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BACKGROUND: Anxiety disorders are common, associated with significant burden of disease, and have high levels of treatment resistance. Low-dose ketamine has been extensively studied in treatment-resistant depression, with fewer reports in treatment-resistant anxiety disorders. AIMS: This systematic review and meta-analysis collected efficacy, safety, and tolerability data for ketamine as a treatment for anxiety spectrum disorders. METHODS: We conducted a systematic search for randomized controlled trials (RCTs) of acute ketamine treatment for patients with anxiety disorders. Open-label trials of ketamine maintenance therapy were also considered. Qualitative and, where possible, quantitative syntheses of findings were performed using Review Manager software (RevMan). Acute dose-response and maintenance treatment data were also collected. RESULTS: There were six eligible acute RCTs - two in social anxiety disorder (SAD), three in post-traumatic stress disorder (PTSD), and one in obsessive-compulsive disorder (OCD). Four of the six showed significant improvement in anxiety rating scores in ketamine compared with control groups. Pooled analysis showed ketamine was associated with an increased likelihood of treatment response for SAD (odds ratio (OR): 28.94; 95% confidence interval [CI]: 3.45-242.57; p = 0.002) but not for PTSD (OR: 2.03; 95% CI: 0.67-6.15; p = 0.21). A dose-response profile was observed for ketamine and changes in SAD symptoms, with doses ⩾0.5 mg/kg associated with greater reduction in anxiety rating scores than lower doses. Ketamine maintenance therapy was associated with sustained anxiolytic effects and improved social and/or work functioning. CONCLUSION: These preliminary analyses suggest that acute ketamine may be broadly effective across treatment-resistant anxiety spectrum disorders. These effects can be prolonged with maintenance treatment. Future studies will be needed to provide critical knowledge gaps around off-label use, side effects, and potential risks for abuse in clinical settings.
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OBJECTIVE: To date, treatment options (i.e. psychotherapy, antidepressant medications) for patients with posttraumatic stress disorder (PTSD), are relatively few, and considering their limited efficacy, novel therapies have gained interest among researchers and treatment providers alike. Among patients with chronic pain (CP) about one third experience comorbid PTSD, which further complicates their already challenging pharmacological regimens. Low dose ketamine infusion has shown promise in PTSD, and in treatment of CP, however they have not been studied in comorbid population and under rigorous control conditions. METHODS: We compared the effects of a single dose of either ketamine (0.5 mg/kg) or ketorolac (15 mg) over a 40-minute of IV infusion in CP patients with and without PTSD, in double blind, randomized study. Measures were collected before, during, one day and seven days after the infusion. A planned sample size of 40 patients randomly assigned to treatment order was estimated to provide 80% power to detect a hypothesized treatment difference after the infusion.Main Outcome and Measures: The primary outcome measures were change in PTSD symptom severity assessed with the Impact of Event Scale-Revised (IES-R) and Visual Analogue Scale (VAS) for pain administered by a study clinician 24 hours post infusion. Secondary outcome measures included Impact of Event Scale-Revised (IES-R), VAS and Brief Pain Inventory (Short Form) for pain 1 week after the infusion. RESULTS: Both treatments offered comparable improvement of PTSD and CP symptoms that persisted for 7 days after the infusion. Patients with comorbid PTSD and CP experienced less dissociative side effects compared to the CP group. Surprisingly, ketorolac infusion resulted in dissociative symptoms in CP patients only. CONCLUSIONS: This first prospective study comparing effects of subanesthetic ketamine versus ketorolac infusions for comorbid PTSD and CP, suggests that both ketamine and ketorolac might offer meaningful and durable response for both PTSD and CP symptoms.
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A novel interdisciplinary team approach within a primary care setting may be a promising model for delivering effective comprehensive treatment options for patients with chronic pain.
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HDL and apolipoprotein A1 (apoA1) concentrations inversely correlate with risk of death from ischemic heart disease; however, the role of apoA1 in the myocardial response to ischemia has not been well defined. To test whether apoA1, the primary HDL apolipoprotein, has an acute anti-inflammatory role in ischemic heart disease, we induced myocardial infarction via direct left anterior descending coronary artery ligation in apoA1 null (apoA1(-/-)) and apoA1 heterozygous (apoA1(+/-)) mice. We observed that apoA1(+/-) and apoA1(-/-) mice had a 52% and 125% increase in infarct size as a percentage of area at risk, respectively, compared with wild-type (WT) C57BL/6 mice. Mitochondrial oxidation contributes to tissue damage in ischemia-reperfusion injury. A substantial defect was present at baseline in the electron transport chain of cardiac myocytes from apoA1(-/-) mice localized to the coenzyme Q (CoQ) pool with impaired electron transfer (67% decrease) from complex II to complex III. Administration of coenzyme Q10 (CoQ10) to apoA1 null mice normalized the cardiac mitochondrial CoQ pool and reduced infarct size to that observed in WT mice. CoQ10 administration did not significantly alter infarct size in WT mice. These data identify CoQ pool content leading to impaired mitochondrial function as major contributors to infarct size in the setting of low HDL/apoA1. These data suggest a previously unappreciated mechanism for myocardial stunning, cardiac dysfunction, and muscle pain associated with low HDL and low apoA1 concentrations that can be corrected by CoQ10 supplementation and suggest populations of patients that may benefit particularly from CoQ10 supplementation.
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Antioxidantes/metabolismo , Apolipoproteína A-I/metabolismo , Modelos Animales de Enfermedad , Mitocondrias Cardíacas/metabolismo , Infarto del Miocardio/terapia , Miocardio/metabolismo , Ubiquinona/análogos & derivados , Animales , Antioxidantes/administración & dosificación , Antioxidantes/farmacocinética , Antioxidantes/uso terapéutico , Apolipoproteína A-I/sangre , Apolipoproteína A-I/genética , Cardiotónicos/administración & dosificación , Cardiotónicos/metabolismo , Cardiotónicos/farmacocinética , Cardiotónicos/uso terapéutico , Suplementos Dietéticos , Transporte de Electrón/efectos de los fármacos , Complejo II de Transporte de Electrones/química , Complejo II de Transporte de Electrones/metabolismo , Complejo III de Transporte de Electrones/química , Complejo III de Transporte de Electrones/metabolismo , Corazón/efectos de los fármacos , Hipoalfalipoproteinemias/fisiopatología , Inyecciones Intraperitoneales , Absorción Intestinal , Masculino , Ratones , Ratones Noqueados , Mitocondrias Cardíacas/efectos de los fármacos , Mitocondrias Cardíacas/enzimología , Infarto del Miocardio/etiología , Infarto del Miocardio/metabolismo , Infarto del Miocardio/patología , Daño por Reperfusión Miocárdica/sangre , Daño por Reperfusión Miocárdica/metabolismo , Daño por Reperfusión Miocárdica/patología , Daño por Reperfusión Miocárdica/prevención & control , Miocardio/enzimología , Miocardio/patología , Distribución Tisular , Ubiquinona/administración & dosificación , Ubiquinona/metabolismo , Ubiquinona/farmacocinética , Ubiquinona/uso terapéuticoRESUMEN
Plasminogen activator inhibitor-1 (PAI-1) is an oxidant-sensitive protease inhibitor that is inactivated by oxidation and has a critical role in ventricular remodeling post myocardial infarction (MI). PAI-1 knockout (KO) mice die within 7days of myocardial infarction post MI due to increased plasmin activity leading to ventricular rupture. The goal of this study was to assess the relevant pathways of leukocyte-derived oxidants post MI that alter PAI-1 activity. Transplantation of wild-type (WT) bone marrow into PAI-1 null mice prolonged survival after MI (WT marrow: 41.66% vs. PAI-1 KO marrow: 0% in PAI-1 KO mice at day 7 (p<0.02). To determine relevant enzyme systems, we transplanted marrow from mice with specific deletions relevant to leukocyte-derived oxidants (NAD(P)H oxidase, iNOS, myeloperoxidase (MPO)) to determine which deletion controls PAI-1 oxidative inactivation and prolongs survival. MI was induced by ligation of the left anterior descending artery (LAD) and the incidence of cardiac rupture was monitored. PAI-1 KO transplanted with MPO KO, or iNOS KO bone marrow died within 9 days after MI. PAI-1 KO mice transplanted with p47(phox) KO marrow exhibited prolonged survival 21 days after MI (30% survival, p<0.03, n=10) compared to WT marrow (8.3%, n=12). Three days after MI, PAI-1 KO mice transplanted with p47(phox) KO marrow had increased PAI-1 activity and decreased nitration of PAI-1 in myocardial tissue compared to PAI-1 KO mice transplanted with WT marrow. These data suggest that modulating O(2)(â¢-) generation by NAD(P)H oxidase appears to be a therapeutically relevant target for increasing myocardial PAI-1 levels after MI, whereas downstream enzymes like MPO and iNOS may not be.
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Rotura Cardíaca Posinfarto/metabolismo , Rotura Cardíaca/metabolismo , Ventrículos Cardíacos/patología , Leucocitos/metabolismo , NADPH Oxidasas/sangre , Inhibidor 1 de Activador Plasminogénico/metabolismo , Animales , Trasplante de Médula Ósea , Rotura Cardíaca/enzimología , Rotura Cardíaca/patología , Rotura Cardíaca Posinfarto/sangre , Rotura Cardíaca Posinfarto/enzimología , Rotura Cardíaca Posinfarto/patología , Leucocitos/enzimología , Masculino , Ratones , Ratones Noqueados , NADPH Oxidasas/biosíntesis , Óxido Nítrico Sintasa de Tipo II/metabolismo , Oxidación-Reducción , Peroxidasa/metabolismo , Inhibidor 1 de Activador Plasminogénico/sangre , Remodelación Ventricular/fisiologíaRESUMEN
Despite advances in chemotherapeutic agents, the prognosis for some cancers remains extremely poor, suggesting the need for other treatment modalities. Immunotherapy appears an ideal approach because the mechanisms of tumor cell killing induced by tumor vaccines are different from those from chemotherapy. Various investigations are ongoing to identify suitable targets for this purpose. Sperm protein 17 (Sp17) was originally identified by our group as a novel cancer-testis antigen in various malignancies, including multiple myeloma. Sp17 is a highly immunogenic protein and the observation that more than 90% of vasectomized males develop immunity against Sp17 suggests the opportunity and safety of Sp17 for tumor vaccines. Recent works by other workers suggest a low level of expression of Sp17 in some normal tissues, and investigators have questioned whether Sp17 is in fact a suitable target for immunotherapy. In this paper, we review the general principles of immunotherapy and provide evidence supporting the highly immunogenic nature of Sp17. We also address the discrepancies between the objectives of oncologists involved in treating cancer patients and their familiarity with acceptable levels of toxicity of any effective therapy and those of pure laboratory-based investigators. Finally, we present some early clinical data supporting the rationale for further investigations of Sp17 for tumor vaccines.
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Autoantígenos/inmunología , Proteínas Portadoras/inmunología , Inmunoterapia/métodos , Antígenos de Neoplasias/inmunología , Antígenos de Superficie , Proteínas de Unión a Calmodulina , Vacunas contra el Cáncer/uso terapéutico , Humanos , Masculino , Proteínas de la Membrana , Neoplasias Testiculares/inmunología , Neoplasias Testiculares/terapiaRESUMEN
The clinical significance of tumor-infiltrating dendritic cells has been reported in a variety of human solid tumors as shown by the correlations found between the presence of tumor-infiltrating dendritic cells and clinical prognosis. In this study, we evaluated whether there is an association between the presence and maturation status of tumor-infiltrating dendritic cells, T lymphocytes, and clinical course in 104 primary tumor samples of patients with colorectal cancer. Dendritic cells were identified with four different markers (S-100, HLA class II, CD208, and CD1a) in double immunohistochemistry, with laminin as second marker to support the exact localization. Tumor-infiltrating dendritic cells showed a distinct infiltration pattern based on their maturation status. CD1a-positive dendritic cells resided in the advancing tumor margins in relatively high numbers, whereas mature CD208-positive dendritic cells were sparsely present in the tumor epithelium but mainly distributed in the tumor stroma and advancing tumor margin. Furthermore, high infiltration of CD1a-positive dendritic cells in the tumor epithelium was significantly correlated to the infiltration of CD4 lymphocytes (P = 0.006). Patients with relatively high numbers of mature CD208-positive infiltrating dendritic cells in the tumor epithelium had a shorter overall survival (P = 0.004). In addition, patients with relatively high numbers of CD1a-positive dendritic cells in the advancing margin of the tumor had a shorter disease-free survival (P = 0.03). We found that tumor-infiltrating dendritic cells had preferential infiltration sites within a tumor, affected local tumor cell-immune cell interactions, and correlated to the clinical prognosis of colorectal cancer patients.