Fluoxetine in Progressive Multiple Sclerosis (FLUOX-PMS) : study protocol for a randomized controlled trial

Background: Currently available disease-modifying treatments acting by modifying the immune response are ineffective in progressive multiple sclerosis (MS), which is caused by a widespread axonal degeneration. Mechanisms suspected to be involved in this widespread axonal degeneration are reduced axonal energy metabolism, axonal glutamate toxicity, and reduced cerebral blood flow. Fluoxetine might theoretically reduce axonal degeneration in MS because it stimulates energy metabolism through enhancing glycogenolysis, stimulates the production of brain-derived neurotrophic factor, and dilates cerebral arterioles. The current document presents the protocol of a clinical trial to test the hypothesis that fluoxetine slows down the progressive phase of MS. Methods/Design: The FLUOX-PMS trial is a multi-center, randomized, controlled and double-blind clinical study. A total of 120 patients with the diagnosis of either secondary or primary progressive MS will be treated either by fluoxetine (40 mg daily) or placebo for a total period of 108 weeks. The primary endpoint is the time to confirmed disease progression defined as either at least a 20% increase in the timed 25-Foot Walk or at least a 20% increase in the 9-Hole Peg Test. Secondary endpoints include the Hauser ambulation index, cognitive changes, fatigue, magnetic resonance imaging of the brain, and in a small subgroup optical coherence tomography. Discussion: The FLUOX-PMS trial will gives us information as to whether fluoxetine has neuroprotective effects in patients with progressive MS

Methylation Defect in Imprinted Genes Detected in Patients with an Albright's Hereditary Osteodystrophy Like Phenotype and Platelet Gs Hypofunction

Pseudohypoparathyroidism (PHP) indicates a group of heterogeneous disorders whose common feature is represented by impaired signaling of hormones that activate Gsalpha, encoded by the imprinted GNAS gene. PHP-Ib patients have isolated Parathormone (PTH) resistance and GNAS epigenetic defects while PHP-Ia cases present with hormone resistance and characteristic features jointly termed as Albright's Hereditary Osteodystrophy (AHO) due to maternally inherited GNAS mutations or similar epigenetic defects as found for PHP-Ib. Pseudopseudohypoparathyroidism (PPHP) patients with an AHO phenotype and no hormone resistance and progressive osseous heteroplasia (POH) cases have inactivating paternally inherited GNAS mutations.We here describe 17 subjects with an AHO-like phenotype that could be compatible with having PPHP but none of them carried Gsalpha mutations. Functional platelet studies however showed an obvious Gs hypofunction in the 13 patients that were available for testing. Methylation for the three differentially methylated GNAS regions was quantified via the Sequenom EpiTYPER. Patients showed significant hypermethylation of the XL amplicon compared to controls (36 ± 3 vs. 29 ± 3%; p<0.001); a pattern that is reversed to XL hypomethylation found in PHPIb. Interestingly, XL hypermethylation was associated with reduced XLalphaS protein levels in the patients' platelets. Methylation for NESP and ExonA/B was significantly different for some but not all patients, though most patients have site-specific CpG methylation abnormalities in these amplicons. Since some AHO features are present in other imprinting disorders, the methylation of IGF2, H19, SNURF and GRB10 was quantified. Surprisingly, significant IGF2 hypermethylation (20 ± 10 vs. 14 ± 7%; p<0.05) and SNURF hypomethylation (23 ± 6 vs. 32 6%; p<0.001) was found in patients vs. controls, while H19 and GRB10 methylation was normal.In conclusion, this is the first report of methylation defects including GNAS in patients with an AHO-like phenotype without endocrinological abnormalities. Additional studies are still needed to correlate the methylation defect with the clinical phenotype

Impact of luteal phase support with vaginal progesterone on the clinical pregnancy rate in intrauterine insemination cycles stimulated with gonadotropins: a randomized multicenter study

To evaluate the effect of luteal phase support (LPS) in intrauterine insemination (IUI) cycles stimulated with gonadotropins.publisher: Elsevier articletitle: Impact of luteal phase support with vaginal progesterone on the clinical pregnancy rate in intrauterine insemination cycles stimulated with gonadotropins: a randomized multicenter study journaltitle: Fertility and Sterility articlelink: http://dx.doi.org/10.1016/j.fertnstert.2016.07.1096 content_type: article copyright: Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.status: publishe

Impact of luteal phase support with vaginal progesterone on the clinical pregnancy rate in intrauterine insemination cycles stimulated with gonadotropins: a randomized multicenter study.

OBJECTIVE: To evaluate the effect of luteal phase support (LPS) in intrauterine insemination (IUI) cycles stimulated with gonadotropins. DESIGN: Randomized multicenter trial. SETTING: Academic tertiary care centers and affiliated secondary care centers. PATIENT(S): Three hundred and ninety-three normo-ovulatory patients, <43 years, with body mass index ≤30 kg/m2, in their first IUI cycle, with at least one patent tube, a normal uterine cavity, and a male partner with total motile sperm count ≥5 million after capacitation. INTERVENTION(S): Gonadotropin stimulation, IUI, randomization to LPS using vaginal progesterone gel (n = 202) or no LPS (n = 191). MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, live-birth rate, miscarriage rate, and duration of the luteal phase. RESULT(S): The primary outcome, the clinical pregnancy rate, was not statistically different between the treatment group (16.8%) and the control group (11%) (relative risk [RR] 1.54; 95% confidence interval [CI], 0.89-2.67). Similarly, the secondary outcome, the live-birth rate, was 14.9% in the treatment group and 9.4% in the control group (RR 1.60; 95% CI, 0.89-2.87). The mean duration of the luteal phase was about 2 days longer in the treatment group (16.6 ± 2.2 days) compared with the control group (14.6 ± 2.5 days) (mean difference 2.07; 95% CI, 1.58-2.56). CONCLUSION(S): Although a trend toward a higher clinical pregnancy rate as well as live-birth rate was observed in the treatment group, the difference with the control group was not statistically significant. CLINICAL TRIAL REGISTRATION NUMBER: NCT01826747

Primers used in the Sequenom study to amplify <i>IGF2</i>, <i>ICR1/H19</i> and <i>GRB10</i> regions.

<p>Primers used in the Sequenom study to amplify <i>IGF2</i>, <i>ICR1/H19</i> and <i>GRB10</i> regions.</p

Clinical patients' characteristics and platelet Gs activity.

*<p>Small-for-Gestational-Age (SGA); ∧Gilles de la Tourette; °ADHD; SSC: subcutaneous calcifications; Ob: obesity; RF: round face; ID: Intellectual disability; NA: not available.</p>**<p>vs. crls, p<0.05 The concentration of Gsα agonist to inhibit the collagen-induced platelet aggregation by 50 % (IC₅₀) is indicated between brackets for 24 normal controls. A Gsα hypofunction is defined as requiring a significantly higher IC₅₀ value.</p

XLalphaS and Gsalpha expression in platelets from AHO-like patients.

<p>XLalphaS, CAP1 and Gsalpha expression in AHO-like platelets. A. Immunoblot analysis of XLalphas, CAP1 and Gsalpha protein in platelet lysates from XL hypermethylated AHO-like patients 12, 13, 10, 14, 15, 16 and 3 controls and B. correspondent densitometric scanning of XLalphaS protein in platelet lysates from AHO-like patients with XL hypermethylation (patients 6 to 16) and 5 controls (Controls). Results are expressed as percentage of controls (taken as 100%). Mean as well as SD are depicted as black horizontal and vertical lines, respectively. *, p value<0.05, two-tailed unpaired T-test.</p

Chromosomal location of the <i>IGF2</i>, <i>H19</i> and <i>GRB10</i> amplicons used in the Sequenom study.

*<p>Nucleotide positions according to the February 2009 human reference sequence (GRCh37/hg19) produced by the International Human Genome Sequencing Consortium.</p

Phenotypic, Molecular Genetic and Platelet Gs protein activity in relation to <i>GNAS</i> pathology.

<p>Phenotypic, Molecular Genetic and Platelet Gs protein activity in relation to <i>GNAS</i> pathology.</p

Overall <i>GNAS</i>, <i>IGF2</i>, <i>H19</i>, <i>SNURF</i> and <i>GRB10</i> methylation in AHO-like patients.

<p>Dot plot representation of overall methylation values (averages expressed as % of methylation) for NESP, XL, Exon A/B (A), <i>IGF2</i>, <i>H19</i> (B), <i>SNURF</i> and <i>GRB10</i> (C) in AHO-like patients (indicated as ‘PPHP’) vs. the control population (indicated as ‘crls’). Individuals with significant hyper- or hypomethylation (patients 1 to 5) in the NESP, Exon A/B, H19 and GRB10 are indicated as follow: patient 1 =  red, 2 =  green, 3 =  blue, 4 =  brown, 5 =  yellow. Medians are displayed as black lines. ** p<0.01 and * p<0.05, two-tailed unpaired T-test.</p