Effectiveness of Pregabalin as Monotherapy or Combination Therapy for Neuropathic Pain in Patients Unresponsive to Previous Treatments in a Spanish Primary Care Setting

BACKGROUND AND OBJECTIVE Patients from a previous study of neuropathic pain (NP) in the Spanish primary care setting still had symptoms despite treatment. Subsequently, patients were treated as prescribed by their physician and followed up for 3 months. Since pregabalin has been shown to be effective in NP, including refractory cases, the objective of this study was to assess the effectiveness of pregabalin therapy in patients with NP refractory to previous treatments. METHODS This was a post hoc analysis of pregabalin-naïve NP patients treated with pregabalin in a 3-month follow-up observational multicenter study to assess symptoms and satisfaction with treatment. Patients were evaluated with the Douleur Neuropathique en 4 questions (DN4), the Brief Pain Inventory (BPI) and the Treatment Satisfaction for Medication Questionnaire (SATMED-Q) overall satisfaction domain. RESULTS 1,670 patients (mean age 58 years, 59 % women), previously untreated or treated with ≥1 drug other than pregabalin, were treated with pregabalin (37 % on monotherapy). At 3 months, pain intensity and its interference with activities decreased by half (p < 0.0001), while the number of days with no or mild pain increased by a mean of 4.5 days (p < 0.0001). Treatment satisfaction increased twofold (p < 0.0001). Patients with a shorter history of pain and those with neuralgia and peripheral nerve compression syndrome (PCS) as etiologies had the highest proportion on monotherapy and showed the greatest improvements in pain-related parameters in their respective group categories. CONCLUSION Treatment with pregabalin (as monotherapy or combination therapy) provides benefits in pain and treatment satisfaction in patients with NP, including refractory cases. Shorter disease progression and neuralgia and PCS etiologies are favorable factors for pregabalin treatment response.

A study of the translational regulation exerted by some neuroactive substances on the expression of the monocarboxylate transporter MCT2 in cultured cortical neurons

Summary of the thesis Glucose has been considered the major, if not the exclusive, energy substrate for the brain. But under certain conditions other substrates, namely monocarboxylates (lactate, pyruvate, and ketone bodies), can contribute significantly to satisfy brain energy demands. These monocarboxylates need to be transported across the blood brain barrier as well as out of astrocytes into the extracellular space and taken up into neurons. It has been shown that monocarboxylates are transported by a family of proton-linked transporters called monocarboxylate transporters (MCTs). In the central nervous system, MCT2 is the predominant neuronal form and little is known about the regulation of its expression. The neurotransmitter noradrenaline (NA) was shown previously to enhance the expression of MCT2 in cultured cortical neurons via a translational mechanism. Here, we demonstrate that two other substances, namely, insulin and IGF-1 enhance MCT2 protein expression in cultured mouse cortical neurons in a time- and concentrationdependent manner without affecting MCT2 mRNA levels. This result confirmed that MCT2 protein expression is translationally regulated and extend the observation to different types of neuroactive substances. Then we sought to determine by which signaling pathway(s) NA, insulin and IGF-1 can induce MCT2 protein expression. First, we observed by Western blot that all three substances cause activation of the MAP kinase ERK as well as the kinase Akt via their phosphorylation. Moreover, the mTOR/S6K pathway which is known to play an important role in translation initiation regulation was also strongly stimulated by all three substances. Second, we sought to determine the implication of these signaling pathways on the NA-, insulin- and IGF-1-induced enhancement of MCT2 protein expression and used specific inhibitors of these signaling pathways. We observed that the Pia kinase and mTOR inhibitors LY294002 and rapamycin respectively, strongly prevent the enhancement. of MCT2 expression caused by either NA, insulin ar IGF-1. In contrast, the MEK inhibitor PD98059 and the p38 MAP kinase inhibitor SB202190 had only a slight effect on the enhancement of MCT2 expression in all three cases. These results suggest that NA, insulin and IGF-1 regulate MCT2 protein expression by a common mechanism most likely involving the Akt/PKB pathway and translational activation via mTOR. In conclusion, considering the roles of NA, insulin and IGF-1 in synaptic plasticity, the tight translational regulation of MCT2 expression by these substances may represent a common mechanism through which supply of potentiated synapses with nonglucose energy substrates can be adapted to the level of activity. Résumé du travail de thèse Le glucose représente le substrat énergétique majeur pour le cerveau. Cependant, dans certaines conditions physiologiques ou pathologiques, le cerveau a la capacité d'utiliser des substrats énergétiques appartenant à la classe des monocarboxylates (lactate, pyruvate et corps cétoniques) afin de satisfaire ses besoins énergétiques. Ces monocarboxylates doivent être transportés à travers la barrière hématoencéphalique mais aussi hors des astrocytes vers l'espace extracellulaire puis re-captés par les neurones. Leur transport est assuré par une famille de transporteurs spécifiques, protons-dépendants, appelés transporteurs aux monocarboxylates (MCTs). Dans le système nerveux central, les neurones expriment principalement l'isoforme MCT2 mais peu d'informations sont disponibles concernant la régulation de son expression. Il a été montré que le neurotransmetteur noradrénaline (NA) augmente l'expression de MCT2 dans les cultures de neurones corticaux de souris par le biais d'un mécanisme de régulation traductionnel. La présente étude nous a permis de démontrer que deux autres substances, l'insuline et 17GF-1, induisent une augmentation de la protéine MCT2 dans ces mêmes cultures selon un décours temporel et une gamme de concentrations particulière. Etonnamment, aucun changement n'a été observé concernant les niveaux d'ARNm de MCT2. Ce résultat .confirme que la protéine MCT2 est régulée de manière traductionnelle et révèle que différentes substances neuro-actives peuvent réguler l'expression de MCT2. Compte tenu de ces observations, nous avons voulu déterminer par quelle(s) voie(s) de signalisation la NA, l'insuline et l'IGF-1 exercent leur effet sur l'expression de MCT2. Dans un premier temps, nous avons pu observer par Western blot que ces trois substances activent la MAP kinase ERK ainsi que la kinase Akt via leur phasphorylation. De plus, la voie mTOR/S6K, connue pour son implication dans la régulation de l'initiation de la traduction est aussi fortement activée par ces trois substances. Dans un second temps, nous avons voulu déterminer I implication de chacune de ces voies de signalisation dans l'augmentation de l'expression de la protéine MCT2 observée après stimulation à la NA, à l'insuline et à l'IGF-1. Pour ce faire, nous avons utilisé des inhibiteurs spécifiques de chacune de ces voies. (Vous avons observé que les inhibiteurs des voies PI3 kinase et mTOR (LY294002 et rapamycin respectivement), prévenaient fortement l'augmentation de l'expression de MCT2 induite par la NA, l'insuline ou (IGF-1. A l'inverse, les inhibitions de la MAP kinase .kinase MEK ainsi que de la MAP kinase p38 (par l'utilisation des inhibiteurs spécifiques PD98059 et SB202190 respectivement) n'ont eu qu'un léger effet dans ces mêmes conditions. Ces résultats suggèrent que la NA, 'l'insuline et I~GF-1 régulent l'expression de la protéine MCT2 par un mécanisme commun impliquant probablement la voie Akt/PKB et l'activation de la traduction via mTOR. En conclusion, considérant l'implication de la NA, de l'insuline et de I`IGF-1 dans la plasticité synaptique, le contrôle traductionnel étroit exercé par ces substances sur l'expression de MCT2 pourrait être un moyen d'alimenter en substrats énergétiques autres que le glucose les synapses activées et également d'adapter l'approvisionnement en substrats énergétiques au niveau d'activité. Résumé « grand public » Le cerveau est un organe qui réalise des tâches complexes nécessitant un apport important en énergie. La principale source d'énergie du cerveau est le glucose. Bien que le cerveau ne représente que 2% de la masse corporelle, il consomme à lui seul plus de 25% du glucose et 20% de l'oxygène provenant de la circulation sanguine. La nécessité d'un tel apport en énergie réside dans la nature -même du fonctionnement des milliards de neurones qui utilisent des signaux électriques et chimiques pour communiquer entre eux. Hormis l'utilisation massive du glucose comme source d'énergie, le cerveau est capable de consommer d'autres substrats énergétiques dans certaines conditions physiologiques ou pathologiques. Les monocarboxylates (lactate, pyruvate et corps cétoniques) font partie de ces autres sources d'énergie. Contrairement au glucose, les monocarboxylates ne diffusent pas facilement de la circulation sanguine vers les neurones. Afin de pouvoir être consommés par les neurones, ils doivent être transportés par un système adapté. Ce sont des transporteurs appelés transporteurs aux monocarboxylates ou MCT qui permettent le passage de ces substrats énergétiques du sang vers les neurones. Le but de ce travail de thèse a été de comprendre comment est régulée l'expression de MCT2, l'un de ces transporteurs exprimé spécifiquement à la surface des neurones. Cette étude nous a permis de mettre en évidence que le neurotransmetteur noradrénaline ainsi que les hormones insuline et IGF-1 (insulinlike growth factor-1) sont capables d'induire une augmentation d'expression de MCT2 à la surface des neurones en culture. Nous avons ensuite voulu déterminer par quels mécanismes de signalisation ces substances agissent sur l'expression de MCT2. Nous avons pu observer que la surexpression de la protéine MCT2 est due à une augmentation d'activité traductionnelle (la traduction étant une des étapes qui permet la synthèse des protéines) induite par le biais d'une voie de signalisation particulière. En conclusion, lorsque la noradrénaline, l'insuline ou 17GF-1 agissent sur les neurones, la traduction de la protéine MCT2 est activée et on observe une augmentation de l'expression de MCT2. Ce mécanisme pourrait permettre d'augmenter l'apport énergétique au niveau des neurones en augmentant le nombre de transporteurs pour les substrats énergétiques que sont les monocarboxylates. D'un point de vue physiologique, cette régulation d'expression pourrait jouer un rôle primordial dans des situations d'apprentissage et de mémorisation. Sur le plan pathologique, cela pourrait permettre de prévenir les dommages causes aux neurones dans certains cas d'atteintes cérébrales.

Leishmania amazonensis exhibits phosphatidylserine-dependent procoagulant activity, a process that is counteracted by sandfly saliva

Leishmania parasites expose phosphatidylserine (PS) on their surface, a process that has been associated with regulation of host's immune responses. In this study we demonstrate that PS exposure by metacyclic promastigotes of Leishmania amazonensis favours blood coagulation. L. amazonensis accelerates in vitro coagulation of human plasma. In addition, L. amazonensis supports the assembly of the prothrombinase complex, thus promoting thrombin formation. This process was reversed by annexin V which blocks PS binding sites. During blood meal, Lutzomyia longipalpis sandfly inject saliva in the bite site, which has a series of pharmacologically active compounds that inhibit blood coagulation. Since saliva and parasites are co-injected in the host during natural transmission, we evaluated the anticoagulant properties of sandfly saliva in counteracting the procoagulant activity of L. amazonensis . Lu. longipalpis saliva reverses plasma clotting promoted by promastigotes. It also inhibits thrombin formation by the prothrombinase complex assembled either in phosphatidylcholine (PC)/PS vesicles or in L. amazonensis . Sandfly saliva inhibits factor X activation by the intrinsic tenase complex assembled on PC/PS vesicles and blocks factor Xa catalytic activity. Altogether our results show that metacyclic promastigotes of L. amazonensis are procoagulant due to PS exposure. Notably, this effect is efficiently counteracted by sandfly saliva.

Combining rimonabant and fentanyl in a single entity: preparation and pharmacological results.

Based on numerous pharmacological studies that have revealed an interaction between cannabinoid and opioid systems at the molecular, neurochemical, and behavioral levels, a new series of hybrid molecules has been prepared by coupling the molecular features of two wellknown drugs, ie, rimonabant and fentanyl. The new compounds have been tested for their affinity and functionality regarding CB1 and CB2 cannabinoid and μ opioid receptors. In [(35)S]-GTPγS (guanosine 5'-O-[gamma-thio]triphosphate) binding assays from the post-mortem human frontal cortex, they proved to be CB1 cannabinoid antagonists and μ opioid antagonists. Interestingly, in vivo, the new compounds exhibited a significant dual antagonist action on the endocannabinoid and opioid systems.

A neuron-glia signalling network in the active brain.

Glial cells are active partners of neurons in processing information and synaptic integration. They receive coded signals from synapses and elaborate modulatory responses. The active properties of glia, including long-range signalling and regulated transmitter release, are beginning to be elucidated. Recent insights suggest that the active brain should no longer be regarded as a circuitry of neuronal contacts, but as an integrated network of interactive neurons and glia.

Moderate-Vigorous Physical Activity across Body Mass Index in Females: Moderating Effect of Endocannabinoids and Temperament.

BACKGROUND Endocannabinoids and temperament traits have been linked to both physical activity and body mass index (BMI) however no study has explored how these factors interact in females. The aims of this cross-sectional study were to 1) examine differences among distinct BMI groups on daytime physical activity and time spent in moderate-vigorous physical activity (MVPA), temperament traits and plasma endocannabinoid concentrations; and 2) explore the association and interaction between MVPA, temperament, endocannabinoids and BMI. METHODS Physical activity was measured with the wrist-worn accelerometer Actiwatch AW7, in a sample of 189 female participants (43 morbid obese, 30 obese, and 116 healthy-weight controls). The Temperament and Character Inventory-Revised questionnaire was used to assess personality traits. BMI was calculated by bioelectrical impedance analysis via the TANITA digital scale. Blood analyses were conducted to measure levels of endocannabinoids and endocannabinoid-related compounds. Path-analysis was performed to examine the association between predictive variables and MVPA. RESULTS Obese groups showed lower MVPA and dysfunctional temperament traits compared to healthy-weight controls. Plasma concentrations of 2-arachidonoylglyceryl (2-AG) were greater in obese groups. Path-analysis identified a direct effect between greater MVPA and low BMI (b = -0.13, p = .039) and high MVPA levels were associated with elevated anandamide (AEA) levels (b = 0.16, p = .049) and N-oleylethanolamide (OEA) levels (b = 0.22, p = .004), as well as high Novelty seeking (b = 0.18, p<.001) and low Harm avoidance (b = -0.16, p<.001). CONCLUSIONS Obese individuals showed a distinct temperament profile and circulating endocannabinoids compared to controls. Temperament and endocannabinoids may act as moderators of the low MVPA in obesity.

Influence of gender on long-term prognosis of patients with chronic heart failure seen in heart failure clinics.

BACKGROUND Controversy exists concerning the influence of gender in the prognosis of patients with heart failure and no evidence is available from specific heart failure clinics. HYPOTHESIS Women with ambulatory heart failure are managed differently than men, although their prognosis might be better than men. METHODS AND RESULTS We analyzed the clinical characteristics, complementary test results, treatment, and prognosis in 4720 patients with chronic heart failure seen in 62 specialized clinics forming part of a multicenter registry during a mean follow-up of 40 months. The mean age was 65 +/- 12 years and 71% were men. The men were younger than the women and more often had a history of hyperlipidemia and ischemic heart disease. The men had a more advanced heart failure New York Heart Association (NYHA) functional class (III-IV) than the women and a greater frequency of systolic ventricular dysfunction. The men more often received treatment with beta-blockers, vasodilators, and antiplatelet aggregators as well as higher mean doses as compared with the women. The overall survival after the follow-up was similar for both genders, although the women had lower rates of survival free of admission for heart failure. CONCLUSIONS Despite the mortality of women and men with heart failure being similar, the rate of readmission for heart failure is greater in women in specialized heart failure clinics. These results may be associated with the pharmacological treatment differences observed.

The role of astroglia in neuroprotection.

Astrocytes are the main neural cell type responsible for the maintenance of brain homeostasis. They form highly organized anatomical domains that are interconnected into extensive networks. These features, along with the expression of a wide array of receptors, transporters, and ion channels, ideally position them to sense and dynamically modulate neuronal activity. Astrocytes cooperate with neurons on several levels, including neurotransmitter trafficking and recycling, ion homeostasis, energy metabolism, and defense against oxidative stress. The critical dependence of neurons upon their constant support confers astrocytes with intrinsic neuroprotective properties which are discussed here. Conversely, pathogenic stimuli may disturb astrocytic function, thus compromising neuronal functionality and viability. Using neuroinflammation, Alzheimer's disease, and hepatic encephalopathy as examples, we discuss how astrocytic defense mechanisms may be overwhelmed in pathological conditions, contributing to disease progression.

The administration of atomoxetine during alcohol deprivation induces a time-limited increase in alcohol consumption after relapse.

The administration of selective serotonin reuptake inhibitors (SSRIs) typically used as antidepressants increases alcohol consumption after an alcohol deprivation period in rats. However, the appearance of this effect after the treatment with selective noradrenaline reuptake inhibitors (SNRIs) has not been studied. In the present work we examined the effects of a 15-d treatment with the SNRI atomoxetine (1, 3 and 10 mg/kg, i.p.) in male rats trained to drink alcohol solutions in a 4-bottle choice test. The treatment with atomoxetine (10 mg/kg, i.p.) during an alcohol deprivation period increased alcohol consumption after relapse. This effect only lasted one week, disappearing thereafter. Treatment with atomoxetine did not cause a behavioral sensitized response to a challenge dose of amphetamine (1.5 mg/kg, i.p.), indicating the absence of a supersensitive dopaminergic transmission. This effect is markedly different from that of SSRI antidepressants that produced both long-lasting increases in alcohol consumption and behavioral sensitization. Clinical implications are discussed.

Localization of the cannabinoid CB1 receptor and the 2-AG synthesizing (DAGLα) and degrading (MAGL, FAAH) enzymes in cells expressing the Ca(2+)-binding proteins calbindin, calretinin, and parvalbumin in the adult rat hippocampus.

The retrograde suppression of the synaptic transmission by the endocannabinoid sn-2-arachidonoylglycerol (2-AG) is mediated by the cannabinoid CB1 receptors and requires the elevation of intracellular Ca(2+) and the activation of specific 2-AG synthesizing (i.e., DAGLα) enzymes. However, the anatomical organization of the neuronal substrates that express 2-AG/CB1 signaling system-related molecules associated with selective Ca(2+)-binding proteins (CaBPs) is still unknown. For this purpose, we used double-label immunofluorescence and confocal laser scanning microscopy for the characterization of the expression of the 2-AG/CB1 signaling system (CB1 receptor, DAGLα, MAGL, and FAAH) and the CaBPs calbindin D28k, calretinin, and parvalbumin in the rat hippocampus. CB1, DAGLα, and MAGL labeling was mainly localized in fibers and neuropil, which were differentially organized depending on the hippocampal CaBPs-expressing cells. CB(+) 1 fiber terminals localized in all hippocampal principal cell layers were tightly attached to calbindin(+) cells (granular and pyramidal neurons), and calretinin(+) and parvalbumin(+) interneurons. DAGLα neuropil labeling was selectively found surrounding calbindin(+) principal cells in the dentate gyrus and CA1, and in the calretinin(+) and parvalbumin(+) interneurons in the pyramidal cell layers of the CA1/3 fields. MAGL(+) terminals were only observed around CA1 calbindin(+) pyramidal cells, CA1/3 calretinin(+) interneurons and CA3 parvalbumin(+) interneurons localized in the pyramidal cell layers. Interestingly, calbindin(+) pyramidal cells expressed FAAH specifically in the CA1 field. The identification of anatomically related-neuronal substrates that expressed 2-AG/CB1 signaling system and selective CaBPs should be considered when analyzing the cannabinoid signaling associated with hippocampal functions.

A role for glutamate transporters in the regulation of insulin secretion.

In the brain, glutamate is an extracellular transmitter that mediates cell-to-cell communication. Prior to synaptic release it is pumped into vesicles by vesicular glutamate transporters (VGLUTs). To inactivate glutamate receptor responses after release, glutamate is taken up into glial cells or neurons by excitatory amino acid transporters (EAATs). In the pancreatic islets of Langerhans, glutamate is proposed to act as an intracellular messenger, regulating insulin secretion from β-cells, but the mechanisms involved are unknown. By immunogold cytochemistry we show that insulin containing secretory granules express VGLUT3. Despite the fact that they have a VGLUT, the levels of glutamate in these granules are low, indicating the presence of a protein that can transport glutamate out of the granules. Surprisingly, in β-cells the glutamate transporter EAAT2 is located, not in the plasma membrane as it is in brain cells, but exclusively in insulin-containing secretory granules, together with VGLUT3. In EAAT2 knock out mice, the content of glutamate in secretory granules is higher than in wild type mice. These data imply a glutamate cycle in which glutamate is carried into the granules by VGLUT3 and carried out by EAAT2. Perturbing this cycle by knocking down EAAT2 expression with a small interfering RNA, or by over-expressing EAAT2 or a VGLUT in insulin granules, significantly reduced the rate of granule exocytosis. Simulations of granule energetics suggest that VGLUT3 and EAAT2 may regulate the pH and membrane potential of the granules and thereby regulate insulin secretion. These data suggest that insulin secretion from β-cells is modulated by the flux of glutamate through the secretory granules.

Left ventricular assist device.

To the Editor: The value of angiotensin-converting– enzyme (ACE) inhibitors, beta-blockers, and spironolactone has been well established by the results of numerous clinical trials. About 70 percent of the patients described by Rose et al. were treated with ACE inhibitors or angiotensin II–receptor antagonists; 35 to 40 percent received spironolactone, and only about 20 percent received beta-blockers. Thus, this population cannot have been considered to be optimally treated from the point of view of medical therapy.

A Lower Olfactory Capacity Is Related to Higher Circulating Concentrations of Endocannabinoid 2-Arachidonoylglycerol and Higher Body Mass Index in Women.

The endocannabinoid (eCB) system can promote food intake by increasing odor detection in mice. The eCB system is over-active in human obesity. Our aim is to measure circulating eCB concentrations and olfactory capacity in a human sample that includes people with obesity and explore the possible interaction between olfaction, obesity and the eCB system. The study sample was made up of 161 females with five groups of body mass index sub-categories ranging from under-weight to morbidly obese. We assessed olfactory capacity with the "Sniffin´Sticks" test, which measures olfactory threshold-discrimination-identification (TDI) capacity. We measured plasma concentrations of the eCBs 2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine or anandamide (AEA), and several eCB-related compounds, 2-acylglycerols and N-acylethanolamines. 2-AG and other 2-acylglycerols fasting plasma circulating plasma concentrations were higher in obese and morbidly obese subjects. AEA and other N-acylethanolamine circulating concentrations were lower in under-weight subjects. Olfactory TDI scores were lower in obese and morbidly obese subjects. Lower TDI scores were independently associated with higher 2-AG fasting plasma circulating concentrations, higher %body fat, and higher body mass index, after controlling for age, smoking, menstruation, and use of contraceptives. Our results show that obese subjects have a lower olfactory capacity than non-obese ones and that elevated fasting plasma circulating 2-AG concentrations in obesity are linked to a lower olfactory capacity. In agreement with previous studies we show that eCBs AEA and 2-AG, and their respective congeners have a distinct profile in relation to body mass index. The present report is the first study in humans in which olfactory capacity and circulating eCB concentrations have been measured in the same subjects.

Thyroid metastasis as initial presentation of clear cell renal carcinoma.

INTRODUCTION Metastatic tumors account for 1.4-2.5% of thyroid malignancies. About 25-30% of patients with clear cell renal carcinoma (CCRC) have distant metastasis at the time of diagnosis, being the thyroid gland a rare localization [5%]. PRESENTATION OF THE CASE A 62-year woman who underwent a cervical ultrasonography and a PAAF biopsy reporting atypical follicular proliferation with a few intranuclear vacuoles "suggestive" of thyroid papillary cancer in the context of a multinodular goiter was reported. A total thyroidectomy was performed and the histology of a clear cell renal carcinoma (CCRC) was described in four nodules of the thyroid gland. A CT scan was performed and a renal giant right tumor was found. The patient underwent an eventful radical right nephrectomy and the diagnosis of CCRC was confirmed. DISCUSSION Thyroid metastasis (TM) from CCRC are usually apparent in a metachronic context during the follow-up of a treated primary (even many years after) but may sometimes be present at the same time than the primary renal tumor. Our case is exceptional because the TM was the first evidence of the CCRC, which was subsequently diagnosed and treated. CONCLUSION The possibility of finding of an incidental metastatic tumor in the thyroid gland from a previous unknown and non-diganosed primary (as CCRC in our case was) is rare and account only for less than 1% of malignancies. Nonetheless, the thyroid gland is a frequent site of metastasis and the presence of "de novo" thyroid nodules in oncologic patients must be always considered and studied.