Baseline differences in A1C explain apparent differences in efficacy of sitagliptin, rosiglitazone and pioglitazone.

AIM: Published studies of patients treated with rosiglitazone or pioglitazone have reported greater reductions in HbA1c (A1C) than studies of patients treated with sitagliptin. However, studies of thiazolidinediones tended to enroll patients with higher baseline A1C levels. This meta-analysis investigates the relationship between baseline A1C and perceived efficacy of treatment. METHODS: This report describes a Bayesian random effects analysis of 23 published studies. We constructed a random effects model including a factor adjusting for between-study differences in baseline A1C levels. RESULTS: The random effects model correctly predicts post-treatment A1C levels from baseline A1C within a 95% confidence interval (CI) for each of the 23 studies included in the meta-analysis. After applying the model to adjust for differences in baseline A1C, we found that the difference in efficacy between rosiglitazone and sitagliptin was not significantly different from zero (0.12; 95% CI -0.09 to 0.34). Similarly, no significant differences are observed between the effects of pioglitazone and sitagliptin (0.01; 95% CI -0.21 to 0.22) or between rosiglitazone and pioglitazone (0.11; 95% CI -0.37 to 0.146). When baseline values are omitted from the Bayesian model, the findings suggest that rosiglitazone is superior to pioglitazone or sitagliptin. CONCLUSIONS: These results illustrate the necessity for careful application of appropriate methodology when comparing results of different studies. When between-study differences in treatment effects are adjusted for baseline differences, then the findings suggest that none of the treatments has an effect that is superior to any of the other treatments.

Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature.

We conducted a systematic literature review and analysis of programs for evaluating swallowing in order to prevent aspiration pneumonia. This article derives from an evidence report on diagnosis and treatment of swallowing disorders (dysphagia) in acute-car stroke patients prepared by us as an Evidence-based Practice Center (EPC) under contract to the U.S. Agency for Healthcare Research and Quality (AHRQ). Available evidence on the diagnosis and treatment of dysphagia for preventing pneumonia is limited. We found reported pneumonia rates in one historical controlled study of a program using bedside exams (BSE) for acute stroke patients; one uncontrolled case series study of acute stroke patient-reporting of swallowing difficulty; one controlled case series study of videofluoroscopic study of swallowing (VFSS) for acute stroke patients; and one historical controlled study of fiberoptic endoscopic examination of swallowing (FEES) for patients referred for swallowing evaluation in rehabilitation centers. Comparing these results with historical controls indicates that implementation of dysphagia programs is accompanied by substantial reductions in pneumonia rates. While all these methods appeared effective, the small sizes of available studies did not allow determination of the relative efficacy of BSE, VFSS, or FEES.

Activation of protein kinase C induces gamma-aminobutyric acid type A receptor internalization in Xenopus oocytes.

The inhibition of gamma-aminobutyric acid (GABA)-gated chloride currents by the protein kinase C (PKC) activator 4beta-phorbol 12-myristate 13-acetate (PMA) was investigated using recombinant human GABAA receptors expressed in Xenopus oocytes. PMA (5 nM) reduced the GABA response in oocytes expressing the alpha1 beta2 gamma2L receptor construct, as measured by the two-electrode voltage-clamp method. GABA responses declined to approximately 25% of their pretreatment value within 45 min. GABA responses in oocytes expressing a receptor construct from which the known PKC phosphorylation sites were absent, alpha1 beta2(S410A), were comparably inhibited. Phorbol 12-monomyristate (PMM; 5 nM), which does not activate PKC, did not alter the GABA response in either construct, while the PKC inhibitor calphostin C (0.5 microM) prevented the PMA effect. To further investigate PMA inhibition of the GABA response, a GABAA receptor alpha1 subunit/green fluorescent protein (GFP) chimera (alpha1GFP) was used to visualize GABAA receptor distribution. Similar to the wild type constructs, PMA robustly decreased GABA responses in oocytes expressing alpha1GFP beta2 gamma2L and alpha1GFP beta2(S410A) receptor constructs. Following PMA treatment, GFP fluorescence in the oocyte plasma membrane was decreased to approximately 45% of the pretreatment values indicating GABAA receptor internalization. This effect of PMA was prevented by calphostin C and was not produced by PMM. Experiments with bd24, a monoclonal antibody which recognizes an extracellular epitope of the alpha1 subunit, were used to demonstrate that PMA, but not PMM, decreases alpha1 subunit immunoreactivity in the plasma membrane of intact oocytes expressing the alpha1 beta2 gamma2L construct, thus confirming the results obtained with the chimeric receptor. It is concluded that, in Xenopus oocytes, PMA induces an internalization of the GABAA receptor through PKC-mediated phosphorylation of an unidentified protein(s) and that this contributes to the decrease in electrophysiological responses to GABA following PKC activation.

Direct channel-gating and modulatory effects of triiodothyronine on recombinant GABA(A) receptors.

We have previously shown that triiodothyronine (T3) inhibits gamma-aminobutyric acid type A (GABA(A)) receptors in synaptoneurosomes and transfected cells. To further characterize this phenomenon, the effect of T3 on recombinant GABA(A) receptors expressed in Xenopus oocytes was investigated using the two-electrode voltage-clamp method. T3 inhibited GABA-gated chloride currents in a non-competitive manner and yielded an IC50 of 7.3 +/- 0.8 microM in oocytes coexpressing alpha1beta2gamma2L receptor subunits. T3 had no inhibitory effect on alpha6beta2gamma2L or beta2gamma2L receptor constructs, indicating that the alpha1 subunit imparts T3 sensitivity to the receptor. In addition to the inhibitory effect of T3 on GABA responses, T3 alone induced a current in oocytes expressing alpha1beta2gamma2L, alpha6beta2gamma2L and beta2gamma2L constructs. This current displayed a reversal potential identical to that of GABA-gated chloride currents, and was blocked by picrotoxin (10 microM), but not by bicuculline (50 microM), indicating that T3 gates the chloride channel by binding to a site other than the GABA-binding site. The direct channel-gating action of T3 was concentration-dependent, with an EC50 of 23 +/- 5 microM. The actions of T3 are unique in that T3 acts as a noncompetitive antagonist in the presence of GABA but can directly gate the chloride channel in the absence of GABA.

Effects of PKC activation and receptor desensitization on neurosteroid modulation of GABA(A) receptors.

The effect of calcium-phospholipid-dependent protein kinase (PKC) activation on neurosteroid modulation of the GABA(A) receptor was examined in Xenopus oocytes expressing human recombinant alpha1beta2gamma2L GABA(A) receptors. GABA-gated chloride currents were measured using the two-electrode voltage-clamp technique. The peak amplitude of GABA-gated chloride currents was reduced by the PKC activator phorbol 12-myristate 13-acetate (PMA), but not by the inactive analog phorbol 12-mono-myristate (PMM). This effect of PMA was inhibited by the protein kinase inhibitor staurosporine. To investigate whether the activation of PKC could alter neurosteroid modulation of the GABA(A) receptor, the effect of PMA was studied on the positive allosteric modulatory steroid 3alpha,21-dihydroxy-5alpha-pregnan-20-one (THDOC) and the negative modulatory neurosteroid pregnenolone sulfate (PS). THDOC potentiation of GABA-gated chloride currents was found to be increased by approximately 120% following PMA treatment, while PS inhibition was not affected. The increase in THDOC potentiation by PMA was blocked by staurosporine. No change in THDOC potentiation was observed following PMM treatment. The enhancement of THDOC potentiation following PMA treatment was not due to a shift in the GABA EC50. In addition to inhibiting the peak amplitude of the GABA response, PMA treatment resulted in non-desensitizing GABA responses. Similarly, GABA responses of receptors which had been desensitized with prolonged GABA application also showed a reduction in peak amplitude and reduced desensitization. THDOC potentiation of desensitized receptors was enhanced approximately 70% with respect to non-desensitized receptors. The present results demonstrate that protein phosphorylation and receptor desensitization alter modulation of the GABA(A) receptor complex by some neurosteroids.

In vitro binding of synaptic vesicles to the synaptic plasma membrane: lack of effect of beta-bungarotoxin.

To help characterize the mechanisms of neurotransmitter release, and the role of the specific neurotoxin beta-bungarotoxin in inhibiting release, the interaction of synaptic vesicles with the synaptic plasma membrane was investigated using two in vitro systems. Binding of radiolabeled synaptic vesicles to immobilized synaptic plasma membrane was specific, protein-dependent, and modulated by phosphorylation of membrane proteins. Stimulation of phosphorylation by phorbol ester increased binding, and reduction of phosphorylation by alkaline phosphatase or staurosporine reduced binding. beta-Bungarotoxin did not alter basal binding of synaptic vesicles to synaptic plasma membrane, nor did it affect the increase in binding induced by phorbol esters. Under conditions which stimulate acetylcholine release from synaptosomes, both phorbol ester and 4-aminopyridine caused an increase in attachment of the synaptic vesicle marker protein synaptophysin to the synaptic plasma membrane. beta-Bungarotoxin did not alter the change in localization of synaptophysin induced by either drug, under conditions in which it inhibits ACh release induced by 4-aminopyridine. It is concluded that beta-bungarotoxin inhibition probably does not occur at the level of the interaction of the synaptic vesicle and the synaptic plasma membrane, but occurs at an earlier stage in the neurotransmission process.

Specificity of action of beta-bungarotoxin on acetylcholine release from synaptosomes.

Presynaptically acting phospholipase A2 (PLA2) neurotoxins such as beta-bungarotoxin (beta-BuTX) specifically modify the release of acetylcholine (ACh) in the periphery, whereas in the central nervous system (CNS) the release of other neurotransmitters such as norepinephrine (NE) and serotonin (5-HT) are also modified. In addition, ACh release in the periphery is modified in a triphasic manner (decrease, then increase, then block), while in the CNS only the increase has been demonstrated. To determine the specificity of the central effects of beta-BuTX we compared the effects of beta-BuTX and N. n. atra PLA2 on the release from rat cerebrocortical synaptosomes of ACh, NE, and 5-HT. We also measured the leakage of lactate dehydrogenase (LDH) in order to determine whether membrane permeablization was responsible for neurotransmitter leakage. Both the PLA2 neurotoxin (5.0 nM) and the non-neurotoxic enzyme (0.5 nM) stimulated the loss of NE and 5-HT, but only at concentrations which induced leakage of LDH. Conversely, beta-BuTX stimulated the release of ACh at a concentration (0.5 nM) which caused no leakage of LDH, while N. n. atra PLA2 (0.5 nM) did not stimulate ACh release. beta-Bungarotoxin thus exerts a specific effect on cholinergic nerve terminals, while the leakage of NE and 5-HT induced by beta-BuTX and N. n. atra PLA2 correlates with membrane disruption due to their PLA2 activities. Within 20 min, 0.5 nM beta-BuTX increased the resting release of ACh and decreased the stimulated release induced by depolarization with 4-aminopyridine, while N. n. atra PLA2 (0.5 nM) did not stimulate ACh release and required 45 min to exert an inhibitory effect. beta-BuTX (5.0 nM) also exerted an inhibitory effect on ACh release stimulated by veratridine, but not by high KCl. It is concluded that in low concentrations that do not disrupt membrane permeability, beta-BuTX acts specifically on cholinergic terminals in rat synaptosomes, where it exerts both stimulatory and inhibitory effects.