動物実験における症候評価の問題点

YGY-E is an active ingredient in traditional Chinese medical herbs which have anti-ischemic activity. The present work was designed to study its therapeutic time window in cerebral ischemic injury as well as its effect on neuronal apoptosis. Animals received an intravenous injection of YGY-E at 1, 3, and 6 h, respectively, after permanent focal cerebral ischemia induced by electrocoagulation of the middle cerebral artery. Infarct ratio and neurological function were employed to assess the effects of YGY-E on the therapeutic time window in this animal model. Furthermore, we evaluated effects of this compound on neuronal apoptosis and synthesis of Bcl-2 and Bax in ischemic brain tissue with in situ DNA end labeling (TUNEL), immunohistochemistry assay, and Western blot analysis. YGY-E (2-8 mg/kg) delivered at all the three time points dosedependently decreased infarct ratio, neurological deficits, percentage of TUNEL-positive cells (p < 0.01) and Bax-positive cells (p < 0.01 or p < 0.05). In contrast, it increased the percentage of Bcl-2 positive cells (p < 0.01 or p < 0.05). These data demonstrated that YGY-E had protective effects against cerebral ischemia injuries in rats. But more importantly, they indicate that YGY-E has an unusually long (up to 6 h) therapeutic time window relative to classical drugs in treating cerebral ischemia. In addition, our results suggest that the anti-apoptotic effects of YGY-E are due to its regulation of the balance between Bcl-2 and Bax protein levels.

A statistical approach to identify optimal inclusion criteria: An application to acute stroke clinical trials

Introduction: Informed consent for clinical trials in acute stroke is challenging. Enrollment decisions must be made quickly, in stressful situations, and typically by a surrogate. Moreover, trials are complex and unfamiliar. Understanding patients’ and surrogates’ experiences may help maximize respect for them while facilitating important studies. Methods: Telephone interviews were conducted with consented patients or surrogates for patients enrolled in acute stroke trials at 3 US sites between 2011 and 2016. Interviews assessed trial recall, experiences with consent, and preferences regarding consent. Questions were primarily closed-ended. Descriptive statistics were calculated, and bivariate analyses (Fisher’s exact) were conducted to examine predictors of consent preference. Results: Eighty-four respondents (69 surrogates, 15 patients) across 3 sites and 10 trials were interviewed and included in final analysis. Nine did not recall enrollment, and only about half (53%) recalled that the trial involved an intervention. Of 75 respondents who remembered enrolling, 65 (87%) remembered signing a consent form, 52 (80%) of whom said they read at least some of it. Most respondents reported being treated respectfully during consent. Only 12 respondents (16%) wished they had been enrolled in the trial without prospective consent. Individuals with low health literacy were less likely to prefer enrollment without consent (p&lt;0.0007) but more likely to wish they had not had to sign a consent form (p&lt;0.0001). Forty-six (61%) recalled someone talking with them about the study after enrollment. Conclusions: Patients and surrogates in stroke trials reported mostly positive consent experiences and generally appreciated having been asked for consent prior to enrollment. Recall of trial details, however, was low, and post-enrollment contact was recalled to be somewhat infrequent. Further work may help to identify the most context-appropriate strategies.

The conducting of effective clinical trials in acute stroke is beset with a range of problems. The entire community involved in such trials (both investigators and sponsors) must attempt to develop high quality protocols; to be responsible for the selection of credible trial centres and to ensure that members of the trial committee are appropriately chosen. The question of who initiates the trial (trialist or sponsor); who collects and analyses the data and the creation of a suitable structure of reimbursement must be addressed. Local Ethics Committees are not suitably equipped for this task which must become the responsibility of a larger, international body.

The aim is to study the neuroprotective effect and optimize the therapeutic dose and time window of picrosede II by orthogonal test in cerebral ischemic injury in rats. The forebrain ischemia models of rats were established by bilateral common carotid artery occlusion (BCCAO) methods. The successful models were randomly grouped according to orthogonal experimental design and treated by injecting picroside II intraperitonenally with different therapeutic dose at different ischemic time. The contents of aquaporins 4 (AQP4), matrix metalloproteinases 9 (MMP 9) and cyclooxygenase 2 (COX2) in brain tissue were determined by enzyme linked immunosorbent assay to evaluate the therapeutic effect of picroside II on cerebral ischemic injury. The results indicated that the best therapeutic time window and dose of picroside II in cerebral ischemic injury should be 1) ischemia 1.5 h with 20 mg/kg body weight according to the content of AQP4; 2) ischemia 2.0 h with 20 mg/kg according to the content of MMP9; and 3) ischemia 1.5 h with 20 mg/kg according to the content of COX2 inbrain tissue. It is concluded that the optimized therapeutic dose and time window is injecting picroside II peritonenally with 10 - 20 mg/kg body weight at ischemia 1.5 - 2.0 h in cerebral ischemic injury according to the principle of lowest therapeutic dose with longest time window.

Biochemical markers of cerebral damage

Despite several national coordinated research networks, enrollment in many cerebrovascular trials remains challenging. An electronic tool was needed that would improve the efficiency and efficacy of screening for multiple simultaneous acute clinical stroke trials by automating the evaluation of inclusion and exclusion criteria, improving screening procedures and streamlining the communication process between the stroke research coordinators and the stroke clinicians. A multidisciplinary group consisting of physicians, study coordinators, and biostatisticians designed and developed an electronic clinical trial screening tool on a HIPAA (Health Insurance Portability and Accountability Act)-compliant platform. A web-based tool was developed that uses branch logic to determine eligibility for simultaneously enrolling clinical trials and automatically notifies the study coordinator teams about eligible patients. After 12 weeks of use, 225 surveys were completed, and 51 patients were enrolled in acute stroke clinical trials. Compared with the 12 weeks before implementation of the tool, there was an increase in enrollment from 16.5% of patients screened to 23.4% of patients screened (P<0.05). Clinicians and coordinators reported increased satisfaction with the process and improved ease of screening. We created a semiautomated electronic screening tool that uses branch logic to screen patients for stroke clinical trials. The tool has improved efficiency and efficacy of screening, and it could be adapted for use at other sites and in other medical fields.

Several trials in acute stroke are underway or have been completed recently. Among the latter, ECASS 3 was a milestone regarding the extension of the rigid 3-h time window out to 4.5 h for intravenous thrombolysis with recombinant tissue plasminogen activator. Several other approaches are being tested for thrombolytic therapy, among them modern imaging-based patient selection of patients and interventional approaches. Other pharmaceutical strategies include neuroprotection, and restoration, biophysical approaches, such as near infrared laser therapy, hemodynamic augmentation, and sphenopalatine ganglion stimulation. This perspective will cover the recently completed and currently recruiting acute stroke trials with respect to their potential role in expanding the therapeutic time window for acute ischemic stroke.

In this paper the authors review the clinical trials of neuroprotection that have been performed for the treatment of acute spinal cord injury (SCI). The biological rationale for the selection of each treatment modality is discussed with reference to current knowledge of the principles in the management of acute SCI as well as the primary and secondary injury mechanisms identified by experimental and clinical studies of the pathophysiology of acute SCI. The trials are evaluated with regard to the availability and use of accurate clinical outcome measures, and the methodologies of the trials are critically evaluated with an emphasis on prospective randomized controlled studies. A detailed description and critical analysis are provided of the results of the 10 clinical trials conducted to date in which a randomized prospective controlled design has been used. The issue of the therapeutic time window in acute SCI is discussed. To date, methylprednisolone is the only effective neuroprotective agent that has been established for use in human SCI, and the only therapeutic time window established in human SCI is a maximum trauma-to-treatment time of 8 hours.

Neurovascular protection against cerebral ischemia is not consistently observed with a postischemia hypotensive dose of candesartan. The aim of this study was to determine the levels of brain angiotensin II after reperfusion and the efficacy and therapeutic time window of postischemic treatments with hypotensive doses of candesartan for the treatment of cerebral ischemia. Occlusions of the right middle cerebral artery (60 min) followed by reperfusion were performed using the thread method under halothane anesthesia in Sprague-Dawley (SD) rats. Protein levels of brain angiotensin II and mRNA levels of renin-angiotensin system components were evaluated following reperfusion (n=184 in total). Low-dose or high-dose treatments with candesartan cilexetil (1 or 10 mg/kg per day, respectively) were administered orally immediately following reperfusion once daily for 4 or 7 days (n = 119 in total). An additional group was treated with low-dose candesartan cilexetil after a 12-h delay based on the brain angiotensin II levels (n = 14). Levels of brain angiotensin II transiently increased 4-12 h after reperfusion, which followed an increase in angiotensinogen mRNA. Candesartan cilexetil treatments significantly reduced blood pressure (BP) in rats administered the high dose and moderately in rats receiving the low dose. A low dose of candesartan cilexetil reduced the infarct size, cerebral edema, and neurological deficits, whereas the high-dose treatments showed limited reductions. Furthermore, oxidative stress following reperfusion was reduced with the low-dose treatments. The therapeutic time window was open for at least 12 h after reperfusion when brain angiotensin II levels had peaked. Postischemic treatments using low hypotensive doses of candesartan cilexetil provided protection against cerebral ischemic injury and may have a clinically relevant therapeutic time window.

Acute stroke clinical trials are conducted primarily at academic medical centers. As a result, patients living in rural areas are excluded from participation, results may not be generalizable to nonacademic settings, and studies may be slow to recruit subjects. Telemedicine can provide rural patients with emergency neurovascular consultation. We sought to determine whether telemedicine facilitates enrollment into acute stroke trials. We have an established rural "hub and spoke" telestroke network. From 2005 to 2009, we participated in 2 time-sensitive acute stroke trials: Factor Seven for Acute Hemorrhagic Stroke and Minocycline to Improve Neurological Outcome. Candidates for the 2 trials could be identified at either the hub or at the spokes, with patients presenting to the latter transferred to the hub for enrollment. We analyzed the times from symptom onset to consultation via telemedicine, arrival at the hub, and to initiation of a study drug to determine the impact of telemedicine on study enrollment. Nineteen of 28 subjects enrolled in the 2 trials were identified initially at an outside facility via a telemedicine link. An additional 9 candidates identified by telemedicine could not be enrolled because of transportation time. Arrival at the hub was 127 minutes later (median, 207 [95% CI, 145 to 255] versus 80 [95% CI, 55 to 142]; P=0.0002), and study drug was started 74 minutes later (median, 298 [95% CI, 218 to 352] versus 225 [95% CI, 147 to 330]; P=0.05) for subjects who were identified via telemedicine and required transport to the hub compared with local subjects who presented directly to the hub. Telemedicine can enhance enrollment into time-sensitive acute stroke trials. However, transfer of subjects to the hub results in delays in study initiation for some and precludes enrollment for others similar to the weaknesses of "ship and drip" thrombolytic strategies. To save time, efforts are needed to enroll clinical trial subjects and begin the research drug at the remote site under telemedicine guidance.

Background: The Multi-arm Optimization of Stroke Thrombolysis (MOST) was a multicenter, single-blind, randomized controlled phase 3 hyperacute clinical trial conducted through the National Institute of Health (NIH) StrokeNet at 57 sites across the United States. A centralized 24/7 hotline was established to provide support to study personnel at enrolling sites. Calls were answered by principal investigators (PI). We evaluated calls to identify themes and understand the utility of the hotline. Methods: From October 2019 to July 2023, MOST enrolled 514 patients. Beginning in June 2022, all hotline calls were recorded. After IRB approval, two investigators listened to recorded calls. Six themes were identified: eligibility, consent, study drug administration, protocol related, adverse event, and other. Discrepancies in categorization were resolved through discussion with a third reviewer. Results: Of 201 total recorded hotline calls, 21 were excluded due hangups, voicemails, etc. Of the 180 analyzed calls, 121 (67%) were made for enrolled or soon-to-be enrolled patients (70 unique) and 59 (33%) were made for non-enrolled patients (48 unique). Of all calls, 68% (n=128) were made by study coordinators, 30% (n=54) by physicians, and 2% (n=3) by other site personnel. The median call length was 81 seconds. The most frequent call type was eligibility-related (n=68). Of the 24 eligibility exception requests, 7 were granted and enrolled and 17 were not. Study drug calls (n=42) mainly requested giving the drug outside the 75-minute window (n=22); 20 of these requests were approved. Adverse events calls (n=28) frequently led to study drug discontinuation (n=23). Protocol clarification calls (n=31) involved sites asking about study drug timing between the 60- and 75-minute windows (n=12), IV compatibility (n=6), the use of concomitant procedures and medications (n=6) and other protocol questions (n=7). Consent-related callers (n=13) had questions regarding remote and eConsent (n=10) or identifying an appropriate surrogate (n=3). All other calls (n=3) were related to operational support. Conclusion: In MOST, the major hotline call theme was eligibility, followed by study drug timing, protocol clarification, and adverse event management. To our knowledge, this is the first report of hotline call content during an acute stroke clinical trial. Our findings could inform opportunities to optimize trial operations in the planning of future acute stroke trials.

BackgroundTraditionally in acute stroke clinical trials, the primary clinical outcome employed is a dichotomized modified Rankin Scale (mRS). New statistical methods, such as responder analysis, are being used in stroke studies to address the concern that baseline prognostic variables, such as stroke severity, impact the likelihood of a successful outcome. Responder analysis allows the definition of success to vary according to baseline prognostic variables, producing a more clinically relevant insight into the actual effect of investigational treatments. It is unclear whether or not statistical analyses should adjust for prognostic variables when responder analysis is used, as the outcome already takes these prognostic variables into account. This research aims to investigate the effect of covariate adjustment in the responder analysis framework in order to determine the appropriate analytic method.MethodsUsing a current stroke clinical trial and its pilot studies to guide simulation parameters, 1,000 clinical trials were simulated at varying sample sizes under several treatment effects to assess power and type I error. Covariate-adjusted and unadjusted logistic regressions were used to estimate the treatment effect under each scenario. In the case of covariate-adjusted logistic regression, the trichotomized National Institute of Health Stroke Scale (NIHSS) was used in adjustment.ResultsUnder various treatment effect settings, the operating characteristics of the unadjusted and adjusted analyses do not substantially differ. Power and type I error are preserved for both the unadjusted and adjusted analyses.ConclusionsOur results suggest that, under the given treatment effect scenarios, the decision whether or not to adjust for baseline severity when using a responder analysis outcome should be guided by the needs of the study, as type I error rates and power do not appear to vary largely between the methods. These findings are applicable to stroke trials which use the mRS for the primary outcome, but also provide a broader insight into the analysis of binary outcomes that are defined based on baseline prognostic variables.Trial registrationThis research is part of the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial, Identification Number NCT01369069.

Dual detoxification and inflammatory regulation by ceria nanozymes for drug-induced liver injury therapy

l-Theanine (l-THE) is a nonproteinogenic amino acid derived from green tea (Camellia sinensis), which exhibits strong antioxidant-like properties and contributes to the favourable umami taste sensation. Several studies have reported that the consumption of this amino acid has many therapeutic effects, including improvements in brain and gastrointestinal function, cancer drug therapeutic efficacies, antihypertensive effects, and improved immune function. Considering the recent Western commercialisation and popularity of green tea consumption as a nootropic agent in humans, the aims of this review were to consolidate the existing knowledge from ex vivo and in vitro animal models and attempt to highlight the applicability of l-THE towards the human clinical trials. Considering the anti-inflammatory and antioxidants effects of l-THE presented in the current review, further research must translate the existing knowledge gained from animal and cell models to exploring the potential metabolic health benefits and moderating effects on the pathogenesis of conditions such as obesity, arthritis, depression, and type 2 diabetes in human trials. This will bridge the gap in literature and provide more insights into the mechanisms driving pathologies characterised by the inflammatory response and oxidative stress.