Continuous daily assessment of multiple sclerosis disability using remote step count monitoring.

Disability measures in multiple sclerosis (MS) rely heavily on ambulatory function, and current metrics fail to capture potentially important variability in walking behavior. We sought to determine whether remote step count monitoring using a consumer-friendly accelerometer (Fitbit Flex) can enhance MS disability assessment. 99 adults with relapsing or progressive MS able to walk ≥2-min were prospectively recruited. At 4 weeks, study retention was 97% and median Fitbit use was 97% of days. Substudy validation resulted in high interclass correlations between Fitbit, ActiGraph and manual step count tally during a 2-minute walk test, and between Fitbit and ActiGraph (ICC = 0.76) during 7-day home monitoring. Over 4 weeks of continuous monitoring, daily steps were lower in progressive versus relapsing MS (mean difference 2546 steps, p < 0.01). Lower average daily step count was associated with greater disability on the Expanded Disability Status Scale (EDSS) (p < 0.001). Within each EDSS category, substantial variability in step count was apparent (i.e., EDSS = 6.0 range 1097-7152). Step count demonstrated moderate-strong correlations with other walking measures. Lower average daily step count is associated with greater MS disability and captures important variability in real-world walking activity otherwise masked by standard disability scales, including the EDSS. These results support remote step count monitoring as an exploratory outcome in MS trials.

Meta-analysis: outcomes of total knee arthroplasty in the haemophilia population.

INTRODUCTION: People with haemophilia (PWH) experience end stage joint disease as a result of repeated hemarthrosis, commonly leading to total knee arthroplasty (TKA). AIM: The goal of this meta-analysis is to calculate expected outcomes for range of motion (ROM), functional mobility, and complication rates in PWH following TKA. METHODS: Studies published between 1980 and 2015 were identified. INCLUSION CRITERIA: PWH having TKA, reporting Hospital for Special Surgery Knee Score or Knee Society Score, knee ROM, and incidence of complications for more than 5 TKAs. Inhibitor status, haemophilia severity and HIV status were not criteria for inclusion or exclusion. Meta-analysis was performed using mean, standard deviation, or P-value data to create effect sizes (ES) and 95% confidence intervals for each variable. RESULTS: Twenty studies met inclusion criteria; ten had sufficient data for meta-analyses. A total of 336 TKAs in 254 PWH were analysed with mean follow-up of 6.3 years. Statistically significant ROM improvements were found with 9.72° improvement of flexion contracture (-0.73 effect size (ES) (-0.91 to -0.56)), and 15.69°increase into flexion (0.63 ES (0.34-0.91)). Knee scores showed statistically significant improvements: clinically, 37.9 point increase (3.21 ES [1.79-4.63]) and functionally, 13.50 point increase (1.50 ES [0.80-2.21]). A 31.5% complication rate was calculated with 106 reported in 336 TKAs. CONCLUSIONS: TKA is an effective procedure for improving ROM and decreasing functional deficits resulting from haemophilic arthropathy. Knee score data shows TKA improves overall function. This study guides clinicians regarding outcome expectations post-TKA in PWH.

NGP1-01, a multi-targeted polycyclic cage amine, attenuates brain endothelial cell death in iron overload conditions.

Development and progression of neurodegenerative disorders have, amongst other potential causes, been attributed to a disruption of iron regulatory mechanisms and iron accumulation. Excess extracellular iron may enter cells via nontraditional routes such as voltage-gated calcium channels and N-methyl-d-aspartate (NMDA) receptors leading to intracellular oxidative damage and ultimately mitochondrial failure. Nimodipine, an L-type calcium channel blocker has been shown to reduce iron-induced toxicity in neuronal and brain endothelial cells. Our current study investigates NGP1-01, a multimodal drug acting as an antagonist at both the NMDA receptor and the L-type calcium channel. Our previous studies support NGP1-01 as a promising neuroprotective agent in diseases involving calcium-related excitotoxicity. We demonstrate here that NGP1-01 (1 and 10µM) pretreatment abrogates the effects of iron overload in brain endothelial cells protecting cellular viability. Both concentrations of NGP1-01 were found to attenuate iron-induced reduction in cellular viability to a similar extent, and were statistically significant. To further verify the mechanism, the L-type calcium channel agonist FPL 64176 was administered to promote iron uptake. Addition of NGP1-01 dose-dependently reduced FPL 64176 stimulated uptake of iron. These data support further evaluation of NGP1-01 as a neuroprotective agent, not only in diseases associated with excitotoxicity, but also in those of iron overload.

Differential effect of nimodipine in attenuating iron-induced toxicity in brain- and blood-brain barrier-associated cell types.

Metal homeostasis is increasingly being evaluated as a therapeutic target in stroke and neurodegenerative diseases. Metal dysregulation has been shown to lead to protein aggregation, plaque formation and neuronal death. In 2007, we first reported that voltage-gated calcium channels act as a facile conduit for the entry of free ferrous (Fe(2+)) ions into neurons. Herein, we evaluate differential iron toxicity to central nervous system cells and assess the ability of the typical L-type voltage-gated calcium channel blocker nimodipine to attenuate iron-induced toxicity. The data demonstrate that iron sulfate induces a dose-dependent decrease in cell viability in rat brain endothelial cells (RBE4; LC(50) = 150 µM), neuronal cells (Neuro-2α neuroblastoma; LC(50) = 400 µM), and in astrocytes (DI TNC1; LC(50) = 1.1 mM). Pre-treatment with nimodipine prior to iron sulfate exposure provided a significant (P < 0.05) increase in viable cell numbers for RBE4 (2.5-fold), Neuro2-α (~2-fold), and nearly abolished toxicity in primary neurons. Astrocytes were highly resistant to iron toxicity compared to the other cell types tested and nimodipine had no (P > 0.05) protective effect in these cells. The data demonstrate variable susceptibility to iron overload conditions in different cell types of the brain and suggest that typical L-type voltage-gated calcium channel blockers (here represented by nimodipine), may serve as protective agents in conditions involving iron overload, particularly in cell types highly susceptible to iron toxicity.

Motor scores on the functional independence measure after pediatric spinal cord injury.

STUDY DESIGN: Retrospective descriptive analysis. OBJECTIVES: The purpose of this study was to report the functional ability of children with spinal cord injury (SCI) as recorded on motor items of the functional independence measure (FIM) and to examine the factors associated with FIM motor admission and post-discharge gain scores. METHODS: Scores on FIM motor items were analyzed from 941 children (age range: 0-21 years; mean: 13 years 4 months; s.d.: 4 years 8 months) admitted in acute-to-chronic time periods post-SCI to Shriners Hospitals for Children (USA). FIM motor scores at admission and gains at discharge were examined along with neurological level, completeness of injury, age, etiology of injury, and length of time between injury and admission and admission and discharge. RESULTS: The FIM motor scores at admission were negatively correlated with age, neurological level and completeness of injury. Gain in FIM motor scores was significant across neurological levels, and was associated with lower admission FIM motor scores, lower neurological level, incomplete injury, traumatic injury and less time between injury and admission. CONCLUSIONS: The motor function of children after pediatric SCI depends on neurological level and completeness of injury, among other factors. FIM motor scores can improve with intervention even several years after the injury.

Norchloro-fluoro-homoepibatidine (NCFHEB) - a promising radioligand for neuroimaging nicotinic acetylcholine receptors with PET.

Cholinergic neurotransmission depends on the integrity of nicotinic acetylcholine receptors (nAChRs), and impairment of both is characteristic for various neurodegenerative diseases. Visualization of specific receptor subtypes by positron emission tomography (PET) has potential to assist with diagnosis of such neurodegenerative diseases and with design of suitable therapeutic approaches. The goal of our study was to evaluate in vivo the potential of (18)F-labelled (+)- and (-)-norchloro-fluoro-homoepibatidine ([(18)F]NCFHEB) in comparison to 2-[(18)F]F-A-85380 as PET tracers. In the brains of NMRI mice, highest levels of radioactivity were detected at 20 min post-injection of (+)-[(18)F]NCFHEB, (-)-[(18)F]NCFHEB, and 2-F-[(18)F]-A-85380 (7.45, 5.60, and 3.2% ID/g tissue, respectively). No marked pharmacological adverse effects were observed at 25 mug NCFHEB/kg. Uptake studies in RBE4 cells and in situ perfusion studies suggest an interaction of epibatidine and NCFHEB with the carrier-mediated choline transport at the blood-brain barrier. The data indicate that (+)- and (-)-[(18)F]NCFHEB have potential for further development as PET tracers.

The blood-brain barrier and brain drug delivery.

The present report encompasses a thorough review of drug delivery to the brain with a particular focus on using drug carriers such as liposomes and nanoparticles. Challenges in brain drug delivery arise from the presence of one of the strictest barriers in vivo-the blood-brain barrier (BBB). This barrier exists at the level of endothelial cells of brain vasculature and its role is to maintain brain homeostasis. To better understand the principles of brain drug delivery, relevant knowledge of the blood-brain barrier anatomy and physiology is briefly reviewed. Several approaches to overcome the BBB have been reviewed including the use of carrier systems. In addition, strategies to enhance brain drug delivery by specific brain targeting are discussed.

Chronic nicotine exposure alters blood-brain barrier permeability and diminishes brain uptake of methyllycaconitine.

Methyllycaconitine (MLA) is reported to be a selective antagonist for the nicotinic acetylcholine receptor alpha7 subtype and has been found in animal behavioral studies to reduce nicotine self-administration and attenuate nicotine withdrawal symptoms. While MLA crosses the blood-brain barrier (BBB), no studies have assessed brain uptake in animals subjected to chronic nicotine exposure. Given that chronic nicotine administration has been reported to alter BBB parameters that may affect the kinetic BBB passage of MLA, we evaluated MLA brain uptake in naive and S-(-)nicotine-exposed rats (4.5 mg/kg/day for 28 days; osmotic minipumps) using in situ rat brain perfusions. Our results demonstrate that in situ(3)H-MLA brain uptake rates in naive animals approximate to intravenous kinetic data (K(in), 3.24 +/- 0.71 x 10(-4) mL/s/g). However, 28-day nicotine exposure diminished (3)H-MLA brain uptake by approximately 60% (K(in), 1.29 +/- 0.4 x 10(-4) mL/s/g). This reduction was not related to nicotine-induced (3)H-MLA brain efflux or BBB transport alterations. Similar experiments also demonstrated that the passive permeation of (14)C-thiourea was diminished approximately 24% after chronic nicotine exposure. Therefore, it appears that chronic nicotine exposure diminishes the blood-brain passive diffusion of compounds with very low extraction rates (i.e. permeability-limited compounds). These findings imply that the pharmacokinetics of neuropharmaceutical agents that are permeability limited may need to be re-evaluated in individuals exposed to nicotine.

Brain uptake kinetics of nicotine and cotinine after chronic nicotine exposure.

Blood-brain barrier (BBB) nicotine transfer has been well documented in view of the fact that this alkaloid is a cerebral blood flow marker. However, limited data are available that describe BBB penetration of the major tobacco alkaloids after chronic nicotine exposure. This question needs to be addressed, given long-term nicotine exposure alters both BBB function and morphology. In contrast to nicotine, it has been reported that cotinine (the major nicotine metabolite) does not penetrate the BBB, yet cotinine brain distribution has been well documented after nicotine exposure. Surprisingly, therefore, the literature indirectly suggests that central nervous system cotinine distribution occurs secondarily to nicotine brain metabolism. The aims of the current report are to define BBB transfer of nicotine and cotinine in naive and nicotine-exposed animals. Using an in situ brain perfusion model, we assessed the BBB uptake of [3H]nicotine and [3H]cotinine in naive animals and in animals exposed chronically to S-(-)nicotine (4.5 mg/kg/day) through osmotic minipump infusion. Our data demonstrate that 1) [3H]nicotine BBB uptake is not altered in the in situ perfusion model after chronic nicotine exposure, 2) [3H]cotinine penetrates the BBB, and 3) similar to [3H]nicotine, [3H]cotinine BBB transfer is not altered by chronic nicotine exposure. To our knowledge, this is the first report detailing the uptake of nicotine and cotinine after chronic nicotine exposure and quantifying the rate of BBB penetration by cotinine.

The blood-brain barrier choline transporter as a brain drug delivery vector.

Choline is a ubiquitous molecule, found throughout almost every tissue in the body. Given it is a charged cation, nearly every cellular membrane has a transport mechanism to meet the intracellular and membrane need for choline. The blood-brain barrier is no exception in that a carrier-mediated transport mechanism is present to deliver choline from plasma to brain. The carrier consists of an anionic binding area that attracts positively charged quaternary ammonium groups or simple cations. Recent reports have shown this vector to be efficacious in delivering quaternary ammonium analogs of nicotine to brain. Future work is being completed to determine if other cationic or positively charged therapeutics can be effectively delivered to brain via this carrier.

Evaluation of blood-brain barrier thiamine efflux using the in situ rat brain perfusion method.

Thiamine is an essential, positively charged (under physiologic conditions), water-soluble vitamin requiring transport into brain. Brain thiamine deficiency has been linked to neurodegenerative disease by subsequent impairment of thiamine-dependent enzymes used in brain glucose/energy metabolism. In this report, we evaluate brain uptake and efflux of [3H]thiamine using the in situ rat brain perfusion technique. To confirm brain distribution was not related to blood-brain barrier endothelial cell uptake, we compared parenchymal and cell distribution of [3H]thiamine using capillary depletion. Our work supports previous literature findings suggesting blood-brain barrier thiamine uptake is via a carrier-mediated transport mechanism, yet extends the literature by redefining the kinetics with more sensitive methodology. Significantly, [3H]thiamine brain accumulation was influenced by a considerable efflux rate. Evaluation of the efflux mechanism demonstrated increased stimulation by the presence of increased vascular thiamine. The influx transport mechanism and efflux rate were each comparable throughout brain regions despite documented differences in glucose and thiamine metabolism. The observation that [3H]thiamine blood-brain barrier influx and efflux is regionally homogenous may have significant relevance to neurodegenerative disease linked to thiamine deficiency.

The transport of choline.

Choline has many physiological functions throughout the body that are dependent on its available local supply. However, since choline is a charged hydrophilic cation, transport mechanisms are required for it to cross biological membranes. Choline transport is required for cellular membrane construction and is the rate-limiting step for acetylcholine production. Transport mechanisms include: (1) sodium-dependent high-affinity uptake mechanism in synaptosomes, (2) sodium-independent low-affinity mechanism on cellular membranes, and (3) unique choline uptake mechanisms (e.g., blood-brain barrier choline transport). A comprehensive overview of choline transport studies is provided. This review article examines landmark and current choline transport studies, molecular mapping, and molecular identification of these carriers. Information regarding the choline-binding site is presented by reviewing choline structural analog (hemicholinium-3 and 15, and other nitrogen/methyl-hydroxyl compounds) inhibition studies. Choline transport in Alzheimer's disease, brain ischemic events, and aging is also discussed. Emphasis throughout the article is placed on targeting the choline transporter in disease and use of this carrier as a drug delivery vector.

Novel choline transport characteristics in Caco-2 cells.

UNLABELLED: Choline transport is characterized by sodium-dependent high-affinity, sodium-independent low-affinity, and sodium-independent blood-brain barrier transport mechanisms. Each defined mechanism has specific characteristics with regard to affinity for choline, transport capacity, and inhibition by hemicholinium. The purpose of this study is to determine the characteristics of choline transport across Caco-2 monolayers. METHODS: Choline transport across Caco-2 cell monolayers was determined in both the apical to basal direction and the opposite direction. Further, the determination of calcium dependence and specific inhibitors was made. Determination of the apparent permeability of choline was calculated by established methods. RESULTS: The apical to basal Caco-2 permeability coefficient is 11.11 +/- 0.33 x 10(-6) cm/sec with 21.3% of the choline associating with the cells. Meanwhile the basal to apical value is approximately 50% less (5.55 +/- 0.14 x 10(-6) cm/sec), suggesting an active apical to basal transport mechanism. Choline transport in this system was inhibited by nifedipine (82%), verapamil (80%), EGTA (36%), and cyclosporin (15%). CONCLUSIONS: Choline transport across Caco-2 cells is demonstrated to be active and both pH- and Ca(2+)-dependent. Furthermore, choline transport across Caco-2 monolayers has unique characteristics when compared to traditional choline transport models.

Nanoparticle technology for drug delivery across the blood-brain barrier.

Nanoparticles (NP) are solid colloidal particles ranging in size from 1 to 1000 nm that are utilized as drug delivery agents. The use of NPs to deliver drugs to the brain across the blood-brain barrier (BBB) may provide a significant advantage to current strategies. The primary advantage of NP carrier technology is that NPs mask the blood-brain barrier limiting characteristics of the therapeutic drug molecule. Furthermore, this system may slow drug release in the brain, decreasing peripheral toxicity. This review evaluates previous strategies of brain drug delivery, discusses NP transport across the BBB, and describes primary methods of NP preparation and characterization. Further, influencing manufacturing factors (type of polymers and surfactants, NP size, and the drug molecule) are detailed in relation to movement of the drug delivery agent across the BBB. Currently, reports evaluating NPs for brain delivery have studied anesthetic and chemotherapeutic agents. These studies are reviewed for efficacy and mechanisms of transport. Physiological factors such as phagocytic activity of the reticuloendothelial system and protein opsonization may limit the amount of brain delivered drug and methods to avoid these issues are also discussed. NP technology appears to have significant promise in delivering therapeutic molecules across the BBB.

Inhibition of the rat blood-brain barrier choline transporter by manganese chloride.

Choline transport has been characterized by multiple mechanisms including the blood-brain barrier (BBB), and high- and low-affinity systems. Each mechanism has unique locations and characteristics yet retain some similarities. Previous studies have demonstrated cationic competition by monovalent cations at the BBB and cation divalent manganese in the high-affinity system. To evaluate the effects of divalent manganese inhibition as well as other cationic metals at the BBB choline transporter, brain choline uptake was evaluated in the presence of certain metals of interest in Fischer-344 rats using the in situ brain perfusion technique. Brain choline uptake was inhibited in the presence of Cd(2+) (73 +/- 2%) and Mn(2+) (44 +/- 6%), whereas no inhibition was observed with Cu(2+) and Al(3+). Furthermore, it was found that manganese caused a reduction in brain choline uptake and significant regional choline uptake inhibition in the frontal and parietal cortex, the hippocampus and the caudate putamen (45 +/- 3%, 68 +/- 18%, 58 +/- 9% and 46 +/- 15%, respectively). These results suggest that choline uptake into the CNS can be inhibited by divalent cationic metals and monovalent cations. In addition, the choline transporter may be a means by which manganese enters the brain.

Prepharmacy predictors of success in pharmacy school: grade point averages, pharmacy college admissions test, communication abilities, and critical thinking skills.

Good admissions decisions are essential for identifying successful students and good practitioners. Various parameters have been shown to have predictive power for academic success. Previous academic performance, the Pharmacy College Admissions Test (PCAT), and specific prepharmacy courses have been suggested as academic performance indicators. However, critical thinking abilities have not been evaluated. We evaluated the connection between academic success and each of the following predictive parameters: the California Critical Thinking Skills Test (CCTST) score, PCAT score, interview score, overall academic performance prior to admission at a pharmacy school, and performance in specific prepharmacy courses. We confirmed previous reports but demonstrated intriguing results in predicting practice-based skills. Critical thinking skills predict practice-based course success. Also, the CCTST and PCAT scores (Pearson correlation [pc] = 0.448, p < 0.001) were closely related in our students. The strongest predictors of practice-related courses and clerkship success were PCAT (pc=0.237, p<0.001) and CCTST (pc = 0.201, p < 0.001). These findings and other analyses suggest that PCAT may predict critical thinking skills in pharmacy practice courses and clerkships. Further study is needed to confirm this finding and determine which PCAT components predict critical thinking abilities.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Characterization of the blood-brain barrier choline transporter using the in situ rat brain perfusion technique.

Choline enters brain by saturable transport at the blood-brain barrier (BBB). In separate studies, both sodium-dependent and passive choline transport systems of differing affinity have been reported at brain capillary endothelial cells. In the present study, we re-examined brain choline uptake using the in situ rat brain perfusion technique. Saturable brain choline uptake from perfusion fluid was best described by a model with a single transporter (V:(max) = 2.4-3.1 nmol/min/g; K(m) = 39-42 microM) with an apparent affinity (1/Km)) for choline five to ten-fold greater than previously reported in vivo, but less than neuronal 'high-affinity' brain choline transport (K(m) = 1-5 microM). BBB choline uptake from a sodium-free perfusion fluid using sucrose for osmotic balance was 50% greater than in the presence of sodium suggesting that sodium is not required for transport. Hemicholinium-3 inhibited brain choline uptake with a K(i) (57 +/- 11 microM) greater than that at the neuronal choline system. In summary, BBB choline transport occurs with greater affinity than previously reported, but does not match the properties of the neuronal choline transporter. The V:(max) of this system is appreciable and may provide a mechanism for delivering cationic drugs to brain.

Impaired cholinergic function in cell lines derived from the cerebral cortex of normal and trisomy 16 mice.

Murine trisomy 16 is an animal model of human Down's syndrome. We have successfully established permanently growing cell lines from the cerebral cortex of normal and trisomy 16 foetal mice using an original procedure. These lines, named CNh (derived from a normal animal) and CTb (derived from a trisomic foetus), express neuronal markers. Considering that Down's syndrome exhibits cholinergic deficits, we examined cholinergic function in these lines, using incorporation of [3H]-choline and fractional release studies. After 1, 3 and 5 min of [3H]-choline incubation, CTb cell uptake was lower by approximately 50% compared to controls. Hemicholinium-3 significantly reduced the incorporation of [3H]-choline in both CNh and CTb cells at high concentration (10 microM), suggesting high-affinity choline transport. However, CTb cells exhibited greater sensitivity to the blocker. For fractional release experiments, the cells were stimulated by K+ depolarization, glutamate or nicotine. When depolarized, CTb cells showed a 68% reduction in fractional release of [3H]-acetylcholine compared to CNh cell line, and a 45% reduction when stimulated by nicotine. Interestingly, glutamate induced similar levels of release in both cell types. The results indicate the existence of cholinergic dysfunction in CTb cells when compared to CNh, similar to that reported for primary cultures of trisomy 16 brain tissue (Fiedler et al. 1994, Brain Res., 658, 27-32). Thus, the CTb cell line may serve as a model for the study of Down's syndrome pathophysiology.

The distribution of aluminum into and out of the brain.

The extent, rate and possible mechanism(s) by which aluminum enters and is removed from the brain are presented. Introduction of Al into systemic circulation as Al.transferrin, the predominant Al species in plasma, resulted in about 7 x 10(-5) of the dose in the brain 1 day after injection. This brain Al entry could be mediated by transferrin-receptor-mediated endocytosis (TfR-ME). When Al.citrate, the predominant small molecular weight Al species in blood plasma, is introduced systemically, Al rapidly enters the brain. The rate of Al.citrate brain influx suggests a more rapid process than mediated by diffusion or TfR-ME. The question has been raised: "Is the brain a 'one-way sink' for aluminum?". Clinical observations are a basis for this suggestion. Rat brain 26Al concentrations decreased only slightly from 1 to 35 days after systemic 26Al injection, in the absence or presence of the aluminum chelator desferrioxamine, suggesting prolonged brain Al retention. However, studies of brain and blood extracellular Al at steady state, using microdialysis, suggest brain Al efflux exceeds influx, suggesting carrier-mediated brain Al efflux. The predominant brain extracellular fluid Al species is probably Al.citrate. The hypothesis that brain Al efflux, presumably of Al.citrate, is mediated by the monocarboxylate transporter was tested and supported. Although some Al that enters the brain is rapidly effluxed, it is suggested that a fraction enters brain compartments within 24 h from which it is only very slowly eliminated.