Efficacy of galcanezumab in patients with episodic migraine and a history of preventive treatment failure: results from two global randomized clinical trials.

BACKGROUND AND PURPOSE: The efficacy of galcanezumab, a monoclonal antibody for migraine prevention, has been demonstrated in two pivotal trials in patients with episodic migraine. METHODS: EVOLVE-1 and EVOLVE-2 were identical phase 3, randomized, double-blind, placebo-controlled studies in patients with episodic migraine. Mean migraine headache days per month at baseline was 9. Patients were randomized 2:1:1 to monthly injections of placebo, galcanezumab 120 mg/240 mg during the 6-month double-blind treatment period. Key efficacy outcomes were assessed in subgroups amongst patients for whom, previously, for efficacy and/or safety/tolerability reasons (i) one or more (≥1) preventives failed, (ii) two or more (≥2) preventives failed and (iii) preventives were never used, or used but not failed (no prior failure). RESULTS: In an integrated analysis of EVOLVE studies, galcanezumab 120 mg/240 mg versus placebo led to larger overall mean (SE) reductions in monthly migraine headache days across 6 months in patients with prior preventive failures (P < 0.001): ≥1 failure: 120 mg: -4.0 (0.4); 240 mg: -4.2 (0.5); placebo: -1.3 (0.4); ≥2 failures: 120 mg: -3.1 (0.7); 240 mg: -3.8 (0.8); placebo: -0.5 (0.6). Similar results were observed amongst patients with no prior failure, but the placebo response was larger: 120 mg: -4.7 (0.2); 240 mg: -4.5 (0.2); placebo: -3.0 (0.2) (P < 0.001 versus placebo). Significant improvements were observed with galcanezumab versus placebo for ≥50% and ≥75% reduction in monthly migraine headache days. CONCLUSION: In patients with episodic migraine treated with galcanezumab, those with ≥1 or ≥2 prior preventive failures had significantly larger improvements, versus placebo, in efficacy outcomes. Similar results were observed in patients with no prior failure, with a larger placebo response.

Remembering what could have happened: neural correlates of episodic counterfactual thinking.

Recent evidence suggests that our capacities to remember the past and to imagine what might happen in the future largely depend on the same core brain network that includes the middle temporal lobe, the posterior cingulate/retrosplenial cortex, the inferior parietal lobe, the medial prefrontal cortex, and the lateral temporal cortex. However, the extent to which regions of this core brain network are also responsible for our capacity to think about what could have happened in our past, yet did not occur (i.e., episodic counterfactual thinking), is still unknown. The present study examined this issue. Using a variation of the experimental recombination paradigm (Addis, Pan, Vu, Laiser, & Schacter, 2009. Neuropsychologia. 47: 2222-2238), participants were asked both to remember personal past events and to envision alternative outcomes to such events while undergoing functional magnetic resonance imaging. Three sets of analyses were performed on the imaging data in order to investigate two related issues. First, a mean-centered spatiotemporal partial least square (PLS) analysis identified a pattern of brain activity across regions of the core network that was common to episodic memory and episodic counterfactual thinking. Second, a non-rotated PLS analysis identified two different patterns of brain activity for likely and unlikely episodic counterfactual thoughts, with the former showing significant overlap with the set of regions engaged during episodic recollection. Finally, a parametric modulation was conducted to explore the differential engagement of brain regions during counterfactual thinking, revealing that areas such as the parahippocampal gyrus and the right hippocampus were modulated by the subjective likelihood of counterfactual simulations. These results suggest that episodic counterfactual thinking engages regions that form the core brain network, and also that the subjective likelihood of our counterfactual thoughts modulates the engagement of different areas within this set of regions.

The impact of maternal serum screening on the birth prevalence of Down's syndrome and the use of amniocentesis and chorionic villus sampling in South Australia.

OBJECTIVES: To describe the impact of maternal serum screening on the birth prevalence of Down's syndrome and on the use of amniocentesis and chorionic villus sampling in South Australia. DESIGN: A descriptive population-based study. SETTING: South Australia (population 1.48 million persons; approximately 20,000 births per year). PARTICIPANTS: Women who had births or terminations of pregnancy with Down's syndrome in 1982-1996, women who had maternal serum screening in 1991-1996, amniocentesis or chorionic villus sampling in 1986-1996. METHODS: Analysis of data from multiple sources on maternal serum screening, amniocentesis and chorionic villus sampling, births and terminations of pregnancy. MAIN OUTCOME MEASURES: Total prevalence and birth prevalence of Down's syndrome each year in 1982-1996; proportion of pregnant women using maternal serum screening in 1991-1996, and proportion using amniocentesis and chorionic villus sampling by indication in 1986-1996, by age group. RESULTS: Use of maternal serum screening for Down's syndrome increased from 17% when introduced in 1991 to 76% of women who gave birth in 1996. Between 1982 and 1986 and 1996, terminations of pregnancy for fetal Down's syndrome increased from 7.1 % to 75% and the birth prevalence of Down's syndrome fell by 60% from 1.05 to 0.42 per 1,000 births, against the background of an increase in total prevalence due to increasing maternal age. The use of amniocentesis increased from 5.8% in 1991 to 10.1% in 1996 mainly due to the increase among women younger than 35 years with maternal serum screening as the main reason. The increasing chorionic villus sampling rate among younger women stabilised at 0.4%, while the rate among older women decreased from 11.0% to 7.4%. CONCLUSIONS: The introduction of maternal serum screening in South Australia has resulted in increased use of any prenatal testing for Down's syndrome from about 7% (mainly older women having amniocentesis or chorionic villus sampling) to 84% of women (about 8% having direct amniocentesis or chorionic villus sampling and 76% having maternal serum screening first). This has resulted in a significant fall in the birth prevalence of Down's syndrome. maternal serum screening was the first indication of Down's syndrome for about half the terminations of pregnancy for Down's syndrome in 1993-1996, including three quarters of those in younger women.

VACTERL with hydrocephalus: family with X-linked VACTERL-H.

We describe in a five generation family four affected males with hydrocephalus (4 offspring/4 examined) due to aqueductal stenosis (3/3), symmetrical radial ray abnormalities (4/4), renal anomalies (2/3), anal atresia (3/4), hypoplastic penis/abnormal testes (2/3), and cardiac abnormalities (1/3). X-linked inheritance seems certain in this family. These abnormalities are characteristic of the rare X-linked VACTERL-H syndrome. In addition, one maternal female cousin had a severe tracheo-esophageal fistula. This may represent partial manifestation in a female carrier. Chromosomes were apparently normal (46XY) with no spontaneous or excess induced breakages in one of the affected offspring and his mother. In the absence of a genetic marker, diagnostic ultrasonography is the investigation of choice for early in utero detection of this syndrome. A confident ultrasonographic diagnosis was possible by 20 weeks in the 2 cases examined.

Sporadic chromosome abnormalities in human lymphocytes and previous exposure to chemicals.

Sporadic abnormalities in lymphocyte cultures are often attributed to in vitro culture variations of no clinical significance. The data presented here compare the findings from 11,873 cells of 230 patients referred with histories of previous chemical exposure (usually to mixtures of solvents and/or pesticides) with 27,050 cells from 855 patients referred for other reasons. Detection of 0.38% or more, structural abnormalities (approximately 1 in 30 cells) was 27.2 times more likely in exposed persons than in controls and the finding of a single autosomal trisomic cell was 14.4 times more likely in exposed persons. These highly statistically significant findings were similar to the frequencies of abnormalities reported in other studies of persons exposed to benzene, pesticides, herbicides and irradiation. It is recommended that findings of sporadic abnormalities in lymphocytes be routinely recorded, and patients with positive findings followed up to discover whether there are past histories of significant exposures.

Lack of correlation between conceptual karyotype and maternal response to placentation.

The placental karyotype was correlated with the morphology of the placental bed in miscarriages. Abnormal placentation was as likely to be seen in euploid conceptions as in aneuploid conceptions, whereas normal placentation was seen with both euploid and aneuploid pregnancies. No consistent chromosomal abnormality was found with abnormal placentation. Since abnormal placentation is implicated in the pathogenesis of preeclampsia and miscarriages, these findings may be useful with respect to the localization of a candidate 'preeclampsia gene' by identifying a specific chromosome associated with abnormal placentation.

Does aneuploidy per se cause developmental abnormalities?

The following questions are addressed: (A) What are aneuploidogens and how do they act? (B) Is there any evidence that aneuploidy per se causes malformations? (C) What examples are there of abnormalities, apparently attributable to aneuploidogens acting as teratogens? (D) Do abnormalities of cell division cause both teratogenesis and aneuploidy? Considerable research has addressed question (A), but there is little which addresses the other three questions. The question of whether aneuploidy per se causes malformations remains open. Some suggestions for further research are made.

A 13-year cytogenetic study of spontaneous abortion: clinical applications of testing.

Chromosome analysis was performed on 1,543 specimens of first trimester miscarriage received between 1982 and 1994. Comparisons with earlier studies show that some findings are absolutely consistent between different years and populations, but some major differences are also found. The results are considered in the light of several recent genetic, environmental and physiological studies. Trisomy 16, and probably trisomy 22, is entirely dependent on maternal age; other trisomies show both maternal age and other environmental or genetic effects. Monosomy X and mosaic aneuploidy arise postzygotically by chromosome loss, a normal control mechanism. Some trisomy, dipaternal triploidy and tetraploidy probably occur because of pre- or postovulatory 'overripeness'; either due to transient or chronic maternal conditions or delayed fertilization. Unbalanced structural abnormalities, most apparently of de novo origin, are markedly increased compared to earlier studies and are possibly due to paternal environmental exposures. It is concluded that when considering histories of abortion, studies of the chromosomes of the aborted products are much more informative and cost-effective than studies of parental bloods. Where available, studies of products should be undertaken for preference, but only by experienced and committed laboratories.

The human glycine receptor beta subunit: primary structure, functional characterisation and chromosomal localisation of the human and murine genes.

The inhibitory glycine receptor (GlyR) is a pentameric receptor comprised of alpha and beta subunits, of which the beta subunit has not been characterised in humans. A 2106 bp cDNA, isolated from a human hippocampal cDNA library, contained an open reading frame of 497 amino acids which encodes the beta subunit of the human GlyR. The mature human GlyR beta polypeptide displays 99% amino acid identity with the rat GlyR beta subunit and 48% identity with the human GlyR alpha 1 subunit. Neither [3H]strychnine binding nor glycine-gated currents were detected when the human GlyR beta subunit cDNA was expressed in the human embryonic kidney 293 cell line. However, co-expression of the beta subunit cDNA with the alpha 1 subunit cDNA resulted in expression of functional GlyRs which showed a 4-fold reduction in the EC50 values when compared to alpha 1 homomeric GlyRs. Glycine-gated currents of alpha 1/beta GlyRs were 17-fold less sensitive than homomeric alpha 1 GlyRs to the antagonists picrotoxin, picrotoxinin and picrotin, providing clear evidence that heteromeric alpha 1/beta GlyRs were expressed. The beta subunit appears to play a structural rather than ligand binding role in GlyR function. Fluorescence in situ hybridisation was used to localise the gene encoding the human GlyR beta subunit (GLRB) to chromosome 4q32, a position syntenic with mouse chromosome 3. In situ hybridisation using the human GlyR beta subunit cDNA showed that the murine GlyR beta subunit gene (Glrb) maps to the spastic (spa) locus on mouse chromosome 3 at bands E3-F1. This is consistent with the recent finding that a mutation in the murine GlyR beta subunit causes the spa phenotype. It also raises the possibility that mutations in the human beta subunit gene may cause inherited disorders of the startle response.

Chemiluminescence emission during reactions between superoxide and selected aliphatic and aromatic halocarbons in aprotic media.

The reactions between superoxide free radical anion (.O2-) with the halocarbons CCl4. CHCl3, BrCH2CH2Br(EDB), decachlora-biphenyl (DCBP), and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in dimethyl sulphoxide (DMSO) results in the emission of chemiluminescence (CL). The chemiluminescence reactions are characterized as having biphasic second order kinetics, CL wavelengths between 350 nm and 650 nm, and exhibiting perturbation by chemicals reactive with singlet oxygen. These data suggest that singlet oxygen species are the excited state responsible for the light emissions. Polarographic studies confirm .O2- consumption and halide release in the reactions, while gas liquid chromatography and NBT reduction demonstrate the decomposition of the halocarbons into products. A chemiluminescent reaction mechanism is proposed involving reductive dehalogenation of the halocarbons and the generation of singlet oxygen. The significance of singlet oxygen generation is discussed with respect to a general mechanism for explaining the rapid initiation of lipid peroxidative membrane damage in halocarbon toxigenicity in animal and plant tissues.

The gene encoding human glutathione synthetase (GSS) maps to the long arm of chromosome 20 at band 11.2.

Two forms of glutathione synthetase deficiency have been described. While one form is mild, causing hemolytic anemia, the other more severe form causes 5-oxo-prolinuria with secondary neurological involvement. Despite the existence of two deficiency phenotypes, Southern blots hybridized with a glutathione synthetase cDNA suggest that there is a single glutathione synthetase gene in the human genome. Analysis of somatic cell hybrids showed the human glutathione synthetase gene (GSS) to be located on chromosome 20, and this assignment has been refined to subband 20q11.2 using in situ hybridization.

Pregnancy and lifestyle study: the long-term use of the contraceptive pill and the risk of age-related miscarriage.

Maternal ageing is a very important factor in aneuploidy. It is associated with an increased risk of a liveborn trisomy, especially Down's syndrome, and with a dramatic increase in trisomic conceptions, the majority of which miscarry. A total of 585 volunteer couples who were planning pregnancies participated in a prospective study of reproduction. The couples answered extensive questionnaires and early pregnancy tests (day 28) were conducted each month. The number of years of contraceptive pill use was correlated with pregnancy outcome. Lowered rates of miscarriage were found with increased years of pill use. The cut-off point for this positive effect appeared to be 9 years. Use of oral contraceptives for > or = 9 years was associated with a spontaneous abortion rate of 11.3%, which is about half the rate (23%) which was found in couples who had not used the pill. However, the effect of pill taking was correlated with female age, and when age was examined as an independent factor, the reduction in miscarriage was only statistically significant in women > 30 years old, where the rate of abortion reduced from 28 to 7%. Because age-related aneuploidy in humans probably occurs as a direct or an indirect result of follicle depletion, it is proposed that the long-term use of the oral contraceptive pill protects against abortion due to aneuploidy by preserving the number of follicles.

PIP: The impact of oral contraceptive use on ovarian follicular dynamics--considered to be a key determinant of trisomic conceptions--was investigated in a prospective study of 585 Australian women who were planning pregnancy. Urine samples were collected on the last day of each menstrual cycle in which conception was attempted; outcomes were classified as live birth of a normal infant, spontaneous abortion, or persisting infertility. Only 39 women had never used oral contraceptives (OCs); the majority had used the pill for at least six months. The age-related miscarriage rate was 13.4% in women aged 25-29 years, 17.3% in those aged 30-34 years, and 28.3% in those aged 35-39 years. The frequency of miscarriage showed a pattern of decline with increasing years of OC use: 0-2, 22.2%; 3-4, 17.3%; 5-6, 19.6%; 7-8, 16.7%; and 9 or more, 11.4%. However, the addition of maternal age to the logistic regression model revealed that the association between OC use duration and miscarriage was significant (p 0.001) only for women 30 years of age and over. In this latter group. the mean miscarriage rate decreased from 28% with 0-2 years of OC use to 7% with 9 or more years of use. It is hypothesized that the decrease of about 15% in the rate of miscarriage among longterm pill users aged 30 years or over is attributable to OC-related preservation of ovarian follicles and a subsequent reduction in spontaneous abortion due to aneuploidy--a defect related to pre-menopausal declines in follicle numbers.

Insertional mutagenesis inducing hypomyelination in transgenic mice.

Investigations of myelin disorders, in particular multiple sclerosis (MS), have concentrated on immunemediated damage to formed myelin, while there has been less emphasis on the molecular genetics of myelin formation. We have generated a transgenic mouse mutant (designated 2-50) which carries an insertional mutation in a locus regulating myelination. These mice carry a transgene comprising 1.3 Kb of the mouse myelin basic protein (MBP) promoter conjugated to a fragment containing exons 2 and 3 of the human c-myc gene. Positive mice show a significant reduction in myelin compared to controls and a shivering phenotype. Unlike other myelin mutants, all 2-50 mice lose the shivering phenotype and breed normally. Expression of c-myc is detectable in only 65% of transgene-carrying mice, and when present occurs at extremely low levels. This shows that the phenotype is caused by insertional inactivation of a gene necessary for myelination rather than ectopic expression of the transgene. The transgene was found by in situ hybridization to be inserted into a single site which is very distally located on chromosome 9. The 2-50 mice represent a unique model which will be ideal for investigating the molecular basis of myelin assembly and for developing gene therapy to promote remyelination in conditions such as MS.

PALS (pregnancy and lifestyle study): association between occupational and environmental exposure to chemicals and reproductive outcome.

A prospective study examined the reproductive outcome, live birth, miscarriage or 9 months infertility, in 585 participating couples. Examination of the data relating to environmental and occupational exposure to chemicals and radiation revealed the following associations. Infertility was significantly associated with male factors of age, occupational exposure to dusts and occupation of labourer in men aged 35 or older. Female factors associated with infertility were age and home renovating if aged 35 or older. First trimester spontaneous miscarriage was associated with male factors of age, X-rays of the abdomen or back, occupation as a tradesperson, home exposure to glues, oil paints or oven cleaners. Female factors included age, visiting factories in the course of work, X-rays of the abdomen, home use of glues and working at home if aged less than 35. The most significant findings of the study are the poor outcomes associated with abdominal/back X-rays and home exposure to chemicals. The possible effects of having different numbers of positive factors was examined for each of miscarriage and 9 months infertility. Nine factors were examined for miscarriage and couples were found to have from zero to seven of these. The observed rate of pregnancy loss ranged from 3.7% to 75% with increasing numbers of factors. For infertility, four factors were examined and couples were found to have from zero to four of these. The observed rate of 'infertility' ranged from 8.4% to 33.3% with increasing numbers of factors. The statistical significance of both sets of results is p = < 0.0001. The effects of these exposures on outcome is thus cumulative.

A fluorescent in situ hybridization analysis of the chromosome constitution of ejaculated sperm in a 47,XYY male.

Two semen samples from a 47,XXY male were examined using chromosome-specific DNA probes and fluorescent in situ hybridization (FISH) to determine the distribution of sex chromosomes and an autosome (chromosome 17) in the sperm. A motile population of sperm was also prepared from one sample using the swim-up technique to compare the motile and total sperm populations. Chromosomes were localized using single FISH and a biotinylated chromosome 17 probe (TR17), or double FISH using a biotinylated X chromosome probe (TRX) and a digoxigenin-labelled Y chromosome probe (HRY). Labelling efficiencies were 95-98%. Ploidy levels were estimated by measurement against a microscope eye-piece graticule. The overall ratio of X- to Y-bearing sperm was 47% to 48.4% in the neat samples, and 48.4% to 45.3% in the swim-up fraction. Neither of the ratios was significantly different from 1:1. The frequencies of monosomic and disomic (but otherwise haploid sperm) were not different from the frequencies we observed in normal donors. In contrast, the frequencies of both diploid and tetraploid cells were increased in the neat samples of the XYY male. In the swim-up fractions, however, none of these parameters differed from those of ten normal semen donors. These results support the hypothesis that the extra Y chromosome in XYY men is eliminated during spermatogenesis.

Detection of X- and Y-bearing human spermatozoa after motile sperm isolation by swim-up.

OBJECTIVE: To assess the ratio of X- to Y-bearing human spermatozoa in motile fractions isolated by the swim-up technique. DESIGN: The proportions of X- and Y-bearing sperm were determined in neat semen samples (control) and in motile fractions isolated from the same samples by swim-up. X- and Y-bearing sperm were simultaneously identified using chromosome-specific DNA probes and double fluorescence in situ hybridization. SETTING: Hospital-based university department. PARTICIPANTS: Ten healthy donors with normal semen characteristics. MAIN OUTCOME MEASURES: The distribution of haploid cells (X or Y), normal size cells with two sex chromosome (XX, YY, or XY), and large cells containing two (XX, YY, or XY) or four (XXYY) sex chromosomes were measured in neat semen samples and in motile fractions prepared by swim-up. RESULTS: Overall, 95% of sperm in the neat semen and swim-up fractions were labeled with the probes. The ratios of X- to Y-bearing sperm were 47.3:46.9 (neat semen) and 48.4:47.1 (swim-up fractions), which were not significantly different from a 1:1 ratio. The frequencies of sperm with normal size nuclei and two sex chromosomes (XX, YY, or XY) in the swim-up fractions were not significantly different from the controls, but there was a significant reduction in the proportion of cells with large nuclei and two (XX, YY, or XY) or four (XXYY) sex chromosomes in the swim-up fractions. CONCLUSIONS: The swim-up technique does not selectively enrich either X- or Y-bearing sperm. Because the isolation of motile spermatozoa is an important procedure for routine IUI, IVF-ET, and GIFT, the results of this study are important reassurance that the sex ratio is not altered by this method of sperm preparation.