Faculty Bibliography

PURPOSE/OBJECTIVE:Rindopepimut is a vaccine targeting the tumor-specific EGF driver mutation, EGFRvIII. The ReACT study investigated whether the addition of rindopepimut to standard bevacizumab improved outcome for patients with relapsed, EGFRvIII-positive glioblastoma. PATIENTS AND METHODS/METHODS:In this double-blind, randomized, phase II study (NCT01498328) conducted at 26 hospitals in the United States, bevacizumab-naïve patients with recurrent EGFRvIII-positive glioblastoma were randomized to receive rindopepimut or a control injection of keyhole limpet hemocyanin, each concurrent with bevacizumab. The primary endpoint was 6-month progression-free survival (PFS6) by central review with a one-sided significance of 0.2. RESULTS:< 0.0001). CONCLUSIONS:.

BACKGROUND:High-efficacy therapies in multiple sclerosis are traditionally used after unsuccessful treatment with first-line disease modifying therapies. We hypothesised that early commencement of high-efficacy therapy would be associated with reduced long-term disability. We therefore aimed to compare long-term disability outcomes between patients who started high-efficacy therapies within 2 years of disease onset with those who started 4-6 years after disease onset. METHODS:In this retrospective international observational study, we obtained data from the MSBase registry and the Swedish MS registry, which prospectively collect patient data that are specific to multiple sclerosis as part of routine clinical care. We identified adult patients (aged ≥18 years) with relapsing-remitting multiple sclerosis, with at least 6 years of follow-up since disease onset, and who started the high-efficacy therapy (rituximab, ocrelizumab, mitoxantrone, alemtuzumab, or natalizumab) either 0-2 years (early) or 4-6 years (late) after clinical disease onset. We matched patients in the early and late groups using propensity scores calculated on the basis of their baseline clinical and demographic data. The primary outcome was disability, measured with the Expanded Disability Status Score (EDSS; an ordinal scale of 0-10, with higher scores indicating increased disability), at 6-10 years after disease onset, assessed with a linear mixed-effects model. FINDINGS/RESULTS:We identified 6149 patients in the MSBase registry who had been given high-efficacy therapy, with data collected between Jan 1, 1975, and April 13, 2017, and 2626 patients in the Swedish MS Registry, with data collected between Dec 10, 1997, and Sept 16, 2019. Of whom, 308 in the MSBase registry and 236 in the Swedish MS registry were eligible for inclusion. 277 (51%) of 544 patients commenced therapy early and 267 (49%) commenced therapy late. For the primary analysis, we matched 213 patients in the early treatment group with 253 in the late treatment group. At baseline, the mean EDSS score was 2·2 (SD 1·2) in the early group and 2·1 (SD 1·2) in the late group. Median follow-up time for matched patients was 7·8 years (IQR 6·7-8·9). In the sixth year after disease onset, the mean EDSS score was 2·2 (SD 1·6) in the early group compared with 2·9 (SD 1·8) in the late group (p<0·0001). This difference persisted throughout each year of follow-up until the tenth year after disease onset (mean EDSS score 2·3 [SD 1·8] vs 3·5 [SD 2·1]; p<0·0001), with a difference between groups of -0·98 (95% CI -1·51 to -0·45; p<0·0001, adjusted for proportion of time on any disease-modifying therapy) across the 6-10 year follow-up period. INTERPRETATION/CONCLUSIONS:High-efficacy therapy commenced within 2 years of disease onset is associated with less disability after 6-10 years than when commenced later in the disease course. This finding can inform decisions regarding optimal sequence and timing of multiple sclerosis therapy. FUNDING/BACKGROUND:National Health and Medical Research Council Australia and MS Society UK.

BACKGROUND AND PURPOSE/OBJECTIVE:Acute rehabilitation is known to enhance stroke recovery. However, poststroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke complicated by poststroke fatigue and lethargy early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute inpatient rehabilitation or home. METHODS:We retrospectively reviewed a cohort of patients with acute stroke admitted to the stroke service over a 3-year period. All patients 18 years or older with confirmed ischemic or hemorrhagic stroke, an NIHSS greater than or equal to 5 and documentation of fatigue/lethargy in clinical documentation were included. We compared patients that were treated with modafinil 50-200 mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was 90 day modified Rankin score (mRS). Statistical significance was determined using chi-square test for association and logistic regression models. Logistic regression models were derived in 2 ways with both raw data and an adjusted model that accounted for age, sex, and NIHSS score to account for the lack of randomization. RESULTS:This study included 199 stroke patients (145 ischemic, 54 hemorrhagic). Seventy-two (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute inpatient rehabilitation, while none were recommended for discharge home. Median NIHSS for modafinil patients was 13.5 versus 11 for standard care patients (P = .059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days defined as mRS less than or equal to 2 occurred more frequently with modafinil (5.6% versus 3.3%) but this did not achieve statistical significance (P > .1). These results occurred despite the modafinil group requiring longer ICU stays and having more in-hospital complications such as infections and need for percutaneous gastrostomy tubes. The benefit of modafinil was seen across all subgroups except those with severe stroke (NIHSS ≥ 15). There were no significant adverse events associated with modafinil administration. CONCLUSIONS:Modafinil use in acute in-hospital stroke patients with moderate stroke complicated by lethargy and fatigue was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this patient population.

Background: Alzheimer's disease (AD) is a progressive neurodegenerative disease that currently accounts for over 70% of cases of dementia in adults over 65 worldwide, and is the only cause of death among the top ten with no effective treatments. Clinically, AD is characterized by progressive deterioration in memory and other areas of cognitive function. Neuropathologically, the disease is characterized by extracellular aggregations of amyloid-B (AB) and intraneuronal neurofibrillary tangles (NFTS) composed of abnormally phosphorylated tau, causing progressive neuronal death. The aim of this study was to investigate whether the affibody ZSYM73-ABD (a portion of the active antibody molecule) can reverse AD pathology in an AD mouse model, without also causing significant neuroinflammation and/or microhemorrhage.
Method(s): APP/PS1 double transgenic mice were injected twice weekly with either ZSYM-ABD or a non-AB specific affibody, Ztaq2, as a control. Mice underwent behavioral testing and their brains were then sacrificed for immunohistochemistry.
Result(s): Semi-quantitative analysis of amyloid burden, performed using 6E10/4G8 antibodies, showed a statistically significant reduction in amyloid burden in the hippocampus, and a trend towards reduction in amyloid burden in the cortex. Inflammation was assessed using GFAP and Iba1(markers of gliosis) which showed a statistically significant reduction of GFAP in the cortex and in the hippocampus, and a slight reduction of microgliosis in ZSYM73-ABD affibody treated mice. Finally, mice treated with ZSYM73-ABD performed significantly better on a novel object recognition task than control mice, suggesting a correlation between the histological findings above and improvement in cognitive function.
Conclusion(s): In conclusion, this study demonstrates that passive immunization with an affibody molecule improves cognitive function and significantly decreases amyloid burden in the hippocampus of a transgenic mouse model of AD, without inducing inflammation. This has potential implications for treatment of AD in humans

Pathophysiological understanding of gait and balance disorders in Parkinson's disease is insufficient and late recognition of fall risk limits efficacious follow-up to prevent or delay falls. We show a distinctive reduction of glucose metabolism in the left posterior parietal cortex, with increased metabolic activity in the cerebellum, in parkinsonian patients 6-8 months before their first fall episode. Falls in Parkinson's disease may arise from altered cortical processing of body spatial orientation, possibly predicted by abnormal cortical metabolism.

Deep brain stimulation (DBS) is an effective treatment for Parkinson's disease (PD) patients with motor fluctuations and dyskinesias. The key DBS efficacy studies were performed in PD patients with unknown genotypes; however, given the estimated monogenic mutation prevalence of approximately 5-10%, most commonly LRRK2, PRKN, PINK1 and SNCA, and risk-increasing genetic factors such as GBA, proper characterization is becoming increasingly relevant. We performed a systematic review of 46 studies that reported DBS effects in 221 genetic PD patients. The results suggest that monogenic PD patients have variable DBS benefit depending on the mutated gene. Outcome appears excellent in patients with the most common LRRK2 mutation, p.G2019S, and good in patients with PRKN mutations but poor in patients with the more rare LRRK2 p.R1441G mutation. The overall benefit of DBS in SNCA, GBA and LRRK2 p.T2031S mutations may be compromised due to rapid progression of cognitive and neuropsychiatric symptoms. In the presence of other mutations, the motor changes in DBS-treated monogenic PD patients appear comparable to those of the general PD population.

Introduction: The prevalence of attention deficit hyperactivity disorder (ADHD) in older adults is estimated to be between 1.5 - 3.3 % across studies (Kooji et al, 2016). Older adults constitute a group in which ADHD is frequently underdiagnosed, undertreated, and often overlooked in both clinical practice and research. It is believed that older adults may have experienced longitudinal impact and a lifelong consequences of ADHD symptoms, in the absence of support for their problems in child- or adulthood (Michielson et al, 2015). Nadeau reported that age related cognitive changes, worsening physical health, and the lack of structure that often comes with retirement frequently tend to perpetuate symptoms of inattention (Nadeau, 2018). We present the case of an elderly man with ADHD. This will be followed by a review of the literature on ADHD in older adults.
Method(s): Case of Mr. R: We present the case of Mr. R, a 75-year old man who presented for evaluation of cognitive complaints. He reported chronic difficulties with attention and concentration, with recent worsening of focus, attention, concentration, and memory. Assessment consisted of evaluation of the patient, collateral information from his wife, brain imaging, and neuropsychological testing. His presentation was felt to be consistent with chronic untreated ADHD, now superimposed with mild cognitive changes across other domains. A trial of low dose methylphenidate was associated with marked improvement in his ability to focus, to follow conversations, and his working memory. The subjective changes were corroborated on the Montreal cognitive assessment (MOCA) which showed improvement in his scores, especially in the area of attention. Electronic searches of The Cochrane Central Register of Controlled Trials and the standard bibliographic databases PubMed, MEDLINE, EMBASE, and PsycINFO will be performed for papers which focus on ADHD in older adults. Keywords include "late life," "elderly," "aged," "senior citizen," or "geriatric" combined with the keywords "ADHD" or "attention deficit," Original research, case reports, and reviews will be included.
Result(s): Preliminary search conducted yielded five papers. Data from the included papers will be extracted. The epidemiology of ADHD in older adults will be discussed. This will be followed by a description of diagnostic assessment and diagnostic issues specific to older adults. The impact of ADHD in older adults will be outlined, which emphasis on its difference from that in the younger population. This will be followed by treatment considerations unique to older adults. Finally, the relationship between ADHD and cognitive impairment will be explored.
Conclusion(s): ADHD is frequently underdiagnosed and undertreated in older adults. Timely and accurate diagnosis followed by treatment results in significant improvement in symptoms and functionality. This research was funded by: None
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INTRODUCTION/BACKGROUND:This clinical trial evaluates the efficacy and safety of a 6-week course of daily neuroAD™ therapy. METHODS:131 subjects between 60 and 90 years old, unmedicated for Alzheimer's disease (AD), or on stable doses of an acetylcholinesterase inhibitor and/or memantine, with Mini-Mental State Examination scores between 18 and 26, clinical dementia rating scale scores of 1 or 2, enrolled for a prospective, randomized, double-blind, sham-controlled, multicenter clinical trial. Structural brain MRIs were obtained for transcranial magnetic stimulation targeting. Baseline Alzheimer's disease assessment scale-cognitive (ADAS-Cog) and Clinical Global Impression of Change were assessed. 129 participants were randomized to active treatment plus standard of care (SOC) or sham treatments plus SOC. RESULTS:Subjects with baseline ADAS-Cog ≤ 30 (~85% of study population) showed a statistically significant benefit favoring active over sham. Responder analysis showed 31.7% participants in the active group with ≤ -4 point improvement on ADAS-Cog versus 15.4% in the sham group. DISCUSSION/CONCLUSIONS:neuroAD™ Therapy System provides a low-risk therapeutic benefit for patients with milder AD (baseline ADAS-Cog ≤30) beyond pharmacologic SOC.

Williams syndrome (WS) is a rare neurodevelopmental disorder caused by the hemideletion of approximately 25-28 genes at 7q11.23. Its unusual social and cognitive phenotype is most strikingly characterized by the disinhibition of social behavior, in addition to reduced global IQ, with a relative sparing of language ability. Hypersociality and increased social approach behavior in WS may represent a unique inability to inhibit responses to specific social stimuli, which is likely associated with abnormalities of frontostriatal circuitry. The striatum is characterized by a diversity of interneuron subtypes, including inhibitory parvalbumin-positive interneurons (PV+) and excitatory cholinergic interneurons (Ch+). Animal model research has identified an important role for these specialized cells in regulating social approach behavior. Previous research in humans identified a depletion of interneuron subtypes associated with neuropsychiatric disorders. Here, we examined the density of PV+ and Ch+ interneurons in the striatum of 13 WS and neurotypical (NT) subjects. We found a significant reduction in the density of Ch+ interneurons in the medial caudate nucleus and nucleus accumbens, important regions receiving cortical afferents from the orbitofrontal and ventromedial prefrontal cortex, and circuitry involved in language and reward systems. No significant difference in the distribution of PV+ interneurons was found. The pattern of decreased Ch+ interneuron densities in WS differs from patterns of interneuron depletion found in other disorders.