:65, 1976
114. Juvakowski T, Lassus A: A double-clind cross-over evaluation of ketoprofen and indomethacin in Reiter's disease. Scand J Rheumatol 11:106, 1982
115. Flores D et al: Reactive arthritis: Newer developments. Rheum Dis Clin North Am 29:37, 2003
116. Thiers BH: The use of topical calcipotriene/calcipotriol in conditions other than plaque-type psoriasis. J Am Acad Dermatol 37:S69, 1997
117. Egsmose C et al: Limited effect of sulfasalazine treatment in reactive arthritis. A randomized double blind placebo controlled trial. Ann Rheum Dis 56:32, 1997
118. Clegg DO et al: Comparison of sulfasalazine and placebo in the treatment of reactive arthritis (Reiter's syndrome). A Department of Veterans Affairs Cooperative Study. Arthritis Rheum 39:2021, 1996
119. Flagg SD et al: Decreased pain and synovial inflammation after etanercept therapy in patients with reactive and undifferentiated arthritis: An open-label trial. Arthritis Rheum 53:613, 2005
120. Haibel H, Brandt J, Rudawaleit M: Therapy of chronic enteral reactive arthritis with infliximab [abstract]. Ann Rheum Dis 62:AB0380, 2003
121. Oili KS et al: Treatment of reactive arthritis with infliximab. Scand J Rheumatol 32:122, 2003
122. Schrafranski MD: Infliximab for reactive arthritis secondary to Chalmydia trachomatis infection. Rheumatol Int 30:679, 2010
123. Ko JM, Gottlieb AB, Kerbleski JF: Induction and exacerbation of psoriasis with TNF-blockade therapy: A review and analysis of 127 cases. J Dermatolog Treat 20:100, 2009
124. Lauhio A et al: Double-blind, placebo-controlled study of three-month treatment with lymecycline in reactive arthritis, with special reference to Chlamydia arthritis. Arthritis Rheum 34:6, 1991
125. Smieja M et al: Randomised, blinded, placebo controlled trial of doxycycline for chronic seronegative arthritis. Ann Rheum Dis 60:1088, 2001
126. Wakefield D et al: Ciprofloxacin treatment does not influence course or relapse rate of reactive arthritis and anterior uveitis. Arthritis Rheum 42:1894, 1999
127. Yli-Kerttula T et al: Effect of a three month course of ciprofloxacin on the outcome of reactive arthritis. Ann Rheum Dis 59:565, 2000
128. Sieper J et al: No benefit of long-term ciprofloxacin in patients with reactive arthritis and undifferentiated oligoarthritis: A three-month, multicenter, double-blind, randomized, placebo-controlled study. Arthritis Rheum 42:1386, 1999
129. Carter JD et al: Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis. Arthritis Rheum Feb 12, 2010. [Epub ahead of print]
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Limit my search to Computational and Systems Biology
Mapping and analysis of Caenorhabditis elegans transcription factor sequence specificities
Kamesh Narasimhan,
Samuel A Lambert,
Ally WH Yang,
Jeremy Riddell,
Sanie Mnaimneh,
Hong Zheng,
Mihai Albu,
Hamed S Najafabadi,
John S Reece-Hoyes,
Juan I Fuxman Bass,
Albertha JM Walhout,
Matthew T Weirauch ,
Timothy R Hughes ,
University of Toronto, Canada;
University of Cincinnati, United States;
University of Massachusetts Medical School, United States;
Cincinnati Children's Hospital Medical Center, United States;
Canadian Institutes For Advanced Research, Canada;
Caenorhabditis elegans is a powerful model for studying gene regulation, as it has a compact genome and a wealth of genomic tools. However, identification of regulatory elements has been limited, as DNA-binding motifs are known for only 71 of the estimated 763 sequence-specific transcription factors (TFs). To address this problem, we performed protein binding microarray experiments on representatives of canonical TF families in C. elegans, obtaining motifs for 129 TFs. Additionally, we predict motifs for many TFs that have DNA-binding domains similar to those already characterized, increasing coverage of binding specificities to 292 C. elegans TFs (∼40%). These data highlight the diversification of binding motifs for the nuclear hormone receptor and C2H2 zinc finger families and reveal unexpected diversity of motifs for T-box and DM families. Motif enrichment in promoters of functionally related genes is consistent with known biology and also identifies putative regulatory roles for unstudied TFs.
Many scientists use 'model' species—such as the fruit fly or a nematode worm called Caenorhabditis elegans—in their research because these organisms have useful features that make it easier to carry out many experiments. For example, C. elegans has a smaller genome compared to many other animals, which is useful for studying the roles of individual genes or stretches of DNA.
Transcription factors are a type of protein that can bind to specific stretches of DNA and help to switch certain genes on or off. These 'motifs' may be close to the gene or further away in the genome, and therefore, must stand out amongst the rest of the DNA, like lights on a landing strip. However, the motifs for only 10% of the estimated 763 transcription factors in C. elegans have been identified so far.
In this study, Narasimhan, Lambert, Yang et al. used a technique called a 'protein binding microarray' to identify the motifs for many more of the C. elegans transcription factors. These findings were then used to predict motifs for other transcription factors. Together, these methods increased the proportion of C. elegans transcription factors with known DNA-binding motifs from 10% to around 40%.
Now that more DNA motifs have been identified, it is possible to look for similarities and differences between them. For example, Narasimhan, Lambert, Yang et al. found that transcription factors with similar sequences can bind to very varied motifs. On the other hand, some transcription factors that are very different are able to recognize very similar motifs. The experiments also indicate that motifs found very close to genes—in sequences known as 'promoters'—may be able to interact with many proteins to influence the activity of genes.
Narasimhan, Lambert, Yang et al.'s findings increase the number of C. elegans transcription factors with a motif, bringing the knowledge of these proteins more in line with the better-studied transcription factors of humans and fruit flies. The next challenge is to identify DNA motifs for the remaining 60% of transcription factors.
Transcription factors (TFs) are sequence-specific DNA-binding proteins that control gene expression, often regulating specific biological processes such as pluripotency and differentiation (Takahashi and Yamanaka, 2006), tissue patterning (Lemons and McGinnis, 2006), the cell cycle (Evan et al., 1994), metabolic pathways (Blanchet et al., 2011), and responses to environmental stimuli (Benizri et al., 2008). The nematode Caenorhabditis elegans is a powerful model for studying gene regulation as it is a complex and motile animal, yet has a compact genome (∼100 Mbp) (C. elegans Sequencing Consortium, 1998) featuring relatively short intergenic regions (mean 1389 bp; median 662 bp). Indeed, the observation that proximal promoter sequence is often sufficient to produce complex tissue-specific gene expression patterns (Dupuy et al., 2004; Zhao et al., 2007; Grove et al., 2009; Sleumer et al., 2009; Niu et al., 2011) indicates that long-range gene regulation through enhancers is not as abundant in C. elegans as it is in flies or mammals (Gaudet and McGhee, 2010; Reinke et al., 2013).
C. elegans has 934 annotated TFs (Reece-Hoyes et al., 2005), and 744 proteins that possess a well-characterized sequence-specific DNA-binding domain (DBD) (Weirauch and Hughes, 2011; Weirauch et al., 2014). C. elegans contains major expansions of several specific TF families, with nuclear hormone receptor (NHR), Cys2His2 (C2H2) zinc finger, homeodomain, bHLH, bZIP, and T-box together comprising 74% of the TF repertoire (Reece-Hoyes et al., 2005; Haerty et al., 2008). The lineage-specific expansion of C2H2 zinc finger (ZF) TFs is similar to that observed in many animals, including diversification of DNA-contacting 'specificity residues', suggesting diversification in DNA-binding specificity (Stubbs et al., 2011). The C. elegans genome encodes an unusually large number of NHRs (274 members), more than five times the number in human (48 members) (Enmark and Gustafsson, 2001; Reece-Hoyes et al., 2005). It is speculated that the NHRs may serve as environmental sensors (Enmark and Gustafsson, 2001; Arda et al., 2010), providing a possible explanation for their variety and numbers. Five of the six major NHR sub-families found across metazoa are also found in C. elegans (NR3 is lacking), but the vast majority of C. elegans NHRs define novel sub-families that are not present in other metazoans (Van Gilst et al., 2002) and which are derived from an ancestral gene most closely resembling HNF4 (aka NR2A) (Robinson-Rechavi et al., 2005). Extensive variation in the DNA-contacting recognition helix (RH) or 'P-box' suggests that C. elegans NHRs, like C2H2 and bHLH families, have diversified DNA-sequence specificities, and that many will recognize novel motifs (Van Gilst et al., 2002). The T-box gene family presents another example of a nematode-specific expansion, with 22 members in C. elegans, of which 18 lack one-to-one orthologs in other metazoan lineages (Minguillon and Logan, 2003). Only four have known binding motifs, and unlike most other TFs, T-box binding motifs are virtually identical across the metazoa (Sebé-Pedrós et al., 2013; Weirauch et al., 2014); the diversification of TFs is often associated not only with changes in DNA-sequence specificity but also alteration in protein–protein interactions and expression of the TF gene itself (Grove et al., 2009; Reece-Hoyes et al., 2013).
Despite extensive study of gene regulation, including several large-scale efforts (Deplancke et al., 2006; Grove et al., 2009; Lesch et al., 2009; Gerstein et al., 2010; Niu et al., 2011; Sarov et al., 2012; Reece-Hoyes et al., 2013; Araya et al., 2014), the landscape of C. elegans TF-sequence specificities remains largely unknown. To our knowledge, motifs are currently known for only 71 C. elegans TFs, including those determined in single-gene studies, previous protein binding microarray (PBM) analyses, and modENCODE TF ChIP-seq data (Matys et al., 2006; Araya et al., 2014; Mathelier et al., 2014; Weirauch et al., 2014). It has been surprisingly difficult to obtain motifs from ChIP-seq data (Niu et al., 2011; Araya et al., 2014), possibly due to indirect binding, or a dominant role of chromatin structure in either determining in vivo binding sites (Song et al., 2011) or in the purification of chromatin fragments (Teytelman et al., 2013). Yeast one-hybrid (Y1H) assays (Reece-Hoyes et al., 2011) cannot be used easily to derive TF motifs, because the DNA sequences tested are too large (∼2 kb on average). However, there is a strong statistical correspondence between motifs determined by PBMs and Y1H data (Reece-Hoyes et al., 2013). Computational approaches coupling promoter sequence conservation and/or gene expression data to identify TF motifs de novo have collectively produced many more motifs than there are TFs (Beer and Tavazoie, 2004; Sleumer et al., 2009; Zhao et al., 2012) and also do not inherently reveal the cognate TFs that correspond to each putative motif. Multimeric binding represents one possible complication in the analysis of in vivo TF-binding data (Ao et al., 2004). Indeed, TF co-associations were identified based on ChIP-seq peak-binding overlaps in C. elegans modENCODE studies (Araya et al., 2014), but the underlying sequence recognition mechanisms were not apparent.
Here, we use PBMs to systematically identify C. elegans TF DNA-binding motifs. We selected a diverse set of TFs to assay, ultimately obtaining 129 motifs from different TF families and subclasses. The data show that the expansion of most major TF families is associated with diversification of DNA-binding motifs. Motif enrichment in promoters reveals that our motif collection readily associates individual TFs with putative regulated processes and pathways.
Overview of the PBM data
The key goal of this project was to expand our knowledge of DNA-sequence specificities of C. elegans TFs. To do this, we analyzed a diverse set of TF DBDs (see below) with PBM assays (Berger et al., 2006; Weirauch et al., 2014). Briefly, the PBM method works by 'hybridizing' a glutathione S-transferase (GST)-tagged DNA-binding protein (in our assays, the DBD of a TF plus 50 flanking amino acids) to an array of ∼41,000 defined 35-mer double-stranded DNA probes. The probes are designed such that all 10-mer sequences are present once, and all non-palindromic 8-mers are, thus, present 32 times in difference sequence contexts (palindromic 8-mers occur 16 times). A fluorescently labelled anti-GST antibody illuminates the extent to which each probe is bound by the assayed TF. Using the signal intensity for each probe, the specificity of the TF is derived. For each individual 8-mer, we derive both E-scores (which represent the relative rank of microarray spot intensities, and range from −0.5 to +0.5 [Berger et al., 2006]) and Z-scores (which scale approximately with binding affinity [Badis et al., 2009]). PBMs also allow derivation of position weight matrices (PWMs) up to 14 bases long (Berger et al., 2006; Mintseris and Eisen, 2006; Badis et al., 2009; Weirauch et al., 2013) (hereafter, we take 'motif' to mean PWM). To determine PWMs, we used the data from PBM assays performed on two different array designs to score the performance of PWMs obtained from different algorithms, as previously described (Weirauch et al., 2013, 2014).
In this study, we selected TFs to analyze on the basis of their DBD sequence, aiming to examine at least one TF from each group of paralogous TFs, and biasing against TFs that have known PBM motifs, or close orthologs or paralogs with known motifs (see 'Materials and methods' for full description of selection scheme). The selections were guided by previous PBM analyses that determined sequence identity thresholds for each DBD class that correspond to motif identity (Weirauch et al., 2014). To identify TFs, we used the Cis-BP definition of DBDs (Weirauch et al., 2014), which employs a list of well-characterized eukaryotic DBDs and a distinct significance threshold for each DBD class. CisBP identified 744 C. elegans proteins, encompassing 52 domain types (listed in Figure 1—source data 1). 689 (93%) of these 744 are present in the wTF catalog of 934 annotated TFs (Reece-Hoyes et al., 2005); thus, these sets are largely overlapping. We manually examined the differences between the two TF lists (see Supplementary file 1) and found that most of them can be accounted for by (i) changes to the C. elegans protein catalog over time, (ii) differences in domain classes included, (iii) differences in domain score threshold, (iv) fewer manual annotations in Cis-BP, and (v) ambiguity in classifying C2H2 zinc fingers as TFs. Overall, wTF2.0 contains only 19 proteins that are not in Cis-BP and that are very likely bona fide sequence-specific TFs. wTF2.0 also contains 83 C2H2 proteins that fall below the CisBP score threshold, 52 of which have only a single C2H2 domain. DNA recognition typically requires multiple C2H2 domains; however, some fungal TFs do bind DNA with a single C2H2, employing additional structural elements (Wolfe et al., 2000). Thus, these proteins have an ambiguous status. In general, Cis-BP excludes proteins with lower domain scores and those with little or no evidence for sequence-specific DNA binding, and we, therefore, refer to the 744 in CisBP plus the 19 additional bona fide TFs as the 763 'high confidence' C. elegans TFs.
We attempted to clone DBDs from 552 unique high confidence TFs, ultimately obtaining clones for 449, all of which we assayed by PBMs. After employing stringent success criteria (see 'Materials and methods') we obtained sequence-specificity data (8-mer scores and motifs) for 129 DBDs. PBM 'failures' may be due to any of several causes, including protein misfolding, requirement for cofactors or protein modifications (e.g., phosphorylation), or bona fide lack of sequence-specific DNA-binding activity. The overall success rate (29%) is comparable to that we have observed from the analysis of thousands of DBDs from diverse species (35%) (Weirauch et al., 2014).
A summary of our results is presented in Figure 1, broken down by motif numbers and percent coverage for individual DBD classes. Our motif collection encompasses 26 different DBD classes, and greatly increases the number and proportion of C. elegans TFs for which motifs have been identified experimentally, from 71 (10%) to 195 (26%) (five of the 129 had previously-known motifs). The new data encompass all of the large TF families, including C2H2 zinc fingers, NHRs, bZIPs, homeodomains, DM domains, and GATA proteins.
Motif status by DBD class.
Stacked bar plot depicting the number of unique C. elegans Transcription factors (TFs) for which a motif has been derived using PBM (this study), previous literature (including PBMs), or by homology-based prediction rules (see main text). The y-axis is displayed on a log2 scale for values greater than zero. See Figure 1—source data 1 for DNA-binding domain (DBD) abbreviations. Correspondence between motifs identified in current study and previously reported motifs is shown in Figure 1—figure supplement 1.
Table of C. elegans TF repertoire motif coverage and list of TF DBDs present in C. elegans.
The number of unique C. elegans TFs by DNA-binding domain family for which a motif has been derived using PBM (this study), previous literature (including PBMs), or by homology-based prediction rules and the list of C. elegans TFs by DNA-binding domain family type.
Validation of motifs, motif novelty, and motifs predicted using homology
We next asked whether our new data are consistent with previous knowledge. Of the 129 TFs, only five have previously known motifs, all of which we recapitulated (Figure 1—figure supplement 1). The sequence preferences for most of the 129 TFs were different from those of any previously assayed TF, however. The boxplots in Figure 2A–C and Figure 2—figure supplements 1–4 show that, on average, the new TFs we analyzed bound a set of 8-mers that was largely non-overlapping with that of the most similar protein that had been analyzed previously by PBM (red circles indicate the 8-mer overlap between individual TFs analyzed by PBM in our study, and the most similar TF analyzed by PBM in any study). Nonetheless, some pairs of TFs have DBDs that are highly similar and bind highly overlapping 8-mers. These observations are quantitatively consistent with the prior study we used for guidance in selecting TFs (black box plots) (Weirauch et al., 2014), and thus, we expect that the scheme for predicting sequence specificity via amino acid identity that was proposed in the prior study can also be used in C. elegans. In this scheme, TFs without DNA-binding data are simply assigned the motifs and 8-mer data for other TFs with DBD amino acid similarity above a threshold, if those data exist. These TFs can be from C. elegans or from other species. If we include these predicted motifs, then the number of C. elegans TFs with an associated motif increases to 292 (39%), including TFs with motifs predicted from other C. elegans TFs (24) and those with motifs predicted from other species (79).
Motif prediction, motif clustering, and identification of representative motifs.
(A–C) Boxplots depict the relationship between the %ID of aligned AAs and % of shared 8-mer DNA sequences with E-scores exceeding 0.45, for the three DBD classes, as indicated. %ID bins range from 0 to 100, of size 10, in increments of five. Red dots indicate individual TFs in this study, vs the next closest TF with PBM data. Vertical lines indicate AA %ID threshold above which motifs can be predicted using homology, taken from (Weirauch et al., 2014). Boxplots for all other DBDs in current study are shown in Figure 2—figure supplements 1–4. (D) Clustering analysis of motifs of bZIP domains using position-weight matrices (PWM)clus (Jiang and Singh, 2014). Colored gridlines indicate clusters. Cluster centroids are shown along the diagonal; expert curated motifs are shown within the box at right. 'E' indicates experimentally determined motifs; 'P' indicates predicted motifs. Source of motif is also indicated. Results of motif curation for GATA family TFs is displayed in Figure 2—figure supplement 5.
Expert curation of motifs
The entire C. elegans motif collection, including our new data, previously published motifs, and those predicted by homology from other TFs in C. elegans and other species, encompasses 1769 unique motifs representing only 292 TFs. About half (157, or 54%) of the 292 TFs with motifs are represented by only a single motif, as there were no data prior to our study for these TFs or their close homologs. Some TFs (e.g., homeodomains, PAX, and forkheads), however, are highly conserved and thus have many orthologs above the prediction threshold. In addition, TFs that are known developmental regulators tend to be well studied, and often possess multiple associated motifs. To gain an overview of the full motif collection and to compare among the multiple motifs for each protein, we used the PWMclus tool (Jiang and Singh, 2014), with default settings, to obtain groups of highly related motifs from all TFs within each DBD class. This tool uses an information-content weighted Pearson correlation between aligned PWM columns as a similarity measure for hierarchical clustering, and then selects branches within which the average internal correlation exceeds R ≥ 0.8. This procedure collapsed the 1769 motifs into a set of 424 clusters. This number is still larger than the number of TFs with either known or predicted motifs (292), since there are many cases in which motifs for a single TF are distributed across multiple clusters, although in 67% of cases in which there are multiple known and predicted motifs for a given protein, the majority of them do form a single cluster.
There appear to be several explanations for this phenomenon, as exemplified by the bZIP family shown in Figure 2D. First, different studies and different experimental (or computational) techniques often yield motifs for the same protein that are clearly related by visual examination, but score as different from each other using PWMclus. For example, there are four different motifs for SKN-1 (from PBM, Chip-seq, and Transfac) that all contain the same half-site, ATGA, but have different flanking sequence preferences. Similarly, for Forkhead TFs FKH-1 and UNC-130, different methods produce variants with differences in the sequences flanking the core TGTTT Forkhead binding site. A related explanation is that a single motif may not adequately capture all aspects of TF sequence preferences, such as the ability of many TFs to bind as both a monomer and a homodimer (or multimer) with preferred spacing and orientation, variability in the preferred spacing, changes to the preferred monomeric sites that are associated with dimerization, and effects of base stacking that result in preferred polynucleotides at some positions (Jolma et al., 2013). In addition, different experimental methods may capture some aspects of DNA-binding complexity better than others.
It is inconvenient to have a large number of motifs for a single protein for several reasons. First, it is difficult to peruse the full motif collection. In addition, comprehensive motif scanning is slower with a large number of motifs, and the motif scans produce partially redundant results that require deconvolution and reduce statistical power. We, therefore, sought to identify a single motif or set of motifs for each protein that are minimally redundant and are best supported by existing data. We used a semi-automated scheme that considers all data available (similar to that described in (de Boer and Hughes, 2012); see 'Materials and methods'). Briefly, we prioritized motifs that are (a) measured experimentally, rather than predicted; (b) more similar to other motifs for the same TF, or highly similar TFs, especially if they are derived from in vitro data, which would be free of confounding effects present in vivo; (c) assigned to the cluster that contains the majority of motifs for that TF; (d) most consistent with the type of sequences that a given DBD class typically binds; (e) best supported by ChIP-seq or Y1H data, if available (see below).
This procedure resulted in a set of 284 motifs representing the 292 C. elegans TFs with experimentally determined or predicted motifs (Supplementary file 2). The outcome for the bZIP family is shown on the right of Figure 2D, which illustrates that the motif curation procedure produces motifs that are consistent with known bZIP class binding sites. The curated set also contains 16 cases in which the same protein is represented by multiple motifs (exemplified by the GATA family TF ELT-1, which binds as both a monomer and a homodimer, Figure 2—figure supplement 5), and 11 cases in which more than one protein is represented by the same motif (e.g., GATA family TFs MED-1 and MED-2, Figure 2—figure supplement 5; in all of these cases, the TFs are highly similar proteins). We also note that PWMclus subdivides the 284 curated motifs into only 127 different clusters (data not shown), because the motif(s) contained in many of the 424 original clusters met few or none of the selection criteria above.
Overview of PBM 8-mer data
The majority of the expert curated motifs (237, or 84%) are derived from the PBM data described in this study or from previous studies (compiled in [Weirauch et al., 2014]), which are the only data available for the majority of the 292 TFs with motifs. We reasoned that the PBM data should facilitate direct comparison among TF sequence preferences, as they were generated using identical methodology. In addition, PBMs facilitate comparisons because they produce scores for individual DNA 8-mers. Thus, to complement the PWM analysis above, we examined as a composite 8-mer E-score data for all of the TFs analyzed in this study by using PBMs. Figure 3 illustrates that the 8-mers recognized by each individual protein are in general distinct and further highlights the distinctiveness of the sequences preferred by different TFs that share the same type of DBD. For example, C. elegans homeodomain and Sox TFs display different sequence preferences that largely reflect the known subclasses (Figure 3 and data not shown; all data and motifs are available in the Cis-BP database (see 'Data Access' section below)). We also observed subtle differences in Forkhead DNA-sequence preferences: despite the motifs having similar appearance, the proteins prefer slightly different sets of 8-mers, as previously observed using PBM data (Badis et al., 2009; Nakagawa et al., 2013). Other large C. elegans TF families display undocumented and unexpected diversity in their DNA-sequence preferences, which we next examined in greater detail.
Overview of 8-mer sequences preferences for the 129 C. elegans TFs analyzed by PBM in this study.
2-D Hierarchical agglomerative clustering analysis of E-scores performed on all 5728 8-mers bound by at least one TF (average E > 0.45 between ME and HK replicate PBMs). Colored boxes represent DBD classes for each TF. Average E-score data is available in Figure 3—source data 1.
Table showing 8-mers bound by at least one TF with an average E-score ≥0.45 for all the 129 C. elegans TFs analyzed by PBMs in this study.
Complex relationships between protein sequences and motifs recognized by the NHR family
Previously, the literature contained motifs for only eight of the 271 C. elegans NHRs, while motifs for an additional 13 could be predicted from orthologs and paralogs (Hochbaum et al., 2011; Weirauch et al., 2014). It has also been reported that additional C. elegans NHRs bind sequences similar to those bound by their counterparts in other vertebrates (Van Gilst et al., 2002), but the data available do not lend itself to motif models that can be used for scanning. We obtained new PBM data for 20 C. elegans NHRs (Figure 4), among which only one had a previously known motif (DAF-12, which yielded a motif identical to one found by ChIP–chip [Hochbaum et al., 2011]). None of the remaining 19 could have been predicted by simple homology; due to their widespread divergence, and absence of motifs for most NHRs, few motifs can be predicted by homology among the C. elegans NHR class at our threshold for motif prediction (70% identity for NHRs). However, these 19 new NHR motifs do lead to predicted motifs for eight additional C. elegans NHRs.
8-mer binding profiles of NHR family reveal distinct sequence preferences.
Left, ClustalW phylogram of nuclear hormone receptor (NHR) DBD amino acid sequences with corresponding motifs. TF labels are shaded according to motif similarity groups identified by PWMclus. Center, heatmap showing E-scores. NHRs are ordered according to the phylogram at left. The 1406 8-mers with E-score > 0.45 for at least one family member on at least one PBM array were ordered using hierarchical agglomerative clustering. Each TF has one row for each of two-replicate PBM experiments (ME or HK array designs). Right; recognition helix (RH) sequences for the corresponding proteins, with identical RH sequence types highlighted by colored asterisks. Variant RH residues are underlined at bottom. Right, matrix indicates cluster membership according to PWMclus. Top and bottom, pullouts show re-clustered data including only the union of the top ten most highly scoring 8-mers (taking the average E-score from the ME and HK arrays) for each of the selected proteins. E-scores for k-mers in all three heatmaps are available in Figure 4—source data 1.
Table showing 8-mer E-score profiles of NHRs analyzed by PBMs.
8-mers bound by at least one NHR with an E-score ≥0.45 for all the C. elegans NHRs that have been analyzed by PBMs (center panel) and a table of pullouts (top and bottom panel) showing average (ME and HK) E-scores of the union of the top ten highly scoring 8-mers bound by at least one NHR within the selected motif cluster.
The most striking feature of the NHR motifs is their diversity, but an equally surprising observation is that very different NHRs can bind very similar sets of sequences. Data from the 27 NHRs that have been analyzed by PBMs in our study or others are shown in Figure 4. We obtained 13 different groups of motifs, using the PWMclus methodology described above (indicated by shading of dendrogram labels in Figure 4). We expected that all 27 of these NHRs might have yielded a distinct motif, as no two are more than 70% identical to each other. In several cases, however, NHRs with very different overall DBD sequences (below the threshold for predicting motif identity) in fact display similar sequence preferences, while more similar NHR TFs often bind different motifs, as the shading on the labels in Figure 4 does not strictly reflect the dendrogram. We also note that the data for individual 8-mers appear more complex than the motif groups capture (see heatmaps in Figure 4). For example, the individual 8-mer scores for TFs represented by the two largest groups of motifs—sets binding sequences related to G(A/T)CACA and (A/T)GATCA, respectively—indicate that they may in fact possess distinct DNA-sequence preferences (Figure 4, top and bottom). These subtle and complex differences are presumably obscured by the motif derivation process, which tends to produce degenerate (i.e., low information content) motifs for most of these TFs. In addition, or possibly as a consequence, the default correlation threshold used by the PWMclus algorithm groups these TFs together.
To examine the determinants of NHR sequence preferences more closely, we considered NHR RH sequences (Figure 4, middle). Of the 95 unique RH sequences found in C. elegans NHRs, 15 are found in our data, including multiple representatives of most of the populous RHs (our data contain ten of the 75 with RA-AA; 3 of the 19 with NG-KT; 2 of the 10 with NG-KG; and one of the seven with AA–AA). It is believed that identity in the RH corresponds to identity in sequence preference (Van Gilst et al., 2002); surprisingly, however, we found that TFs with identical RH sequences can bind very different DNA sequences. For example, NHR-177 shares the RA-AA RH with nine other NHRs examined in our study, yet binds a completely different set of sequences (resembling CGAGA, unlike the CACA-containing motifs of the others). Conversely, NHRs with different RH sequences can have very similar DNA-sequence preferences. NHR-66 and NHR-70, for example, differ at two of the four variable residues in the RH (AA-SA vs RA-AA), and share only ∼49% amino acid identity (and NHR-66 contains a three-residue insertion). Yet, they bind highly overlapping sets of 8-mers and produce motifs featuring CTACA. Thus, there is an imperfect correspondence between identity in the RH and identity in DNA-binding sequence preferences, suggesting that additional residues within (or flanking) the DBD contribute to the specificity of C. elegans NHR proteins. These observations also show that, when NHRs with very different overall DBD sequences bind similar motifs, it is typically not due to the two proteins sharing the same RH.
Only one NHR, SEX-1, produced a motif strongly resembling the canonical steroid hormone response element (SHRE) (GGTCA); SEX-1 shares three of four variable residues in the RH with canonical SHRE binding TFs such as the estrogen receptor (SEX-1: EG-KG; ER: EG-KA). Moreover, none of the NHRs examined produced a motif matching that of HNF4, the presumed ancestor of most C. elegans NHRs.
Motifs for C. elegans C2H2 TFs are supported by the recognition code
We obtained new PBM data for 42 C2H2 ZF TFs (Figure 5), only one of which was previously known (Figure 1—figure supplement 1). Previously there were only six experimentally-determined C. elegans C2H2 motifs in the literature, and 11 that could be predicted by homology, all of which are well conserved in distant metazoans (members of KLF, SP1, EGR, SNAIL, OSR, SQZ, and FEZF families); seven of these are among our data and have PBM motifs consistent with those predicted (data not shown). Only two additional TFs (ZTF-25 and ZTF-30) can be assigned motifs by homology using our new data. Together, the new data and predictions bring the total number of C. elegans C2H2 TFs with motifs to 53 (∼50% of the 107 C2H2s in our list of 763 TFs).
C2H2 motifs relate to DBD similarity and to the recognition code.
Left, ClustalW phylogram of C2H2 zinc finger (ZF) amino acid sequences with corresponding motifs. Right, examples in which motifs predicted by the ZF recognition code are compared to changes in DNA sequences preferred by paralogous C2H2 ZF TFs. Cartoon shows individual C2H2 ZFs and their specificity residues. Dashed lines correspond to 4-base subsites predicted from the recognition code.
The C2H2 motifs are diverse (Figure 5), but unlike the NHR family, the molecular determinants of C2H2 DNA sequence specificities are more readily understood. The motifs we obtained are broadly consistent with previously determined relationships between DNA contacting residues and preferred bases (the so-called 'recognition code') (Wolfe et al., 2000), although the motifs predicted by the recognition code are not sufficiently accurate to be used in motif scans (median R2 = 0.21 vs predictions made by an updated recognition code that surpasses all previous recognition codes when compared against gold standards (Najafabadi et al., 2015)). While most of the motifs are similar to those predicted by the recognition code (Figure 5—figure supplement 1), lower similarity is observed for TFs with unusual inter-C2H2 linker lengths and atypical zinc-coordinating residues (Figure 5—figure supplement 1). In some cases, differences in the motifs obtained from related C2H2 TFs can be rationalized: Figure 5 (right) shows the example of paralogs EGRH-1 and EGRH-3, in which the motifs obtained by PBM closely reflect those predicted by the recognition code, which differ at several positions. Figure 5 also shows the example of Snail homologs CES-1 and K02D7.2, in which a short linker between fingers 2 and 3 may explain the truncated motif in K02D7.2, and may also explain the differences previously observed between these two proteins in Y1H assays (Reece-Hoyes et al., 2009).
Unexpected diversity in T-box DNA-binding specificities
We obtained motifs for four nematode-specific T-box TFs (i.e., lacking one-to-one orthologs in other phyla): TBX-33, TBX-38, TBX-39, and TBX-43. In addition, TBX-40 was previously analyzed by PBM, and our motif for the related protein TBX-39 (93% identical) is very similar. T-box TFs can bind to dimeric sites, with the characteristic spacing and orientation varying among different T-box proteins (Jolma et al., 2013). The monomeric sequence preference (resembling 'GGTGTG') is thought to be constant, however, as it is observed across different T-box classes and in distant phyla (Sebé-Pedrós et al., 2013; Weirauch et al., 2014). Strikingly, our new PBM data indicate that monomeric T-box sites can also vary considerably (Figure 6A). While the motifs for TBX-38 and TBX-43 are highly similar to the canonical 'GGTGTG' motif, TBX-33, TBX-39, and TBX-40 exhibit novel recognition motifs.
Nematode-specific sequence preferences in T-box and DM TFs.
PBM data heatmaps of preferred 8-mers for T-box (A), and DM (B) TFs. TFs are clustered using ClustalW; 8-mers were selected (at least one instance of E > 0.45) and clustered using hierarchical agglomerative clustering, as in Figures 4, 5. Ten representative 8-mers (those with highest E-scores) are shown below for each of the clusters indicated in cyan. C. elegans TFs with data from this study are bolded. E-score data for T-box and DM TFs available in Figure 6—source data 1.
Table showing 8-mer E-score profiles of T-box and DM TFs from C. elegans and other metazoans that have been analyzed by PBMs.
The primary determinants of sequence specificity of T-box TFs are believed to reside in amino-acid residues located in α-helix 3 and the 310-helixC, which contact the major and minor groove, respectively (Muller and Herrmann, 1997; Coll et al., 2002; Stirnimann et al., 2002), and indeed, the DNA contacting residues in TBX-33, TBX-39, and TBX-40 are different from those in T-box TFs that bind the canonical motif (Figure 6—figure supplement 1). In addition, TBX-39 and TBX-40 exhibit sequence deletion in the 'variable region', and TBX-33 has an 18 amino acid insertion in the region leading up to the β-strand e′, which could also potentially alter sequence preferences via structural rearrangements.
Variation in motifs for DM domains highlights nematode-specific expansions
DM TFs are well studied because of their established roles in sex determination, and previous analyses established that different DM TFs often bind distinct motifs that typically contain a TGTAT core, including Drosophila doublesex, for which the family is named (Gamble and Zarkower, 2012). C. elegans and other nematodes encode several lineage-specific DM TFs in addition to orthologs shared across metazoans, with eight of the eleven C. elegans DM domains having less than 85% identity (our threshold for DM motif prediction) to any DM domain in insects and vertebrates (Weirauch et al., 2014). Accordingly, most of the C. elegans DM domains have highest preference for sequences that are different from TGTAT, although in all but two cases the motifs do contain a TGT (Figure 6B). DM domains encode intertwined CCHC and HCCC-zinc binding sites and are hypothesized to bind primarily in the minor groove (Zhu et al., 2000; Narendra et al., 2002). A DNA-protein structure has not yet been described for any DM protein, however; mapping the determinants of their variable DNA sequence preferences will therefore require further study.
Motif enrichment in Y1H and ChIP-seq data
We next examined whether motifs from our collection correspond to modENCODE TF ChIP-seq data (Araya et al., 2014), and to TF prey—promoter bait interactions from Y1H experiments ([Reece-Hoyes et al., 2013] and JF-B and AJMW, unpublished data). Among the 40 TFs analyzed by ChIP-seq and present in our motif collection, peaks for 20 TFs displayed central enrichment of motif scores (q-value < 0.05) using the CentriMo algorithm on the top 250 peaks (Bailey and Machanick, 2012) (Figure 7). Similarly, among 145 TFs both analyzed by Y1H and present in our motif collection, motif affinity scores for 103 were significantly enriched (Mann–Whitney U test; q-value < 0.05) among promoter sequences scoring as positive by Y1H, relative to those scoring as negative by Y1H (Figure 7—figure supplement 1). The correspondence among these data sets is presumably imperfect due to indirect DNA binding in vivo, and/or the impact of chromatin and cofactors on binding site selection (Liu et al., 2006), both of which occur in C. elegans and yeast. We note that, among the 25 TFs that are present in Y1H data, ChIP-seq data, and our motif collection, 11 are only significantly enriched in Y1H (using the cutoff above), five are only significantly enriched in ChIP-seq, and only five are significantly enriched in both. Thus, most motifs (21/25; 84%) can be supported by independent assays, although the in vivo assays appear to capture different aspects of TF binding. Overall, the clear relationship between our motifs and independent data sets strongly supports direct in vivo relevance of the motifs.
The C. elegans curated motif collection explains ChIP-seq and Y1H TF binding data.
Heatmap of CentriMo −log10 (q-values) for central enrichment of TF motifs in the top 250 peaks for each ChIP experiment. Motif enrichment in Y1H data is presented in Figure 7—figure supplement 1. Both ChIP-seq and Y1H heatmaps use a common colour and annotation scale. Heatmaps are symmetric with duplicate rows to ensure the diagonal represents TF-motif enrichment in it's matching data set(s). Red and blue coloring depicts statistically significant enrichments and depletions (q ≤ 0.05).
We also examined whether we could detect multimeric or composite motifs (CMs) in existing ChIP-seq data sets by searching for the enrichment of patterns in which there is fixed spacing and orientation between two or more motifs within the peaks, one of which corresponds to the TF that was ChIPed. We identified 185 significantly enriched CMs (see 'Materials and methods') involving 11/40 ChIPed TFs, and 14 different TF families (including partner motifs) (Figure 8, Figure 8—source data 1). As an example, the most highly significant result involves NHR-28 in which the six-base core sequence 'ACTACA' (which could correspond to NHR-28 or NHR-70) is found repeated in both dimeric and trimeric patterns (Figure 8A, top). We also identified a CM involving LSY-2 (a C2H2 ZF protein) and NHR-232 with a spacing of one base between the core motifs (Figure 8A, middle). A subset of these instances included a ZIP-6 (bZIP) motif at a one base distance 3′ of the NHR-232 motif, yielding a multi-family trimeric CM (Figure 8A, bottom).
Composite motifs enriched in C. elegans ChIP-seq peaks.
(A) Stereospecificity plots showing enriched CM configurations for pairs of TF motifs. The identical '1F2F' and '2F1F' results in A (top row) demonstrate homodimer and homotrimer CMs, while those involving LSY-2, NHR-232, and R07H5.10 demonstrate heterodimer and heterotrimer CMs (middle and bottom rows, respectively). Black arrows represent orientation of the motif within CMs, while gray dashed arrows designate shadow motifs within trimeric CMs. Error bars are ± S.D., *corrected p < 0.05. (B) Forest plot of odds ratios for TF family enrichment in CMs vs input TF list. (C) Venn diagram showing overlap of significant CMs identified by null model 1 (dinucleotide shuffled sequence) and null model 2 (motif shuffling). (D) Number of significant CMs identified relative to dinucleotide scrambled sequences using shuffled and non-shuffled non-ChIPed motifs, as a function of motif pair distance.
Table displaying enrichment statistics, spacing and orientations between PWMs for CMs identified in modENCODE ChIP-seq data.
Download elife-06967-fig8-data1-v2.xls
PWMclus grouped the 185 CMs into 37 clusters (Figure 8—figure supplements 1–5). Most of the CMs were identified repeatedly for the same TF ChIPped in different developmental stages; these instances were considered separately in the analysis above and highlight the robustness of the observations. Some of the clusters also correspond to CMs containing motifs for related TFs, demonstrating robustness to the exact motif employed. Our methodology allowed the individual motifs to overlap, and half of the 37 CM clusters represent such overlaps. However, the majority of overlaps occur in the flanking low-information-content sections of motifs, such that most the 37 CM clusters resemble a concatenation of two motif 'cores' with or without a small gap (1–4 bases). Surprisingly, 17 of the 37 clusters (∼46%) were obtained from the embryonic ChIP-seq data for the poorly-characterized, essential bZIP protein F23F12.9 (ZIP-8), which is most similar to human ATF TFs and binds both the ATF site and the CREB site (Figure 8—figure supplements 1–3). In total, these results suggest that multimeric interactions within and between TF families may be a prevalent phenomenon in C. elegans.
Motif enrichment in tissue and developmental-stage specific expression data
To identify potential roles for TFs in the regulation of specific groups of functionally related genes, we asked whether the set of promoters containing a strong motif match to each TF (FIMO p-value < 10−4 in the region −500 to +100 relative to TSS) overlapped significantly with any tissue expression (Spencer et al., 2010), Gene Ontology (GO) categories (Ashburner et al., 2000), or Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways (Kanehisa et al., 2014) (Fisher's exact test, one-sided probability, false discovery rate (FDR) corrected q-value < 0.05). We obtained dozens of significant relationships (Figure 9), including known roles for GATA TFs in the regulation of intestinal gene expression (and related GO categories) (Pauli et al., 2006; McGhee, 2007), HLH-1 in the regulation of muscle gene expression (Fukushige et al., 2006), DAF-19 (an RFX TF) in the regulation of ciliary genes (Swoboda et al., 2000), and PHA-4 in development of the pharynx (Gaudet and Mango, 2002) (boxed in Figure 9). We also note that the association of the motif for ZTF-19 (PAT-9), a C2H2 ZF protein, with genes expressed in L2 body wall muscle tissue is consistent with observed expression patterns for this gene in body wall muscle, as well as defective muscle development in a mutant (Liu et al., 2012). The ZTF-19 binding motif may, therefore, enable the identification of specific downstream targets. Most of the associations in Figure 9, however, appear to represent putative regulatory interactions, suggesting that the motif collection can be used to gain new biological insight.
Enrichment of motifs upstream of gene sets.
Each row of the heatmap represents a motif from our curated collection that is enriched (q < 0.05) in at least one gene set category. Known regulatory interactions between TFs and gene sets are highlighted (black outlines). 'E' indicates experimentally determined motifs; 'P' indicates predicted motifs. Source of motif is also indicated. Enrichment q-values are available in Figure 9—source data 1.
Table of motif enrichments −log10 (p-values) in the promoters of gene set categories identified from KEGG pathway modules, Gene Ontology processes, and tissue/developmental stage specific expression lists.
The collection of motifs described here will further advance C. elegans as a major model system for the study of gene regulation. TF DNA-binding motifs enable dissection of promoters, prediction of new targets of TFs, and identification of putative new regulatory mechanisms. Statistical associations between motif matches in promoters and expression patterns or functional categories of genes also provide a ready starting point for directed experimentation, for example, analysis of gene expression in mutants. Apparent position and orientation constraints between motif matches also suggest functional relationships. Our observation that the largely unstudied bZIP TF F23F12.9 (ZIP-8) was involved in almost half of all CMs identified in this study suggests that it may function as a cofactor for targeting to open chromatin: pioneer TF activity and partnering with other TFs has previously been proposed for other Creb/ATF proteins in mouse embryonic stem cells (Sherwood et al., 2014).
A key observation in this study is that all the large groups of TFs in C. elegans are malleable in their DNA-binding sequence preferences. The NHR is a striking case, even more so when we consider that our motifs encompass only monomeric binding sites. A previous analysis classified the C. elegans NHRs into four subtypes, on the basis of their RH sequences, and predicted that all of those in Class I (those most similar to canonical NHRs such as the estrogen receptor) would likely bind canonical SHRE GGTCA subsites (Van Gilst et al., 2002). Instead, we find that those in Class I (the entire lower half in Figure 4) bind a wide range of sequences, and that the RH cannot be the only determinant of sequence specificity. Our observations are consistent with the previous demonstration that mutation of one or a few residues in the NHR RH can result in dramatic changes in sequence preferences, but that mutations elsewhere in the DBD play a role in sequence selectivity (e.g., McKeown et al., 2014). Recent analyses of other DBD classes (e.g., C2H2 and Forkhead) also highlight the importance of residues beside the canonical specificity residues (Nakagawa et al., 2013; Siggers et al., 2014). Together, these analyses strongly confirm that alteration of binding motifs is widespread among TF classes throughout evolution.
Our study experimentally determined motifs for 129 TFs, all but five of which were previously unstudied, bringing the total number of C. elegans TFs with motifs to 292 (including predicted motifs and data already in the literature). We estimate that the remaining 453 C. elegans TFs encode as many as 409 different DNA-binding motifs, most of which correspond to NHRs, C2H2 ZFs, bHLHs, and homeodomains (Supplementary file 3). Additional effort will thus be required to obtain a complete motif collection. For instance, even with our new motifs, and including motifs predicted by homology, coverage for the C. elegans NHR family is only 17%.
For some classes of DBDs, most of the PBM assays yielded negative data. The NHRs in particular yielded only 20% success (27/135). In addition, of the 108 that failed by PBM, we have tested 100 by Y1H, of which only 17 succeeded (three or more detected interactions; data not shown). We observed no obvious property of their DNA-contacting residues that strongly predicts success or failure and hypothesize that requirement for ligand binding, dimerization, cofactors, or protein modifications may represent other potential explanations for failures in heterologous assays. Like human NHRs, the C. elegans NHRs have a ligand-binding domain that is distinct from the DNA-binding domain and is thought to primarily regulate interactions with coactivators and corepressors (Sonoda et al., 2008). Thus, ligand-dependent DNA binding seems unlikely, especially for an in vitro assay. Yeast two-hybrid screens have identified several interactions between different NHRs (Simonis et al., 2009; Reece-Hoyes et al., 2013), suggesting that heterodimerization may be prevalent. If DNA binding is often dependent on heterodimerization, then ChIP-seq should often succeed where PBMs and Y1H fail, and heterodimeric motifs should be identified. To the best of our knowledge, however, there is only one published ChIP-seq data set for a C. elegans NHR that has yielded a motif de novo (NHR-25) (Araya et al., 2014; Boyle et al., 2014). We did not test NHR-25 by PBM, although our predicted monomeric motif (from Drosophila Ftz-f1) resembles the motif identified by ChIP-seq. As noted above, our motif for DAF-12 is also consistent with the motif obtained by ChIP–chip (Hochbaum et al., 2011). In support of heteromeric binding, however, CMs involving NHRs and other TF families were prevalent in modENCODE ChIP-seq data (Figure 8—source data 1). Further analysis will be required to explore the role of multimerization in C. elegans TF DNA binding and gene regulation.
Finally, we note that there are numerous similarities between the TF collections of human, Drosophila, and C. elegans. First, the total number TFs containing a canonical DBD varies only by a factor of ∼2 (∼1734, 701, and 744 for human, Drosophila, and C. elegans, respectively [Weirauch et al., 2014]). The total number of groups of closely related paralogs (taken using the thresholds established in Weirauch et al. (2014)), which should approximate the number of distinct motifs that can eventually be expected, also varies by only a factor of ∼2 (the TFs fall into 1339, 656, and 632 groups of proteins expected to have very similar sequence specificity, respectively). Our study also brings the proportion of C. elegans TFs with a known or predicted motif much closer to the proportion in human and Drosophila, (56.1%, 54.1%, and 39.2% for human, Drosophila, and C. elegans, respectively). In addition, all three species possess a large number of diverse lineage-specific TFs, which are known or expected to bind different motifs: in human, ∼700 C2H2 ZF TFs; in Drosophila, 230 C2H2 ZF TFs; and in C. elegans, 266 NHRs, 99 C2H2 ZF TFs and—as we show here—roughly a dozen T-box and DM TFs. Thus, despite widespread conservation in TF number and gene expression (Stuart et al., 2003) among metazoans, extensive rewiring of the metazoan trans regulatory network is apparently common.
Selection of TFs for analysis
We compiled a list of 874 known and putative C. elegans TFs. We took 740 from build 0.90 of the Cis-BP database (Weirauch et al., 2014), plus additional candidate TFs that lack canonical DBDs (Reece-Hoyes et al., 2005). We considered selecting each TF for characterization using the following criteria:
Include the TF if its characterization would provide multiple-motif predictions for other TFs based on established prediction thresholds for the given DBD class (Weirauch et al., 2014);
Include the TF if it is a member of a DBD class with relatively little available motif information;
Include the TF if it has a known important biological role;
Exclude the TF if it has already been characterized by PBM in another study;
Exclude the TF if it is a member of a DBD class with a low-PBM success rate;
Exclude the TF if the resulting construct would be excessively long (for example, exclude C2H2 ZF TFs with many DBDs).
Cloning of C. elegans TF DBDs
We identified putative DBDs for all TFs by scanning their protein sequences using the HMMER tool (Eddy, 2009), and a collection of 81 Pfam (Finn et al., 2010) models taken from (Weirauch and Hughes, 2011), as described previously (Weirauch et al., 2014). For some TFs, we could not identify DBDs using this procedure. In such cases, DBDs were manually detected by lowering HMMER scanning thresholds, using DBDs annotated in the SMART database (Letunic et al., 2012), or performing literature searches. Using the above criteria for selection of TFs, we initially chose 398 TFs from the Walhout clone collection for characterization. We designed primers (Supplementary file 4) to clone open reading frames (ORFs) comprising the DBDs plus additional flanking sequences (50 endogenous amino acid flanking residues, or until the end of the protein). We inserted the resulting sequences using AscI and SbfI restriction sites into a modified T7-driven expression vector (pTH6838) that expresses N-terminal GST fusion proteins (Supplementary file 5). In the first round of cloning, we attempted cloning using both individual plasmids and pooled mRNA (by RT-PCR) or cDNA. After PBM analysis with the resulting clones, we then considered remaining uncharacterized TFs and selected an additional 154 TFs using the same criteria as above. The DBDs and flanking bases of these TFs were created using gene synthesis (BioBasic, Canada) and inserted into vectors as described above. Primers and insert sequences are provided on our project Web site. All clones were sequence verified.
PBMs and data processing
PBM laboratory methods were identical to those described previously (Lam et al., 2011; Weirauch et al., 2013). Each plasmid was analyzed in duplicate on two different arrays with differing probe sequences. Microarray data were processed by removing spots flagged as 'bad' or 'suspect' and employing spatial de-trending (using a 7 × 7 window centered on each spot) (Weirauch et al., 2013). Calculation of 8-mer Z- and E-scores was performed as previously described (Berger et al., 2006). Z-scores are derived by taking the average spot intensity for each probe containing the 8-mer, then subtracting the median value for each 8-mer, and dividing by the standard deviation, thus yielding a distribution with a median of zero and a standard deviation of one. E-scores are a modified version of the AUROC statistic, which consider the relative ranking of probes containing a given 8-mer, and range from −0.5 to +0.5, with E > 0.45 taken as highly statistically significant (Berger et al., 2008). We deemed experiments successful if at least one 8-mer had an E-score > 0.45 on both arrays, the complimentary arrays produced highly correlated E- and Z-scores, and the complimentary arrays yielded similar PWMs based on the PWM_align algorithm (Weirauch et al., 2013).
Generation of PWMs from PBMs
Motif derivation followed steps as outlined previously (Weirauch et al., 2014). Briefly, to obtain a single representative motif for each protein, we generated motifs for each array using four different algorithms: BEEML-PBM (Zhao and Stormo, 2011), FeatureREDUCE (manuscript in prep, source code available at http://rileylab.bio.umb.edu/content/software), PWM_align (Weirauch et al., 2013), and PWM_align_Z (Ray et al., 2013). We scored each motif on the complimentary array using the energy scoring system utilized by the BEEML-PBM algorithm (Zhao and Stormo, 2011). We then compared these PWM-based probe score predictions with the actual probe intensities using (1) the Pearson correlation coefficient and (2) the AUROC of 'bright probes' (defined by transforming all probe intensities to Z-scores, and selecting probes with Z-scores ≥ 4), following (Weirauch et al., 2013). Finally, we chose a single PWM for each DBD construct using these two criteria, as previously described (Weirauch et al., 2014).
Expert curation
For every TF with motif information, we selected a representative motif, or motifs if that TF appears to have multiple-binding modes (e.g., multimers), using the following scheme. If the TF has an experimentally derived motif, it is selected as the primary motif. If there are multiple such motifs, we selected one that was derived in vitro, if any. If the TF had multiple in vitro motifs, then we ranked PBM > B1H > SELEX, to maximize comparability among motifs, and excluded motifs that are inconsistent with known motifs for the same or highly related proteins. If the TF had only predicted motifs, we selected a motif from a highly similar TF that is: preferably derived from an in vitro method (PBM > B1H > SELEX); assigned to the cluster that contains the majority of motifs for that TF in our PWMclus analysis; consistent with known DBD preferences; and best supported by ChIP-seq or Y1H data, if available.
Motif enrichment with Y1H and ChIP-seq data
We calculated motif enrichment in ChIP-seq peaks using CentriMo (Bailey and Machanick, 2012), which uses TF motifs to look for central enrichment of motifs in ChIP-seq peaks, as an indication of direct binding by that TF. We obtained ChIP-seq peaks from the C. elegans modENCODE consortium (Araya et al., 2014). We used the top 250 peaks ranked by Irreproducible Discovery Rate (Landt et al., 2012) as the input data sets. We scored the curated set of motifs for TFs with peak data sets across all the peaks. We report false discovery rate (FDR)-adjusted p-values for a motif's central enrichment in TF-peak data sets.
For yeast one-hybrid (Y1H) data, we assigned motif scores to promoter bait sequences using the BEEML scoring system (Zhao et al., 2009). We included TFs in the analysis only if they bound five or more promoters in Y1H (those with 3 or 4 promoters bound were excluded to minimize sampling error in Mann–Whitney tests). We scored only the promoter-proximal 500 bp of Y1H bait sequences, as activating TF-binding sites are mainly effective within a few hundred bases of TSS in Saccharomyces cerevisiae (Dobi and Winston, 2007). We calculated motif enrichment or depletion for motifs using a two-tailed Mann–Whitney U test and reported with FDR-corrected p-values, with Y1H interactors as positives and the remaining non-interacting baits as the background.
We performed composite motif (CM) analysis by scanning 77 C. elegans ChIP-seq top 250 peak sequences for all pairwise combinations between the 40 ChIPed TFs (using the curated list of PWMs) and 129 PBM-derived PWMs from this study. Relative PWM spacing was restricted to −5 (overlapping) to +10 (gapped) bp separation, with four possible stereospecific arrangements of TFs: TF-1 forward TF-2 forward (1F2F), TF-1 forward TF-2 reverse (1F2R), 2R1F, and 2F1F, yielding 64 stereospecific combinations. We identified sequence matches using the standard log-likelihood scoring framework (Stormo, 2000), with a threshold of 0.50*max_score for each PWM, where max_score is the highest possible score for the given PWM. We created 10 sets of background sequences by scrambling the input sequences (maintaining dinucleotide frequencies). We calculated sample Z-scores and p-values by comparing the number of sequence matches observed in the 'real' sequence to the number observed in the random sequences and applied a Bonferroni correction to each p-value. To identify significant composite motifs, we filtered to retain only results with sequence match counts ≥10% of the number of input peak sequences and Bonferroni-adjusted p-values ≤ 0.05 (alpha = 0.05). We also considered an alternative null model, in which we shuffled the non-ChIPed motif, and counted matches in the original DNA sequences (this procedure was repeated 10×). Overall, we found very good agreement using this approach and our original null model. Out of the 635,712 possible patterns we tested, both methods call 635,483 insignificant, both call 49 positive, and they disagree on 180 (Figure 8C). Figure 8D plots the number of significant hits identified relative to dinucleotide scrambled sequences using shuffled (blue) and non-shuffled (red) non-ChIPed motifs. This plot indicates, however, that the shuffled motif null model over-estimates the significance of CMs as the overlap of their constituent motifs increases, presumably due to dispersal of high-information content 'core' positions, which are typically adjacent in the real motifs. We, therefore, use and report results based only on null model 1. Sequence logos were constructed using the actual matches obtained in the ChIP-seq peak sequences, and the WebLogo 3.4 tool (Crooks et al., 2004). For each TF family F, we calculated an odds ratio (OR) comparing the ratio of families in CMs to the ratio of families in the motif list. We define OR as (a/b)/(c/d), where a is the number of TFs of family F involved in a CM; b is the total number of unique TF pairs involved in a CM, minus a; c is the number of TFs of family F in the motif list; and d is the total number of TFs in the motif list, minus c. We calculated the standard error as √(1/a + 1/b + 1/c + 1/d), and the 95% confidence interval as eln(OR) ± 1.96SE.
Motif enrichment in co-regulated tissue/developmental stage-specific genes, KEGG and GO categories
We obtained selectively enriched gene sets for each tissue from (http://www.vanderbilt.edu/wormdoc/wormmap/), GO annotations from (http://www.geneontology.org/), and KEGG pathway modules (http://www.genome.jp/kegg/module.html). We ran FIMO (Grant et al., 2011) with default parameters.
PBM-microarray data are available at GEO (www.ncbi.nlm.nih.gov/geo/) under accession number GSE65719. Motifs and 8-mer data (E- and Z-scores) are available at www.cisbp.ccbr.utoronto.ca. Supplementary data files, including plasmid and primer information, motifs, source data for figure heatmaps, and lists of TFs are found on our project web site http://hugheslab.ccbr.utoronto.ca/supplementary-data/CeMotifs/.
Environmentally induced foregut remodeling by PHA-4/FoxA and DAF-12/NHR
W Ao
WJ Kent
S Muttumu
SE Mango
Regulatory analysis of the C. elegans genome with spatiotemporal resolution
CL Araya
T Kawli
A Kundaje
L Jiang
B Wu
D Vafeados
R Terrell
P Weissdepp
L Gevirtzman
D Mace
W Niu
AP Boyle
D Xie
JI Murray
V Reinke
RH Waterston
M Snyder
Functional modularity of nuclear hormone receptors in a Caenorhabditis elegans metabolic gene regulatory network
HE Arda
S Taubert
LT MacNeil
CC Conine
B Tsuda
M Van Gilst
L Doucette-Stamm
KR Yamamoto
AJ Walhout
Molecular Systems Biology 6:367.
https://doi.org/10.1038/msb.2010.23
Gene ontology: tool for the unification of biology. The Gene Ontology Consortium
M Ashburner
CA Ball
JA Blake
D Botstein
H Butler
JM Cherry
AP Davis
K Dolinski
SS Dwight
JT Eppig
MA Harris
DP Hill
L Issel-Tarver
A Kasarskis
S Lewis
JC Matese
JE Richardson
M Ringwald
GM Rubin
G Sherlock
Nature Genetics 25:25–29.
Diversity and complexity in DNA recognition by transcription factors
G Badis
MF Berger
AA Philippakis
S Talukder
AR Gehrke
SA Jaeger
ET Chan
G Metzler
A Vedenko
X Chen
H Kuznetsov
CF Wang
D Coburn
DE Newburger
Q Morris
TR Hughes
ML Bulyk
Inferring direct DNA binding from ChIP-seq
TL Bailey
P Machanick
https://doi.org/10.1093/nar/gks433
Predicting gene expression from sequence
MA Beer
S Tavazoie
The magic of the hypoxia-signaling cascade
E Benizri
A Ginouvés
E Berra
Cellular and Molecular Life Sciences 65:1133–1149.
Variation in homeodomain DNA binding revealed by high-resolution analysis of sequence preferences
L Peña-Castillo
TM Alleyne
S Mnaimneh
OB Botvinnik
F Khalid
W Zhang
D Newburge
QD Morris
Compact, universal DNA microarrays to comprehensively determine transcription-factor binding site specificities
AM Qureshi
FS He
PW Estep III
Nature Biotechnology 24:1429–1435.
https://doi.org/10.1038/nbt1246
E2F transcription factor-1 regulates oxidative metabolism
E Blanchet
JS Annicotte
S Lagarrigue
V Aguilar
C Clape
C Chavey
V Fritz
F Casas
F Apparailly
J Auwerx
L Fajas
Nature Cell Biology 13:1146–1152.
Comparative analysis of regulatory information and circuits across distant species
C Brdlik
P Cayting
C Cheng
Y Cheng
K Gardner
LW Hillier
J Janette
D Kasper
P Kheradpour
JJ Li
EJ Rehm
J Rozowsky
M Slattery
R Spokony
D Wang
P Weisdepp
YC Wu
KK Yan
EA Feingold
PJ Good
MJ Pazin
H Huang
PJ Bickel
SE Brenner
M Gerstein
KP White
M Kellis
Genome sequence of the nematode C. elegans: a platform for investigating biology
C. elegans Sequencing Consortium
Structure of the DNA-bound T-box domain of human TBX3, a transcription factor responsible for ulnar-mammary syndrome
M Coll
JG Seidman
CW Muller
Structure 10:343–356.
WebLogo: a sequence logo generator
GE Crooks
G Hon
JM Chandonia
https://doi.org/10.1101/gr.849004
YeTFaSCo: a database of evaluated yeast transcription factor sequence specificities
CG de Boer
Nucleic Acids Research 40:D169–D179.
https://doi.org/10.1093/nar/gkr993
A gene-centered C. elegans protein-DNA interaction network
B Deplancke
A Mukhopadhyay
AM Elewa
CA Grove
NJ Martinez
JS Reece-Hoyes
IA Hope
HA Tissenbaum
Analysis of transcriptional activation at a distance in Saccharomyces cerevisiae
KC Dobi
F Winston
https://doi.org/10.1128/MCB.00459-07
A first version of the Caenorhabditis elegans Promoterome
D Dupuy
QR Li
M Boxem
T Hao
P Lamesch
S Bosak
DE Hill
M Vidal
A new generation of homology search tools based on probabilistic inference
SR Eddy
Genome Informatics International Conference on Genome Informatics 23:205–211.
Comparing nuclear receptors in worms, flies and humans
E Enmark
JA Gustafsson
Trends in Pharmacological Sciences 22:611–615.
Integrated control of cell proliferation and cell death by the c-myc oncogene
G Evan
E Harrington
A Fanidi
H Land
B Amati
M Bennett
Philosophical Transactions of the Royal Society of London 345:269–275.
The Pfam protein families database
RD Finn
J Mistry
J Tate
P Coggill
A Heger
JE Pollington
OL Gavin
P Gunasekaran
G Ceric
K Forslund
L Holm
EL Sonnhammer
A Bateman
Defining the transcriptional redundancy of early bodywall muscle development in C. elegans: evidence for a unified theory of animal muscle development
T Fukushige
TM Brodigan
LA Schriefer
M Krause
Sex determination
T Gamble
Regulation of organogenesis by the Caenorhabditis elegans FoxA protein PHA-4
Recent advances in understanding the molecular mechanisms regulating C. elegans transcription
JD McGhee
Developmental Dynamics 239:1388–1404.
https://doi.org/10.1002/dvdy.22246
Integrative analysis of the Caenorhabditis elegans genome by the modENCODE project
MB Gerstein
ZJ Lu
EL Van Nostrand
BI Arshinoff
T Liu
KY Yip
R Robilotto
A Rechtsteiner
K Ikegami
P Alves
A Chateigner
M Perry
M Morris
RK Auerbach
J Leng
A Vielle
K Rhrissorrakrai
A Agarwal
RP Alexander
G Barber
CM Brdlik
J Brennan
JJ Brouillet
A Carr
MS Cheung
H Clawson
S Contrino
LO Dannenberg
AF Dernburg
A Desai
L Dick
AC Dosé
J Du
T Egelhofer
S Ercan
G Euskirchen
B Ewing
R Gassmann
P Green
F Gullier
M Gutwein
MS Guyer
L Habegger
T Han
JG Henikoff
SR Henz
A Hinrichs
H Holster
T Hyman
AL Iniguez
M Jensen
M Kato
E Kephart
V Khivansara
E Khurana
JK Kim
P Kolasinska-Zwierz
EC Lai
I Latorre
A Leahey
P Lloyd
L Lochovsky
RF Lowdon
Y Lubling
R Lyne
M MacCoss
SD Mackowiak
M Mangone
S McKay
D Mecenas
G Merrihew
DM Miller III
A Muroyama
SL Ooi
H Pham
T Phippen
EA Preston
N Rajewsky
G Rätsch
H Rosenbaum
K Rutherford
P Ruzanov
M Sarov
R Sasidharan
A Sboner
P Scheid
E Segal
H Shin
C Shou
FJ Slack
C Slightam
R Smith
WC Spencer
EO Stinson
S Taing
T Takasaki
K Voronina
NL Washington
CM Whittle
G Zeller
Z Zha
M Zhong
X Zhou
modENCODE Consortium
J Ahringer
S Strome
KC Gunsalus
G Micklem
XS Liu
SK Kim
S Henikoff
F Piano
L Stein
JD Lieb
FIMO: scanning for occurrences of a given motif
CE Grant
WS Noble
Bioinformatics 27:1017–1018.
https://doi.org/10.1093/bioinformatics/btr064
A multiparameter network reveals extensive divergence between C. elegans bHLH transcription factors
F De Masi
MI Barrasa
MJ Alkema
Comparative analysis of function and interaction of transcription factors in nematodes: extensive conservation of orthology coupled to rapid sequence evolution
W Haerty
C Artieri
N Khezri
RS Singh
BP Gupta
BMC Genomics 9:399.
https://doi.org/10.1186/1471-2164-9-399
DAF-12 regulates a connected network of genes to ensure robust developmental decisions
D Hochbaum
C Stuckenholz
P Labhart
V Alexiadis
R Martin
HJ Knolker
AL Fisher
CCAT: combinatorial code analysis tool for transcriptional regulation
https://doi.org/10.1093/nar/gkt1302
DNA-binding specificities of human transcription factors
A Jolma
T Whitington
J Toivonen
KR Nitta
P Rastas
E Morgunova
M Enge
M Taipale
K Palin
JM Vaquerizas
R Vincentelli
NM Luscombe
P Lemaire
E Ukkonen
T Kivioja
J Taipale
Data, information, knowledge and principle: back to metabolism in KEGG
M Kanehisa
S Goto
Y Sato
M Kawashima
M Furumichi
M Tanabe
Sequence specificity is obtained from the majority of modular C2H2 zinc-finger arrays
KN Lam
H van Bakel
AG Cote
A van der Ven
https://doi.org/10.1093/nar/gkq1303
ChIP-seq guidelines and practices of the ENCODE and modENCODE consortia
SG Landt
GK Marinov
F Pauli
S Batzoglou
BE Bernstein
P Bickel
G DeSalvo
C Epstein
KI Fisher-Aylor
J Gertz
AJ Hartemink
MM Hoffman
VR Iyer
YL Jung
S Karmakar
PV Kharchenko
Q Li
A Milosavljevic
PJ Park
MD Perry
D Raha
TE Reddy
N Shoresh
A Sidow
JA Stamatoyannopoulos
MY Tolstorukov
S Xi
PJ Farnham
BJ Wold
https://doi.org/10.1101/gr.136184.111
Genomic evolution of Hox gene clusters
D Lemons
W McGinnis
Transcriptional regulation and stabilization of left-right neuronal identity in C. elegans
BJ Lesch
SMART 7: recent updates to the protein domain annotation resource
I Letunic
T Doerks
P Bork
C. elegans PAT-9 is a nuclear zinc finger protein critical for the assembly of muscle attachments
Q Liu
TI Jones
RA Bachmann
M Meghpara
L Rogowski
BD Williams
PL Jones
Cell & Bioscience 2:18.
https://doi.org/10.1186/2045-3701-2-18
Whole-genome comparison of Leu3 binding in vitro and in vivo reveals the importance of nucleosome occupancy in target site selection
X Liu
CK Lee
JA Granek
ND Clarke
JASPAR 2014: an extensively expanded and updated open-access database of transcription factor binding profiles
A Mathelier
X Zhao
AW Zhang
F Parcy
R Worsley-Hunt
DJ Arenillas
S Buchman
CY Chen
A Chou
H Ienasescu
J Lim
C Shyr
G Tan
M Zhou
B Lenhard
A Sandelin
WW Wasserman
TRANSFAC and its module TRANSCompel: transcriptional gene regulation in eukaryotes
V Matys
OV Kel-Margoulis
E Fricke
I Liebich
S Land
A Barre-Dirrie
I Reuter
D Chekmenev
M Krull
K Hornischer
N Voss
P Stegmaier
B Lewicki-Potapov
H Saxel
AE Kel
E Wingender
https://doi.org/10.1093/nar/gkj143
The C. elegans intestine
https://doi.org/10.1895/wormbook.1.133.1
Evolution of DNA specificity in a transcription factor family produced a new gene regulatory module
AN McKeown
JT Bridgham
DW Anderson
MN Murphy
EA Ortlund
JW Thornton
Cell 159:58–68.
The comparative genomics of T-box genes
C Minguillon
M Logan
Briefings in Functional Genomics & Proteomics 2:224–233.
https://doi.org/10.1093/bfgp/2.3.224
Design of a combinatorial DNA microarray for protein-DNA interaction studies
J Mintseris
MB Eisen
BMC Bioinformatics 7:429.
Crystallographic structure of the T domain-DNA complex of the Brachyury transcription factor
BG Herrmann
C2H2 zinc finger proteins greatly expand the human regulatory lexicon
HS Najafabadi
FW Schmitges
M Garton
A Yang
M Albu
MT Weirauch
E Radovani
PM Kim
J Greenblatt
BJ Frey
Nature Biotechnology, 10.1038/nbt.3128.
DNA-binding specificity changes in the evolution of forkhead transcription factors
S Nakagawa
SS Gisselbrecht
JM Rogers
DL Hartl
Sex-specific gene regulation. The Doublesex DM motif is a bipartite DNA-binding domain
U Narendra
L Zhu
B Li
J Wilken
MA Weiss
Diverse transcription factor binding features revealed by genome-wide ChIP-seq in C. elegans
E Preston
C Slightham
AA Hyman
Genome Research 21:245–254.
Chromosomal clustering and GATA transcriptional regulation of intestine-expressed genes in C. elegans
Y Liu
YA Kim
PJ Chen
https://doi.org/10.1242/dev.02185
A compendium of RNA-binding motifs for decoding gene regulation
D Ray
H Kazan
KB Cook
S Gueroussov
H Na
M Irimia
LH Matzat
RK Dale
CA Yarosh
SM Kelly
B Nabet
W Li
RS Laishram
HD Lipshitz
AH Corbett
RP Carstens
RA Anderson
KW Lynch
LO Penalva
EP Lei
AG Fraser
BJ Blencowe
The C. elegans Snail homolog CES-1 can activate gene expression in vivo and share targets with bHLH transcription factors
J Hatzold
RB Smit
PA Pope
B Conradt
A compendium of Caenorhabditis elegans regulatory transcription factors: a resource for mapping transcription regulatory networks
J Shingles
Genome Biology 6:R110.
https://doi.org/10.1186/gb-2005-6-13-r110
Enhanced yeast one-hybrid assays for high-throughput gene-centered regulatory network mapping
A Diallo
B Lajoie
A Kent
S Shrestha
S Kadreppa
C Pesyna
J Dekker
CL Myers
Nature Methods 8:1059–1064.
Extensive rewiring and complex evolutionary dynamics in a C. elegans multiparameter transcription factor network
C Pons
A Mori
J Nelson
S Diprima
A Dricot
BR Lajoie
PS Ribeiro
Transcriptional regulation of gene expression in C. elegans
P Okkema
Explosive lineage-specific expansion of the orphan nuclear receptor HNF4 in nematodes
M Robinson-Rechavi
CV Maina
CR Gissendanner
V Laudet
A Sluder
Journal of Molecular Evolution 60:577–586.
A genome-scale resource for in vivo tag-based protein function exploration in C. elegans
K Schanze
A Pozniakovski
K Angermann
S Hasse
M Rupprecht
E Vinis
M Tinney
A Zinke
S Enst
T Teichgraber
K Reis
S Janosch
S Schloissnig
RK Ejsmont
X Xu
Early evolution of the T-box transcription factor family
A Sebé-Pedrós
A Ariza-Cosano
S Leininger
G Torruella
M Adamski
M Adamska
JL Gómez-Skarmeta
I Ruiz-Trillo
Discovery of directional and nondirectional pioneer transcription factors by modeling DNase profile magnitude and shape
RI Sherwood
T Hashimoto
CW O'Donnell
AA Barkal
JP van Hoff
V Karun
T Jaakkola
DK Gifford
Nature Biotechnology 32:171–178.
https://doi.org/10.1038/nbt.2798
Diversification of transcription factor paralogs via noncanonical modularity in C2H2 zinc finger DNA binding
T Siggers
J Reddy
B Barron
Empirically controlled mapping of the Caenorhabditis elegans protein-protein interactome network
N Simonis
JF Rual
AR Carvunis
M Tasan
I Lemmens
T Hirozane-Kishikawa
JM Sahalie
K Venkatesan
F Gebreab
S Cevik
N Klitgord
C Fan
P Braun
N Li
N Ayivi-Guedehoussou
E Dann
N Bertin
D Szeto
MA Yildirim
C Lin
AS de Smet
HL Kao
C Simon
A Smolyar
JS Ahn
M Tewari
S Milstein
H Yu
M Dreze
J Vandenhaute
ME Cusick
J Tavernier
FP Roth
Nature Methods 6:47–54.
Caenorhabditis elegans cisRED: a catalogue of conserved genomic elements
MC Sleumer
M Bilenky
A He
G Robertson
N Thiessen
SJ Jones
https://doi.org/10.1093/nar/gkn1041
Open chromatin defined by DNaseI and FAIRE identifies regulatory elements that shape cell-type identity
L Song
Z Zhang
LL Grasfeder
PG Giresi
BK Lee
NC Sheffield
S Gräf
M Huss
D Keefe
Z Liu
D London
RM McDaniell
Y Shibata
KA Showers
JM Simon
T Vales
T Wang
D Winter
E Birney
GE Crawford
TS Furey
Nuclear receptors: decoding metabolic disease
J Sonoda
L Pei
RM Evans
FEBS Letters 582:2–9.
https://doi.org/10.1016/j.febslet.2007.11.016
A spatial and temporal map of C. elegans gene expression
JD Watson
KL Watkins
RD McWhirter
S Petersen
VT Sreedharan
C Widmer
J Jo
L Petrella
SE Von Stetina
M Katz
S Shaham
Structural basis of TBX5-DNA recognition: the T-box domain in its DNA-bound and -unbound form
CU Stirnimann
D Ptchelkine
C Grimm
DNA binding sites: representation and discovery
GD Stormo
Bioinformatics 16:16–23.
https://doi.org/10.1093/bioinformatics/16.1.16
A gene-coexpression network for global discovery of conserved genetic modules
JM Stuart
D Koller
Function and evolution of C2H2 zinc finger arrays
L Stubbs
D Caetano-Anolles
Sub-Cellular Biochemistry 52:75–94.
The RFX-type transcription factor DAF-19 regulates sensory neuron cilium formation in C. elegans
HT Adler
Molecular Cell 5:411–421.
Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors
K Takahashi
S Yamanaka
Highly expressed loci are vulnerable to misleading ChIP localization of multiple unrelated proteins
L Teytelman
DM Thurtle
J Rine
Diversity and function of orphan nuclear receptors in nematodes
AE Sluder
Critical Reviews in Eukaryotic Gene Expression 12:65–88.
https://doi.org/10.1615/CritRevEukaryotGeneExpr.v12.i1.40
Evaluation of methods for modeling transcription factor sequence specificity
A Cote
R Norel
M Annala
Y Zhao
TR Riley
J Saez-Rodriguez
T Cokelaer
DREAM5 Consortium
HJ Bussemaker
G Stolovitzky
A catalogue of eukaryotic transcription factor types, their evolutionary origin, and species distribution
Determination and inference of eukaryotic transcription factor sequence specificity
A Montenegro-Montero
P Drewe
SA Lambert
I Mann
K Cook
S Govindarajan
G Shaulsky
FY Bouget
G Ratsch
LF Larrondo
JR Ecker
DNA recognition by Cys2His2 zinc finger proteins
SA Wolfe
L Nekludova
CO Pabo
Annual Review of Biophysics and Biomolecular Structure 29:183–212.
https://doi.org/10.1146/annurev.biophys.29.1.183
Conserved motifs and prediction of regulatory modules in Caenorhabditis elegans
G Zhao
N Ihuegbu
M Lee
L Schriefer
G3 2:469–481.
https://doi.org/10.1534/g3.111.001081
Identification of muscle-specific regulatory modules in Caenorhabditis elegans
Inferring binding energies from selected binding sites
D Granas
PLOS Computational Biology 5:e1000590.
https://doi.org/10.1371/journal.pcbi.1000590
Quantitative analysis demonstrates most transcription factors require only simple models of specificity
Sexual dimorphism in diverse metazoans is regulated by a novel class of intertwined zinc fingers
NB Phillips
G Chan
SM Stratton
SB Kent
https://doi.org/10.1101/gad.189500
Nir Friedman
Reviewing Editor; The Hebrew University of Jerusalem, Israel
Thank you for sending your work entitled "Mapping and analysis of Caenorhabditis elegans transcription factor sequence specificities" for consideration at eLife. Your article has been favorably evaluated by Naama Barkai (Senior editor) and three reviewers, one of whom is a member of our Board of Reviewing Editors.
The Reviewing editor and the other reviewers discussed their comments before we reached this decision.
The authors describe a large-scale project to systematically characterize the DNA preferences of transcription factors in the C. elegans model organism. They use a well-established in-vitro method (PBMs) combined with validation again previous experimental results (both detailed and high-throughput assays). The authors provide a detailed comprehensive analysis of the data they collected. I commend them on the thoroughness of their investigation.
This manuscript presents a massive resource that I am sure will be useful for many researchers studying transcriptional regulation in C. elegans, and ones studying evolution of transcription factors and regulatory networks.
Several minor comments were raised that require your attention before publication:
In the Abstract, the authors should be more explicit about the number of TF for which a motifs has been determined directly for the first time thanks to this study: 71 old + (129 new-5 duplicate) + 97 predicted.
Figure 1, left panel: The use of a quadratic horizontal scale is non-standard potentially quite confusing since people expect a logarithmic scale but also see the zero. How about using a log scale but set zero to small positive value so that they are still visible?
Figure 1, right panel: These coverage values are quite meaningless, given the very small sample size for most families. We suggest removing this panel altogether.
Figure 2, panels A-C: The labels on the horizontal axis are unreadable. Use larger font.
Figure 4: The relationship between the colored heat map panel on the left of the amino-acid sequences and the black and white panel to the right of it is unclear. Also, why did the authors reverse the row order in the "blowup" panels on top and bottom compared to the full panels? This is unnecessarily confusing for the reader.
In the second paragraph of the Results section, we suggest the authors add "protein modifications (e.g. phosphorylation)" to the list of possible failures. The same could be added to the third paragraph of the Discussion section, and in fact protein modification is often used to control dimerization.
In the last paragraph of the subsection headed "Motif enrichment with Y1H and ChIP-seq data": the sum of the different, mutually exclusive classes is larger than the total.
We have now revised the Abstract to be more explicit about the number of motifs that have been determined directly, and the total number that are either measured or inferred. Because the number of words is restricted to 150, we do not explain the five duplicates—this is a relatively minor point, and it is made clear in the text—,and to reduce confusion, we also state that we can predict "many" rather than "97".
We have revised Figure 1 as the referee recommends. The left panel is now presented on log2 scale.
Figure 1, right panel: These coverage values are quite meaningless, given the very small sample size for most families. I suggest removing this panel altogether.
We have revised Figure 1 as the referee recommends. This panel has been removed.
We have increased the font size to match that of the rest of the sub-panels. This operation required removing some of the labels for the X-axis values, but they are easily interpolated and are explained in the figure legend.
We have updated Figure 4 and its legend to address these issues. The black and white panel represents clusters of motifs, and was intended to illustrate that these clusters do not correspond closely to the sequence identities of the corresponding proteins (which are shown on the left), and the heat maps are intended to illustrate that the 8-mer data is more complex than the motifs can capture. We have revised the Figure 4, the Figure 4 legend, and the main text in an effort to clarify these points (see modifications to the second paragraph of the subsection entitled "Complex relationships between protein sequences and motifs recognized by the NHR family").
To make the figure less complicated, we now highlight groups of related motifs on the dendrogram, using shading. This change is explained in the legend.
The reversal of row order in the blowup panels was unintentional and has now been corrected. We have also added NHR-204 to the bottom panel, which was also omitted in error. We apologize for these embarrassing errors.
We apologize that the text describing Figure 8C was incorrect. Figure 8C is itself correct and the manuscript now contains corrected text to reflect the figure. The passage in question now reads: "Out of the 635,712 possible patterns we tested, both methods call 635,483 insignificant, both call 49 positive, and they disagree on 180 (Figure 8C)."
Kamesh Narasimhan
Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Canada
KN, Acquisition of data, Analysis and interpretation of data, Drafting or revising the article
Samuel A Lambert and Ally WH Yang
Samuel A Lambert
Department of Molecular Genetics, University of Toronto, Toronto, Canada
SAL, Acquisition of data, Analysis and interpretation of data, Drafting or revising the article
Kamesh Narasimhan and Ally WH Yang
Ally WH Yang
AWHY, Acquisition of data
Kamesh Narasimhan and Samuel A Lambert
Jeremy Riddell
Department of Molecular and Cellular Physiology, Systems Biology and Physiology Program, University of Cincinnati, Cincinnati, United States
JR, Analysis and interpretation of data, Drafting or revising the article
Sanie Mnaimneh
SM, Acquisition of data, Drafting or revising the article
Hong Zheng
HZ, Acquisition of data
Mihai Albu
MA, Acquisition of data
Hamed S Najafabadi
HSN, Analysis and interpretation of data
John S Reece-Hoyes
Program in Systems Biology, University of Massachusetts Medical School, Worcester, United States
JSR-H, Drafting or revising the article, Contributed unpublished essential data or reagents
Juan I Fuxman Bass
JIFB, Drafting or revising the article, Contributed unpublished essential data or reagents
Albertha JM Walhout
AJMW, Drafting or revising the article, Contributed unpublished essential data or reagents
Matthew T Weirauch
Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
Divisions of Biomedical Informatics and Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
Department of Pediatrics, University of Cincinnati, Cincinnati, United States
MTW, Acquisition of data, Analysis and interpretation of data, Drafting or revising the article
[email protected]
Timothy R Hughes
Canadian Institutes For Advanced Research, Toronto, Canada
TRH, Conception and design, Analysis and interpretation of data, Drafting or revising the article
[email protected]
Canadian Institutes of Health Research (Operating grant MOP-111007)
Canadian Institutes of Health Research (Operating grant MOP-77721)
Canadian Institutes of Health Research (Banting Fellowship)
Ontario Council on Graduate Studies, Council of Ontario Universities (Ontario Graduate Scholarship)
This work was supported by CIHR Operating grants MOP-111007 and MOP-77721 to TRH SAL is supported by an Ontario Graduate Scholarship. HSN is supported by a CIHR Banting Fellowship. We are grateful to Andy Fraser, Susan Mango, Bob Waterston, Carlos Araya, and Don Moerman for helpful discussions and materials.
Nir Friedman, The Hebrew University of Jerusalem, Israel
Received: February 13, 2015
Accepted: April 22, 2015
Accepted Manuscript published: April 23, 2015 (version 1)
Version of Record published: May 18, 2015 (version 2)
© 2015, Narasimhan et al.
Article citation count generated by polling the highest count across the following sources: Crossref, Scopus, PubMed Central.
binding specificities
protein-binding microarray
nuclear hormone receptor
Kinesin-4 KIF21B limits microtubule growth to allow rapid centrosome polarization in T cells
Peter Jan Hooikaas et al.
When a T cell and an antigen-presenting cell form an immunological synapse, rapid dynein-driven translocation of the centrosome toward the contact site leads to reorganization of microtubules and associated organelles. Currently, little is known about how the regulation of microtubule dynamics contributes to this process. Here, we show that the knockout of KIF21B, a kinesin-4 linked to autoimmune disorders, causes microtubule overgrowth and perturbs centrosome translocation. KIF21B restricts microtubule length by inducing microtubule pausing typically followed by catastrophe. Catastrophe induction with vinblastine prevented microtubule overgrowth and was sufficient to rescue centrosome polarization in KIF21B-knockout cells. Biophysical simulations showed that a relatively small number of KIF21B molecules can restrict mirotubule length and promote an imbalance of dynein-mediated pulling forces that allows the centrosome to translocate past the nucleus. We conclude that proper control of microtubule length is important for allowing rapid remodeling of the cytoskeleton and efficient T cell polarization.
Biological constraints on GWAS SNPs at suggestive significance thresholds reveal additional BMI loci
Reza K Hammond et al.
To uncover novel significant association signals (p<5×10−8), genome-wide association studies (GWAS) requires increasingly larger sample sizes to overcome statistical correction for multiple testing. As an alternative, we aimed to identify associations among suggestive signals (5 × 10−8≤p<5×10−4) in increasingly powered GWAS efforts using chromatin accessibility and direct contact with gene promoters as biological constraints. We conducted retrospective analyses of three GIANT BMI GWAS efforts using ATAC-seq and promoter-focused Capture C data from human adipocytes and embryonic stem cell (ESC)-derived hypothalamic-like neurons. This approach, with its extremely low false-positive rate, identified 15 loci at p<5×10−5 in the 2010 GWAS, of which 13 achieved genome-wide significance by 2018, including at NAV1, MTIF3, and ADCY3. Eighty percent of constrained 2015 loci achieved genome-wide significance in 2018. We observed similar results in waist-to-hip ratio analyses. In conclusion, biological constraints on sub-significant GWAS signals can reveal potentially true-positive loci for further investigation in existing data sets without increasing sample size.
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Depression is like a rain cloud that follows you wherever you go. Not only does it affect you, but also your family and friends. Luckily, taking antidepressants can effectively attenuate most symptoms of depression. There is just one problem: unpleasant side effects that deter people from treatment, although knowing that the medication can alleviate their depression symptoms. Did you know that in a study conducted back in 2002, it was observed that the frequency of antidepressants induced side effects can be as high as 75%? Genetic factors affect drug metabolism and efficacy, as well as the risk of common antidepressant-induced side effects including sexual dysfunction, weight gain, and risk of suicide.
Genes are the blueprint of life, and differences in our genetic makeup give rise to variations in each individual. We now know that genetic variation can cause a person to more likely experience adverse side effects that comes from antidepressants. Therefore, by determining person's genetic background before prescribing a certain type of antidepressant, it is possible to minimize the risk of related adverse side effects, and ensure effective treatment of depression. This way, a person will more likely continue with their antidepressant medication, leading to better quality of life.
Many studies seek to determine a relationship between genetic variations and antidepressant induced side effects. In a recent study conducted by Dr. McGuffin at the Social, Genetic and Developmental Psychiatry Centre of King's College London, from a group of 811 treatment seeking adults with moderate to severe depression symptoms, Dr. McGuffin and team have identified that variation in the gene HTR2C would make someone taking the antidepressant Escitalopram to more likely experience serotonin-related side effects, including nausea, diarrhea, decreased appetite, insomnia and sexual problems. Serotonin is a neurotransmitter produced in brain that controls important bodily functions such as appetite and sleep. Reduced production of serotonin was linked to depression and drugs that block serotonin reuptake (SSRIs) elevate mood. Too much serotonin in your brain can cause mood disorders such as obsessive-compulsive disorder, anxiety, panic, and even excess anger.
HTR2C is a gene that makes a protein that takes up serotonin into our brain cells, a process that can be blocked by the antidepressant Escitalopram, which is one of SSRIs. A small variation in HTR2C will increase the risk of a person experiencing serotonin-related side effects when taking this antidepressant. It is therefore beneficial for individuals to check for HTR2C variation before they start using Escitalopram to minimize the chance of adverse reactions. It is known that another antidepressant, Nortriptyline, which does not block serotonin uptake, fight the symptoms of depression just as well as in individuals with increased sensitivity to Escitalopram and other SSRIs. In this present study, fewer participants taking Nortriptyline reported serotonin-related related side effects. Nowadays technology allows for a quick genetic test to identify DNA variations in genes like HTR2C. Physicians began to use genetic testing to guide therapy selection. If particular genetic variation in HTR2C is identified it is easy to switch to antidepressants that do not target serotonin uptake thus reduce the chance of adverse side effects. Reducing unwanted side effects from antidepressant medication will allow you to go through with treatment, rescuing you from the depths of depression and improving quality of life for you and those you care the most. If are interested to learn more about genetic testing for antidepressants please read Anna's story.
If you would like to learn more about depression treatment, continue reading this related blog post: "Antidepressants: Understanding and Mitigating the Risks of Side Effects". If you find this post useful and want to read more, please follow us on Twitter or become a fan on Facebook.
Should I pay or should I go? Or what do we really know about mutations and disease liability?
Can ibuprofen and celecoxib help treat my depression?
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Clinical depression in the elderly is common. … But only 10% receive treatment for depression. The likely reason is that the elderly often display symptoms of depression differently. Depression in the elderly is also frequently confused with the effects of multiple illnesses and the medicines used to treat them.
Geriatric depression is a mental and emotional disorder affecting older adults. Feelings of sadness and occasional "blue" moods are normal.
What are the signs of depression in the elderly?
There is evidence that some natural body changes associated with aging may increase a person's risk of experiencing depression. … Regardless of its cause, depression can have alarming physical effects on older people.
What causes depression in elderly?
Physical conditions like stroke, hypertension, atrial fibrillation, diabetes, cancer, dementia, and chronic pain further increase the risk of depression. Additionally, the following risk factors for depression are often seen in the elderly: Loneliness, Isolation, bereavement, other people's dependency for daily living help.
It's important to be aware that medical problems can cause depression in older adults and the elderly, either directly or as a psychological reaction to the illness. Any chronic medical condition, particularly if it is painful, disabling, or life-threatening, can lead to depression or make your depression symptoms worse.
As we age, we experience many losses. Loss is painful—whether it's a loss of independence, mobility, health, your long-time career, or someone you love. Grieving over these losses is normal and healthy, even if the feelings of sadness last for a long time.
Distinguishing between grief and clinical depression isn't always easy, since they share many symptoms. However, there are ways to tell the difference.
Grief is a roller coaster involving a wide variety of emotions and a mix of good and bad days. Even when you'll still have moments of pleasure or happiness.
With depression, on the other hand, the feelings of emptiness and despair are constant.
While there's no set timetable for grieving, if it doesn't let up over time or extinguishes all signs of joy—laughing at a good joke, brightening in response to a hug, appreciating a beautiful sunset—it may be depression.
Symptoms of depression can also occur as a side effect of many commonly prescribed drugs. You're particularly at risk if you're taking multiple medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because, as we age, our bodies become less efficient at metabolizing and processing drugs.
By understanding the causes, signs and symptoms of depression, care and healthcare professionals can ensure their provision fully supports the clients needs.
Prepare2Care can provide courses that give your staff the skills and understanding they need to provide outstanding care.
Contact us to find out how we can support your companies needs.
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USF Health's Anthony Odibo, MD, MSCE, FRCOG, FACOG, has been selected as the new editor in chief of Ultrasound and Obstetrics and Gynecology. In this new role, Dr. Odibo will contribute his expert knowledge as an internationally respected maternal fetal medicine physician and his extensive use of ultrasound in high risk fetal care procedures.
Dr. Odibo directs the Ultrasound and Fetal Therapy Program at USF Health and is a co-principal investigator for a $4-million NIH funded study employing new imaging technologies and test biomarkers in the blood to determine whether abnormalities in the smallest blood vessels of the placenta and negative environmental influences, particularly smoking, cause fetal growth restriction. The ultimate goal of the four-year study is to design a reliable way to predict poor growth of the fetus earlier in pregnancy so that physicians can intervene sooner to help prevent stillbirth, Cesarean delivery, decreased oxygen levels and other adverse outcomes.
At USF Health, Dr. Odibo currently serves as a professor of obstetrics and gynecology in the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology.
Dr. Odibo, who is one of few physicians skilled in twin-to-twin transfusion syndrome in Florida, cares for families coping with the uncertainty of high risk pregnancies at the Women's Center at Tampa General Hospital. After these babies are born, he continues to monitor their progress as they receive specialized care at TGH's Jennifer Leigh Muma Neonatal Intensive Care Unit offering level III neonatal care, the highest level available.
USF Health's Fetal Care Center of Tampa Bay is the leading fetal care center in Florida and the South East region, and remains among the most successful in treating twin-to-twin transfusion syndrome.
He completed his medical school training at the University of Benin, Nigeria, his residency training in Obstetrics and Gynecology in the United Kingdom and at Thomas Jefferson University in Philadelphia, and a Fellowship in Maternal Fetal Medicine at the University of Connecticut's School of Medicine. In addition, he earned additional fellowship training in Clinical Epidemiology, resulting in a master's degree from the University of Pennsylvania.
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Pain management is extremely problematic both physically and socioeconomically. Possibility for pain relief depends on the location and origin of pain. The difference between acute and chronic pain is also one of the important factors. Pain mechanisms are complex and all aspects of peripheral and central nervous system must be considered.
Low-frequency pulsed magnetic therapy affects pain perception in many different ways, both directly and indirectly.
Clinical studies describe for example direct effects of pulsed magnetic therapy on neuron firing, cellular mechanisms of calcium transfer, membrane potential, regeneration of nerve tissue and the levels of endorphin, dopamine and nitric oxide.
The indirect effects of pulsed magnetic therapy on physiological functions of circulation, swelling, muscles, tissue oxygenation, inflammation, healing, prostaglandins, cellular metabolism and cellular energy are also often explored.
However, the principal effect of pulsed magnetic therapy is that it alters neural processing of pain.
Read the results of the following clinical studies that demonstrate how pulsed magnetic therapy helps to relieve pain.
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(-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition
Eri Matsubara, Mio Fukagawa, Tsuyoshi Okamoto, Koichiro Ohnuki, Kuniyoshi Shimizu, Ryuichiro Kondo
Division for Theoretical Natural Science
Sustainable Bioresources Science
(-)-Bornyl acetate is the main volatile constituent in numerous conifer oils and has a camphora-ceous, pine-needle-like odor. It is frequently used as the conifer needle composition in soap, bath products, room sprays, and pharmaceutical products. However, the psychophysiological effects of (-)-bornyl acetate remained unclear. We investigated the effects of breathing air mixed with (-)-bornyl acetate at different doses (low-dose and high-dose conditions) on the individuals during and after VDT (visual display terminal) work using a visual discrimination task. The amounts of (-)-bornyl acetate through our odorant delivery system for 40 min were 279.4 μg in the low-dose and 716.3 μg in the high-dose (-)-ornyl acetate condition. (-)-Bornyl acetate induced changes of autonomic nervous system for relaxation and reduced arousal level after VDT work without any influences of task performance in low-dose condition, but not in high-dose condition.
Task Performance and Analysis
Soaps (detergents)
bornyl acetate
Matsubara, E., Fukagawa, M., Okamoto, T., Ohnuki, K., Shimizu, K., & Kondo, R. (2011). (-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition. Biomedical Research, 32(2), 151-157. https://doi.org/10.2220/biomedres.32.151
(-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition. / Matsubara, Eri; Fukagawa, Mio; Okamoto, Tsuyoshi; Ohnuki, Koichiro; Shimizu, Kuniyoshi; Kondo, Ryuichiro.
In: Biomedical Research, Vol. 32, No. 2, 01.04.2011, p. 151-157.
Matsubara, E, Fukagawa, M, Okamoto, T, Ohnuki, K, Shimizu, K & Kondo, R 2011, '(-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition', Biomedical Research, vol. 32, no. 2, pp. 151-157. https://doi.org/10.2220/biomedres.32.151
Matsubara E, Fukagawa M, Okamoto T, Ohnuki K, Shimizu K, Kondo R. (-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition. Biomedical Research. 2011 Apr 1;32(2):151-157. https://doi.org/10.2220/biomedres.32.151
Matsubara, Eri ; Fukagawa, Mio ; Okamoto, Tsuyoshi ; Ohnuki, Koichiro ; Shimizu, Kuniyoshi ; Kondo, Ryuichiro. / (-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition. In: Biomedical Research. 2011 ; Vol. 32, No. 2. pp. 151-157.
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title = "(-)-Bornyl acetate induces autonomic relaxation and reduces arousal level after visual displayy terminal work without any influences of task performance in low-dose condition",
abstract = "(-)-Bornyl acetate is the main volatile constituent in numerous conifer oils and has a camphora-ceous, pine-needle-like odor. It is frequently used as the conifer needle composition in soap, bath products, room sprays, and pharmaceutical products. However, the psychophysiological effects of (-)-bornyl acetate remained unclear. We investigated the effects of breathing air mixed with (-)-bornyl acetate at different doses (low-dose and high-dose conditions) on the individuals during and after VDT (visual display terminal) work using a visual discrimination task. The amounts of (-)-bornyl acetate through our odorant delivery system for 40 min were 279.4 μg in the low-dose and 716.3 μg in the high-dose (-)-ornyl acetate condition. (-)-Bornyl acetate induced changes of autonomic nervous system for relaxation and reduced arousal level after VDT work without any influences of task performance in low-dose condition, but not in high-dose condition.",
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AU - Matsubara, Eri
AU - Fukagawa, Mio
AU - Okamoto, Tsuyoshi
AU - Ohnuki, Koichiro
AU - Shimizu, Kuniyoshi
AU - Kondo, Ryuichiro
N2 - (-)-Bornyl acetate is the main volatile constituent in numerous conifer oils and has a camphora-ceous, pine-needle-like odor. It is frequently used as the conifer needle composition in soap, bath products, room sprays, and pharmaceutical products. However, the psychophysiological effects of (-)-bornyl acetate remained unclear. We investigated the effects of breathing air mixed with (-)-bornyl acetate at different doses (low-dose and high-dose conditions) on the individuals during and after VDT (visual display terminal) work using a visual discrimination task. The amounts of (-)-bornyl acetate through our odorant delivery system for 40 min were 279.4 μg in the low-dose and 716.3 μg in the high-dose (-)-ornyl acetate condition. (-)-Bornyl acetate induced changes of autonomic nervous system for relaxation and reduced arousal level after VDT work without any influences of task performance in low-dose condition, but not in high-dose condition.
AB - (-)-Bornyl acetate is the main volatile constituent in numerous conifer oils and has a camphora-ceous, pine-needle-like odor. It is frequently used as the conifer needle composition in soap, bath products, room sprays, and pharmaceutical products. However, the psychophysiological effects of (-)-bornyl acetate remained unclear. We investigated the effects of breathing air mixed with (-)-bornyl acetate at different doses (low-dose and high-dose conditions) on the individuals during and after VDT (visual display terminal) work using a visual discrimination task. The amounts of (-)-bornyl acetate through our odorant delivery system for 40 min were 279.4 μg in the low-dose and 716.3 μg in the high-dose (-)-ornyl acetate condition. (-)-Bornyl acetate induced changes of autonomic nervous system for relaxation and reduced arousal level after VDT work without any influences of task performance in low-dose condition, but not in high-dose condition.
JO - Biomedical Research
JF - Biomedical Research
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Sickle Cell Disease – Pathophysiology, Clinical and Diagnostic Implications
Alexandra Dorn-Beineke, Thomas Frietsch
We review the current knowledge of the pathophysiology of sickle cell disease (SCD), the clinical complications and the state of the art in SCD diagnostics. Today, a flexible laboratory concept allows the fast and economic clarification of the patients' sickle cell hemoglobin (HbS) status, e.g. additional compound heterozygosities. In contrast to a well-investigated pathophysiology of the disease, factors influencing the severity of symptoms as well as some laboratory findings in SCD still lack a final explanation. In this review, we focus on red cell lysis resistance as an additional diagnostic tool in SCD. There is a need for further studies regarding lysis resistance in blood samples from patients with HbS.
Family Studies: Their Role in the Evaluation of Genetic Cardiovascular Risk Factors
Marianne Mansour-Chemaly, Nadia Haddy, Gérard Siest, Sophie Visvikis
Early epidemiological studies showed that genetic factors contribute to the risk of cardiovascular disease. Genetic epidemiological studies based upon families can be used to investigate familial trait aggregation, to localize genes implicated in cardiovascular diseases in the human genome, and to establish the role of environmental factors. Family studies can be also used to identify the physiological role of candidate genes for cardiovascular diseases, and to characterize shared environmental risk factors and their impact on the expression of genetic predisposition. The present paper reviews the existing family studies with special emphasis on those which have studied healthy populations in relation to cardiovascular disease such as the Framingham Heart Study, the National Heart, Lung, and Blood Institute Family Heart Study, and the STANISLAS cohort.
Polymorphisms in the Lipopolysaccharide-Binding Protein and Bactericidal/Permeability-Increasing Protein in Patients with Myocardial Infarction
Jaroslav A. Hubacek, Jan Pitha, Zdena Skodová, Vera AdámkovÁ, Ivana Podrapska, Gerd Schmitz, Rudolf Poledne
Gram-negative bacterial infection, namely Chlamydia pneumoniae has been recently discussed as a risk factor for myocardial infarction. The lipopolysaccharide-binding protein (LBP) and the bactericidal/permeability-increasing protein (BPI) play a role in the processes leading to recognition and neutralisation of the Chlamydia pneumoniae and their endotoxins – lipopolysaccharides (LPS). LPS interact with plasma LBP, and LBP-LPS complex activates monocytes/ macrophages, which can influence the atherosclerotic process. BPI is cytotoxic for Gram-negative bacteria and BPI-LPS complexes do not activate monocytes. We have analysed the polymorphisms in the LBP gene (Gly 98 →Cys; Pro 436 →Leu) and BPI gene (Lys 216 →Glu; PstI polymorphism in intron-5; G 545 →C) in 313 patients after myocardial infarction (MI) and in 302 control individuals. Genotype frequencies in the LBP gene and BPI gene did not differ between MI patients and control individuals. Our findings suggest that LBP and BPI polymorphisms do not influence the risk of MI.
Effect of S-(1,2-Dicarboxyethyl) Glutathione and S-(1,2-Dicarboxyethyl) Cysteine on the Stimulus-Induced Superoxide Generation and Tyrosyl Phosphorylation of Proteins in Human Neutrophils
Chunlei Wang, Huangwei Lu, Guang Chen, Koichi Yamashita, Masanobu Manabe, Hiroyuki Kodama
We investigated the effects of S-(1,2-dicarboxyethyl) glutathione (DCEG) and S-(1,2-dicarboxyethyl) cysteine (DCEC) on the stimulus-induced superoxide generation and tyrosyl phosphorylation of proteins in human neutrophils. When the cells were preincubated with DCEG, the superoxide generation induced by N-formyl-methionyl-leucyl-phenylalanine (fMLP) was enhanced in concentration-dependent manner but DCEC showed no effect. The influence of DCEG and DCEC on phorbol 12-myristate 13-acetate-induced superoxide generation showed no effect. On the other hand, the superoxide generation induced by arachidonic acid was markedly suppressed by DCEG and DCEC in concentration-dependent manner. The suppression of DCEG was more effective than that of DCEC. The superoxide generation induced by fMLP in the DCEG-treated cells was suppressed by genistein. DCEG enhanced tyrosyl phosphorylation of 80.0 kDa, 60.0 kDa, and 45.0 kDa proteins in human neutrophils. The tyrosyl phosphorylation of 80.0 kDa, 60.0 kDa, and 45.0 kDa proteins was suppressed by genistein. The enhancement of tyrosyl phosphorylation of these proteins in the DCEG-treated cells was parallel to the enhancement of the fMLP-induced superoxide generation.
Hyperhomocysteinemia Is Related to a Decreased Blood Level of Vitamin B12 in the Second and Third Trimester of Normal Pregnancy
Céline Chéry, Françoise Barbé, Catherine Lequere, Idrissia Abdelmouttaleb, Philippe Gérard, Patricia Barbarino, Jean-Louis Boutroy, Jean-Louis Guéant
Hyperhomocysteinemia has been associated with several pregnancy complications. We have investigated the variation of plasma total homocysteine (tHcys) during the 2 last trimesters of normal pregnancy and related it to blood vitamin B 12 and folate and to the excretion of the degraded intrinsic factor receptor (IFCR) in urine, in a follow-up study of 15 cases. A significant rise in tHcys was observed between the beginning of the second trimester and the third trimester with respective values (median) 6.1, 5.8 and 6.7 μmol/l (p = 0.038). The tHcys/albumin ratio also increased significantly, while no correlation was found between albumin and folate blood concentration. In contrast, a significant decrease in vitamin B 12 was observed (279, 225 and 199 pmol/l, between the 4th and 6th, and the 6th and 9th month, respectively (p = 0.017−0.002)). A significant negative correlation was found between tHcys between the 4th and 9th month of pregnancy and the ratio of vitamin B 12 between the 4th and 9th month of pregnancy (r = 0.55, p = 0.037). The urine excretion of IFCR was increased and was not related to vitamin B 12 and tHcys. In conclusion, we have observed a rise in tHcys between the beginning of the second trimester and the third trimester of pregnancy which was related to the decreased blood level of vitamin B 12 . Subclinical deficiency of vitamin B 12 should be further investigated in pregnant women who remain on inadequate diet.
Frequencies of Q188R and N314D Mutations and IVS5-24G>A Intron Variation in the Galactose-1-Phosphate Uridyl Transferase (GALT) Gene in the Slovenian Population
Jana Lukac-Bajalo, Janja Marc, Barbara Mlinar, Natasa Karas, Ciril Krzisnik, Tadej Battelino
Numerous mutations in the galactose-1-phosphate uridyl transferase ( GALT ) gene have been found to impair GALT activity to different extent, causing galactosemia. This disorder exhibits considerable allelic heterogeneity in different populations and ethnic groups. The Q188R mutation accounts for 60–70% of classical galactosemia alleles in the Caucasian population. Individuals homoallelic for Q188R have a severe phenotype with complete loss of enzyme activity. Another form of GALT deficiency is Duarte galactosemia with N314D mutation associated alleles (Duarte-2). Although heterozygotes for classical galactosemia are asymptomatic at birth and Duarte galactosemia appears to be quite benign, there are some indications that these disorders can increase the risk of developing certain diseases later in life. The aim of our study was to analyze a healthy Slovenian population for the frequencies of Q188R and N314D mutations, and for the Duarte-2 indicative intronic variation IVS5-24G>A. DNA samples from 174 healthy subjects were analyzed for all three mutations by polymerase chain reaction and digestion with restriction enzymes. Allele frequencies for Q188R and N314D mutations and IVS5-24G>A intron variation were found to be 0.29%, 8.0% and 5.7%, respectively. These results correlate well with those reported for most other healthy Caucasian populations.
Umbilical Cord and Maternal Blood Leptin Concentrations in Intrauterine Growth Retardation
Leyla Yildiz, Bahattin Avci, Metin Ingeç
Leptin, the ob gene product, plays an important role in the regulation of body fat mass and weight. In previous studies, it was demonstrated that leptin is detectable in human fetal cord blood as early as at 18 weeks of gestation and that serum leptin concentrations are significantly reduced in small gestational age newborns. In the present study, we investigated whether umbilical and maternal serum leptin concentrations correlate with intrauterine growth retardation (IUGR). In addition, we aimed to determine the relationships between leptin concentration in the maternal and cord blood. We studied 40 newborn infants (21 female and 19 male; gestational age, 38–42 weeks) and their mothers. Of the infants studied, 10 had IUGR. Serum leptin concentrations were measured by radioimmunoassay. All newborns had detectable leptin concentrations. Leptin concentrations were significantly lower in newborns with IUGR and in their mothers (n=10; 3.53±1.42 ng/ml, 6.75±1.47 ng/ml, respectively) than in infants experiencing normal growth and their mothers (n=30; 5.58±2.98 ng/ml, 9.85±6.50 ng/ml, respectively) (p<0.01 for newborns, p<0.05 for mothers). There was no significant correlation between umbilical leptin concentration and maternal leptin concentration (r=0.229; p=0.155) in all study groups but, significantly, a correlation was observed in the group with IUGR (r=0.736; p=0.015). There were no significant correlations between both umbilical and maternal leptin concentrations and parity, delivery type and gestational age. There was a correlation between umbilical leptin concentration and birth weight of newborns (r=0.383; p=0.015) but no correlation with body mass index (BMI) of the newborns (r=0.034; p=0.834). Maternal leptin concentrations correlated with maternal weight and BMI (r=0.606; p=0.000, r=0.535; p=0.000, respectively). There was no correlation between maternal leptin concentrations and birth weight of the newborns (r=0.179; p=0.269) and with BMI of the newborns (r=0.146; p=0.367). There was no gender difference in leptin concentrations in the newborns (n=21; 5.50±3.37 ng/ml, for females; n=19; 4.58±1.98 ng/ml for males) (p=0.296). In summary, we have shown that IUGR is associated with a decreased leptin concentration in newborns and their mothers. The association between umbilical serum leptin and birth weight in this and other studies suggests a pivotal role of fetal leptin in regulating fetal growth and development.
Blood Concentrations of Selenium, Zinc, Iron, Copper and Calcium in Patients with Hepatocellular Carcinoma
Wang Chin-Thin, Chang Wei-Tun, Pan Tzu-Ming, Wang Ren-Tse
We used an atomic absorption spectrophotometric method to determine the concentration of selenium, zinc, iron, copper and calcium in the whole blood of patients with hepatocellular carcinoma. The results demonstrate that these patients have a lower concentration of selenium (0.18±0.02 μg/ml vs. 0.28±0.06 μg/ml) and zinc (11.2±2.75 μg/ml vs. 18.2± 7.33 μg/ml) than healthy controls (p<0.05). On the other hand, the hepatocellular carcinoma patients have higher mean concentrations of iron (651.9±66.2 μg/ml vs. 473.0±88.0 μg/ml; p<0.05), copper (1.43±0.33 μg/ml vs. 0.95±0.19 μg/ml; p<0.05) and calcium (75.0± 13.1 μg/ml vs. 39.9±12.3 μg/ml; p<0.01) than healthy controls. Thus, hepatocellular carcinoma seems to be associated with the changes in the whole blood concentrations of selenium, zinc, iron, copper and calcium.
TaqMan Systems for Genotyping of Disease-Related Polymorphisms Present in the Gene Encoding Apolipoprotein E
Werner Koch, Angela Ehrenhaft, Korinna Griesser, Arne Pfeufer, Jakob Müller, Albert Schömig, Adnan Kastrati
Polymorphisms of the gene encoding apolipoprotein E have been implicated in the pathogenesis of peripheral and coronary artery disease and neurodegenerative disorders such as sporadic and late-onset familial forms of Alzheimer's disease. We have developed TaqMan assay systems for the single nucleotide polymorphisms −219G/T, located in the promoter of the apolipoprotein E gene, 113G/C, present in the transcriptional enhancer element of intron 1, 334T/C, determining Cys or Arg as amino acid residue 112 of mature apolipoprotein E, and 472C/T, determining Arg or Cys as residue 158. The accuracy of genotype determination with the TaqMan systems was demonstrated by analyses with restriction endonucleases. We determined the genotypes of the apolipoprotein E polymorphisms in 2349 study subjects. The genotypes were distributed as: −219GG=27.3%, −219GT=49.1%, and −219TT=23.6% (p=0.435); 113GG=41.3%, 113GC=45.2%, and 113CC=13.5% (p=0.343); 334TT=73.4%, 334TC=24.7%, and 334CC=1.9% (p=0.539); 472CC=86.3%, 472CT=12.8%, and 472TT=0.9% (p=0.004) (Hardy-Weinberg equilibrium estimates are given in parentheses). The allele combinations which define the three major isoforms of apolipoprotein E, namely apoE2, apoE3, and apoE4, had the following allele frequencies: 334T/472T ( ∊2 ; 112Cys/158Cys)=7.3%, 334T/472C ( ∊3 ; 112Cys/158Arg)=78.4%, and 334C/472C ( ∊4 ; 112Arg/158Arg)=14.2%, respectively. ApoE genotypes were distributed as: ∊2∊2 =0.9%, ∊2∊3 =11.2%, ∊2∊4 =1.6%, ∊3∊3 =61.3%, ∊3∊4 =23.1%, and ∊4∊4 =1.9% (p=0.014). The TaqMan assays allow for fast and sensitive genotyping and are especially suitable for studies including large numbers of participants.
Antioxidant Status in Thyroid Dysfunction
Ulrike Resch, Gwen Helsel, Franz Tatzber, Helmut Sinzinger
Our study was designed to test and compare the levels of enzymatic antioxidants (ARS), endogenous peroxides (POX), non-enzymatic antioxidants (Antiox-cap) and anti-oxidized low-density lipoprotein (LDL) antibody titers (oLAb) in hyperthyroid and hypothyroid patients. We measured POX, ARS, Antiox-cap and oLAb in the plasma from 68 patients (34 patients with hyperthyroidism, thyroid-stimulating hormone (TSH) <0.04; and 34 patients with hypothyroidism, TSH >4.0) and 34 healthy euthyroid controls. POX were highest in hyperthyroid patients, but differences between hyperthyroid and hypothyroid patients and controls were not significant. ARS were significantly higher in patients compared to controls. Antiox-cap were significantly lower in patients compared to controls. oLAb were significantly higher in hypothyroid patients compared to controls and hyperthyroid patients. Our study shows that both hyperthyroidism and hypothyroidism are associated with enhanced oxidative stress involving enzymatic and non-enzymatic antioxidants. Higher POX in hyperthyroid patients might reflect the hypermetabolic state of these patients. oLAb, indicating progression of atherosclerosis, were highest in hypothyroid patients.
Diagnostic Efficiency of Cystatin C and Serum Creatinine as Markers of Reduced Glomerular Filtration Rate in the Elderly
Heinrich Burkhardt, Gero Bojarsky, Rainer Gladisch
This is a secondary analysis of data from a cross-sectional study to evaluate the diagnostic efficiency of cystatin C as a marker of the glomerular filtration rate in the elderly. Thirty patients (15 male, 15 female, mean age 75.4±7.1 years) attending a geriatric ward were enrolled. Exclusion criteria were previously diagnosed renal disease, dementia and heart failure (NYHA III or IV). Cystatin C in serum was determined by a particle-enhanced turbidimetric assay. Inulin clearance was assessed using a single-shot method. Also, Cockcroft-Gault formula was calculated. Twelve patients had a reduced glomerular filtration rate (<70 ml/min/1.73m 2 ). The mean values were 88.4 μmol/l (±27.7) for serum creatinine, 1.57 mg/l (±0.34) for cystatin C and 88.7 ml/min/1.73 m 2 (±34.6) for inulin clearance. Maximum efficiency was 0.73 for serum creatinine (cut-off limit 82 μmol/l), 0.67 for cystatin C (cut-off limit 1.63 mg/l) and 0.8 for Cockcroft and Gault estimation (cut-off limit 54 ml/min/1.73 m 2 ). A receiver operating characteristics (ROC) analysis did not show any differences between the various methods. Therefore, cystatin C in serum may not improve the diagnostic efficiency in detecting a reduced glomerular filtration rate in the elderly. Furthermore, normal ranges for serum creatinine in the elderly might need to be adjusted.
Comparing Different Methods for Homocysteine Determination
Bruno Zappacosta, Silvia Persichilli, Donata Scribano, Angelo Minucci, Daniele Lazzaro, Pasquale De Sole, Bruno Giardina
Slightly elevated values of homocysteine are commonly associated with thromboembolic diseases, while high values can be found in patients with congenital metabolic defects or nutritional problems. The clinical use of homocysteine as an independent marker of cardiovascular disease was limited in the past by technical problems with its measurement, the instrumentation (HPLC, radioenzymatic assays, gas chromatography-mass spectrometry, etc. ) and the necessary skills required. Commercially available immunoassays now permit a simpler and more rapid measurement of homocysteine, that is more suitable for routine clinical laboratories; in this paper we analyze the results obtained by using three fully automated methods for homocysteine determination (Abbott IMx immunoassay, Abbott AxSYM immunoassay and Immulite 2000 homocysteine immunoassay) and their correlation with the widely used HPLC method. The results clearly indicate that all three automated immunochemical methods correlate well with the HPLC method (slope 0.97–1.03; intercept 0.95–1.91 with a recovery above 95% for all three methods).
Classification of Renal Proteinuria: A Simple Algorithm
Enrique Bergón, Rosario Granados, Pilar Fernández-Segoviano, Elena Miravalles, Marta Bergón
Total protein, albumin, α 1 -microglobulin, and immunoglobulin G (IgG) were analyzed in 1622 urine samples without Bence-Jones proteinuria or gross hematuria. There was correlation with the histological picture obtained on renal biopsy in 61 patients. We established 24-h reference intervals for α 1 -microglobulin and IgG on 659 urine samples with total protein and albumin excretion rates below 100 mg/24 h and 30 mg/24 h, respectively, and creatinine clearance above 80 ml/min. The central 95% reference interval was found to be between 4 and 17 mg/24 h for α 1 -microglobulin and between 3 and 8.5 mg/24 h for IgG. In 80 urine samples with albumin excretion rate above 30 mg/24 h and α 1 -microglobulin and IgG within their reference intervals, we analyzed the 95% central interval of the distribution of the IgG/albumin ratios, and it was found to be within 0.01 and 0.20 (0.90 confidence interval: 0.17–0.24). Proteinuria was considered to be of the selective glomerular type if the albumin excretion rate was abnormal and the IgG/albumin ratio was under 0.20, even when the IgG excretion was within a pathological range. For the classification of proteinuria as predominantly tubular, we estimated the α 1 -microglobulin/albumin ratio in 173 urine samples with normal excretion rates of albumin and IgG and pathological excretion of α 1 -microglobulin. The discriminating value of 0.91 (0.90 confidence interval: 0.78–1.08) was accepted in order to define proteinuria of a tubular origin in the presence of a pathological albumin excretion rate. The association between albumin and IgG excretion rates and tubular reabsorption of the α 1 -microglobulin normally filtered by the glomerulus was studied in 33 urine samples from patients with no histologically significant tubulo-interstitial or vascular disease and a serum creatinine concentration below 141 μmol/l. The optimal curve-fitting function between albumin plus IgG and α 1 -microglobulin excretion rates was of the quadratic type (r=0.927). Mixed proteinuria was considered when both, albumin and α 1 -microglobulin excretion rates were pathological and could not be included in the previously described groups.
Reference Ranges for Serum Concentrations of Lutropin (LH), Follitropin (FSH), Estradiol (E2), Prolactin, Progesterone, Sex Hormone-Binding Globulin (SHBG), Dehydroepiandrosterone Sulfate (DHEAS), Cortisol and Ferritin in Neonates, Children and Young Adults
Martin W. Elmlinger, Werner Kühnel, Michael B. Ranke
The aim of this study was to establish reference ranges for children (neonates to young adults), for serum lutropin (LH), follitropin (FSH), estradiol (E2), progesterone, prolactin, sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), cortisol and ferritin, using the nonisotopic, automated chemiluminescence immunoassay system, Immulite ® (DPC). Serum samples from 762 children (369 female; age 1 day to 19 years) were examined. Of these, 381 were classified as pubertal. Due to non-normal distribution, the 2.5th, 50th and 97.5th percentiles (central 95% interval) were calculated for each group. Statistical differences between the reference ranges were analyzed with respect to age, sex and the stage of sexual maturation. The median concentrations of E2, prolactin, progesterone, DHEAS, cortisol and ferritin were higher during the first 2 weeks post-partum than thereafter. The largest difference was seen with prolactin, which showed up to 27-fold higher values during this period. In contrast, before the onset of puberty, hardly any sex difference was observed and all analyte concentrations remained relatively constant, apart from SHBG which increased steadily after the neonatal period. The increase of gonadal activity in females with the onset of sexual maturation included an increase in LH and FSH, which was accompanied by a strong increase in E2, progesterone and prolactin. Cortisol increased to a lesser extent during puberty. In males, the increase in the median concentrations of the hormones was smaller, except for DHEAS. The concentration of ferritin was high in the neonatal period but did not change during sexual maturation. Our findings agree with earlier studies. The calculated reference intervals can be used to assess the development of children, particularly for measurements performed by the Immulite and Immulite 2000 chemiluminescence assay systems.
Validation of a Kinetic Model for the Reactions in RIA
María J. Duart Duart, Consuelo Olivas Arroyo, José Luis Moreno Frígols
The goal of this work was to check the validity of a model previously described for the study of kinetics of the processes taking place during the immuno-analytical measurement of insulin. The antibody was immobilized on the suface wall of the reaction tube. Tracer and insulin concentration, temperature, viscosity and ionic strength in the reaction medium were taken as independent variables. Biexponential kinetics depending on the concentration was observed. The results of the viscosity study show a clear negative influence of this parameter on the direct reaction velocity. Ionic strength had a slight effect, which suggests that the observed variation due to the addition of glycerol is not induced by the influence of the dielectric constant of the solution used. The effect of the temperature shows activation parameters similar to water flow-viscosity energy, which suggests a diffusion control for the reaction. The proposed model correctly interprets the influence of the studied variables.
Automated Counting of Cells in Cerebrospinal Fluid Using the CellDyn-4000 Haematology Analyser
Johannes J. M. L. Hoffmann, Willy C. M. Janssen
Counting of cells in cerebrospinal fluid is currently performed manually. Because of the inherent analytical and economical disadvantages, we attempted to introduce a fully automated method. Therefore, we validated the Abbott CellDyn-4000 haematology analyser for counting cells in cerebrospinal fluid. The analyser was used in its standard configuration with the simple precaution of a preceding blank sample. As for leukocyte counting the analyser yielded high precision (CV ~5% above the upper reference limit), good linearity, low limit of detection (2/μl) and excellent correlation (r > 0.99) with the counting chamber method. The differential leukocyte count was equally accurate and precise, even in the low concentration range. Performance of the erythrocyte count was impaired by its high limit of detection (6/nl) and it appeared satisfactory only for detecting blood admixture due to traumatic puncture. The specificity of the analyser is excellent, since it correctly classified non-viable leukocytes and excluded yeast cells from the leukocyte count in a patient with cryptococcal meningitis. We conclude that the CellDyn-4000 is well suited for quickly and reliably counting leukocytes in cerebrospinal fluid. Developing some software modifications might make the analyser useful also for performing erythrocyte counting in cerebrospinal fluid.
Urine Trans,trans-muconic Acid Levels in Residents of a Business Area of Bangkok, Thailand
Jamsai Suwansaksri, Viroj Wiwanitkit, Piyapitch Neramitraram, Phubate Praneesrisawasdi
Hemoglobin Electrophoresis in Thai Non-Anemic Pregnant Subjects, a Need for Additional Screening for Hemoglobin E
Nara Paritpokee, Viroj Wiwanitkit, Jamsai Suwansaksri
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Meetings and Awards
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DOI:10.1258/mi.2010.010001
Ten reasons to be happy about hormone replacement therapy: a guide for patients
@article{Studd2010TenRT,
title={Ten reasons to be happy about hormone replacement therapy: a guide for patients},
author={John W. W. Studd},
journal={Menopause International},
pages={44 - 46}
J. Studd
Menopause International
In spite of the negative press reports following the 2002 Women's Health Initiative (WHI) publication, women can be reassured that in the correct circumstances, hormone replacement therapy (HRT) is beneficial and safe, particularly if treatment is started below the age of 60. Transdermal estradiol is probably safer than oral estrogens as coagulation factors are not induced in the liver and HRT is safer if a minimal duration and dose of progestogen is used. HRT is effective for the treatment of…
studd.co.uk
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MPA: medroxy-progesterone acetate contributes to much poor advice for women.
C. Bethea
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Can depression be a menopause-associated risk?
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Skin academy: hair, skin, hormones and menopause - current status/knowledge on the management of hair disorders in menopausal women.
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There is little evidence to support treatment for hair and skin disorders specifically in post-menopausal women, but the proportion of the female population who are in the post- menopausal age group is rising and the prevalence of these dermatological symptoms is likely to increase.
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The meanings of menopause: identifying the bio-psycho-social predictors of the propensity for treatment at menopause
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Research resource: Aorta- and liver-specific ERα-binding patterns and gene regulation by estrogen.
F. Gordon, C. Vallaster, T. Westerling, L. Iyer, Myles Brown, G. Schnitzler
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Medroxyprogesterone acetate antagonizes estrogen up-regulation of brain mitochondrial function.
R. Irwin, Jia Yao, S. S. Ahmed, R. Hamilton, E. Cadenas, R. Brinton
Findings indicate that the effects of MPA differ significantly from the bioenergetic profile induced by progesterone and that, overall, MPA induced a decline in glycolytic and oxidative phosphorylation protein and activity.
Intervertebral disc ageing and degeneration: The antiapoptotic effect of oestrogen
Sidong Yang, F. Zhang, Jiangtao Ma, W. Ding
Ageing Research Reviews
An overview of the literature regarding the antiapoptotic effect of oestrogen in IVDD is performed, indicating that oestrogens can effectively alleviate IVDD development by inhibiting the apoptosis of IVD cells.
Beta-estradiol attenuates hypoxic pulmonary hypertension by stabilizing the expression of p27kip1 in rats
Dun-quan Xu, Ying Luo, +11 authors Zhi-chao Li
Results suggest that β-E2 can effectively attenuate PVSR and HPH, and the underlying mechanism may partially be through the increased p27kip1 by inhibiting Skp-2 through Akt signal pathway.
The Endocrinology of the Mammalian Ovary
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The roles of hormones and paracrine regulators that regulate, or are produced by, the mammalian ovary are emphasized in this chapter as well as aspects of ovarian aging.
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Study explains how low testosterone raises diabetes risk
Published Friday 29 April 2016 Published Fri 29 Apr 2016
Doctors have long known that men with low testosterone are at greater risk for developing type 2 diabetes. For the first time, researchers have identified how testosterone helps men regulate blood sugar by triggering key signaling mechanisms in islets, clusters of cells within the pancreas that produce insulin. The findings, co-authored by Tulane University researchers, are published in the journal Cell Metabolism.
The study could help identify new treatments for type 2 diabetes in the large number of men with low testosterone due to age or prostate cancer therapies.
"We have found the cause -- and a potential treatment pathway -- for type 2 diabetes in testosterone-deficient men," says senior author Dr. Franck Mauvais-Jarvis, Price-Goldsmith professor in the Department of Medicine at Tulane University School of Medicine. "Our study shows that testosterone is an anti-diabetic hormone in men. If we can modulate its action without side effects, it is a therapeutic avenue for type 2 diabetes."
Researchers used specially bred male mice with pancreatic beta cells lacking the receptor to testosterone (the androgen receptor). They fed them a Western diet rich in fats and sugar and tested their response to glucose. The mice without androgen receptors all developed lower insulin secretion, leading to glucose intolerance compared with normal mice in the control group.
To better understand how testosterone interacted with insulin production within the pancreas, researchers administered testosterone and glucose directly to human islet cells treated with an androgen receptor inhibitor and islets cells harvested from mice without androgen receptors. In both cases the islet cells showed decreased insulin production compared to islet cells whose receptor to testosterone was not inhibited or missing.
Further experiments in cultured mouse and human islet cells showed the insulin-producing effect of testosterone could be abolished by inhibiting glucagon-like peptide-1 (GLP-1), a hormone the body produces after a meal. The study suggests that testosterone amplifies the islet impact of the hormone, which is currently used as a diabetes treatment.
Extranuclear Actions of the Androgen Receptor Enhance Glucose-Stimulated Insulin Secretion in the Male. Guadalupe Navarro, Weiwei Xu, David A. Jacobson, Barton Wicksteed, Camille Allard, Guanyi Zhang, Karel De Gendt, Sung Hoon Kim, Hongju Wu, Haitao Zhang, Guido Verhoeven, John A. Katzenellenbogen, Franck Mauvais-Jarvis. Cell Metabolism. DOI:10.1016/j.cmet.2016.03.015. Published online April 28, 2016.
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Source: Tulane University
Additional source: EurekAlert!, the online, global news service operated by AAAS, the science society
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Tulane University. "Study explains how low testosterone raises diabetes risk." Medical News Today. MediLexicon, Intl., 29 Apr. 2016. Web.
Tulane University. (2016, April 29). "Study explains how low testosterone raises diabetes risk." Medical News Today. Retrieved from
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Hello, I am Herry Braun from Leeds, UK and welcome all users at my this introduction posting. I am sales and marketing head at local Leeds cosmetic clinic Call Lane Aesthetics which provides quality anti-aging Botox Leeds treatment.
Hello, I m from United kingdom.Very much interested in health related topics. Professionally I m caregiver of elders.
Hello, I am Dexa Lama from Kathmandu, Nepal. Glad to join this forum.
Hi Dexa Lama. Welcome here.
Hello mate, Glad to see you here.
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I have 21-month daughter who is diagnosed to have autoimmune encephalitis. This diagnosis is probably invalid, but it was made by well known in Poland neurologist. First MRI was done in november, second one yesterday. No changes in comparison to first MRI. Myelin still at 6 month old level (no progress). My daughter doesn't progress and she has had huge hipertonia for more than 9 months. In Poland my daughter got (till now 3 times) steroids (solumedrol) and immune globulines (Ig Vena), but as I said, no progress. She doesn't sit, she doesn't crawl, she doesn't speak, she has hipertonia/spasticity in limbs, hipotonia in neck and spine, she doesn't have control in her arms and hands, she can't hold toys or crisps.
My daughter had an examination by blood on 14.03.2016 and all types of autoimmune encephalitis (NMDA, AMPA1, AMPA2, CASPR2, LGI1, GABARB1/B2) are negative.
She started to regress about a year ago. At first she had an average hipertonia, then she starded to loose her capabilities like holding and eating crisps, so we decided to go to neurologist. The doctor acknowledged, that there was something bad going on with our daughter. In hospital we have done EEG and MRI. EEG was fine, but MRI was not. In digest the myelination stopped at the age of 6 months. There are also some calcifications.
We had a lot of blood examinations and CSF analysis too. It didn't exhibit anything besides high level of neopterin (134,7). They performed neural autoantibody testing. They didn't exhibit anything.
My daughter doesn't have epileptic seizures. For now. Thank God.
Physicians also want to take my daughter's blood for DNA tests. They started to doubt if she really has autoimmune encephalitis. Or they suspect that there is something more than autoimmune encephalitis, some genetic disease. Yesterday I asked a physician why they did NMDA and other antibodies tests by serum, not by CSF and she said that this is better way. Very strange. BTW, keep in mind that all these tests (by serum) were negative. My daughter Liliana was diagnosed autoimmune encephalitis by neurotransmitter (neopterin with a value of 134,7), ANA, ANCA, MRI (myelination process stopped at the age of 6 months) and clinical picture. So is the diagnosis certain? I'm not sure. Now we are back in starting point, like in november, but Liliana is 9 months older.
What would it take to diagnose her? We need complex diagnosis, because definitely Liliana has some kind of neurological/genetic (with neurological symptoms) disease. Do you know approximate costs of that complex diagnosis? More less.
I can translate medical summary/examinations results and post it here if someone is interested.
Help, please. We don't know where to search for help.
One more thing, should we think about transplanting stem cells for myelination purposes? How much does it costs? Where should we search for it?
@lesiu I'm so sorry to hear of your daughter's health issues. I'm sure this must be very frustrating and difficult to not be able to get any answers or a treatment plan. While I have no experience with this type of problem, I am hopeful that someone on Mayo Connect will be able to respond to your query. Best wishes to you and your daughter. I hope that you get the answers that you need.
Recognition for now: pyramidal-extrapyramidal system, myelination delay and abnormal immune reaction. Chronic seborrhea. Child still under diagnosis.
Sorry for bad translation. I did what I could.
@lesiu You are doing wonderful explaining your problem, which is certainly very complex. Please keep in touch with Mayo Connect, I am hopeful that someone in our community will be able to give you some guidance for your child's problem.
Mayo Clinic Connect is an online community where you can share your experiences and find support from other parents. If you would like to seek a professional second opinion about your daughter, please contact the Mayo Clinic international patients department here: http://www.mayoclinic.org/departments-centers/international/appointments They can help answer your questions about diagnosis, encephilitis, stem cell transplantation for myelination, costs and options available at Mayo Clinic.
In the meantime, I would like to introduce you to other parents here on Connect. Please meet @lparr00 and @a44901324 who each have children with Encephilitis (https://connect.mayoclinic.org/discussion/rasmussens-encephilitis/). Also, please meet @fernandavidigal and @jennsprung who know what is like to have a child with a rare genetic diagnosis, and understand the journey you are on.
Lesiu, your English is impeccable. We look forward to getting to know more about you and Liliana, and providing support where we can.
Thank you ladies. My sister, who is a translator comes back from holidays on Sunday, so after Sunday I will post some more information (history from the start) about my daughter's disease.
@colleenyoung, I suspect my daughter Liliana doesn't have autoimmune encephalitis, it was probably an invalid diagnosis and we have treated her for something she doesn't have for 5 months.
Now we are searching for help outside Poland – in Germany, Netherlands, United States. A week ago, when I was looking for autoimmune encephalitis experts I found Barcelona group with Doctor Dalmau. It was a good lead, but for different disease. Now we are beginning from the start. I will appreciate any help.
Lesiu, a translated version your daughter's medical history and diagnosis will be particularly helpful for when you contact Mayo Clinic for a professional opinion http://www.mayoclinic.org/departments-centers/international/appointments It must be so grueling to search for a diagnosis, and finding few answers.
I will definitely contact Mayo Clinic for a professional opinion. I can even fly to US if this helps. I know that clinical picture is also very important so not everything can be done remotely.
I know its MAYO Connect, but maybe you know other places in US, where I could search for help? Or maybe Mayo is the best place to search for help? I know so little about medical care in US.
While Connect is operated by Mayo Clinic, recommendations to other care institutions is permitted. It is important that you find the best specialist for your daughter. I would like to hear from @lparr00 @a44901324 @fernandavidigal and @jennsprung with respect to finding a specialist team and care center.
Mayo Clinic is a fantastic place to start!
The most difficult part is of course all of the waiting you have to do when you are trying to find a diagnosis during the early years. I think this is because there is no true "timetable" of development. We know the average time that certain milestones are supposed to occur. But this is never written in stone- a child that hasn't hit a specific milestone (like standing) by a certain point will most likely have difficulty reaching their next milestone (like walking) within the average age range. Many children have uneven developmental profiles- language skills may be quite advanced, but fine and gross motor skills may be behind. This adds to your frustration most certainly because you want to know the reason WHY, and also makes diagnosis take a little longer. But this time is important! You need a proper diagnosis. You don't want somebody to jump to conclusions.
Finding the right clinician is definitely important. I look for someone that works well with my child. I look for someone that is open minded and easy to talk to. I don't want to be rushed out of the office before I have had a chance to tell the whole story. I also need someone that has the patience to explain their findings and tell me the next steps. I also want to know that I can go back to them if needed over the course of my child's life. In our journey we have had a mix of clinicians. Some have been fabulous and some have been less so. I like the ones that take the time to answer my questions, or if they can't, direct me to someone who can.
My son has hypomyelonation in certain areas of the brain. It is believed to be part of his genetic anomaly, although he is pretty rare. No one else has the exact same genetic blip so we don't know for sure. For him, the comparative MRI's done about 2 years apart showed no change. This is a potentially upsetting result for many but we embraced it. We may not have "fixed" it but he continues to grow and develop and that makes it less frightening. It may also mean that the pattern of hypomyelonation that he has is not a bad one.
I wish you much luck on your journey. Should you ever need to chat don't hesitate to contact me. Mama's need all the support they can get!
I hope these are of help to you and your family in some measure.
I have very bad news. Dutch physicians suspect Aicardi Goutieres syndrome. We have to do genetic WES tests to confirm or deny. It will take 3 months.
Does anybody know if somewhere there they try to treat this cruel disease?
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modern pathology
Morphologic Features of Melanocytes, Pigmented Keratinocytes, and Melanophages by In Vivo Confocal Scanning Laser Microscopy
In vivo multimodal optical imaging of dermoscopic equivocal melanocytic skin lesions
V. Elagin, E. Gubarkova, … E. Zagaynova
Automatic segmentation of skin cells in multiphoton data using multi-stage merging
Philipp Prinke, Jens Haueisen, … Łukasz Piątek
Discrimination of normal and cancerous human skin tissues based on laser-induced spectral shift fluorescence microscopy
A. Niazi, P. Parvin, … A. Moafi
First-in-human clinical study of novel technique to diagnose malignant melanoma via thermal conductivity measurements
Takahiro Okabe, Taku Fujimura, … Shigenao Maruyama
Labeling and tracking of immune cells in ex vivo human skin
Feline E. Dijkgraaf, Mireille Toebes, … Ton N. Schumacher
In vivo non-invasive staining-free visualization of dermal mast cells in healthy, allergy and mastocytosis humans using two-photon fluorescence lifetime imaging
Marius Kröger, Jörg Scheffel, … Maxim E. Darvin
Assessing the progression of systemic sclerosis by monitoring the tissue optic axis using PS-OCT
David C. Adams, Margit V. Szabari, … Melissa J. Suter
Quantifying F-actin patches in single melanoma cells using total-internal reflection fluorescence microscopy
Elham Sheykhi, Behnaz Shojaedin-Givi, … Sharareh Tavaddod
Deep Visual Proteomics defines single-cell identity and heterogeneity
Andreas Mund, Fabian Coscia, … Matthias Mann
Klaus J. Busam M.D.1,
Carlos Charles M.D.2,
Grace Lee M.D.1 &
Allan C Halpern M.D.2
Modern Pathology volume 14, pages 862–868 (2001)Cite this article
Confocal scanning laser microscopy (CSLM) represents a novel imaging technique for in vivo microscopic analysis of skin lesions at a level of resolution that allows morphologic analysis of microanatomic structures. We investigated the feasibility of recognizing the cellular constituents of pigmented skin lesions, such as pigmented keratinocytes, melanocytes, and melanophages, by CSLM. Fifteen pigmented lesions (five pigmented seborrheic keratoses, and 10 compound melanocytic nevi) from 15 patients were studied, as well as normal skin. After the clinical lesions were imaged by CSLM, they were biopsied or excised for examination by conventional histology for comparison of the morphologic features. In images obtained by CSLM, pigmented keratinocytes were seen as polygonal cohesive cells with variably bright granular cytoplasm. Melanocytes appeared as bright round, oval, fusiform, or dendritic cells. The architectural growth pattern of melanocytes could be analyzed. Melanocytes were identified by their nested growth pattern as aggregates of bright round to oval structures at the dermoepidermal junction or in the superficial dermis. Melanocytes were also recognizable as single cells along the dermoepidermal junction, usually separated from each other by a variable number of keratinocytes. Melanophages appeared as large bright plump cells with ill-defined cytoplasmic borders, usually located around or near vessels of the superficial dermis. Our results demonstrate that the cellular constituents of pigmented lesions can be recognized by CSLM. This technique sets a new paradigm for noninvasive quasihistologic examination of pigmented lesions in vivo and merits further evaluation for diagnostic use.
One of the most challenging problems in clinical dermatology is the early detection of malignant melanoma. All noninvasive melanomas and the majority of thin invasive melanomas are cured by complete excision. Delayed recognition of melanoma needs to be avoided because it puts the patient at risk for death from disease once the tumor has progressed to competence for metastasis. Early detection of melanoma currently relies on the critical macroscopic visual analysis of a new or changing pigmented lesion and subsequent biopsy or excision for diagnosis and treatment.
The clinical diagnostic accuracy of physicians, however, is less than perfect (1). The search for new methods that may aid in the early detection of melanomas has led to the development of novel imaging modalities, such as computer-assisted image analysis (2), dermoscopy (3), and confocal scanning laser microscopy (CSLM; 4, 5). Of these techniques, CSLM offers the highest level of resolution approaching histologic detail. It is currently being explored for the diagnosis of a variety of skin lesions (6, 7, 8, 9, 10, 11, 12, 13), including melanoma (14).
Because assessment of a lesion by CSLM relies on the visualization of microanatomic structures, interpretation of images obtained by CSLM represents in principle a histopathologic evaluation. However, little is known about this novel technique, according to the pathology literature. Although CSLM has been pioneered by dermatologists, it is important for pathologists to get involved in the evaluation of this technique and to share their experience in its use. The more lesions are examined in parallel by CSLM and conventional histology, the better we can judge the potential and limitations of this promising new technique.
As a first step to exploring the potential use of CSLM in the analysis of pigmented lesions, we sought to determine whether the cellular constituents of pigmented lesions, in other words, melanocytes, pigmented keratinocytes, and melanophages, can be recognized by CSLM. In this study, we describe the morphologic features of pigmented cells by CSLM in comparison with conventional histology.
Fifteen patients were recruited from the pigmented lesion clinic at Memorial Sloan-Kettering Cancer Center. They gave informed consent for examination of their lesions by CSLM.
Confocal Scanning Laser Microscopy
Confocal imaging was performed with a commercially available, near-infrared, reflectance confocal laser scanning microscope (Vivascope 1000, Lucid, Inc., Henrietta, NY). The instrument uses a diode laser at 830 nm with a power of <35mW at tissue level. A 30 × water-immersion objective lens of numerical aperture 0.9 was used with either water (refractive index, 1.33) or gel (refractive index, 1.3335) as an immersion medium. It images with a spatial resolution of 0.5 to 1.0 μm in the lateral dimension and 4 to 5 μm in the axial dimension. An automated stepper was used to obtain a grid of 16 contiguous horizontal images in <20 seconds to construct a montage image with an effective in vivo field of view of 1.6 × 2.0 mm. All images obtained by CSLM in this study correspond to sections in the horizontal plane.
Punch biopsies or excisions were fixed in formalin and embedded in paraffin. After routine processing, slides were stained with hematoxylin and eosin. In selected cases of clinically homogeneously appearing large lesions, a portion of the lesion was punched out and sectioned en face, in other words, in the horizontal plane, whereas the remainder of the excision was conventionally sectioned in serial vertical planes.
After histologic examination, the lesions of the 15 patients were classified as follows: five pigmented seborrheic keratoses and 10 compound melanocytic nevi. Eight nevi were atypical nevi (nevi with architectural disorder and atypia, "dysplastic" nevi). Two nevi were congenital compound nevi.
Keratinocytes and Melanophages in Normal Skin and Pigmented Seborrheic Keratoses
In normal skin, keratinocytes of the basilar and spinous cell layer appeared as polygonal cells (Fig. 1). Their size ranged from 10 to 20 μm in greatest dimension. They formed a cohesive honeycomb pattern on cross-sections. The intercellular junctions appeared as bright lines. The nuclei corresponded to dark oval or round structures. The cytoplasm showed variable amounts of bright granular material. The brightest signals within the entire epidermis were usually obtained at the level of the granular cell layer.
Normal skin. Keratinocytes form a honeycomb pattern of cohesive polygonal cells. Intercellular junctions appear bright. Dark spaces (arrows) indicate peaks of dermal papillae.
Hyperpigmented basal layer keratinocytes were also brighter than the cells of the spinous cell layer. Pigmented keratinocytes at the dermoepidermal junction of a seborrheic keratosis are illustrated in an optical section by CSLM (horizontal plane) in Figure 2A. Cohesive polygonal cells with variably bright cytoplasm formed rings around papillae. The bright granular material in the cytoplasm of basilar keratinocytes was often eccentrically located at the site, oriented away from the papillae and toward the spinous cell layer. Some dermal papillae contained dark round or canalicular structures corresponding to capillaries. The corresponding conventional histology of a section in the vertical plane is illustrated in Figure 2B. Focally, clusters of melanophages were present in the papillary dermis, as illustrated in Figure 2C (confocal image; horizontal plane) and Figure 2D (conventional image; horizontal plane). In the confocal image, melanophages appeared as plump, bright cells with ill-defined cytoplasmic borders.
Keratinocytes and melanophages in a pigmented seborrheic keratosis. A, optical section obtained by confocal scanning laser microscopy (CSLM; horizontal plane); bright polygonal cells form rings around dermal papillae. Dark canalicular structures are seen in papillae, corresponding to blood vessels. B, hematoxylin and eosin (H&E)–stained section (shown in conventional vertical plane) of the lesion. C, dermal papillae with melanophages (arrow) as seen in optical section by CSLM (in horizontal plane). D, focally, clusters of melanophages are present in dermal papillae (H&E-stained section in horizontal plane).
Five of the 15 examined pigmented lesions of this series were histologically diagnosed as pigmented seborrheic keratosis. In these three cases, confocal microscopy suggested the diagnosis of a probable pigmented keratosis by revealing a hyperplastic epidermis with many bright keratinocytes and no associated melanocytic proliferation.
Melanocytes and Melanocytic Nevi
Melanocytes were usually round or oval, but fusiform and dendritic shapes were also recognized (Fig. 3). Although the size and shape of their cytoplasm could be assessed, nuclear detail could not be evaluated at the level of magnification used in this study. As illustrated for a nevus in Figure 4, a nested growth pattern of melanocytes could be recognized by CSLM in the superficial dermis. The more melanin pigment the cells contained, the brighter they appeared under CSLM. Distinct cellular outlines were usually not seen within nests. Typically, the bright signals of individual cells fused and formed a spherical structure of variable size and shape with no further cellular detail. However, by reducing laser power and by using zooming options, vague cellular outlines could occasionally be detected by CSLM even within nests.
Morphology of individual melanocytes in optical sections obtained by confocal scanning laser microscopy.
Compound melanocytic nevus. A, hematoxylin and eosin–stained section shown in horizontal plane at the level of the dermoepidermal junction and superficial dermis. B, optical section by confocal scanning laser microscopy (horizontal plane) corresponding to the conventional histology section shown in A.
For the distinction of junctional from dermal nests, examination of multiple horizontal sections in various vertical planes was necessary. This is best done in video mode or in serial horizontal optical sections at different depths from the skin surface. An example of three sections at different depths is illustrated in Figure 5. At the level of the granular cells layer (Fig. 5A), keratinocytes appeared very bright. The background became increasingly darker with depth towards the dermoepidermal junction (Fig. 5B) and superficial dermis (Fig. 5C). Bright clusters of round or oval structures represented nests of melanocytes.
Optical sections (horizontal planes) of a compound nevus obtained by CSLM at various depths from the surface. A, level of upper spinous and granular cell layer (16 μm from the skin surface). Keratinocytes of the granular cell layer are very bright. B, level of midepidermis and lower epidermis, including dermoepidermal junction (32 μm from the surface). Dark spaces correspond to peaks of dermal papillae. C, level of dermoepidermal junction and superficial dermis (64 μm from the surface).
Of the 10 examined nevi, 8 were dysplastic nevi and 2 were congenital nevi. The eight dysplastic nevi differed from the congenital compound nevi by a more complex epidermal network, a more prominent single-cell growth of melanocytes at the dermoepidermal junction along elongated rete ridges, and a greater variation in the size and shape of nests with fusion of nests.
The morphologic features of pigmented keratinocytes, melanocytes, and melanophages under CSLM are summarized in Table 1.
TABLE 1 Morphologic Features of Pigmented Cells by Confocal Scanning Laser Microscopy
CSLM is a novel imaging technique that allows in vivo examination of the epidermis and superficial dermis at a resolution approaching histologic detail (4, 5). It sets a new paradigm of instant noninvasive quasihistologic examination of skin lesions in vivo (15). Reflectance CSLM operates by detecting single back-scattered photons from the illuminated in-focus plane of interest (16, 17, 18). High-resolution optical sections are achieved by means of a pinhole placed in an optical conjugated plane in front of the detector that rejects photons coming from out-of-focus planes. Contrast in confocal images is provided by refraction index differences of organelles and other microstructures from the background. This means that highly refractile structures appear white on screen, whereas low-refractile structures appear dark gray to black (4, 5, 18). This technique has been used to image keratinocytic and inflammatory skin lesions (6, 7, 8, 9, 10, 11, 12, 13) and is currently also being investigated for the diagnosis of pigmented skin lesions (14).
Melanin pigment has previously been found to provide a natural contrast for confocal scanning (4). Its presence results in a bright white image signal, which illuminates the cytoplasm of melanin-containing cells. However, little is known about the cellular characteristics of individual pigmented cells by CSLM.
As our results illustrate, melanocytes can be recognized under CSLM as bright round to oval or elongated and fusiform structures with or without processes of various lengths. Melanocytes can be seen as solitary units or nests positioned at the dermoepidermal junction. Within nests, distinct cellular outlines are usually not detectable. Pigmented keratinocytes, on the other hand, appear as polygonal bright structures in cohesive aggregates with distinct cellular outlines. Above the basal cell layer, the network of visible cellular outlines of keratinocytes forms a honeycomb pattern. In basilar keratinocytes, the bright signal corresponding to pigmentation is often eccentrically positioned away from the dermal papillae (Fig. 2B). In melanocytes, the signal intensity is usually present throughout the entire cytoplasm in a uniform pattern (Figs. 3, 4 and 5).
Although individual bright structures of the epidermis seen on confocal images can usually be identified as pigmented keratinocytes or melanocytes, it is often necessary to use architectural context in addition to the cellular morphologic features to identify the correct cell type. Without knowledge of architectural context, such as the location of a bright structure at the dermoepidermal junction and its separation from other such structures by darker polygonal cells, it would many times not be possible to correctly distinguish melanocytes lacking detectable dendritic processes from keratinocytes.
Melanophages are best recognized by their solitary distribution around papillary dermal capillaries. Their cell size is usually larger than that of individual melanocytes, and the bright granular cytoplasmic signal, often coarser.
Our results on normal skin are in agreement with those in previous reports (4, 5). When examining the epidermis from its top towards the superficial dermis, the stratum corneum produces the first bright image because of specular reflection caused by refractive index mismatch between the microscope immersion medium (water) and the skin (4, 5). Keratinocytes of the granular cell layer containing keratohyalin granules give a very bright signal in confocal images. Keratinocytes of the spinous and basal cell layer usually provide less contrast: although intercellular connections are well recognizable, the cytoplasm and especially nuclei appear dark. However, as illustrated in our study, pigmented keratinocytes are bright in confocal images depending on the amount of melanin pigment (Fig. 2).
Near-infrared CSLM is currently an investigational tool approved by the Food and Drug Administration for human use. Although we have demonstrated herein that pigmented keratinocytes, melanocytes, and melanophages can be recognized by CSLM, it remains to be seen how sensitive the detection is for various pigmented lesions and to what extent specific diagnoses can be rendered or at least suspected by CSLM. At its current state of technology, CSLM has two major limitations compared with conventional histology. First, its level of resolution is inferior to that of conventional histology. Although cell size and shape can be determined by CSLM, nuclear features, such as chromatin patterns, nuclear contours, and nucleoli, cannot be evaluated. Second, CSLM can assess microanatomic structures only to a depth of approximately 300 μm4. Thus, processes in the reticular dermis cannot be examined.
Nonetheless, CSLM merits evaluation for use as a screening tool for the examination of skin lesions, including pigmented lesions. As we have demonstrated, CSLM allows the recognition and position of melanocytes within the epidermis. Therefore, it may allow immediate recognition of a pigmented lesion as melanocytic in origin. This is of particular interest for the distinction of pigmented keratoses or solar lentigines from melanoma. In the five patients in this study with pigmented seborrheic keratoses, there was clinical concern about the possibility of malignant melanoma. Confocal microscopy failed to detect a melanocytic proliferation and suggested a pigmented keratosis. Because CSLM is currently an investigational tool, a biopsy was needed to confirm the diagnosis by conventional light microscopy. If future studies on a large number of lesions establish good correlation between CSLM and conventional histology in the distinction of a pigmented keratosis from a melanocytic neoplasm, the use of CSLM may eventually be of great benefit. It may spare some patients a biopsy procedure and save time and costs.
The potential diagnostic use of CSLM may not be limited to the basic distinction between a melanocytic and nonmelanocytic lesion. Once melanocytes are recognized, the ability to analyze their growth pattern within the epidermis should in principle allow a preliminary diagnostic evaluation and a judgement on the need for a biopsy diagnosis or excision. As our preliminary experience suggests, dysplastic nevi differ from congenital nevi by the presence of a more irregular melanocytic growth pattern along the dermoepidermal junction. However, it is too early to judge to what extent confocal microscopy may allow a reliable classification of various nevi. A large number of melanocytic nevi need to be evaluated by CSLM to determine the sensitivity and specificity of the diagnoses that can be rendered using this technique. At its current state of technology, we are skeptical that CSLM can provide sufficient information for histologic typing of nevi. Attempts for technical improvements, however, are already underway and will likely result in better image resolution for more specific diagnoses. Nonetheless, even at its current state, a preliminary evaluation of a pigmented lesion in vivo by confocal microscopy may be of great benefit for clinicians. If a pigmented lesion is recognized as melanocytic in origin by identification of an increased number of melanocytes in the epidermis through CSLM, this is already valuable information. If a melanocytic lesion is then judged as atypical in its intraepidermal growth pattern, such as by identification of solitary melanocytes above the basal cell layer by CSLM, the clinician knows that an excision needs to be performed. Another potential application of CSLM in its current technological state is the noninvasive assessment of the perimeter of a clinically poorly definable melanoma. The use of CSLM may spare a patient multiple punch biopsies for mapping margins of a lesion before final surgical excision. We have already successfully used CSLM in this regard with cases of clinically amelanotic melanoma (19).
The main advantage of CSLM is the fact that it permits noninvasive, quasihistologic assessment of the skin at the bedside, albeit at a level of resolution inferior to that of conventional histology. Different lesions can be examined during the same office visit, and the same lesion can be examined at different points in time. Images are available within seconds, and no tissue processing is necessary. Images can be stored electronically and quickly shared for consultation. Because the evaluation of images obtained by CSLM relies on the analysis of microanatomic structures, experience in histopathology is critical for the diagnostic use of this technique.
In this report, we present for the first time in detail the morphologic features of the cellular constituents of pigmented lesions under near-infrared reflectance CSLM. This technique represents an opportunity for pathologists to expand the realm of their expertise to noninvasive image modalities and allows them to examine lesions on patients in vivo. Although at the present time the technique is predominantly used in dermatology, mucosal surfaces are also amenable to examination by CSLM, and this is already being explored. Thus, analysis of images obtained by CSLM should be of interest to all pathologists.
Grin CM, Kopf AW, Welkovich B, Bart RS, Levenstein MJ . Accuracy in the clinical diagnosis of malignant melanoma. Arch Dermatol 1990; 126: 763–766.
Sober AJ, Burstein JM . Computerized digital image analysis: an aid for melanoma diagnosis —preliminary investigations and brief review. J Dermatol 1994; 21: 885–890.
Pehamberger H, Binder M, Steiner A, Wolff K . In vivo epiluminescence microscopy: improvement of early diagnosis of melanoma. J Invest Dermatol 1993; 100: 356–62S.
Rajadhyaksha M, Grossman M, Esterowitz D, Webb RH, Anderson RR . In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. J Invest Dermatol 1995; 104: 946–952.
Rajadhyaksha M, Gonzalez S, Zavislan JM, Anderson RR, Webb RH . In vivo confocal scanning laser microscopy of human skin II: advances in instrumentation and comparison with histology. J Invest Dermatol 1999; 113: 293–303.
Gonzalez S, Gonzalez E, White WM, Rajadhyaksha M, Anderson RR . Allergic contact dermatitis: correlation of in vivo confocal imaging to routine histology. J Am Acad Dermatol 1999; 40: 708–713.
Gonzalez S, Rajadhyaksha M, Gonzalez-Serva A, White WM, Anderson RR . Confocal reflectance imaging of folliculitis in vivo: correlation with routine histology. J Cutan Pathol 1999; 26: 201–205.
Gonzalez S, Rajadhyaksha M, Rubinstein G, Anderson RR . Characterization of psoriasis in vivo by reflectance confocal microscopy. J Med 1999; 30: 337–356.
Hongcharu W, Dwyer P, Gonzalez S, Anderson RR . Confirmation of onychomycosis by in vivo confocal microscopy. J Am Acad Dermatol 2000; 42: 214–216.
Aghassi D, Anderson RR, Gonzalez S . Time-sequence histologic imaging of laser-treated cherry angiomas with in vivo confocal microscopy. J Am Acad Dermatol 2000; 43: 37–41.
Aghassi D, Anderson RR, Gonzalez S . Confocal laser microscopic imaging of actinic keratoses in vivo: a preliminary report. J Am Acad Dermatol 2000; 43: 42–48.
Aghassi D, Gonzalez E, Anderson RR, Rajadhyaksha M, Gonzalez S . Elucidating the pulsed-dye laser treatment of sebaceous hyperplasia in vivo with real-time confocal scanning laser microscopy. J Am Acad Dermatol 2000; 43: 49–53.
Gonzalez S, White WM, Rajadhyaksha M, Anderson RR, Gonzalez E . Confocal imaging of sebaceous gland hyperplasia in vivo to assess mechanism and efficacy of pulsed dye laser treatment. Lasers Surg Med 1999; 25: 8–12.
Langley RGB, Rajadhyaksha M, Dwyer PJ, Anderson RR, Sober AJ . Confocal scanning laser microscopy of pigmented skin lesions. SID conference 1996 [abstract]. J Invest Dermatol 1996; 106: 836.
Pierard GE . In vivo confocal microscopy: a new paradigm in dermatology. Dermatology 1993; 186: 4–5.
Wilson T, editor. Confocal microscopy. San Diego: Academic Press, 1990.
Webb RH . Confocal optical microscopy. Rep Prog Phys 1996; 59: 427–471.
Dunn AK, Smithpeter C, Welch AJ, Richards-Kortum R . Sources of contrast in confocal reflectance imaging. Appl Opt 1996; 35: 3441–3446.
Busam KJ, Hester K, Charles C, Sachs DL, Gonzalez S, Halpern A . Detection of clinically amelanotic malignant melanoma and mapping of its margins by in vivo confocal laser scanning microscopy (CSLM). Arch Dermatol 2001; 137: 923–929.
This work was supported by Lucid, Inc., Henrietta, New York.
The authors thank Dr. J. Zavislan, Lucid, Inc., Henrietta, NY, for technical support. We thank Dr. S. Gonzalez, Wellman Laboratories, Department of Dermatology, Massachusetts General Hospital, for advice. We are grateful to the technical staff of the Department of Pathology for processing and staining the tissue sections.
Department of Pathology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
Klaus J. Busam M.D. & Grace Lee M.D.
Department of Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
Carlos Charles M.D. & Allan C Halpern M.D.
Klaus J. Busam M.D.
Carlos Charles M.D.
Grace Lee M.D.
Allan C Halpern M.D.
Correspondence to Klaus J. Busam M.D..
Busam, K., Charles, C., Lee, G. et al. Morphologic Features of Melanocytes, Pigmented Keratinocytes, and Melanophages by In Vivo Confocal Scanning Laser Microscopy. Mod Pathol 14, 862–868 (2001). https://doi.org/10.1038/modpathol.3880402
Issue Date: 01 September 2001
DOI: https://doi.org/10.1038/modpathol.3880402
Keratinocytes
Melanocytes
Melanophages
Pigmented lesion on the face: which is the chance of being melanoma using reflectance confocal microscopy features?
Fernanda Berti Rocha Mendes
Juliana Casagrande Tavoloni Braga
Gisele Gargantini Rezze
Archives of Dermatological Research (2022)
Reflectance confocal microscopy evaluation of pigmented lesions on tattooed skin
Catherine Reilly
Nadiya Chuchvara
Babar K. Rao
Lasers in Medical Science (2021)
Morphometry and Modeling of Label-Free Human Melanocytes and Melanoma Cells
Sharareh Tavaddod
Behnaz Shojaedin-Givi
Hossein Naderi-Manesh
Cell Biochemistry and Biophysics (2021)
USCAP Vogel Award
United States & Canadian Academy of Pathology Annual Meeting Abstracts
Modern Pathology (Mod Pathol) ISSN 1530-0285 (online) ISSN 0893-3952 (print)
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Surgery is the elimination of the tumor and surrounding tissue during an operation. Operating room employees must put on sterile apparel ( scrubs , a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves and a surgical mask), and so they must scrub fingers and arms with an permitted disinfectant agent before each process.
Before the appearance of anesthesia , surgery was a traumatically painful process and surgeons were encouraged to be as swift as attainable to reduce patient struggling This additionally meant that operations have been largely restricted to amputations and external development removals.
Prior to surgery, the affected person is given a medical examination , receives sure pre-operative checks, and their bodily standing is rated in response to the ASA physical standing classification system If these results are satisfactory, the patient indicators a consent form and is given a surgical clearance.
The journal additionally publishes papers from the meetings of its sponsoring societies: the Society of University Surgeons , the Central Surgical Association , and the American Affiliation of Endocrine Surgeons The journal ranks among the many most cited journals in the subject and is recommended for preliminary buy within the Brandon-Hill research, Selected List of Books and Journals for the Small Medical Library.
Different procedures that do not essentially fall beneath this rubric, such as angioplasty or endoscopy , could also be thought of surgery in the event that they contain "frequent" surgical process or settings, such as use of a sterile setting, anesthesia , antiseptic conditions, typical surgical instruments , and suturing or stapling All types of surgery are thought-about invasive procedures; so-known as "noninvasive surgery" often refers to an excision that doesn't penetrate the structure being excised (e.g. laser ablation of the cornea) or to a radiosurgical procedure (e.g. irradiation of a tumor).
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Antidepressant Reduces Hot Flashes
Hot flashes are among the most bothersome symptoms for women during menopause. A new study reports that an antidepressant drug may reduce the number and severity of hot flashes.
The main treatment for hot flashes has long been menopausal hormone therapy. But the therapy has been shown in some women to raise the risk of heart disease, stroke, blood clots and breast cancer. The U.S. Food and Drug Administration recommends that hormone therapy be used for the shortest time and at the lowest dose that relieves symptoms.
To look at other options, an NIH-funded clinical trial enrolled more than 200 healthy perimenopausal or postmenopausal women. About half were given a daily dose of the antidepressant drug escitalopram. The others received an inactive pill, or placebo.
After 4 weeks, women taking escitalopram had an average of 44% fewer hot flashes. In comparison, women taking the placebo had an average of 26% fewer hot flashes.
Escitalopram treatment led to further reductions in hot flashes after 8 weeks. Women taking the drug also reported that their hot flashes became less severe and bothersome. Most said they were satisfied with the treatment. They reported few negative side effects.
It's not clear exactly how anti–depressants like escitalopram help to relieve hot flashes. Still, the findings suggest that these drugs might be a safe alternative to menopausal hormone therapy.
Mystified by Menopause?
Menopause: Time for a Change
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The Rodolphe Mérieux Laboratory of Bamako (Mali) is recognized by national authorities as a reference laboratory for the diagnosis of Ebola virus disease, Zika virus infection and other diseases.
The Rodolphe Mérieux Laboratory of Bamako is a medical laboratory within the Charles Mérieux Center for Infectious Disease in Mali. Under the direction of Professor Souleymane Diallo Lassana Timbiné, the laboratory provides a quality diagnostics platform for the local medical and scientific community. It is a member of the GABRIEL network.
Mali's Minister of Health and Public Hygiene has recognized the Rodolphe Mérieux Laboratory as a reference laboratory for the diagnosis of Ebola virus disease, Zika virus infection and Lassa fever, as well as the diagnosis of tuberculosis using molecular biology techniques and the monitoring of patients receiving treatment for tuberculosis.
The laboratory routinely performs clinical biology tests in bacteriology (mycobacteria), hematology, serology (toxoplasmosis, HIV), parasitology (malaria), biochemistry, and molecular biology (HIV viral load, diagnosis of tuberculosis).
In response to the 2014 Ebola virus disease epidemic in West Africa, the Rodolphe Mérieux Laboratory expanded its diagnostic capabilities in 2015, with the addition of a mobile laboratory (of the EM-Lab type) so that testing for the Ebola virus and other high-risk pathogens can be carried out in remote settings.
The Rodolphe Mérieux Laboratory has facilities and equipment making it possible to create an applied research unit and to carry out research projects for the GABRIEL network. Research focuses primarily on infectious diseases: tuberculosis, HIV/AIDS, hepatitis B and C, etc.
The laboratory has also participated in a pneumonia study, working with the pediatrics department of the Gabriel Touré Teaching Hospital in Bamako, in addition to evaluating patients' sensitivity to tuberculosis drugs and identifying multidrug-resistant Mycobacterium tuberculosis strains.
The Rodolphe Mérieux Laboratory is divided into five units: immunoserology, hematology, biochemistry, microbiology, and molecular biology. It was designed to meet the specifications of the ISO 14644 standard, parts 1 and 4 ("Cleanrooms and Associated Controlled Environments").
In addition, the Charles Mérieux Center for Infectious Disease is outfitted with several training laboratories and a multimedia library where training classes are held for biologists and laboratory technicians working for medical laboratories. The center also participates in the West African Network of clinical laboratories (RESAOLAB), which includes seven member countries: Benin, Burkina Faso, Guinea, Mali, Niger, Senegal and Togo.
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Our spine is the foundation of our central nervous system. When we feel pain in our neck, shoulder or back, our spine is misaligned (sublaxation) and communication between our brain and body suffers. An adjustment to correct this condition provided by a qualified chiropractor is beneficial to promote overall health and wellness.
By gently correcting your spine these misalignments can reduce or eliminate your neuropathy and allow your body to function. Patients experience relief from both chronic and acute conditions including, genetic disorders, accidents and muscle spasms.
Your first visit consists of a comprehensive consultation, physical exam and x-rays. Dr. Dawn will adjust you during your appointment, and develop a treatment plan for the future.
We hope you will consider the many benefits offered through chiropractic care and call our offices to schedule your first appointment.
Drop us a line or Call us!
The office is closed 12:00 pm to 3:00 pm on Tuesdays, Wednesdays and Fridays.
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Clinical Trial: Immunogenicity and Safety of Fractional Doses of Yellow Fever Vaccines (YEFE)
U.S., Dec. 15 -- ClinicalTrials.gov registry received information related to the study (NCT02991495) titled 'Immunogenicity and Safety of Fractional Doses of Yellow Fever Vaccines (YEFE)' on Dec. 7. Brief Summary: In July 2016, the demand for yellow fever vaccines in response to the large urban outbreaks occurring concurrently and the risk of further spread through the African continent and even to Asia, was larger than the available supply. In this situation, the World Health Organization (WHO) developed recommendations for the use of fractional-dose of yellow fever vaccine as a dose-sparing strategy. These recommendations were based on limited number of clinical trials and additional studies should assess the applicability of the fractional dose to all WHO-prequalified vaccines, the persistence of neutralizing antibodies and the performance of the fractional dose in young children and populations in Africa including those with HIV. This study aims to respond to some of the research questions that would allow broadening the recommendations on the use of fractional doses of yellow fever vaccine in emergency situations. The study will be conducted in Uganda and Kenya and the main objective is to assess the non-inferiority is seroconversion 28 days after vaccination of a fractional dose compared to full dose for each WHO-prequalified manufacturer. As secondary objectives the study will assess seroprotection 10 days and 1 year after vaccination, to assess rapidity and persistence of protective antibody levels; describe the geometric mean titre and the change in neutralizing antibody on Day 28 days after vaccination with fractional and full doses; and assess the occurrence of adverse events and serious adverse events (SAE) during 28 days after administration of fractional and full doses. The study consists of a randomized non-inferiority trial. The study aims to start in April 2017 in the two sites and aims to recruit 960 adults. Results for the main outcome will be reviewed by the study Data and Safety Monitoring Board and one vaccine will be selected for the studies in children and HIV positive adults. Study Start Date: April 2017 Study Type: Interventional Condition: Yellow Fever Intervention: Biological: Stamaril, Sanofi Pasteur Biological: Yellow fever vaccine, Bio-Manguinhos Biological: Yellow fever vaccine, Institut Pasteur Biological: Yellow fever vaccine, Chumakov Institute Recruitment Status: Not yet recruiting Sponsor: Epicentre Information provided by (Responsible Party): Epicentre
Next Article Clinical Trial: A Study to Investigate the Genetic Variation of Dopamine Pathway Associated With the Observed Effects of a New Treatment in Former Studies in Patients With Chronic PainMonday, February 20, 2017
Clinical Trial: Evaluating the Safety and Immunogenicity of pDNA Vaccines Expressing HIV M Group p24^Gag Conserved Elements and/or p55^Gag, Administered With IL-12 pDNA by Intramuscular Electroporation, in Healthy, HIV-Uninfected Adults Wednesday, June 21, 2017
Clinical Trial: Comparative Study of Rohto Dry-Aid(R) and Systane(R) Ultra in Patients With Dry Eye Wednesday, June 21, 2017
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With Meditropin you have a professional formula for the best anti-aging therapy.
The specific amino acids in MediTropin are associated with positive nitrogen balance*, protein metabolism* and the production of metabolic fuel.* MediTropin works best with brief rests or intervals between dosage regimens.
These breaks help to ensure effectiveness and maintain amino acid receptor site efficiency.
dissolved, stir and drink immediately. It is best to take MediTropin at bedtime 1 to 2 hours after last meal.
Take for 5 days and skip 2 days. Repeat cycle.
Other ingredients: natural flavors, destrose, sorbitol, citric acid, masking agent, silica.
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The gastrointestinal tract of commercial poultry is constantly exposed to a wide variety of potentially harmful factors which can have a detrimental impact on flock health and productivity. Poultry production is becoming ever more challenging. The drive to reduce antibiotic usage has intensified. Maintaining gut health will therefore become increasingly important for farmers when it comes to securing a competitive advantage.
Infection can either result in acute, clinical disease or manifest as a more chronic, subclinical problem. In acute disease, typically there is a sudden increase in flock mortality, often without warning, with up to one percent of the flock dying per day. Although most commonly described in relation to broilers, the consequences of NE are just as severe for layers, where sudden death can occur with, or without, a noticeable drop in egg production. Other signs include those common to most intestinal diseases including depression, dehydration, anorexia, diarrhea and ruffled feathers.1 The signs are usually short-lived, as birds tend to die quickly.
C. perfringens occurs naturally in the gastrointestinal tract of chickens and is ubiquitous in the environment, being present in soil, litter, water and feed. Colonization of the gastrointestinal tract is thought to occur as early as the day of hatch.1 In robust, healthy chickens the bacteria can be present in the birds' intestines without causing any harm. So why does the bacteria cause disease in some birds and not others?
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The ITCR Program funds tools that support the analysis of –omics, imaging, and clinical data, as well as network biology and data standards. All of the tools are free for use by academic and non-profit researchers. Access to tools, code repositories and introductory videos is available through the links below.
3D Slicer is the free open source software for medical image visualization and analysis.
A software pipeline for prediction of allele-specific alternative RNA processing events using single RNA-seq data. The current version focuses on prediction of alternative splicing and alternative polyadenylation modulated by genetic variants.
The tool extracts deep phenotypic information from the clinical narrative at the document-, episode-, and patient-level. The final output is FHIR compliant patient-level phenotypic summary which can be consumed by research warehouses or the DeepPhe native visualization tool.
Bioconductor provides tools for the analysis and comprehension of high-throughput genomic data. R/Bioconductor will be enhanced to meet the increasing complexity of multiassay cancer genomics experiments.
The CDSA is a web-based platform to support the sharing, managment and analysis of digital pathology data. The Emory Instance currently hosts over 23,000 images from The Cancer Genome Atlas, and the software is being developed within the ITCR grant to be deployable as a digital pathology platform for other labs and Cancer Institutes.
CRAVAT is an easy to use web-based tool for analysis of cancer variants (missense, nonsense, in-frame indel, frameshift indel, splice site). CRAVAT provides scores and a variety of annotations that assist in identification of important variants. Results are provided in an interactive, highly graphical webpage and include annotated 3D structure visualization. CRAVAT is also available for local or cloud-based installation as a Docker container. Finally, our new Open-Custom Ranked Analysis of VArants Toolkit is a configurable python package with community developed analysis modules.
Curated and processed human/mouse ChIP/DNase-seq datasets in GEO, allowing users to search, browse, download ChIP-seq data signals, peaks, QC, motifs, target genes and similar datasets.
CIViC is an open access, open source, community-driven web resource for Clinical Interpretation of Variants in Cancer. Our goal is to enable precision medicine by providing an educational forum for dissemination of knowledge and active discussion of the clinical significance of cancer genome alterations.
CORE is a statistically supported computational method for finding recurrently targeted regions in massive collections of genomic intervals, such as those arising from DNA copy number analysis of single tumor cells or bulk tumor tissues.
D2Refine is an integrated platform that enables cancer study data/metadata harmonization and quality assurance. The platform is based on the Open Refine and enhanced with a suite of plugins.
DCMTK is an open source DICOM toolkit.
R tool for analysis of DNA methylation and expression datasets. Integrative analysis allows reconstruction of in vivo transcription factor networks altered in cancer along with identification of the underlying gene regulatory sequences.
The backend database to manage segmentation results, computed image features and annotations. FeatureDB drives the database for the QUIP web-platform.
A unified platform for integrative genomic-proteomic-metabolomic data analysis and informatics in cancer research.
GenePattern is a genomic analysis platform that provides access to hundreds of tools for the analysis and visualization of multiple data types. A web-based interface provides easy access to these tools and allows the creation of multi-step analysis pipelines that enable reproducible in silico research. A new GenePattern Notebook environment allows users to combine GenePattern analyses with text, graphics, and code to create complete reproducible research narratives.
Identification of single-nucleotide variants in RNA-seq data. Current version focuses on detection of RNA editing sites without requiring genome sequence data. New version is under development to separately identify RNA editing sites and genetic variants using RNA-seq data alone.
The Integrative Genomics Viewer (IGV) is a high-performance visualization tool for interactive exploration of large, integrated genomic datasets. It supports a wide variety of data types, including array-based and next-generation sequence data, and genomic annotations.
LSTM-CRF uses Natural Language Processing methods for detecting Adverse Drug Events, Drugname, Indication and other medically relevant information from Electronic Health Records. It implements Recurrent Neural Networks using several CRF based inference methods.
A comprehensive software pipeline and set of Galaxy tools/workflows for integrative analysis of genome-wide DNA methylation and hydroxymethylation data. Data types can be either bisulfite sequencing and/or pull-down methods.
Modified UMLS, modified SemRep and SemMedDB-UTH – these are resources (UMLS, SemMedDB-UT) and tools (SemRep) created and maintained by National Library of Medicine that we have modified for personalized cancer therapy and returned to the NLM.
NDEx is an online commons where scientists can upload, share, and publicly distribute biological networks and pathway models. The NDEx Project maintains a web-accessible public server, a documentation website, provides seamless connectivity to Cytoscape as well as programmatic access using a variety of languages including Python and Java. NDEx users can easily create accounts or sign in using their Google credentials thanks to the supported open authentication (OAUTH2) method and mint DOIs for their networks to use in publications or include in other resources for long term access.
Next-Generation (Clustered) Heat Maps are interactive heat maps that enable the user to zoom and pan across the heatmap, alter its color scheme, generate production quality PDFs, and link out from rows, columns, and individual heatmap entries to related statistics, databases and other information.
OmniSearch is a semantic search software based upon the OMIT ontology. While OmniSearch is by its nature extensible, its initial focus is in human cancer research.
OMIT is a domain ontology specifically designed for the miRNA field.
Extensible open-source zero-footprint web image viewer for oncology imaging. "LesionTracker" is a web browser based platform for viewing and measuring lesion metrics for tracking oncology trials.
owl-qa is an OWL-based QA tool for cancer study CDEs. The tool uses the combination of the NCI Thesaurus and additional disjointness axioms to detect potential errors and duplications in the data element definitions. The tool comprises three modules: Data Integration and Services Module; Compositional Expression Transformation Module; and OWL-based Quality Assurance Module.
Web-based software platform to enable analysis and exploration of publicly available cancer proteomic datasets, such as those generated by the CPTAC program.
Curated website cataloguing clinically actionable information for personalized cancer therapy including clinically significant genetic variants and drug-gene association.
PhenStat is a freely available R package that provides a variety of statistical methods for the identification of phenotypic associations from model organisms developed for the International Mouse Phenotyping Consortium (IMPC at www.mousephenotype.org ). The methods have been developed for high throughput phenotyping pipelines implemented across various experimental designs with an emphasis on managing temporal variation and is being adapted for analysis with PDX mouse strains.
QuIP is an integrated software platform designed to support analysis, management, and exploration of whole slide tissue images for cancer research. The QuIP software platform consists of a set of docker containers, which provide analysis execution and data management backend services, and web applications to load and visualize whole slide tissue images (stored in supported file formats) and explore analysis results.
RADIOMICS.io is a open source platform for informatics developments for radiographic phenotyping using automated algorithms, such as engineered features or using deep learning technologies. With this platform, we aim to establish a reference standard for radiomic analyses, provide a tested and maintained resource, and to grow the community of radiomic developers addressing critical needs in cancer research.
A suite of libraries and runtime to support image analysis.
Projects samples into a GoogleMap explorer to allow overlaying omics attributes to spot patterns quickly. A TumorMap version was built for TCGA analysis.
Freely downloadable pathology viewer which supports viewing, annotation and analysis of Whole Slide Images. Functionality will be extended as part of the Pathology Image Informatics Platform.
ShEx is a QA tool based on the Shape Expressions Language that is an emerging W3C standard to validate RDF graphs.
Diffusion magnetic resonance imaging for neurosurgical planning in 3D Slicer open-source software.
TIES is a service based software system for acquiring, deidentifying, and processing clinical text reports using natural language processing, and also for querying, sharing and using this data to foster tissue and image based research, within and between institutions.
LIBRA is a fully-automatic breast density estimation software solution based on a published algorithm that works on either raw (i.e., "FOR PROCESSING") or vendor post-processed (i.e., "FOR PRESENTATION") digital mammography images. LIBRA has been applied to over 30,000 screening exams and is being increasingly utilized in larger studies.
Trinity Cancer Transcriptome Analysis Toolkit (CTAT) including de novo transcriptome assembly with downstream support for expression analysis and focused analyses on cancer transcriptomes, incorporating mutation and fusion transcript discovery, and single cell analysis.
UCSC Xena securely analyzes and visualizes your private functional genomics data set in the context of public and shared genomic/phenotypic data sets such as TCGA, ICGC, TARGET, GTEx, and GA4GH (TOIL).
Web MeV (Multiple-experiment Viewer) is a web/cloud-based tool for genomic data analysis. Web MeV is being built to meet the challenge of exploring large public genomic data set with intuitive graphical interface providing access to state-of-the-art analytical tools.
XNAT is an open source imaging informatics platform designed to support institutional image repositories, image-based clinical trials, and translational imaging research.
C-BIBOP is a cloud based platform for medical imaging algorithm comparisons. C-BIBOP is used to conduct challenges and benchmarks and uses Docker containers to share algorithm.
The Cancer Proteome Atals is a comprehensive bioinformatic resource for assessing, visualzing and analyzing the functional proteomics data of patient tumor and cell line samples.
AMARETTO for multi-omics data fusion and reformulations for pan-etiology and pan-cancer applications.
A collection of extensions for 3D Slicer to enable quantitative analysis of PET imaging data: image normalization, segmentation, and extraction of quantitative indices.
A platform for quantitative evaluation of intratumoral spatial heterogeneity in multiplexed immunofluorescence images, via characterization of the spatial interactions between different cellular phenotypes and non-cellular constituents in the tumor microenvironment. A plugin mechanism enables researches to add and share their own heterogeneity algorithms.
A PET-CT co-segmentation tool for tumor delineation.
TCIA is NCI's repository for publicly shared cancer imaging data. TCIA collections include radiology and pathology images, clinical and clinical trial data, image derived annotations and quantitative features and a growing collection of related 'omics data both from clinical and pre-clinical studies.
The cBioPortal for Cancer Genomics provides visualization, analysis and download of large-scale cancer genomics data sets.
PDX Finder is a freely available resource that is integrating, archiving and disseminating information about Patient Derived Xenograft models and their associated data.
A collection of tools to promote the adoption of quantitative imaging tools and DICOM standard in medical imaging research.
Globus software services provide secure cancer research data transfer, synchronization, and sharing in distributed environments at large scale. These services can be integrated into applications and research data gateways, leveraging Globus identity management, single sign-on, search, and authorization capabilities. Globus Genomics integrates Globus with the Galaxy genomics workflow engine and Amazon Web Services to enable cancer genomics analysis that can elastically scale compute resources with demand.
Local-assembly based somatic variant caller for short read sequencing data. Lancet detects somatic SNVs, indels, and more complex mutations by jointly analyzing reads from tumor and matched normal samples using colored de Bruijn graphs.
JSON-formatted OWL ontology of chemotherapy regimens, their component drugs, and supporting publications, with >170,000 axioms. The ontology is freely available upon request to academic and non-commercial users through the CC-NC-SA 4.0 license.
EMERSE is an intuitive, user-friendly, and powerful search engine for free text documents from electronic health record (EHR) systems. It can be used for a wide variety of tasks including cohort identification, eligibility determination, looking for adverse events, and general data abstraction needs to support clinical and translational research. It has powerful features like the ability to limit searches to user-defined patient lists, and a powerful query expansion/synonym suggestion feature.
OpenCDS is an open-source framework for enabling standards-based clinical decision support (CDS). It supports HL7 standards including FHIR and CDS Hooks. It is being used within the ITCR grant to support personalized risk assessment for early-onset breast and colorectal cancer.
Open source suite of Web services that enables integration of online clinical evidence resources with Electronic Health Record (EHR) systems using the Health Level Seven (HL7) Infobutton Standard. We are extending the OpenInfobutton suite to include automatic summarization of clinical evidence resources for cancer prevention.
InGRiD (Integrative Genomics Robust iDentification of cancer subgroups) is a statistical approach to improve prediction of cancer subgroups and identification of key genes and pathways by integrating information from biological pathway databases.
GAIL (Gene-gene Association Inference based on biomedical Literature) is a web interface and database that allow investigation, visualization, and mining of human gene-gene networks based on the PubMed articles.
CDGnet is a tool for prioritizing targeted therapies based on an individual's tumor profile. Tumor molecular profiling refers to the use of a panel of genes and proteins that are assessed for potential abnormalities, including genetic changes and over/under expression of genes or proteins, in order to decide on targeted treatment plans. CDGnet incorporates information from biological networks relevant to the cancer type and to the specific alterations, FDA-approved targeted cancer therapies and indications, additional gene-drug information, and data on whether given genes are oncogenes.
GSEA is an open source software tool for the analysis of global transcription profiling data, available as a standalone desktop application and as GenePattern modules. The underlying method determines whether a given gene set, corresponding to a biological process, pathway, phenotype or cellular perturbation, is significantly coordinately up- or down-regulated and thus shed light on underlying mechanism. It can be used to compare phenotypes or used on individual samples. The software provides useful visualizations and reports for interpretation of results. The MSigDB is a companion resource of annotated gene sets for use with GSEA.
Monte Carlo simulation of ionizing radiation transport for medical applications with focus on therapy and imaging with x-rays, electrons, protons and all other forms of ionizing radiation.
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Identify pitfalls associated with caring for the trauma patient.
Review the multidisciplinary course of care for the injured patient (2-3 separate case presentations).
Review appropriate treatments utilized when caring for the trauma patient.
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Do You Have Trouble Swallowing Your Medicine?
A physical factor such as a narrowing of your esophagus, possibly caused by cancer of the esophagus or by annular shrinkage of the esophagus.
Neurological or muscular problems such as those associated with muscular dystrophy and Parkinson's.
A fear of choking (without physical cause).
These factors can occur alone or in combination. In addition, certain medications themselves can increase the difficulty you have swallowing, perhaps because of their taste or because the tablets come in too large a size and are difficult to swallow.
You may get discouraged and "forget" to take your medication, which will reduce the effectiveness of the treatment.
Your resistance to the medication may cause nasal regurgitation or tracheal inhalation, which in turn can result in irritation and complications affecting the bronchi and lungs.
Drink a little water to lubricate the walls of your throat.
Tilt your head slightly back and place the tablet at the back of your tongue.
Take a mouthful of water.
Swallow, as you lower your jaw slowly.
The medication is available in another format (liquid, chewable tablet, suppository, or injection) or the medication can be prepared in a form that is easier for you to take.
The medication can be crushed or cut.
There is another medication that is easier to swallow.
If you have difficulty swallowing your medication, speak with your pharmacist, who is always there to help.
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Better treatment for people with inflammatory bowel disease
Chronic intestinal inflammation requires special individualized treatment. Finding the right treatment for each person may soon become easier.
Finding the right treatment for people living with chronic intestinal inflammation, also known as inflammatory bowel disease (IBD), might soon be getting easier. World IBD Day happens on 19 May each year, with the goal to raise awareness about the disease and urge action.
IBD is a fairly common condition. Between 35 000 and 40 000 people in Norway live with the diagnosis. Each year approximately 3500 people are diagnosed.
However, it has been difficult to find the right treatment since the symptoms, the course of the disease and the effect of medication vary so much from person to person.
"The goal of our research is to develop tools that tell us what the course of the disease will look like for each patient, so that they can receive a more targeted treatment," says associate professor Ann Elisabet Østvik at NTNU's Department of Clinical and Molecular Medicine. She is also a chief physician at St. Olav's Hospital in Trondheim.
IBD can last for decades
Chronic intestinal inflammation often affects young people. Typically, patients are young adults and many are already diagnosed in childhood.
"The complaints range from almost imperceptible to a reduced overall condition, abdominal pain, diarrhoea and the need to always be close to a toilet. Since the complaints can last as long as 30 years, IBD can significantly reduce the quality of life for people who are affected," says Østvik.
No single treatment for everyone
Chronic intestinal inflammation refers to two main conditions: ulcerative colitis and Crohn's disease. Ulcerative colitis affects only the colon, with superficial inflammation. Crohn's disease can affect all parts of the gastrointestinal tract, from the mouth to the anus, but occurs most commonly in the transition between the small intestine and the large intestine.
"The treatment for the two forms is more or less the same. But it's difficult to predict how the disease will develop," says Arne Kristian Sandvik, a professor in NTNU's Department of Clinical and Molecular Medicine and a chief physician at St. Olav's hospital.
Often, doctors try the mildest medications first and work up to stronger ones as needed. But what works for some patients does not necessarily work for others.
Today the health service lacks tools that could predict a probable course of the disease for each patient and the best treatment in each case.
"The goal of the IBD research group is for the research results to make it possible to divide patients with IBD into subgroups, where the course of the disease and the treatment outcomes are more similar. This division will hopefully enable us to provide more effective treatment and follow-up for each individual," says Professor Sandvik.
Breaking patients into these different groups, could for example be done according to where in the intestinal system the inflammation is, what kind of inflammation is involved and molecular differences in the inflammatory process. To get a proper overview, patients need to be tracked for a long time.
Interdisciplinary collaboration
The IBD research group in Trondheim was established in 2007 at the initiative of Professor Sandvik.
This year, the research group has been granted the status of a CAG – Clinical Academic Group, which was established collaboratively by the Central Norway Regional Health Authority and NTNU. CAG is a new model in Norway, intended to bring research closer to patients and to secure research results that will benefit patients quickly.
"As the results of the research emerge, we have ongoing projects in progress, and the results flow continually," says Østvik. "As part of the newly created CAG, we're starting a project that involves collecting patient material and following patients over time, for a total of five years. This longitudinal study will be important in developing precision medicine. We generate results along the way in the course of the collection, and this material provides the basis for important research results for several years to come."
The group is highly interdisciplinary and has grown to 12 employees with backgrounds in gastroenterology, nursing, pathology, molecular biology and cell biology. The IBD research group also includes clinicians who conduct daily treatments of a large number of IBD patients at the various partner hospitals.
The research is a collaboration between NTNU's Department of Clinical and Molecular Medicine, St. Olav's Hospital, the hospitals in Levanger and Molde municipalities, and the Department of Mathematical Sciences at NTNU. The Norwegian Patient Association and the National Association for Digestive Diseases (Landsforeningen mot fordøyelsessykdommer) have actively participated in discussions about the projects.
Read Better treatment for people with inflammatory bowel disease by Steinar Brandslet .
Posted on: August 3 2020
Crohns & Colitis
Sugar may trigger inflammatory bowel disease by breaking down gut mucus
Mice fed sugar-heavy diets have worse colitis and more mucous-degrading gut bacteria
Vitamin D modulates intestinal microbiota in inflammatory bowel diseases
The main micronutrient deficiencies observed in patients with IBD are zinc, iron, vitamin B12, and vitamin D, contributing to a critical condition and influencing on well-being.
Potential preventative treatment demonstrated for Crohn's disease
A potential preventive treatment for Crohn's disease, a form of inflammatory bowel disease, has been demonstrated in a mouse model and using immune-reactive T cells from patients with Crohn's disease.
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Recent updates to OECD developmental/reproductive toxicology guidelines and other regulatory guidelines and guidance require the measurement of thyroid hormone levels in the blood of mammalian laboratory species during development. Preliminary analyses indicate that there is a wide variability across laboratories in the methods being used to measure thyroid hormones in young rodents, as well as in the success of obtaining reliable data. Even though publicly available regulatory guidelines and guidance address study design, they allow varied approaches to thyroid hormone measurement in rodents, and an optimal study design or logical approach to thyroid hormone testing in young rodents has not yet been established in a regulatory testing context. Validity, accuracy, sensitivity and reproducibility of the assays are issues of concern. It is not clear to what extent variability in the data can be attributed to methodological issues or to innate biological variability.
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Romantic relationship satisfaction relates to better overall health, and identifying factors that affect relationship satisfaction could lead to better understanding of romantic relationships. This study examined the correlation between benevolent sexism, a subtle form of sexism resembling chivalry and relationship satisfaction; gender, age, ethnicity, religious beliefs, education, and length of time were also considered as moderators. The ambivalent sexism theory, which posits that sexism is ambivalent and ranges from hostile to benevolent sexism was the theoretical framework guiding this study. Previous research indicated benevolent sexism may predict relationship satisfaction. However, there remained an important gap in the literature; the demographic variables above had not been considered as moderators in those analyses. Thus, the purpose of this non-experimental study using data collected from a U.S. sample of adults who had been in romantic relationships for at least 1 year was to determine if such links existed. Correlation and regression analyses revealed that benevolent sexism, measured by the Ambivalent Sexism Inventory did not predict relationship satisfaction, measured by the Relationship Assessment Scale, and none of the demographic variables served as moderators. Results were trending toward significance though, suggesting that benevolent sexism might influence women's relationship satisfaction. Further research using longitudinal, mixed-method studies of dyads is recommended to gain a clearer understanding of this phenomenon. Findings would make important contributions to existing literature and enhance social change by providing professionals and individuals with awareness of how benevolent sexist attitudes may affect relationship satisfaction.
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The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes
J. Craft, T. Mimori, T. L. Olsen, J. A. Hardin
We identified eight patients whose sera contained autoantibodies to the U2 small nuclear ribonucleoprotein (snRNP), an RNA protein particle involved in the splicing of newly transcribed messenger RNA. Each of these patients had an overlap syndrome that included features of either systemic lupus erythematosus (SLE), scleroderma, and/or polymyositis. We then used these sera to characterize the autoantigenic polypeptides of the U1 and U2 snRNP particles. In immunoblots, all sera contained antibodies to the B″ polypeptide of the U2 snRNP. A subset of these sera that more effectively immunoprecipitated the native U2 particle contained an additional antibody system that recognized the A' polypeptide of this snRNP. Antibodies eluted from the B″ protein bound the A polypeptide of the U1 snRNP and vice versa. Moreover, antibodies to the B″ polypeptide were accompanied by antibodies to the 68K and C polypeptides of the U1 snRNP. Finally, the A' and B″ polypeptides remained physically associated after the U2 particle was cleaved with RNase. Thus these sera contain multiple autoantibody systems that, at one level, target two physically associated antigenic polypeptides of the U2 particle and, at another, target two snRNP particles which are associated during the splicing of premessenger RNA. These linked autoantibody sets provide further evidence that intact macromolecular structures are targeted by the immune response in SLE and related diseases.
Journal of Clinical Investigation
https://doi.org/10.1172/JCI113511
Fingerprint Dive into the research topics of 'The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes'. Together they form a unique fingerprint.
U2 Small Nuclear Ribonucleoproteins Medicine & Life Sciences
Small Nuclear Ribonucleoproteins Medicine & Life Sciences
Undifferentiated Connective Tissue Diseases Medicine & Life Sciences
Autoantigens Medicine & Life Sciences
Peptides Medicine & Life Sciences
Autoantibodies Medicine & Life Sciences
Craft, J., Mimori, T., Olsen, T. L., & Hardin, J. A. (1988). The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes. Journal of Clinical Investigation, 81(6), 1716-1724. https://doi.org/10.1172/JCI113511
The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes. / Craft, J.; Mimori, T.; Olsen, T. L.; Hardin, J. A.
In: Journal of Clinical Investigation, Vol. 81, No. 6, 1988, p. 1716-1724.
Craft, J, Mimori, T, Olsen, TL & Hardin, JA 1988, 'The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes', Journal of Clinical Investigation, vol. 81, no. 6, pp. 1716-1724. https://doi.org/10.1172/JCI113511
Craft J, Mimori T, Olsen TL, Hardin JA. The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes. Journal of Clinical Investigation. 1988;81(6):1716-1724. https://doi.org/10.1172/JCI113511
Craft, J. ; Mimori, T. ; Olsen, T. L. ; Hardin, J. A. / The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes. In: Journal of Clinical Investigation. 1988 ; Vol. 81, No. 6. pp. 1716-1724.
@article{23dd131f4bea42528a8f9271320feddd,
title = "The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes",
abstract = "We identified eight patients whose sera contained autoantibodies to the U2 small nuclear ribonucleoprotein (snRNP), an RNA protein particle involved in the splicing of newly transcribed messenger RNA. Each of these patients had an overlap syndrome that included features of either systemic lupus erythematosus (SLE), scleroderma, and/or polymyositis. We then used these sera to characterize the autoantigenic polypeptides of the U1 and U2 snRNP particles. In immunoblots, all sera contained antibodies to the B″ polypeptide of the U2 snRNP. A subset of these sera that more effectively immunoprecipitated the native U2 particle contained an additional antibody system that recognized the A' polypeptide of this snRNP. Antibodies eluted from the B″ protein bound the A polypeptide of the U1 snRNP and vice versa. Moreover, antibodies to the B″ polypeptide were accompanied by antibodies to the 68K and C polypeptides of the U1 snRNP. Finally, the A' and B″ polypeptides remained physically associated after the U2 particle was cleaved with RNase. Thus these sera contain multiple autoantibody systems that, at one level, target two physically associated antigenic polypeptides of the U2 particle and, at another, target two snRNP particles which are associated during the splicing of premessenger RNA. These linked autoantibody sets provide further evidence that intact macromolecular structures are targeted by the immune response in SLE and related diseases.",
author = "J. Craft and T. Mimori and Olsen, {T. L.} and Hardin, {J. A.}",
doi = "10.1172/JCI113511",
journal = "Journal of Clinical Investigation",
publisher = "The American Society for Clinical Investigation",
T1 - The U2 small nuclear ribonucleoprotein particle as an autoantigen. Analysis with sera from patients with overlap syndromes
AU - Craft, J.
AU - Mimori, T.
AU - Olsen, T. L.
AU - Hardin, J. A.
N2 - We identified eight patients whose sera contained autoantibodies to the U2 small nuclear ribonucleoprotein (snRNP), an RNA protein particle involved in the splicing of newly transcribed messenger RNA. Each of these patients had an overlap syndrome that included features of either systemic lupus erythematosus (SLE), scleroderma, and/or polymyositis. We then used these sera to characterize the autoantigenic polypeptides of the U1 and U2 snRNP particles. In immunoblots, all sera contained antibodies to the B″ polypeptide of the U2 snRNP. A subset of these sera that more effectively immunoprecipitated the native U2 particle contained an additional antibody system that recognized the A' polypeptide of this snRNP. Antibodies eluted from the B″ protein bound the A polypeptide of the U1 snRNP and vice versa. Moreover, antibodies to the B″ polypeptide were accompanied by antibodies to the 68K and C polypeptides of the U1 snRNP. Finally, the A' and B″ polypeptides remained physically associated after the U2 particle was cleaved with RNase. Thus these sera contain multiple autoantibody systems that, at one level, target two physically associated antigenic polypeptides of the U2 particle and, at another, target two snRNP particles which are associated during the splicing of premessenger RNA. These linked autoantibody sets provide further evidence that intact macromolecular structures are targeted by the immune response in SLE and related diseases.
AB - We identified eight patients whose sera contained autoantibodies to the U2 small nuclear ribonucleoprotein (snRNP), an RNA protein particle involved in the splicing of newly transcribed messenger RNA. Each of these patients had an overlap syndrome that included features of either systemic lupus erythematosus (SLE), scleroderma, and/or polymyositis. We then used these sera to characterize the autoantigenic polypeptides of the U1 and U2 snRNP particles. In immunoblots, all sera contained antibodies to the B″ polypeptide of the U2 snRNP. A subset of these sera that more effectively immunoprecipitated the native U2 particle contained an additional antibody system that recognized the A' polypeptide of this snRNP. Antibodies eluted from the B″ protein bound the A polypeptide of the U1 snRNP and vice versa. Moreover, antibodies to the B″ polypeptide were accompanied by antibodies to the 68K and C polypeptides of the U1 snRNP. Finally, the A' and B″ polypeptides remained physically associated after the U2 particle was cleaved with RNase. Thus these sera contain multiple autoantibody systems that, at one level, target two physically associated antigenic polypeptides of the U2 particle and, at another, target two snRNP particles which are associated during the splicing of premessenger RNA. These linked autoantibody sets provide further evidence that intact macromolecular structures are targeted by the immune response in SLE and related diseases.
U2 - 10.1172/JCI113511
DO - 10.1172/JCI113511
JO - Journal of Clinical Investigation
JF - Journal of Clinical Investigation
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3D View: Structure | Ligand Interaction
Global Stoichiometry: Hetero 3-mer - ABC
1EGJ
DOMAIN 4 OF THE BETA COMMON CHAIN IN COMPLEX WITH AN ANTIBODY
DOI: 10.2210/pdb1EGJ/pdb
Organism(s): Mus musculus, Homo sapiens
Deposition Author(s): Rossjohn, J., McKinstry, W.J., Woodcock, J.M., McClure, B.J., Hercus, T.R., Parker, M.W., Lopez, A.F., Bagley, C.J.
Structure of the activation domain of the GM-CSF/IL-3/IL-5 receptor common beta-chain bound to an antagonist.
Rossjohn, J., McKinstry, W.J., Woodcock, J.M., McClure, B.J., Hercus, T.R., Parker, M.W., Lopez, A.F., Bagley, C.J.
(2000) Blood 95: 2491-2498
Heterodimeric cytokine receptors generally consist of a major cytokine-binding subunit and a signaling subunit. The latter can transduce signals by more than 1 cytokine, as exemplified by the granulocyte-macrophage colony-stimulating factor (GM-CSF), ...
Heterodimeric cytokine receptors generally consist of a major cytokine-binding subunit and a signaling subunit. The latter can transduce signals by more than 1 cytokine, as exemplified by the granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and IL-6 receptor systems. However, often the signaling subunits in isolation are unable to bind cytokines, a fact that has made it more difficult to obtain structural definition of their ligand-binding sites. This report details the crystal structure of the ligand-binding domain of the GM-CSF/IL-3/IL-5 receptor beta-chain (beta(c)) signaling subunit in complex with the Fab fragment of the antagonistic monoclonal antibody, BION-1. This is the first single antagonist of all 3 known eosinophil-producing cytokines, and it is therefore capable of regulating eosinophil-related diseases such as asthma. The structure reveals a fibronectin type III domain, and the antagonist-binding site involves major contributions from the loop between the B and C strands and overlaps the cytokine-binding site. Furthermore, tyrosine(421) (Tyr(421)), a key residue involved in receptor activation, lies in the neighboring loop between the F and G strands, although it is not immediately adjacent to the cytokine-binding residues in the B-C loop. Interestingly, functional experiments using receptors mutated across these loops demonstrate that they are cooperatively involved in full receptor activation. The experiments, however, reveal subtle differences between the B-C loop and Tyr(421), which is suggestive of distinct functional roles. The elucidation of the structure of the ligand-binding domain of beta(c) also suggests how different cytokines recognize a single receptor subunit, which may have implications for homologous receptor systems. (Blood. 2000;95:2491-2498)
Ian Potter Foundation Protein Crystallography Laboratory, St. Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia.
CYTOKINE RECEPTOR COMMON BETA CHAIN PRECURSOR
Gene Names: CSF2RB (IL3RB, IL5RB)
Go to Gene View: CSF2RB
ANTIBODY (LIGHT CHAIN)
215 Mus musculus Mutation(s): 0
Find proteins for P01661 (Mus musculus)
ANTIBODY (HEAVY CHAIN)
Gene Names: Igh-1a
Space Group: P 41 21 2
CNS refinement
AMoRE phasing
Type: Version format compliance
Type: Non-polymer description, Version format compliance
Type: Experimental preparation
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Having a bulging disc does not mean that you will necessarily need to undergo surgery. A bulging disc bulges out of the space it should occupy but does not rupture. The disc protrusion may press abnormally on spinal nerves, the spinal nerve root, or the spinal cord, causing pain and inflammation.
Patients with a bulging disc in the lower back may complain they have sciatica. However, sciatica is not a diagnosis but a description of symptoms. The sciatic nerve starts in the lower back and runs through the buttocks and down each leg. Pressure on one or more of the lumbar nerve roots can cause pain in parts or all of the sciatic nerve.
Many people think a bulging disc is the same thing as a herniated disc, but there is a difference. With a herniated or non-contained disc, a crack occurs in the annulus, the tough outer layer of the disc. This allows the soft inner material of the nucleus pulposus to leak out of the disc. When the disc breaks down, inflammatory proteins irritate the surrounding nerves. A contained disc is a herniated disc in which the nucleus pulposus has not ruptured.
If the symptoms of a bulging disc are getting progressively worse, or if you've tried several weeks or even months of non-surgical treatments such as physical therapy and anti-inflammatory medication and are still suffering from chronic back pain, bulging disc surgery may be necessary to relieve the stress caused by the disc protrusion.
The Bonati Spine Procedures utilize patented instruments and methods that were developed by Orthopaedic Surgeon and Bonati Spine Institute founder Alfred O. Bonati. The Bonati Spine Procedures are solely performed by highly experienced surgeons trained exclusively by Dr. Bonati.
A discectomy is performed to remove a portion of a bulging or herniated disc which is pressing on the spinal cord and/or spinal nerve roots, causing pain, radiculitis (pain that radiates to the extremities), numbness, tingling or weakness. The Bonati Discectomy is an outpatient procedure that uses subconscious IV sedation and local anesthesia so that patients are comfortable and able to provide feedback to doctors during the procedure.
A foraminotomy/foraminectomy is a surgical procedure performed to relieve nerve pressure at the site of the intervertebral foramina. The Bonati foraminotomy/foraminectomy is an outpatient procedure that uses conscious IV sedation and local anesthesia so that patients are comfortable, responsive, and able to provide feedback during the procedure. This allows the spine surgeon to target the source of your pain with pinpoint accuracy.
A laminectomy/laminotomy may be performed to remove nerve pressure. The Bonati laminectomy/laminotomy is performed incrementally so that the main causes of pain are addressed first. These are outpatient procedures that utilize conscious IV sedation and local anesthesia so that patients can provide feedback during the surgical procedure. This lets surgeons target the exact source of pain.
Follow your surgeon's instructions about how to prepare for your surgery. General guidelines include no food or drink after midnight the day before your surgery. If you smoke, try to quit, at least temporarily, before your surgery.
In addition, vitamins and herbal medicines may interact with the anesthesia. Discuss with your surgeon and physician your condition and all of your prescription medications for exact instructions on how to manage them before and after surgery.
All procedures are performed with conscious IV sedation and local anesthesia. Your surgeon will communicate with you during the procedure to pinpoint the exact source of your pain and facilitate its alleviation. You may be asked to complete a series of mobility exercises to ensure that the pain has been successfully treated.
After the surgery, you will be transferred to the post-operative care unit for observation and recovery. A post-operative consultation with your surgeon will determine your next steps. Most patients are able to begin walking therapy immediately after their procedure and can return to work and other daily activities within days.
Because the Bonati Spine Procedures do not involve a large incision, they avoid extensive damage to the muscles surrounding the spine. This generally results in less pain after surgery and a faster recovery. The length of recovery time may vary, but most patients are walking the same day and back to everyday activities within days. Your recovery time will depend on your individual procedure and condition.
The Bonati Spine Institute has been regarded as the leader in spine surgery for over 30 years. More than 55,000 of our procedures have been performed, with a patient satisfaction rate of 98.75%.
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Randomized, Controlled Trial of Single Versus 3-Times-Daily Ferrous Sulfate Drops for Treatment of Anemia
Stanley Zlotkin, Paul Arthur, Kojo Yeboah Antwi and George Yeung
Pediatrics September 2001, 108 (3) 613-616; DOI: https://doi.org/10.1542/peds.108.3.613
Stanley Zlotkin
From the *Departments of Paediatrics and Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada;
‡Division of Gastroenterology and Nutrition and Programs in Metabolism and Integrative Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada;
Paul Arthur
§Kintampo Health Research Centre, Ministry of Health, Kintampo, Ghana; and
‖London School of Hygiene & Tropical Medicine, Maternal Child Epidemiology Unit, London, United Kingdom.
Kojo Yeboah Antwi
George Yeung
First Name and Middle Initial *
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. [email protected]
Occupation *
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Competing interests? *
You are going to email the following Randomized, Controlled Trial of Single Versus 3-Times-Daily Ferrous Sulfate Drops for Treatment of Anemia
Stanley Zlotkin, Paul Arthur, Kojo Yeboah Antwi, George Yeung
Pediatrics Sep 2001, 108 (3) 613-616; DOI: 10.1542/peds.108.3.613
Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results
Milk versus medicine for the treatment of iron deficiency anaemia in hospitalised infants
Clinical nutrition: 8. The role of nutrition in the prevention of iron deficiency anemia in infants, children and adolescents
Single-Dose Daily Treatment of Anemia in Infants
ferrous sulfate drops
single versus 3-times-daily treatment
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Chronic unpredictable stress (CUS) can cause behavioral and physiological abnormalities that are important to the prediction of symptoms of depression that may be associated with cerebral glucose metabolic abnormalities. Curcumin showed potential antidepressant effects, but whether or not it can reverse cerebral functional abnormalities and so ameliorate depression remains unknown.
To investigate the effects of curcumin on brain activity in CUS rats, rats were subjected to 3 weeks of CUS and then treated with curcumin orally at a dose of 40 mg/kg/day for one month. 18 F fluorodeoxyglucose (18 F-FDG)-micro positron emission tomography (micro-PET) neuroimaging was used to detect changes in cerebral metabolism. Body weight, sucrose preference, and open field tests were used to record depressive behaviors during CUS and after curcumin treatment.
Three weeks of CUS significantly decreased body weight, sucrose preference, sucrose consumption, total distance travelling, and the number of rearing events. It also induced metabolic alterations in several parts of the brain, showing increased glucose metabolism in the right hemisphere. After curcumin treatment for one month, sucrose preference, sucrose consumption, total distance travelling, and the number of rearing events returned to normal levels. Curcumin treatment also induced strong deactivation of the left primary auditory cortex and activation of amygdalohippocampal cortex.
Curcumin was found to ameliorate the abnormalities in the behavior and brain glucose metabolism caused by CUS, which may account for its antidepressive effects.
Depression is one of the most burdensome diseases in the world. It has been recognized as the alternation of monoamine neurotransmitters serotonin and norepinephrine in the brain. Antidepressants that regulate the monoamine neurotransmitter system have been used successfully in clinical settings, but 20–30% of depressed patients do not experience a satisfactory level of amelioration. For this reason, searching for an alternative biological antidepressant that would be safer and more effective is important. With the development of neuroimaging, many studies have depicted the limbic system in depression, showing changes in the structure and function of the prefrontal cortex, hippocampus, and amygdala. These neuropathologic alterations may mediate or respond to the emotional, behavioral, and cognitive manifestations of depressive episodes. For this reason, there are reports of some antidepressants that ameliorate depression by reversing cerebral functional abnormalities.
Curcumin, a yellow plant pigment extracted from Curcuma longa (turmeric) rhizomes, has wide-ranging neuroprotective effects in the treatment of neuropsychiatric disorders, including Parkinson's disease, Alzheimer's disease, schizophrenia, and epilepsy. It is been reported that curcumin can penetrate the blood–brain barrier and modulate the levels of neurotransmitters like norepinephrine, dopamine, and serotonin in the brain. The antidepressive effects of curcumin have been demonstrated in a variety of animal models, such as the forced swimming test[7, 8], tail suspension, olfactory bulbectomy model, and chronic unpredicted stress (CUS). The mechanisms by which curcumin counteracts depression might be associated with several signaling pathways. For example, it is probable that a monoamine oxidase inhibitor modulates the serotonin and dopamine levels[7, 8], blocks the release of glutamate from rat prefrontal cortex nerve terminals, increases the concentrations of brain-derived neurotrophic factor in the hippocampus and prefrontal cortex, and promote neurogenesis. Curcumin is also believed to have an effect on diabetes mellitus by inhibiting glucose uptake. However, there is little information regarding whether curcumin can reverse dysfunction of the cerebral glucose metabolism, which was impaired in depression.
18 F fluorodeoxyglucose (18 F-FDG) is a high spatial resolution tracer which can be used to perform animal micro-PET imaging, which was used to investigate rat brain activity during acute and chronic stress[15, 16]. In the present study, micro-PET imaging was performed to investigate changes in behavior and brain glucose metabolism during depression after treatment with curcumin in a CUS rat model, which is widely used to evaluate the effects of antidepressants in vivo. In the present study, we want to use 18 F-FDG micro-PET imaging to further explore the effects of curcumin on the behavioral and brain glucose metabolism caused by CUS, which will help to know the anti-depressive mechanism of curcumin and promote its translational development.
All experiments were performed in accordance with the National Institutes of Health Guide for the Care and Use of Laboratory Animals and they were approved by the Committee on Animal Care and Usage of Zhejiang University. A total of 27 male Sprague–Dawley rats with body weights ranging from 280 to 300 g were obtained from Shanghai Institutes for Biological Sciences. The rats were housed in a humidity- and temperature-controlled environment with 12-hour light/dark cycles and free access to food and water. Prior to the experiments, the rats were placed in a new environment for 7 days to allow them to habituate to their housing conditions.
After one-week acclimation, a CUS model was established as described previously in rats. Control animals remained in a comparable environment. Unpredictable stress included water deprivation, empty water bottles, continuous lighting, tilting of the cages, crowded housing, damp bedding, white noise, and strobe lighting. These stress events took place between 9:00 and 10:00 a.m. every day. The specific experimental protocol is as stated in Table 1 and all the experiments lasted for three weeks.
Rats were randomly assigned into two groups: control (n = 14) and CUS (n = 13). After 3-week stress stimulation, CUS rats were further randomly divided into two groups: model (n = 6) and treatment (n = 7). Curcumin (purity ≥ 98%; Nanjing Zelang Medical Technological Co.Ltd., China), was dissolved in rice bran oil to make a 40 mg/kg solution[11, 19]. Starting from the second month, the rats in the treatment group were given curcumin by oral gavage. The model group was fed rice bran oil. All experiments were performed in the morning from 9:00 to 11:00 a.m. The whole experimental procedure is shown in Figure 1.
Schedule of procedures used in the present study. Tests include the open field test, sucrose preference test, and micro-PET.
The open-field test protocol was performed as described in our earlier work. Briefly, spontaneous activity was measured and recorded for 5 min in an open field to evaluate the difference between the groups. Briefly, the test was conducted on white painted plywood (72 cm × 72 cm) with walls 36 cm high in a soundproof room with dim lighting. The rats had not undergone previous habituation to this room. The base was divided into 16 squares using white strips. These constituted the peripheral and central sectors. Rats were initially placed in the central sector and then released to explore the facility for a 5 min period, during which the parameters (e.g. total distance travelling, the number of rearing events) were monitored using a VideoMot2–Video Activity Measuring System (TSE systems GmbH, Germany).
The sucrose preference test procedure was performed as previously described. The rats were initially acclimatized to sucrose and water for three days. For the test, rats were fed 5% sucrose solution (w/v) as follows: two bottles of 5% sucrose solution were placed in each cage for the first day; one bottle of water and one of sucrose were placed in each cage on the second day, and the positions of the bottles were switched to eliminate the effects of side preference. On the third day, rats were deprived of food and water for 24 h. On the fourth day, rats were given one bottle of water and one bottle of sucrose solution. Intakes of water and sucrose solution were quantified by measurement of bottle volumes before and after the test. After 24 h, the volumes of sucrose solution and water consumed were recorded, and the sucrose preference was calculated using the following formula: Sucrose preference = sucrose consumption/(water consumption + sucrose consumption) × 100%.
The micro-PET scan protocol was performed as described in the previous study. Before 18 F-FDG injection, the rats were fasted for 8–12 h with free access to water in order to enhance the uptake of the tracer by the brain and to reduce the interference of other systems, like skeletal muscle. Each rat was placed on a heating pad which was kept at 30°C for at least 30 min prior to 18 F-FDG injection. Rats were briefly anesthetized using halothane gas (1.5 min) in order to maximize tracer uptake by the brain. The rats were then injected with approximately 18.5 MBq (500 μCi) of 18 F-FDG through the tail vein either before administration of curcumin or 0, 2, or 4 weeks after CUS. After 40 min, the rats were placed in a spread-legged prone position with halothane gas anesthesia (5% induction and 1.5% for maintenance) of micro PET R4 (Kyowa micro Knoxville, TN, U.S.), which consists of a ring of 96 position-sensitive γ-ray scintillation detectors 15 cm in diameter, providing a 10.8 cm trans-axial, and a 7.8 cm axial field of view, with an intrinsic resolution < 1.8 mm. The entire static process continued for 15 min.
Areas of the brain were manually extracted from all micro-PET images. These images were normalized using 18 F-FDG rat brain templates. In order to obtain accurate anatomical information, statistical parametric mapping (SPM5) software for PET template normalization into magnetic resonance imaging (MRI) template was used. This system was placed in stereotaxic space. To increase statistical power, all normalized images were smoothed with an isotropic Gaussian kernel (2 mm full width at half-maximum). Voxel-based statistical analyses were carried out with the SPM5 software.
Because the data was not always normally distributed, the difference between the groups was statistically evaluated using nonparametric testing. Body weight was analyzed using a repeated measurement ANOVA (CUS and control groups served as independent factors and time served as a repeated measure). The effects of CUS on sucrose preference, sucrose consumption, total distance travelling, and the number of rearing events were analyzed using the Mann–Whitney U-test. All behavioral results were calculated using the median values. All tests were two-tailed and the P values less than 0.05 were considered significant. Statistical analyses were performed with SPSS version 18.0 (SPSS, Inc., Chicago, IL, U.S.).
A repeated measurement ANOVA (time × group as factors) revealed a main effect of time (F = 80.42, P < 0.05), a main effect of group (F = 66.93, P < 0.05) and significant group by time interaction (P < 0.05). The control and CUS groups had similar body weights before the experiments (P > 0.05). After 3 weeks of chronic stress stimulation, the body weight gain in CUS group was significantly slower than that of the control group. These differences were found to be statistically significant (P < 0.05) (Figure 2A).
Behavioral indicators changed during the CUS procedure and after curcumin treatment. ( A ) Body weight changed during the 3 weeks of chronic unpredictable stress (CUS). ***P < 0.0001 shows the CUS group (n = 13) vs. control group (n = 14). (B) and (C) Sucrose preference and sucrose consumption after 3 weeks of CUS and after 1 month of treatment. *P < 0.05, **P < 0.01 shows the CUS group (n = 13) vs. control group (n = 14). # P < 0.05 shows model group (n = 6) vs. control group (n = 14). + P < 0.05 shows treatment group (n = 7) vs. model group (n = 6). (D) and (E) Open-field test indexes (total distance travelling and the number of rearing events) after 3 weeks of CUS and after 1 month of treatment. *P < 0.05, **P < 0.01 shows CUS group (n = 13) vs. control group (n = 14). # P < 0.05 shows model group (n = 6) vs. control group (n = 14). + P < 0.05 shows treatment group (n = 7) vs. model group (n = 6).
In the sucrose preference test, control and CUS groups showed comparable baseline sucrose preference and sucrose consumption (data not shown). However, after 3 weeks of chronic stress, both sucrose preference and sucrose consumption were significantly lower (5.5% and 6.7%) in the CUS group (Z = −2.706, P = 0.007. Figure 2B; Z = −2.228, P = 0.026. Figure 2C) than in the control group. One month later, the difference was further amplified to 8.7% and 18.6% (Z = −2.557, P = 0.011. Figure 2B; Z = −2.148, P = 0.032. Figure 2C). However, treatment with curcumin successfully reversed the effects of CUS, showing significantly more pronounced sucrose preference and sucrose consumption than in the model group (11.7% and 31.9%. Z = −2.429, P = 0.015. Figure 2B; Z = −2.286, P = 0.022. Figure 2C).
There was no difference between groups with respect to total activity during the 5 min open field test period (data not shown) at the baseline. However, after 3 weeks, CUS rats showed significantly less total distance travelling (23.0%) and significantly fewer rearing events (34.7%) than control rats (Z = −2.205, P = 0.027, Figure 2D; Z = −2.717, P = 0.007, Figure 2E). After one month, model rats also showed a significantly less total distance travelling (20.7%) and significantly fewer rearing events (23.8%) than control rats (Z = −2.062, P = 0.039. Figure 2D; Z = −2.072, P = 0.038, Figure 2E). Curcumin treatment in CUS rats was associated with significantly greater total distance travelling (20.7%) and significantly more rearing events (56.3%) than in the model group (Z = −2.143, P = 0.032. Figure 2D; Z = −2.295, P = 0.022. Figure 2E).
The differences in glucose metabolism in the coronal, sagittal, and horizontal sections among control rats, rats subjected to CUS, and CUS rats treated with curcumin (40 mg/kg) are shown in Table 2. Using Paxinos coordinates (ML, mediolateral; AP, anteroposterior; DV, dorsoventral), CUS induced strong activation of the right prim somatosens, right dorsolateral entorhinal cortex and basilar artery, and strong deactivation of the left mediodorsal thalami nuclear and cingulate cortex. One month later, model rats showed significantly more deactivation on both sides of the amygdalohippocampus than control rats. The administration of curcumin (40 mg/kg) induced strong activation of the left amygdalohippocampus and significant deactivation in the left primary auditory cortex.
aPaxinos coordinates point to the location of the voxel with the t-value ( P < 0.05 for the rest) in the designated brain areas. L, left; R, right.
Figure 3 summarizes these changes in several regions of interest in the three groups. Figure 3A shows the changes in glucose metabolism in coronal, sagittal, and horizontal sections in model rats and in the control group. The changes caused by curcumin comparing treatment group to model group as shown in Figure 3B. Figure 3C shows the administration of curcumin (40 mg/kg) inducing a strong activation of the left amygdalohippocampus (AHiAL, L). In contrast, significant deactivation was observed in the left primary auditory cortex (Au 1).
Glucose metabolism in the brain changed during the CUS procedure and after curcumin treatment. ( A) Parts of the brain that showed significant changes in glucose metabolism induced by chronic unpredictable stress (CUS) relative to the control group. (B) Changes induced by CUS and the administration of curcumin compared with CUS group. (C) Changes in glucose metabolism in the brain. *Values differ significantly between model and control groups, # Values differ significantly between treatment and model groups, according to Mann–Whitney U (*P < 0.05 and # P < 0.05). Au1, primary auditory cortex (ML: -6.0 mm, AP: -4.0 mm, DV: -5.0 mm); AHiAL (L), left amygdalohippocampal area, anterolateral part (ML: -4.0 mm, AP: -9.0 mm, DV: -4.0 mm); AHiAL(R), right amygdalohippocampal area, anterolateral part (ML: +4.0 mm, AP: -9.0 mm, DV: -4.0 mm).
In this study, 3-week CUS significantly decreased body weight, sucrose preference, sucrose consumption, total distance travelling, and number of rearing events in rats. It also induced metabolic alterations in several parts of the brain, such as increased glucose metabolism in the right hemisphere. After one month of curcumin treatment, sucrose preference, sucrose consumption, total distance travelling, and number of rearing events returned to normal levels. These changes were associated with stronger deactivation of the left primary auditory cortex and activation of the amygdalohippocampal cortex than rats not given curcumin treatment. Overall, these data showed that curcumin could improve the behavioral and brain glucose metabolic abnormalities caused by CUS, suggesting that curcumin might have an antidepressive effect.
CUS was induced in male rats and their body weights were recorded for 3 weeks. The open field test is a common qualitative and quantitative measure of general locomotor activity and willingness to explore in rodents. Open-field tests have shown a reduction in the total distance travelling and the number of rearing events in the CUS model, which can be considered indicative of the severity of depressive symptoms. Consistent with a previous study, CUS rats here showed a decrease in sucrose consumption and sucrose preference, which is generally considered an indication of anhedonia. The sucrose preference test is an objective behavioral indicator in rodent CUS model. Here, this test showed that, after CUS, the rewarding value of sucrose solution was disrupted. Combined with the significant weight loss observed after CUS, these data indicate that the CUS model was effective.
The changes in the behavior in CUS rats were accompanied by alterations in glucose metabolism, specifically, increased glucose metabolism in the right prim somatosens, right dorsolateral entorhinal cortex, and basilar artery and decreased metabolism in the left mediodorsal thalami nuclear and cingulate cortex. In human beings, the right hemisphere is primarily responsible for dealing with negative emotions and the formation of pessimistic thinking. The left hemisphere is primarily responsible for processing pleasant experiences, and the relative decay can lead to anhedonia. In neuroimaging studies, unipolar depressed patients show hypoactivity in the left hemisphere and hyperactivity in the right hemisphere[28, 29]. The severity of depression has been shown to be positively correlated with right hemisphere hyperactivity. In these ways, the abnormalities in glucose metabolism here observed in the CUS depression model was consistent with what has been observed in depressed patients, suggesting that this widely used animal model could also be used for further study of alterations in brain activity in depression.
One month of curcumin treatment significantly counteracted the decrease in four parameters, sucrose preference, sucrose consumption, total distance travelling, and number of rearing events. This suggests that curcumin might have a mild antidepressive effect. After one month of curcumin treatment at 40 mg/kg, the discrepancy in glucose metabolism between CUS and control groups was diminished. Nevertheless, several new parts of the brain showed significant differences, mainly gathered at amygdalohippocampus and left primary auditory cortex. It might be due to an extension of the CUS effect, primarily non-responsive parts of the brain start reacting to stress as time goes on.
Both sides of the amygdalohippocampus showed significantly more deactivation in the model rats than control rats, while the treatment of curcumin played a role in resistance to such changes in the present study. In previous studies, patients with major depressive disorders showed abnormal activation in the amygdala when presented with emotional stimuli. These data indicated that the amygdala is involved in the etiopathology of depression and that curcumin might improve emotional processing. The serotonin hypothesis states that serotonin might be an important explanation for the present observed results. It has been reported that curcumin strongly increased the serotonin levels and inhibited monoamine oxidase in mice. One report has suggested that acute serotonin reuptake blockage may affect human amygdala reactivity. In this way, the activation of glucose metabolism in the amygdalohippocampus might contribute to an increase in serotonin caused by curcumin. The amygdalohippocampus, a part of the cortical-amygdal loop, is involved in emotional processing. Previous studies have shown that the amygdalohippocampal area receives dense serotonergic input[24, 25]. The serotonin hypothesis of depression suggests that levels of serotonin metabolites are low in depressed individuals and that levels of central serotonin are low in the brains of suicide victims. The CUS model also suggests a decrease in serotonin metabolites in the frontal cortex, striatum, and hippocampus. Confusingly, previous studies have demonstrated that the resting cerebral blood flow and glucose metabolism are abnormally elevated in the amygdala in patients with major depressive disorder but not in patients with unipolar depression. These data seem to conflict with the present results, but three major factors might explain this contradiction. There are profound differences between different species difference, such as human beings and rodents. There is also a dearth of effective research that illustrates whether emotional processing is consistent across these different species. Another possibility is that, in the present study, the amygdalohippocampus, the caudal third of the amygdala which abuts the hippocampal formation, but not the whole amygdala, showed significant deactivation in model rats. It is possible that different parts of the amygdala have diverse responses to CUS and curcumin, but further research is needed to confirm these conclusions. It should be noted that the amygdala does not show over-activation in patients with unipolar depression, which indicates that abnormally elevation of amygdala may be associated with the manic phase. Previous studies have shown that stimulating the amygdala caused the animal to become more active and to attempt to escape the stimulation, indicating defensive behaviors. Further investigation is needed to address these questions.
Conversely, the auditory cortex showed a significant deactivation after curcumin treatment. The auditory cortex is closely related to the amygdalohippocampus and is also rich in serotonergic fibers. The excitability of the auditory cortex is assumed to be under serotonergic control. Decreases and increases in serotonin function are associated with increased and reduced cortical excitability, respectively. Consistent with this suggestion, the present results showed that curcumin may act as a monoamine oxidase inhibitor can increase the serotonin levels, which cause the deactivation of the auditory cortex. Curcumin, which has multiple bioactivities, also functions as a potent inhibitor of neuronal cell death in response to oxidative stress in auditory neurons. However, the exact mechanism by which curcumin affects cerebral glucose metabolism requires further investigation.
Previous functional neuroimaging studies using 133Xe blood flow, single photon emission computed tomography (SPECT), and PET have consistently demonstrated decreased regional cerebral blood flow (rCBF) or metabolism in the frontal lobe, temporal lobe, or anterior cingulate gyrus of depressed patients. Our results also demonstrated that curcumin can alleviate CUS induced stress through improving cerebral glucose metabolism. Although it is still lack of clinical test, the antidepressant effect of curcumin has been proved by availability of vast preclinical evidence, implying curcumin can alleviate the symptoms of depression by various mechanisms, such as inhibiting monoamine oxidase enzyme, modulating the level of various neurotransmitters, and promoting hippocampal neurogenesis. Thus, based on these studies, it will be helpful for curcumin or related agents translational development in the future.
However, there are some limitations in the present study. First, micro PET technology itself has certain limitations. This may bias the statistical analysis when relatively large parts of the brain are involved, so the present study only measured changes in glucose metabolism in small parts of the brain rather than in the hippocampus or prefrontal cortex. Second, the present study involved a small sample size. Finally, the biggest limitation of the current study is not clearly specified on hypothesis by which mechanism curcumin affects cerebral glucose metabolism. According to the present results, our future research will aim to test the hypothesis of curcumin against depression by inhibiting monoamine oxidase in a large sample.
In summary, CUS induced weight loss and depression or anxiety behaviors in rats. These changes were accompanied by metabolic alterations in several parts of the brain regions, specifically increased glucose metabolism in the right hemisphere. Curcumin treatment reversed these depression and anxiety behaviors and induced strong deactivation of the left primary auditory cortex and activation of amygdalohippocampal cortex. These data suggest that curcumin may act as an antidepressive agent, possibly by reversing the abnormal brain glucose metabolism that occurs in depressed organisms.
This work was supported by grants from National Natural Science Foundation of China (81202947), Natural Science Foundation of Zhejiang Province (Y2100294), Health Department Foundation of Zhejiang Province (2011KYA077), and Education Department Foundation of Zhejiang Province (Y201017831).
ZL conceived and designed the study; ZL, JL, JHL and LGS participated in the experiment; ZL and LGS drafted the manuscript; HH and YRL helped to draft the manuscript; CTZ and WJT participated in performed the statistical analysis; AMB reviewed and edited the manuscript; LX conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
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Late registration available! Please follow the registration link at the top of the page to complete your registration. When available, CAOT offers late registration for workshops at the regular rate plus a $50 administration fee. This administrative fee does not apply to those purchasing the pre-workshop recorded webinar only.
The current demographic shift towards an aging population has led to an increased incidence of age-related visual conditions alongside concurrent medical conditions leading to vision loss (e.g., stroke), warranting a significant need for vision rehabilitation services. This interactive one-day workshop will review the current state of occupational therapy and low vision rehabilitation and focus on building your capacity to support clients with low vision. You will rotate through various stations to engage in experiential learning, build assessment skills, trial adaptive aids and technologies, apply vision rehabilitation strategies to case scenarios, and establish practices for collaborating with other vision rehabilitation team members.
Demonstrate increased awareness of the need and potential for strategies addressing low vision to improve occupational performance in any setting.
Identify current best practices guidelines for low vision rehabilitation.
Review and apply a range of low vision rehabilitation strategies and devices to case scenarios.
Articulate ways in which occupational therapists can work with other low vision rehabilitation professionals and contribute to the health of those with vision loss.
Occupational therapists, occupational therapist assistants, students in occupational therapy or OTA/PTA programs and other health professionals who wish to build their capacity to support adults and older adults with low vision. As many eye conditions are age-related, the current demographic shift towards an aging population has led to an increased incidence of age-related visual conditions alongside concurrent medical conditions leading to vision loss (e.g. stroke), warranting a significant need for vision rehabilitation services.
Please note: Each participant is responsible to ensure they apply the information within the context of their licensure, provincial/territorial legislations, institution regulations, scope of practice, etc.
Laura Yvonne Bulk (OT, BSW), who identifies as a blind OT, practices in British Columbia and is currently doing her PhD with a focus on increasing participation for people who are blind/partially blind.
Patty Mason, MA, BSc(OT) is an occupational therapist at the Vision Rehabilitation Clinic located at VGH Eye Care Centre within Vancouver Coastal Health. The Vision Rehabilitation Clinic provides services to individuals through the province. Patty is a clinical faculty member of Department of Occupational Science & Occupational Therapy at UBC.
Please note that for the 2018-2019 workshops, CAOT has reduced the registration fee for all registrants instead of offering a group rate. When available, CAOT offers late registration for workshops at the regular rate plus a $50 administration fee. We will only be able to accommodate if there is sufficient space.
*In many cases it would be more cost effective to become a CAOT Member or Associate rather than pay the non-member rate. See "Can a non-member register for a Workshop?" in our Workshop FAQ to know which membership category you are eligible for.
One-day workshop, online pre-workshop recorded webinar (approximately 2 hours), electronic copy of presentation slide handouts, coffee/tea/water during mid-morning and mid-afternoon breaks, opportunity to network and make connections with other occupational therapists interested in this topic, one-hour Q&A webinar with the presenters approximately 1 month following the workshop, electronic certificate of attendance.
The Workshop registration fee has been reduced by $40 by not including lunch and snacks. Lunch and snacks are to be done on your own.
Due to the interactive and hands-on nature of the Workshop activities, it is not currently possible to offer it via webinar/videoconference or to provide a recording of the Workshop. However, this Workshop includes approximately 2 hours worth of content delivered online through pre-workshop recorded webinar which may be purchased separately so you can still benefit from some professional development related to vision, vision loss and roles of the interprofessional team in low vision rehabilitation. Please select the registration option "Pre-workshop recorded webinar only". The access will be provided by email in March 2019.
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We invite you to consult the Workshop FAQ for an immediate response to the most frequent questions we receive regarding Workshops. Please do not hesitate to contact us at [email protected] or 1-800-434-2268 ext. 222 should you have additional questions or concerns.
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Elastomers are long-chain polymers which are capable of cross-linking which is referred to as vulcanization. The vulcanization process cross-links the polymer chains via chemical bonds creating the elastic or "rubbery or memory properties".
Elastomers are typically descried by type or family based on the base polymer used in the formulation. These classifications are summarised per the ASTM D 1418 standard below and more detail is available for each of the families by clicking on the Chemical Description contained in the summary.
Vamac ® and Viton ® are registered trademarks of E. I. du Pont de Nemours and Company or affiliates.
Fluorosilicones combine most of the attributes of silicone with resistance to petroleum oils and hydrocarbon fuels.
Low physical strength and abrasion resistance combined with high friction limit fluorosilicone to static seals.
Fluorosilicones are used primarily in aircraft fuel systems.
Silicone is a semi-organic elastomer with outstanding resistance to extremes of temperature with corresponding resistance to compression set and retention of flexibility. Silicone elastomers provide excellent resistance to ozone, oxygen, and moisture.
Low physical strength and abrasion resistance combined with high friction properties limit silicone to static seal applications.
Silicone utilises a flexible siloxane backbone rather than a carbon backbone like many other elastomers and has very low glass transition temperatures.
Millable polyurethane exhibits excellent abrasion resistance and tensile strength as compared to other elastomers providing superior performance in hydraulic applications with high pressures, abrasive contamination and shock loads. Fluid compatibility is similar to that of nitrile at temperatures up to approximately 175 °F. At higher temperatures, polyurethane has a tendency to soften and lose both strength and fluid resistance advantages over other elastomers.
Styrene-Butadiene (SBR) is a copolymer of styrene and butadiene.
SBR compounds have properties similar to those of natural rubber. SBRs primary custom molded application is the use in hydraulic brakes system seals and diaphragms, with the major of the industry usage coming from the Tyre Industry.
SBR features excellent resistance to brake fluids, and good water resistance.
Ethylene-acrylic (Vamac ®) is a terpolymer of ethylene, methyl acrylate, and an acid-containing monomer as a cure site. It exhibits properties similar to those of Polyacrylate, but with extended low temperature range and with enhanced mechanical properties.
Ethylene-acrylic offers a high degree of oil, ozone, UV and weather resistance.
» not recommended for exposure to fuel, brake fluid, aromatic hydrocarbons or phosphate esters.
Polyacrylates are copolymers of ethyl and acrylates which exhibit excellent resistance to petroleum fuels and oils and can retain their properties when sealing petroleum oils at continuous high temperatures up to 300 °F. These properties make polyacrylates suitable for use in automotive automatic transmissions, steering systems, and other applications where petroleum and high temperature resistance are required.
Polyacrylates also exhibit resistance to cracking when exposed to ozone and sunlight.
Polyacrylates are not recommended for applications where the elastomer will be exposed to brake fluids, chlorinated hydrocarbons, alcohol, or glycols.
Neoprene homopolymer of chlorobutadiene and is unusual in that it is moderately resistant to both petroleum oils and weather (ozone, UV, oxygen). This qualifies neoprene uniquely for certain sealing applications where many other materials would not be satisfactory. Neoprene is classified as a general purpose elastomer which has relatively low compression set, good resilience and abrasion, and is flex cracking resistant.
Neoprene has excellent adhesion qualities to metals for rubber to metal bonding applications.
It is used extensively for sealing refrigeration fluids due to its excellence resistance to Freon® and ammonia.
Fluorocarbon exhibits resistance to a broader range of chemicals combined with very good high temperature properties more so than any of the other elastomers. It is the closest available approach to a universal elastomer for sealing in the use of o-rings and other custom seals over other types of elastomers.
Fluorocarbons are highly resistant to swelling when exposed to gasoline as well as resistant to degradation due to expose to UV light and ozone.
When exposed to low temperatures, fluorocarbon elastomers can become quite hard (-4 °F) but can be serviceable at low temperatures, although FKM compounds are not recommended for applications requiring good low temperature flexibility.
Fluorocarbons exhibit low gas permeability making them well suited for hard vacuum service and many formulations are self-extinguishing. FKM materials are not generally recommended for exposure to hot water, steam, polar solvents, low molecular weight esters and ethers, glycol based brake fluids, or hot hydrofluoric or chlorosulfonic acids.
Ethylene-propylene compounds are prepared from ethylene and propylene (EPM) and usually a third monomer (EPDM). These compounds are used frequently to seal in brake systems, and for sealing hot water and steam. Ethylene propylene compounds have good resistance to mild acids, detergents, alkalis, silicone oils and greases, ketones, and alcohols. They are not recommended for applications with petroleum oils, mineral oil, di-ester lubricants, or fuel exposure.
Ethylene Propylene has gained wide seal industry acceptance for its excellent ozone and chemical resistance properties and is compatible with many polar fluids that adversely affect other elastomers.
EPDM compounds are typically developed with a sulphur or peroxide cure system. Peroxide-cured compounds are suitable for higher temperature exposure and typically have improved compression set performance.
» Water system seals, faucets, etc.
HNBR is created by partially or fully hydrogenating NBR. The hydrogenating process saturates the polymeric chain with accompanying improvements to the ozone, heat and aging resistance of the elastomer and improves overall mechanical properties.
HNBR, like Nitrile, increasing the acrylonitrile content increase resistance to heat and petroleum based oils and fuels, but decreases the low temperature performance.
Nitrile is the most widely used elastomer in the seal industry. The popularity of nitrile is due to its excellent resistance to petroleum based oils and fuels, and its ability to be compounded for service over a temperature range of -22°F to 212°F.
Nitrile is a copolymer of butadiene and acrylonitrile. Variation in proportions of these polymers is possible to accommodate specific requirements. An increase in acrylonitrile content increases resistance to heat plus petroleum base oils and fuels but decreases low temperature flexibility. Military AN and MS O ring specifications require nitrile compounds with low acrylonitrile content to insure low temperature performance.
Nitrile provides excellent compression set, tear, and abrasion resistance. The major limiting properties of nitrile are its poor ozone and weather resistance and moderate heat resistance, but in many application these are not limiting factors.
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A study that was aimed to elucidate roles of Gliricidia sepium and Tithonia diversifolia prunings and their extracted humic and fulvic acids on improving phosphorus availability and decreasing aluminum concentration in an Ultisol was conducted in a glasshouse. Thirteen treatments consisting of two prunings, six rates of pruning application (5, 7.5, 10, 20, 40 and 80 t/ha) and one control (no added prunings) were arranged in a randomized block design with four replicates. Each mixture of prunings and soil was placed in a pot containing 8 kg of soil and maize of Srikandi cultivar was grown on it for 45 days. At harvest, soil pH, P content and aluminium concentration were measured. Results of the glasshouse experiment showed that application of Gliricidia and Tithonia prunings significantly increased soil pH, reduced Alo concentration, increased Alp content, increased P availability, and increased P taken up by maize grown for 45 days. The optimum rate of both Gliricidia and Tithonia pruning should be 40 t/ha. However, at the same rate, optimum production gained by Tithonia would be higher than that of Gliricidia.
Appelt, H., Coleman, N.T. and Pratt, P.F. 1975. Interaction between organic compounds, mineral and ions in volcanic ash derived soils. II. Effects of organic compounds on the adsorption of phosphate. Soil Science Society of America Proceeding 39: 623-630.
Bates, T.R. and Lynch, J.P. 2001. Root hairs confer a competitive advantage under low phosphorus availability. Plant and Soil 236: 243-250.
Hairiah, K., Widianto., Utami, S.R., Suprayogo, D., Sunaryo., Sitompul, S.M., Lusiana, B., Mulia, R., van Noordwijk, M. dan Cadish, G. 2000. Pengelolaan Tanah Masam Secara Biologi: Refleksi Pengalaman dari Lampung Utara. ICRAF.
Jufri, J. 1999. Peningkatan Ketersediaan P Oleh Beberapa Macam Bahan Organik Pada Ultisol. Tesis S2 PPS Universitas Brawijaya, Indonesia.
Lindsay, W. L. 1979. Chemical Equilibrium in Soils. John Wiley & Sons. New York.
Mokolobate, M.S. and Haynes, R.J. 2002. Increases in pH and soluble salts influence the effect that additions of organic residues have on concentrations of exchangeable and soil solution aluminium. European Journal of Soil Science 53: 481-489.
Notohadiprawiro, T. 2006. Budidaya Organik: Suatu Sistem Pengusahaan Lahan Bagi Keberhasilan Program Transmigrasi Pola Pertanian Lahan Kering. Repro: Ilmu Tanah UGM-Yogjakarta. h: 1-10.
Prasetyo, B.H. dan Suriadikarta, D.A. 2006. Karakteristik, potensi, danteknologi pengelolaan tanah ultisol untuk pengembangan pertanian lahan kering di Indonesia. Jurnal Litbang Pertanian 25 (4): 39-46.
Radjagukguk, B. 1983. Masalah Pengapuran Tanah Mineral Masam di Indonesia.
Sri Adiningsih, J., Sudjadi, M. and Setyorini, D. 1988. Overcoming soil fertility constraints in acid upland soils for food crop based farming systems in Indonesia. Indonesian Agricultural Research and Development Journal 10: 49 58.
Stevenson, F.J. 1994. Humus Chemistry: Genesis, Composition and Reaction.
Supriyadi. 2003. Studi Penggunaan Biomasa Tithonia diversifolia dan Tephrosia candida Untuk Perbaikan P dan Hasil Jagung (Zea mays L) di Andisol. Disertasi PPS Universitas Brawijaya, Indonesia. 172 h.
Swift, M. J. and Sanchez, P.A. 1984. Biological management of tropical soil fertility for sustained productivity. Nature and Resources 20: 2 10.
Tan, K.H. 1998. Principles of Soil Chemistry. Marcel Dekker Inc., Madison, New York.
Wawan. 2002. Pengelolaan Subsoil Masam Untuk Peningkatan Produksi Tanaman Pangan. Makalah Falsafah Sains. PPS-IPB, Bogor.
Weil, R.R. and Magdof, F. 2004. Significance of soil organic matter to soil quality and health. In: Magdof, F. and Weil, R.R. (eds), Soil Organic Matter in Sustainable Agriculture. pp 1-36.
Yusuf, W.A., Jumberi, A., Haris, A. dan Simatupang, R.S. 2004. Pengaruh pemberian pupuk organik terhadap fitotoksitas aluminium pada tanah masam. Jurnal Tanah Tropika 18: 109-115.
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Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004
Renee I. Matos, John B. Holcomb, Charles Callahan, Philip C. Spinella
Division of Critical Care Medicine
Objective. The objective of this study was to determine whether age ≤8 y is an independent predictor of mortality in noncoalition trauma patients at a US combat support hospital. Methods. A retrospective chart review was conducted of 1132 noncoalition trauma patients who were admitted to a combat support hospital between December 2003 and December 2004. Data on age, severity of injury indices, and in-hospital mortality rates were analyzed. All variables that were associated with death on univariate analysis were analyzed by multivariate logistic regression to determine independent associations with mortality. Results. There were 38 young pediatric patients (aged ≤8 years) and 1094 older pediatric and adult patients (aged >8 years). Penetrating trauma accounted for 83% of all injuries. Young pediatric patients compared with older pediatric and adult patients had increased severity of injury indicated by decreased Glasgow Coma Scale score;increased incidence of hypotension, base deficit, and serum pH on admission; red blood cell transfusion amount; and increased injury severity scores on admission. Young pediatric patients compared with older pediatric and adult patients also had increased ICU lengths of stay (median 2 [interquartile range 0-5] vs median 0 [interquartile range 0-2] days) and in-hospital mortality rate (18% vs 4%), respectively. Multivariate logistic regression indicated that base deficit, injury severity score of ≥15, Glasgow Coma Scale score of ≤8, and age of ≤8 years were independently associated with mortality. Conclusions. Young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries, after adjustment for severity of injury, young children may also have an independent increased risk for death compared with older children and adults. Providing forward-deployed medical staff with pediatric-specific equipment and training in the acute care of young children with severe traumatic injuries may improve outcomes in this population.
e959-e966
https://doi.org/10.1542/peds.2008-1244
Dive into the research topics of 'Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004'. Together they form a unique fingerprint.
Iraq Medicine & Life Sciences 100%
Wounds and Injuries Medicine & Life Sciences 38%
Glasgow Coma Scale Medicine & Life Sciences 19%
Injury Severity Score Medicine & Life Sciences 18%
Hospital Mortality Medicine & Life Sciences 15%
Matos, R. I., Holcomb, J. B., Callahan, C., & Spinella, P. C. (2008). Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004. Pediatrics, 122(5), e959-e966. https://doi.org/10.1542/peds.2008-1244
Matos, Renee I. ; Holcomb, John B. ; Callahan, Charles et al. / Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004. In: Pediatrics. 2008 ; Vol. 122, No. 5. pp. e959-e966.
@article{60af622539c34249bf91e11c6da6dbb7,
title = "Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004",
abstract = "Objective. The objective of this study was to determine whether age ≤8 y is an independent predictor of mortality in noncoalition trauma patients at a US combat support hospital. Methods. A retrospective chart review was conducted of 1132 noncoalition trauma patients who were admitted to a combat support hospital between December 2003 and December 2004. Data on age, severity of injury indices, and in-hospital mortality rates were analyzed. All variables that were associated with death on univariate analysis were analyzed by multivariate logistic regression to determine independent associations with mortality. Results. There were 38 young pediatric patients (aged ≤8 years) and 1094 older pediatric and adult patients (aged >8 years). Penetrating trauma accounted for 83% of all injuries. Young pediatric patients compared with older pediatric and adult patients had increased severity of injury indicated by decreased Glasgow Coma Scale score;increased incidence of hypotension, base deficit, and serum pH on admission; red blood cell transfusion amount; and increased injury severity scores on admission. Young pediatric patients compared with older pediatric and adult patients also had increased ICU lengths of stay (median 2 [interquartile range 0-5] vs median 0 [interquartile range 0-2] days) and in-hospital mortality rate (18% vs 4%), respectively. Multivariate logistic regression indicated that base deficit, injury severity score of ≥15, Glasgow Coma Scale score of ≤8, and age of ≤8 years were independently associated with mortality. Conclusions. Young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries, after adjustment for severity of injury, young children may also have an independent increased risk for death compared with older children and adults. Providing forward-deployed medical staff with pediatric-specific equipment and training in the acute care of young children with severe traumatic injuries may improve outcomes in this population.",
keywords = "Combat, Mortality, Pediatric, Penetrating, Survival, Trauma",
author = "Matos, {Renee I.} and Holcomb, {John B.} and Charles Callahan and Spinella, {Philip C.}",
doi = "10.1542/peds.2008-1244",
pages = "e959--e966",
journal = "Pediatrics",
Matos, RI, Holcomb, JB, Callahan, C & Spinella, PC 2008, 'Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004', Pediatrics, vol. 122, no. 5, pp. e959-e966. https://doi.org/10.1542/peds.2008-1244
Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004. / Matos, Renee I.; Holcomb, John B.; Callahan, Charles et al.
In: Pediatrics, Vol. 122, No. 5, 11.2008, p. e959-e966.
T1 - Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004
AU - Matos, Renee I.
AU - Holcomb, John B.
AU - Callahan, Charles
AU - Spinella, Philip C.
N2 - Objective. The objective of this study was to determine whether age ≤8 y is an independent predictor of mortality in noncoalition trauma patients at a US combat support hospital. Methods. A retrospective chart review was conducted of 1132 noncoalition trauma patients who were admitted to a combat support hospital between December 2003 and December 2004. Data on age, severity of injury indices, and in-hospital mortality rates were analyzed. All variables that were associated with death on univariate analysis were analyzed by multivariate logistic regression to determine independent associations with mortality. Results. There were 38 young pediatric patients (aged ≤8 years) and 1094 older pediatric and adult patients (aged >8 years). Penetrating trauma accounted for 83% of all injuries. Young pediatric patients compared with older pediatric and adult patients had increased severity of injury indicated by decreased Glasgow Coma Scale score;increased incidence of hypotension, base deficit, and serum pH on admission; red blood cell transfusion amount; and increased injury severity scores on admission. Young pediatric patients compared with older pediatric and adult patients also had increased ICU lengths of stay (median 2 [interquartile range 0-5] vs median 0 [interquartile range 0-2] days) and in-hospital mortality rate (18% vs 4%), respectively. Multivariate logistic regression indicated that base deficit, injury severity score of ≥15, Glasgow Coma Scale score of ≤8, and age of ≤8 years were independently associated with mortality. Conclusions. Young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries, after adjustment for severity of injury, young children may also have an independent increased risk for death compared with older children and adults. Providing forward-deployed medical staff with pediatric-specific equipment and training in the acute care of young children with severe traumatic injuries may improve outcomes in this population.
AB - Objective. The objective of this study was to determine whether age ≤8 y is an independent predictor of mortality in noncoalition trauma patients at a US combat support hospital. Methods. A retrospective chart review was conducted of 1132 noncoalition trauma patients who were admitted to a combat support hospital between December 2003 and December 2004. Data on age, severity of injury indices, and in-hospital mortality rates were analyzed. All variables that were associated with death on univariate analysis were analyzed by multivariate logistic regression to determine independent associations with mortality. Results. There were 38 young pediatric patients (aged ≤8 years) and 1094 older pediatric and adult patients (aged >8 years). Penetrating trauma accounted for 83% of all injuries. Young pediatric patients compared with older pediatric and adult patients had increased severity of injury indicated by decreased Glasgow Coma Scale score;increased incidence of hypotension, base deficit, and serum pH on admission; red blood cell transfusion amount; and increased injury severity scores on admission. Young pediatric patients compared with older pediatric and adult patients also had increased ICU lengths of stay (median 2 [interquartile range 0-5] vs median 0 [interquartile range 0-2] days) and in-hospital mortality rate (18% vs 4%), respectively. Multivariate logistic regression indicated that base deficit, injury severity score of ≥15, Glasgow Coma Scale score of ≤8, and age of ≤8 years were independently associated with mortality. Conclusions. Young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries, after adjustment for severity of injury, young children may also have an independent increased risk for death compared with older children and adults. Providing forward-deployed medical staff with pediatric-specific equipment and training in the acute care of young children with severe traumatic injuries may improve outcomes in this population.
KW - Combat
KW - Pediatric
KW - Penetrating
KW - Survival
KW - Trauma
U2 - 10.1542/peds.2008-1244
DO - 10.1542/peds.2008-1244
SP - e959-e966
JO - Pediatrics
JF - Pediatrics
Matos RI, Holcomb JB, Callahan C, Spinella PC. Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004. Pediatrics. 2008 Nov;122(5):e959-e966. doi: 10.1542/peds.2008-1244
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1Department of Chemistry C.P.A. College, Bodinayakanur, Theni District, TamilNadu.
2Department of Chemistry, Madurai Kamaraj University, Madurai-625021. TamilNadu, India.
3Mother Teresa Women's University, Kodaikanal, Dindugal District. TamilNadu.
Determination of glucose is of enormous importance in the fields of biological, environmental and clinical analyses. In recent years, polymer modified metal oxides arrived a great consideration in the detection of glucose. In this study, we have developed a sensitive and selective non-enzymatic glucose sensor by using CuO NMO encapsulation with PEG (poly ethyleneglycol) nanocomposites. The loading content of PEG was incorporated with CuO by weight percentage (wt = 2, 4 & 6%). The fabricated CuO/PEG nanocomposites was utilized as a glucose sensor, it exhibit the tremendous electrocatalytic performances on oxidation of glucose. The electrocatalytic activity enhances with increasing the loading of PEG content. The sensor shows a low detection limit of 0.25 µM with a sensitivity of 113.8 µA mM-1 cm-2, good selectivity and stability. The CuO/PEG nanocomposites are hopeful for the advancement of cost-effective non-enzymatic glucose biosensors.
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| Celebrex. Celebrex has been designed for of patients with symptoms like pain and inflammation. This medicine should be taken by those with no allergic reactions of any kind .
Turmeric and its most active ingredient curcumin have gotten attention for their anti-inflammatory properties. We have heard from readers that this yellow spice allergic to plavix, is there a substitute used in curry .
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Diabetes not only affects daily health, but also puts those with the disease at greater risk for numerous secondary complications, including negative drug interactions, lower-extremity amputations, loss of vision, and teeth and gum problems. For these reasons, the healthcare areas of pharmacy, podiatry, optometry and dentistry – and those who work in them – are especially important in the lives of people with diabetes. They could mean the difference between a life free of complications and a life of unnecessary suffering.
The following four articles deal with these four healthcare areas and are intended to provide general education and to help those with diabetes avoid additional problems related to their disease.
Your Prescription For Good Health – Talk With Your Pharmacist. Those words were the theme of National Pharmacy Week from October 21-27.
Yet, not many people follow that advice. In fact, many consider pharmacists nothing more than men and women in lab coats who count out pills and funnel them from big bottles into smaller ones. But pharmacists today are certainly more than that.
Consumers should look to their pharmacist for medication counseling, including drug regimen reviews and drug interaction checks; coordination of patient care with physicians and other healthcare providers; and monitoring of side effects. Some pharmacists can also perform limited patient testing, such as cholesterol screening, glucose monitoring and blood pressure checks, for serious health-threatening problems. And few people are aware that 31 states even allow pharmacists to give shots to immunize patients against injury and illness.
Pharmacists are clearly unexploited members of the healthcare team, and taking more advantage of them could help patients both medically and financially.
Though medicines can improve the quality of life for millions of Americans, they can also do serious harm if not taken correctly. Americans consume more than 50 billion tablets each year. When taken as directed, they 're safe and effective. But they 're still serious medicine. Even though taking one 's medication properly is one of the best ways to avoid future healthcare costs, a survey shows that nearly half of consumers do not always read product labels, fewer than 40 percent are consulting pharmacists, and one-third are not aware of the risks sometimes associated with these medicines. As a result, each year, thousands of people end up in the hospital, fail to get better, and spend more money than they have to simply because they do not take their medication properly.
This is where highly trained pharmacists come in. Pharmacists typically have completed either a five-year Bachelor of Science in Pharmacy or a six-year Doctor of Pharmacy, and some even specialize in Nuclear Pharmacy, Pharmacotherapy, Psychiatric Pharmacy, Oncology Pharmacy, or Nutrition Support Pharmacy. This extensive training, which is focused on drugs and how they work, makes the pharmacist the most knowledgeable healthcare professional when it comes to medicines and their use. They are, in fact, medication experts.
In what may seem like a simple act of filling a prescription, pharmacists check patients' records to make sure that one prescription doesn't duplicate another or interact badly. They may also ask questions to monitor whether side effects are occurring and to prevent giving medications to which patients may be allergic. Pharmacists know about interactions with food, medicines, or dietary supplements that can affect how medicines work and can sometimes be dangerous. When picking up a new medicine, patients should ask if it will work safely with other prescription and nonprescription medicines and any herbal products they may be taking. Pharmacists often have access to drug interaction databases that can alert them to any dangers. Ginseng, for example, can lower blood sugar too much when mixed with certain diabetes medicines. The prescription blood thinner Coumadin taken with ginkgo biloba, an over-the-counter herbal remedy, can cause dangerous internal bleeding. Some foods can even cause the body to absorb certain medicines more quickly than expected and lead to an overdose. Even eating something as seemingly innocuous as onions can be a hazard if one is taking blood-thinning medication. Some combinations can even be fatal.
Because of the importance of the pharmacist as perhaps the last line of defense against medication errors and accidents, choosing a pharmacist should be a serious matter. When choosing a pharmacist, many people simply look for a pharmacy that is convenient, either close to home or work. But location is only one of the things to consider. Your pharmacist should be someone you know and trust, and you should give as much consideration to choosing him or her as you do to choosing a doctor. How accessible is the pharmacist? Is he or she easy to talk to and willing to hear your concerns? During what hours is the pharmacist available to answer your questions?
It is important to choose one pharmacist with whom you can establish an ongoing relationship. By choosing one pharmacy, a complete record of the medicines you take is in one place, making them easier to coordinate and manage. This way there will be less risk of duplicating medicine or having one prescription interact harmfully with another. This is especially important if you take a number of different medications.
Building a relationship with a pharmacist can also save you time and money. For example, you might ask your pharmacist if there is a generic version of the medication you take. These are products the Food and Drug Administration (FDA) has judged equivalent to the brand-name product, but they are usually less expensive than their brand-name counterparts. Your pharmacist can answer any questions concerning your use of these medications.
In some cases, a pharmacist might be able to help you with special circumstances, such as when you are taking care of an elderly relative. If you have aging parents who live nearby, you might ask, for example, if it is possible to deliver prescriptions to their home and send the bill to you.
Pharmacists can also be allies in overcoming problems with insurance coverage. While consumers also need to inquire of their employer and/or insurer about how their prescription coverage is designed, pharmacists can help identify those medications that are and are not covered. If you are having financial problems, your pharmacist may be able to refer you to a county or city agency or a manufacturer that assists residents with healthcare costs. Some local organizations will help members of the community on a short-term basis to get them through a rough spot.
Unfortunately, because of the increased volume of prescriptions, the increasing hassles of insurance coverage, and an apparent shortage of licensed pharmacists, overburdened pharmacists may sometimes be distracted from looking for or noticing all potentially problematic drug combinations for one customer as they rush to move on to the next customer. Indeed, studies have demonstrated that pharmacists sometimes give hazardous drug combinations to patients without warning. The possibility of such errors is greatly increased when patients purchase the conflicting products at different times or at different pharmacies. Taking a proactive stance as a patient by asking your pharmacist about interactions might cause him or her to take more time checking your specific medications.
Although pharmacists are indeed busy and under stress, they should never be too busy to answer patients ' questions and try to alleviate their concerns. In fact, some pharmacists have even begun to take their patients ' feelings into concern and have begun to set aside special rooms where they can consult with patients privately. As patients begin to become aware of the many services that highly trained pharmacists can provide, and as pharmacists begin to consider patients ' needs, a new type of relationship may be fostered between pharmacists and patients – a relationship that should be good for all involved. Although managing one 's healthcare is ultimately the responsibility of the patient, a knowledgeable, caring pharmacist can play a vital role in ensuring a positive outcome. Talking with your pharmacist may indeed be your prescription for better health.
Diabetes mellitus affects approximately 16 million Americans, or 5 percent of the population. Unfortunately, one-third of those with the disease remain undiagnosed and are not even aware they have it. Fully 15 percent of people with diabetes will develop an open sore on their feet at some time in their life. The consequences of these sores can be devastating. Diabetes is the leading cause of no traumatic lower-extremity amputations in the United States. Recent statistics reveal that there are over 86,000 lower-extremity amputations performed each year on people with diabetes. Foot disease in people with diabetes costs the nation more than $1 billion each year.
The causes of foot problems in people with diabetes are related to two factors. First and foremost, diabetes can cause nerve damage, called diabetic neuropathy, in the feet and legs. This leads to loss of feeling and loss of protective sensation, leaving people with diabetic neuropathy unable to feel injury to their feet. Even seemingly minor injuries, a pebble in their shoe or a scrape to their toes, are imperceptible to them. When an injury occurs, there is no pain response to get them to look at their feet and evaluate the problem; therefore, minor injuries can progress to major injury, infection, tissue loss, and amputation.
Secondly, diabetes can also affect the circulation in the feet and legs. Most commonly, people with diabetes develop calcifications within the arteries of the feet and legs. This usually starts in the small blood vessels of the toes and can progress higher into the legs. If an injury or open sore occurs, these people do not have adequate circulation to heal these wounds. With the combination of neuropathy, poor circulation, and an injury, it is easy to imagine why there are so many amputations in people with diabetes. However, if you have diabetes, there is every reason to be optimistic. It is estimated that two-thirds of these amputations can be prevented with appropriate foot care. Just because you have poor circulation or neuropathy, it does not mean that you are destined to have an amputation. It usually requires an "event" (some injury or sore on the foot) that leads to an infection that does 't heal. Consequently, there are very concrete self-management practices and professional evaluation and treatment protocols that can markedly reduce your risk of amputation.
The primary treatment in preventing foot disease in those with diabetes is keeping your blood sugar (glucose), blood pressure, and cholesterol under good control. It is a combination of these three factors that is directly responsible for the development of poor circulation and neuropathy. Good control of these factors can only be accomplished by consistent exercise, an appropriate diet, and taking prescribed medications properly. The effects of elevated blood sugar, high blood pressure, and cholesterol are cumulative. The longer these remain elevated, the greater the chance of developing neuropathy and poor circulation. Additionally, once you develop neuropathy or poor circulation, this is usually not reversible. So if you already have diabetes with neuropathy or poor circulation, self- management behaviors and professional care become increasingly more important.
All people with diabetes should develop daily self-management practices, even if they have no evidence of neuropathy or poor circulation. These practices begin with visually inspecting their feet daily. Particular attention should be paid to the area between the toes and to the bottoms of the feet. You are looking for open cuts, sores, redness, swelling, bruising, or anything else that wasn't there the day before. If there is evidence of these items, you should immediately contact your healthcare provider. Early detection and treatment are the keys to preventing amputations. The feet should be washed and dried thoroughly each day. Make sure that the area between the toes is completely dry. Make sure that you have properly fitting shoes and socks. The socks should be nonconstricting, as they can affect circulation. Shoes should have good arch support and a broad toe box area for maximum room. Shoes with laces are the most appropriate for substantial walking or standing. People with diabetes should never walk barefooted. Shoes are the single most important protection your feet can have and they can save limbs! Nails should be trimmed straight across. If you have thick or curved nails, you need to seek professional care from a podiatrist to treat these problems. Additionally, if you have corns or calluses, do not use over-the-counter corn or callus removers. These can cause chemical burns that can directly lead to infection. Seek professional podiatric care for these problems as well. Finally, if you smoke, quit. Smoking markedly decreases circulation to the feet increasing the risk of amputation significantly.
All people with diabetes should receive at least an annual comprehensive foot examination. This examination must include evaluation of your circulation, a comprehensive neurological examination, evaluation of the skin and nails for evidence of disease or problems, and an evaluation of your foot structure (looking for bunions, hammertoes, arch structure) and shoes. All of these components should be looked at comprehensively. Your primary care provider can perform this if he or she is adept at this type of comprehensive examination. If not, you will be referred to a podiatrist to have this examination performed. If there is a problem with any of the elements of the comprehensive foot examination, your podiatrist may determine that you require periodic "preventative foot care." This may include trimming of nails, trimming of corns and calluses, and shoe inserts or custom-made shoes to remove pressure areas and prevent them from developing open sores. Lastly, take every opportunity for regular professional inspection of your feet. When you see your primary care provider for your blood sugar, blood pressure, and cholesterol checks, take your shoes and socks off! This will remind your primary care provider to take a look at your feet. Remember, early detection and treatment are the keys to amputation prevention.
If you develop an open sore on your feet, immediate attention is required. The vast majority of wounds can be successfully treated and healed with appropriate medical attention. Most wounds require debridement (removal of devitalized or dead tissue) and off-weighting (removing pressure on the wound). Additionally, if the wound is infected, treatment may require oral or intravenous antibiotics. Only providers well-versed in treating diabetic wounds should perform this.
Recent advancements in medical technology make it possible to treat and heal complex diabetic wounds that previously were untreatable. Regranex ® (Becaplermin) Gel 0.01%is a topically applied diabetic wound healing agent. It is a genetically engineered platelet-derived factor, which can actively stimulate the body to form new tissue to heal these wounds. It works by stimulating migration of cells to the wound site, encouraging the body to form new tissue to heal the wound. Other advances in medical technology are in the area of skin substitutes. Products include Apligraf ® and Dermagraft ®.Both of these products are skin substitutes that are placed over diabetic wounds to act as a lattice or scaffolding for the migration of cells to heal the wound. These dressings require surgical placement to the wound by a foot-care specialist. Additionally, wound debridement and off-weighting are essential to the successful use of any of these newer wound healing technologies. Finally, because most wounds will heal with conventional debridement and off-weighting, these products are medically indicated only after a period of conventional wound treatment has been attempted.
People with diabetes are at a two-and-a-half to four times greater risk of amputation than the general population. However, fully two-thirds of all amputations in people with diabetes are preventable. Paying appropriate attention to control of blood sugar, blood pressure, and cholesterol is the first step in amputation prevention. Next, practicing self-management behaviors is the key to prevention and early detection of foot wounds. Lastly, annual comprehensive professional foot examinations and regular treatment are essential to preventing amputations. By adhering to these principles, people with diabetes can lead healthy, productive, and fulfilling lives and can have "feet that last a lifetime"!
Ross E. Taubman, DPM, is a nationally recognized podiatrist practicing in Clarksville, Maryland. Dr. Taubman serves on the American Podiatric Medical Association 's Board of Trustees and chairs the APMA Diabetes Advisory Committee. He was recently appointed to the Amputee Coalition 's Medical Advisory Committee.
• Nearly all patients who have type 1 diabetes for about 20 years will have evidence of diabetic retinopathy.
• As many as 21 percent of people with type 2 diabetes have retinopathy when they are first diagnosed with diabetes, and most will eventually develop some degree of retinopathy.
• In the United States, diabetes is responsible for 8 percent of legal blindness, making it the leading cause of new cases of blindness in adults 20-74 years of age. Each year, from 12,000 to 24,000 people lose their sight because of diabetes.
• Glaucoma, cataract and corneal disease are more common in people with diabetes and contribute to the high rate of blindness.
Can Aspirin Save Your Sight?
Researchers who study retinopathy say the condition appears to be caused in part by hundreds of microscopic blood clots that form in the eye.
The group's research shows evidence that blood clots may explain loss of vision in people with diabetes. They found four times as many blood clots in the eyes of people with diabetes as in people without the disease. As the number of clots increases, the clots block blood flow to the retina, setting into motion a series of changes in the eye that lead to blindness. This means that aspirin may play a new role in retinopathy. For aspirin therapy to be effective, however, it must begin in the early stages of the disease.
Approximately 15.7 million people, or 5.9 percent of the United States population, have diabetes. While an estimated 10.3 million have been diagnosed, approximately 5.4 million people do not know they have the disease. Many become aware only when they develop one of diabetes ' life-threatening complications.
Diabetes is the seventh leading cause of death (sixth leading cause of death by disease) in the United States. Death certificate data indicates that diabetes contributed to 193,140 deaths in 1996.It is a chronic disease that has no cure, and in many cases it causes blindness.
The leading cause of diabetes-related blindness is retinopathy. Between 12,000 and 24,000 new cases are reported in people ages 20-74 every year. The term "retinopathy " is used for abnormalities of the small blood vessels of the retina caused by the disease, and it is a common complication associated with both type 1 and type 2 diabetes.
• People with type 1 diabetes should see their eye care professional annually for a dilated eye examination, beginning five years after the onset of diabetes.
• Women with type 1 who are pregnant should have a comprehensive eye examination in the first trimester and close follow-up throughout pregnancy.
• Patients with type 2 diabetes should see their eye care professional for a dilated eye examination shortly after diagnosis of diabetes and annually thereafter.
• Because diabetes is a multi-system chronic disease, it is important that all healthcare professionals who make up the "team " be kept informed of any health and treatment changes as soon as they occur, even when they are separate from their particular specialty.
Diabetic retinopathy is treatable. Your eye care professional may suggest laser surgery in which a strong light beam is aimed onto the retina to shrink the abnormal vessels. This surgery has been proved to reduce the risk of severe vision loss from this type of diabetic retinopathy by 90 percent. If you have macular edema, laser surgery may also be used. In this case, the laser beam is used to seal or destroy the leaking blood vessels. Another procedure, called a vitrectomy, cleans blood from the eye. Unfortunately, laser surgery often cannot restore vision that has already been lost. That is why detecting diabetic retinopathy early is the best way to prevent vision loss.
Retinopathy is not totally treatable, but your risk can be greatly reduced. The Diabetes Control and Complications Trial (DCCT) showed that better control of blood sugar levels slows the onset and progression of retinopathy and lessens the need for laser surgery for severe retinopathy.
If you have diabetes, you are also at risk for other diabetic eye diseases. Studies show that you are twice as likely to get a cataract as a person who does not have the disease. Also, cataracts develop at an earlier age in people with diabetes. Cataracts can usually be treated by surgery.
In ideal circumstances, patients with diabetes will have their disease under good control and be monitored frequently by a healthcare team knowledgeable in the care of diabetes. If you have diabetes, be sure to have your eyes checked regularly by a medical professional, and be sure to tell him or her that you have diabetes.
Diabetes mellitus is a serious disease that requires the attention of both patients and healthcare providers. It is important to monitor health on a regular basis, including measuring blood sugar, blood pressure and cholesterol. Sometimes, caring for the mouth gets overlooked in the process of trying to control all of these other problems. Yet, diabetes can affect the oral cavity, and proper care of the mouth can actually help patients achieve better glycemic control.
Diabetes-related problems that can occur in the mouth include burning sensations known as burning mouth syndrome, overgrowth of gum (gingival) tissue, abnormal wound healing, dental decay, gingivitis, periodontal disease and fungal infections. Some individuals with diabetes notice a fruity (acetone) breath on occasion. Others may notice frequent dry mouth or a change in the thickness of their saliva. These findings are associated with a number of changes that occur related to diabetes, such as excessive loss of fluids due to frequent urination, the altered ability to respond to infections, changes in very small blood vessels, and increased glucose concentrations in the saliva.
Of particular concern to dentists and dental hygienists are the effects of diabetes on the health of the gums and periodontal tissues. People with diabetes are more susceptible to more severe gum disease (also called periodontal disease).
Periodontal disease is an infection of the tissues that hold the teeth in place. In its early stages, gum disease can cause the gums to become reddened and swollen and to sometimes bleed during tooth brushing. This disease, called gingivitis, can usually be reversed with regular cleaning (prophylaxis) by a dental health professional and diligent daily tooth brushing and flossing.
If untreated, gum disease may lead to the gums pulling away from the teeth and destruction of the fibers and bone that hold the teeth in the jaws. This disease process, which is called periodontitis, can in the most severe cases lead to the loss of some or all of the teeth. Periodontal disease can be aggravated by poor glycemic control. The increased levels of glucose in the blood and saliva may lead to a more severe infection of the gums by impairing the body 's ability to respond to periodontal disease-causing bacteria and their toxic products and by weakening the body 's ability to heal.
Common signs of periodontal disease are gums that bleed easily; red, swollen or tender gums; gums that have pulled away from the teeth; pus between the gums when the gums are pressed; persistent bad breath or bad taste in the mouth; permanent teeth that are loose or separating; any change in the way the teeth fit together when the patient bites; or any change in the fit of partial dentures. However, most people do not experience pain with periodontal disease, and some people can have periodontal disease and not have any of these symptoms.
If you have diabetes, it is important to perform daily mouth care as recommended by your dentist or dental hygienist. A daily regimen of brushing teeth to remove plaque after eating and flossing at least once each day is advised. Keeping dental plaque at a minimal level will help reduce the likelihood of dental decay and periodontal disease. Your dentist or dental hygienist can demonstrate how to brush and floss properly and recommend products that will assist you in controlling dental plaque.
Everybody likes to snack between meals. If you prefer to snack, choose foods that are low in sugar and fat to avoid the risk of dental decay and to maintain glycemic control.
Ask your dentist or dental hygienist to teach you how to perform a mouth self-examination. Then examine your mouth on a monthly basis. Contact your oral health professional if you notice signs of infection, such as sore, swollen or bleeding gums or mouth ulcers.
It is recommended that individuals with diabetes not smoke or use chewing tobacco products. If you do use smoking products, we encourage you to reduce your intake and quit. Giving up nicotine products is difficult, but your dentist and dental hygienist can help you by offering a smoking cessation program.
Another thing that you can do to care for your mouth is schedule regular visits with your dentist and dental hygienist. These oral health professionals can monitor and treat changes that may be occurring in your mouth due to diabetes. You may be asked to schedule appointments as frequently as every three months depending upon the extent of changes that have occurred in your mouth and your level of glycemic control.
When visiting the dentist and dental hygienist, it is important to update them on your diabetes health status. Make sure that they know your current symptoms as well as the medications you are taking, the dosages and how often you take them. If you use insulin, inform them of the type, how often it is taken and when peak insulin activity occurs. It is also helpful for the dentist and dental hygienist to know when you had your last meal and the type of carbohydrates consumed.
In terms of your diabetes control status, tell your oral health professionals how often you have glucose testing and what your latest A1c and self-monitored blood glucose levels were. Also, inform them of the frequency of hypoglycemic episodes.
Depending on the type of oral health treatment needed, you may be scheduled for a morning appointment. Or, depending on the type of insulin or oral diabetes medications you are taking, the dental health professional may schedule your appointment before or after the time of your diabetes medicine 's peak activity to help avoid hypoglycemia. If you require a longer appointment for a particular dental procedure, bring a snack and your medications. The dentist or dental hygienist can plan a short break to make sure that you are comfortable and not experiencing hypoglycemia.
Finally, tell your dentist or dental hygienist of any changes you have noticed in your mouth since the last appointment. Identifying oral health problems early will help ensure that appropriate treatment is provided and that your glycemic control can be maintained.
Individuals with diabetes need to pay attention to their oral health. Dental professionals can help you develop a program that will enable you to maintain a healthy mouth, which will assist you in achieving glycemic control. Talk to your dentist and dental hygienist today.
JoAnn R. Gurenlian, RDH, PhD,is the owner of Gurenlian & Associates, which offers continuing education and consulting services o healthcare professionals. In addition to having clinical experience working in periodontal, general, orthodontic and pediatric practices, Dr. Gurenlian is an internationally recognized author, research consultant and speaker.
Dr. George W. Taylor is an associate professor at the University of Michigan School of Dentistry. He conducts research to study relationships between oral diseases and other systemic disease. He also practices and teaches clinical general dentistry.
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Home / News & opinion / News / June / The chewing gum test that could prevent blindness and save lives
Researchers from the University of Sydney's Save Sight Institute have reported a simple 'chewing gum' test that could be the key to identifying and treating Giant Cell Arteritis (GCA), a disease that causes blindness, strokes and death.
GCA is caused by inflammation of the lining of arteries in the head, most commonly in the temples, which restricts arterial blood flow. Symptoms can include headaches, scalp tenderness, jaw pain and vision problems. GCA is most commonly observed among people aged 50 and older.
The condition can be hard to diagnose because early symptoms are often subtle and found in a range of other diseases. For example, claudication of the jaw muscles (cramping pain caused by inadequate arterial blood flow) is a specific indicator of GCA, but there is no current clinical test to differentiate it from other causes of jaw pain. GCA patients with jaw claudication have a higher risk of permanent visual loss, but this symptom isn't commonly reported because many people favour soft food as they age.
Save Sight Institute researchers have developed a straightforward 'chewing gum' test designed to unmask this important jaw symptom. By chewing gum at a rate of one chew per second the test can reproduce a patient's telltale pain, prompting further investigation with a blood test and an arterial biopsy to confirm diagnosis.
In a letter published in this month's New England Journal of Medicine, researchers presented two cases where the chewing gum test allowed clinicians to better characterise jaw pain, confirm a diagnosis and successfully treat both patients.
GCA is one of the most common causes of blindness in older people. Not only can it send you blind, but it can kill you.
Professor Peter McCluskey
"GCA is one of the most common causes of blindness in older people," says Dr Peter McCluskey, Director of the Save Sight Institute and a professor of clinical ophthalmology at the University of Sydney. "Not only can it send you blind, but it can kill you. It also can affect vision extremely quickly. If one eye is already involved, around one third of people go blind in the other eye within a day, another third within a week and the remaining third within a month. It's a very serious condition which requires rapid and correct diagnosis."
The research team is doing further research to validate the chewing gum test, and will incorporate dentistry, rheumatology and nuclear medicine specialist researchers.
Fast facts: factors can raise the risk of developing giant cell arteritis
Age: Giant cell arteritis affects adults only, and rarely those under 50. Most people with this condition first experience warning signs between the ages of 70 and 80
Sex: Women are about twice as likely to develop the condition than men
Race and geographic region: Giant cell arteritis is most common among white-skinned people from northern Europe
Polymyalgia rheumatic: Having polymyalgia rheumatica puts you at increased risk of developing giant cell arteritis
Family history: The condition sometimes runs in families.
How to support more research like the 'chewing gum' test
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In a world first, Australian leaders in corneal bioengineering have collaborated to form BIENCO, a consortium that will develop bioengineered eye tissue to treat corneal blindness.
Study advances knowledge of what happens in our cells after exercise
An international team of researchers has developed a new approach to pinpoint which proteins in our cells are most critical for increasing sugar absorption after exercise - an important benefit of exercise that can help maintain good blood sugar levels.
Two-year follow up shows delaying umbilical cord clamping saves babies' lives
An Australian-led study finds that aiming to wait just 60 seconds to clamp the umbilical cord of very premature babies at birth continues to have benefits two years on - decreasing the child's risk of death or major disability.
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This formula is specifically designed for pets with lost mobility and joint paindue to hip dysplasia and osteoarthritis. The combined ingredients help to decrease joint pain and inflammation while assisting with the rehabilitation of damaged cartilage, renewal of synovial (joint) fluids, and the reinforcement of pliable and flexible joint tissue. Combined with the Whole Body Health benefits of Virgin Organic Coconut Oil.
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by Weizmann Institute of Science
A new computer algorithm can predict in the early stages of pregnancy, or even before pregnancy has occurred, which women are at a high risk of gestational diabetes, according to a study by researchers at the Weizmann Institute of Science reported today in Nature Medicine. The study analyzed data on nearly 600,000 pregnancies available from Israel's largest health organization, Clalit Health Services. Based on these predictions, it may be possible to prevent gestational diabetes using nutritional and lifestyle changes.
"Our ultimate goal has been to help the health system take measures so as to prevent diabetes from occurring in pregnancy," says senior author Prof. Eran Segal of the Computer Science and Applied Mathematics and the Molecular Cell Biology Departments.
Gestational diabetes is characterized by high blood sugar levels that develop during pregnancy in women who did not previously have diabetes. It occurs in 3 to 9 percent of all pregnancies and is fraught with risks for both mother and baby. Typically, gestational diabetes is diagnosed between the 24th and 28th weeks of pregnancy, with the help of a glucose tolerance test in which the woman drinks a glucose solution and then undergoes a blood test to see how quickly the glucose is cleared from her blood.
In the new study, Segal and colleagues started out by applying a machine learning method to Clalit's health records on some 450,000 pregnancies in women who gave birth between 2010 and 2017. Gestational diabetes had been diagnosed by glucose tolerance testing in about 4 percent of these pregnancies. After processing big data—an enormous dataset made up of more than 2,000 parameters for each pregnancy, including the woman's blood test results and her and her family's medical histories—the scientists' algorithm revealed that nine of the parameters were sufficient to accurately identify the women who were at a high risk of developing gestational diabetes. The nine parameters included the woman's age, body mass index, family history of diabetes and results of her glucose tests during previous pregnancies (if any).
Next, to make sure that the nine parameters could indeed accurately predict the risk of gestational diabetes, the researchers applied them to Clalit's health records on about 140,000 additional pregnancies that had not been part of the initial analysis. The results validated the study's findings: The nine parameters helped to accurately identify the women who ultimately developed gestational diabetes.
These findings suggest that by having a woman answer just nine questions, it should be possible to tell in advance whether she is at a high risk of developing gestational diabetes. And if this information is available early on—in the early stages of pregnancy or even before the woman has gotten pregnant—it might be possible to reduce her risk of diabetes through lifestyle measures such as exercise and diet. On the other hand, women identified by the questionnaire as being at a low risk of gestational diabetes may be spared the cost and inconvenience of the glucose testing.
Click here to access the self-assessment questionnaire for gestational diabetes.
In more general terms, this study has demonstrated the usefulness of large human-based datasets, specifically electronic health records, for deriving personalized disease predictions that can lead to preventive and therapeutic measures.
Prenatal antidepressant use may up risk for gestational diabetes
More information: Nitzan Shalom Artzi et al. Prediction of gestational diabetes based on nationwide electronic health records, Nature Medicine (2020). DOI: 10.1038/s41591-019-0724-8
Journal information: Nature Medicine
Provided by Weizmann Institute of Science
Citation: Algorithm can predict gestational diabetes using nutritional and lifestyle changes (2020, January 14) retrieved 21 January 2020 from https://medicalxpress.com/news/2020-01-algorithm-gestational-diabetes-nutritional-lifestyle.html
Blood test may identify gestational diabetes risk in first trimester
Pregnant smokers at higher risk for gestational diabetes
Pregnant mom's high blood sugar affects kids at ages 10 to 14
Daily folic acid supplement may reduce risk of gestational diabetes
High sugar levels during pregnancy could lead to childhood obesity
Research shows real risks associated with cannabis exposure during pregnancy
When pregnant moms are stressed out, babies' brains suffer
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London: Researchers have identified a bacterial protein that resides on human skin and has the potential to protect individuals from several skin diseases including atopic dermatitis, psoriasis and skin cancer.
The skin bacterium -- Propionibacterium acnes -- is a commonly known bacteria that resides on human skin and takes its name from being first discovered on a patient with severe acne.
But whether it causes acne is uncertain -- it may have been present merely because it is so common, the researchers said.
The study found that the propionibacterium acnes secretes a protein called RoxP. This protein protects against what is known as oxidative stress, a condition in which reactive oxygen species damage cells.
"This protein is important for the bacterium's very survival on our skin. The bacterium improves its living environment by secreting RoxP, but in doing so it also benefits us," said Rolf Lood from Lund University in Sweden.
The protein has an equally strong effect on dangerous oxygen species as known antioxidants such as vitamin C and vitamin E, the study stated.
A common cause of oxidative stress -- considered to be a contributing factor in several skin diseases, including atopic dermatitis, psoriasis and skin cancer -- on the skin is ultra-violet (UV) radiation from the sun.
The researchers plan to conduct further studies involving both humans and animal models.
"If the study results are positive, they could lead to the inclusion of RoxP in sunscreens and its use in the treatment of psoriasis and atopic dermatitis," Lood added, in the paper published in the journal Scientific Reports.
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Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma
V. Porciatti, B. Falsini, S. Brunori, A. Colotto, G. Moretti
Pattern electroretinograms (PERGs) in response to 8.3 Hz alternating gratings (16.6 rev/sec) of different spatial frequencies were recorded in normal subjects as well as in patients affected by early glaucoma and ocular hypertension. In normal subjects the PERG response is spatially tuned, with a maximum at about 1.5 cycles/deg and attenuation at higher and lower spatial frequencies. In all cases of early glaucoma and in the great majority of cases of ocular hypertension the PERG was reduced, as compared with that of normal subjects, mainly in the medium range of spatial frequencies (at which the PERG has its maximal amplitude).
Documenta Ophthalmologica
ocular hypertension
pattern electroretinogram
spatial frequency
Dive into the research topics of 'Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma'. Together they form a unique fingerprint.
Ocular Hypertension Medicine & Life Sciences 100%
Glaucoma Medicine & Life Sciences 75%
Porciatti, V., Falsini, B., Brunori, S., Colotto, A., & Moretti, G. (1987). Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma. Documenta Ophthalmologica, 65(3), 349-355. https://doi.org/10.1007/BF00149941
Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma. / Porciatti, V.; Falsini, B.; Brunori, S.; Colotto, A.; Moretti, G.
In: Documenta Ophthalmologica, Vol. 65, No. 3, 03.1987, p. 349-355.
Porciatti, V, Falsini, B, Brunori, S, Colotto, A & Moretti, G 1987, 'Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma', Documenta Ophthalmologica, vol. 65, no. 3, pp. 349-355. https://doi.org/10.1007/BF00149941
Porciatti V, Falsini B, Brunori S, Colotto A, Moretti G. Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma. Documenta Ophthalmologica. 1987 Mar;65(3):349-355. https://doi.org/10.1007/BF00149941
Porciatti, V. ; Falsini, B. ; Brunori, S. ; Colotto, A. ; Moretti, G. / Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma. In: Documenta Ophthalmologica. 1987 ; Vol. 65, No. 3. pp. 349-355.
@article{8ec16a0840474f8cac1b5d17efc5fd33,
title = "Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma",
abstract = "Pattern electroretinograms (PERGs) in response to 8.3 Hz alternating gratings (16.6 rev/sec) of different spatial frequencies were recorded in normal subjects as well as in patients affected by early glaucoma and ocular hypertension. In normal subjects the PERG response is spatially tuned, with a maximum at about 1.5 cycles/deg and attenuation at higher and lower spatial frequencies. In all cases of early glaucoma and in the great majority of cases of ocular hypertension the PERG was reduced, as compared with that of normal subjects, mainly in the medium range of spatial frequencies (at which the PERG has its maximal amplitude).",
keywords = "glaucoma, ocular hypertension, pattern electroretinogram, spatial frequency",
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T1 - Pattern electroretinogram as a function of spatial frequency in ocular hypertension and early glaucoma
AU - Porciatti, V.
AU - Falsini, B.
AU - Brunori, S.
AU - Colotto, A.
AU - Moretti, G.
N2 - Pattern electroretinograms (PERGs) in response to 8.3 Hz alternating gratings (16.6 rev/sec) of different spatial frequencies were recorded in normal subjects as well as in patients affected by early glaucoma and ocular hypertension. In normal subjects the PERG response is spatially tuned, with a maximum at about 1.5 cycles/deg and attenuation at higher and lower spatial frequencies. In all cases of early glaucoma and in the great majority of cases of ocular hypertension the PERG was reduced, as compared with that of normal subjects, mainly in the medium range of spatial frequencies (at which the PERG has its maximal amplitude).
AB - Pattern electroretinograms (PERGs) in response to 8.3 Hz alternating gratings (16.6 rev/sec) of different spatial frequencies were recorded in normal subjects as well as in patients affected by early glaucoma and ocular hypertension. In normal subjects the PERG response is spatially tuned, with a maximum at about 1.5 cycles/deg and attenuation at higher and lower spatial frequencies. In all cases of early glaucoma and in the great majority of cases of ocular hypertension the PERG was reduced, as compared with that of normal subjects, mainly in the medium range of spatial frequencies (at which the PERG has its maximal amplitude).
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JO - Documenta Ophthalmologica
JF - Documenta Ophthalmologica
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BACKGROUND: Degludec is an ultralong-acting, once-daily basal insulin that is approved for use in adults, adolescents, and children with diabetes. Previous open-label studies have shown lower day-to-day variability in the glucose-lowering effect and lower rates of hypoglycemia among patients who received degludec than among those who received basal insulin glargine. However, data are lacking on the cardiovascular safety of degludec.
METHODS: We randomly assigned 7637 patients with type 2 diabetes to receive either insulin degludec (3818 patients) or insulin glargine U100 (3819 patients) once daily between dinner and bedtime in a double-blind, treat-to-target, event-driven cardiovascular outcomes trial. The primary composite outcome in the time-to-event analysis was the first occurrence of an adjudicated major cardiovascular event (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) with a prespecified noninferiority margin of 1.3. Adjudicated severe hypoglycemia, as defined by the American Diabetes Association, was the prespecified, multiplicity-adjusted secondary outcome.
RESULTS: Of the patients who underwent randomization, 6509 (85.2%) had established cardiovascular disease, chronic kidney disease, or both. At baseline, the mean age was 65.0 years, the mean duration of diabetes was 16.4 years, and the mean (±SD) glycated hemoglobin level was 8.4±1.7%; 83.9% of the patients were receiving insulin. The primary outcome occurred in 325 patients (8.5%) in the degludec group and in 356 (9.3%) in the glargine group (hazard ratio, 0.91; 95% confidence interval, 0.78 to 1.06; P<0.001 for noninferiority). At 24 months, the mean glycated hemoglobin level was 7.5±1.2% in each group, whereas the mean fasting plasma glucose level was significantly lower in the degludec group than in the glargine group (128±56 vs. 136±57 mg per deciliter, P<0.001). Prespecified adjudicated severe hypoglycemia occurred in 187 patients (4.9%) in the degludec group and in 252 (6.6%) in the glargine group, for an absolute difference of 1.7 percentage points (rate ratio, 0.60; P<0.001 for superiority; odds ratio, 0.73; P<0.001 for superiority). Rates of adverse events did not differ between the two groups.
N Engl J Med. 2017 Aug 24;377(8):723-732.
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