The Glasgow Coma Scale (GCS) has limited utility in intubated patients due to the inability to assign verbal subscores. The verbal subscore can be derived from the eye and motor subscores using a mathematical model, but the advantage of this method and its use in outcome prognostication in traumatic brain injury (TBI) patients remains unknown. We compared the validated "Core+CT"-IMPACT-model performance in 251 intubated TBI patients prospectively enrolled in the longitudinal OPTIMISM study between November 2009 and May 2015 when substituting the original motor GCS (mGCS) with the total estimated GCS (teGCS; with estimated verbal subscore). We hypothesized that model performance would improve with teGCS. Glasgow Outcome Scale (GOS) scores were assessed at 3 and 12 months by trained interviewers. In the complete case analysis, there was no statistically or clinically significant difference in the discrimination (C-statistic) at either time-point using the mGCS versus the teGCS (3 months: 0.893 vs. 0.871;12 months: 0.926 vs. 0.92). At 3 months, IMPACT-model calibration was excellent with mGCS and teGCS (Hosmer-Lemeshow "goodness-of-fit" chi square p value 0.9293 and 0.9934, respectively); it was adequate at 12 months with teGCS (0.5893) but low with mGCS (0.0158), possibly related to diminished power at 12 months. At both time-points, motor GCS contributed more to the variability of outcome (Nagelkerke ΔR) than teGCS (3 months: 5.8% vs. 0.4%; 12 months: 5% vs. 2.6%). The sensitivity analysis with imputed missing outcomes yielded similar results, with improved calibration for both GCS variants. In our cohort of intubated TBI patients, there was no statistically or clinically meaningful improvement in the IMPACT-model performance by substituting the original mGCS with teGCS.
INTRODUCTION: Pre-clinical interventions to the CNS require direct cranial administration of drugs for relevant therapeutic concentrations since the efficacy of systemic administration is hindered by the blood-brain barrier (BBB). We used MR-guided Focused Ultrasound (MRgFUS) to deliver primary-patient derived mesenchymal stem cells (hMSCs) for the first time, with sub-millimeter precision, in preselected areas. This method is a revolutionary way to deliver cellular therapy to delicate or inoperable regions obviating the need for invasive surgical intervention. METHOD: MRgFUS mediates BBB opening when low intensity FUS is applied to brain vasculature containing circulating microbubbles. This causes high intensity oscillation leading to a pore formation in BBB. hMSCs were injected intracardially in mice as a proof-of-principal delivery system. Under guidance of MRI, 0.4-1MPa in situpressures at 1 MHz, 1ms bursts and 1Hz pulse repetition frequency for 120 seconds were administered on the left hemisphere. Each animal's contralateral brain served as its own control RESULTS: We demonstrate that MRgFUS augments permeability of BBB. Each animal (n=3) received 3 cavitation parameters ranging from .4-1MPa in situ pressures at time points 2, 6 and 24hrs. Immunohistochemistry identified hMSC localization on sonicated points. Further analysis showed blood cell extravasation and capillary damage due to higher pressures and increased shear force from microbubble stream. The consequence is a cavitation pore larger than intended, necessitating further optimization. There were no observed behavioral complications after sonication and no hMSCs localization in non-pulsed regions demonstrating precise localization and no off-target delivery. CONCLUSION: The global hurdle of systemic therapy due to the BBB makes access of cellular therapy to the brain parenchyma, nearly impossible. This study investigates for the first time the utility of FUS to non-destructively permeabilize the BBB by creating a transient pore big enough for hMSC access.
INTRODUCTION Pre clinical interventions to the CNS require direct cranial administration of drugs for relevant therapeutic concentrations since the efficacy of systemic administration is hindered by the blood-brain barrier (BBB). We used MR-guided Focused Ultrasound (MRgFUS) to deliver primary-patient derived mesenchymal stem cells (hMSCs) for the first time, with sub-millimeter precision, in preselected areas. This method is a revolutionary way to deliver cellular therapy to delicate or inoperable regions obviating the need for invasive surgical intervention. METHODS MRgFUS mediates BBB opening when low intensity FUS is applied to brain vasculature containing circulating microbubbles. This causes high intensity oscillation leading to a pore formation in BBB. hMSCs were injected intracardially in mice as a proof-of-principal delivery system. Under guidance of MRI, 0.4-1MPa in situ pressures at 1 MHz, 1ms bursts and 1Hz pulse repetition frequency for 120 seconds were administered on the left hemisphere. Each animals contralateral brain served as its own control. RESULTS >We demonstrate that MRgFUS augments permeability of BBB. Each animal (n = 3) received 3 cavitation parameters ranging from .4-1MPa in situ pressures at time points 2, 6 and 24 hrs. Immunohistochemistry identified hMSC localization on sonicated points. Further analysis showed blood cell extravasation and capillary damage due to the indices being sonicated so close together causing a larger sheer force from the fluid stream of injected microbubbles. The consequence is a cavitation pore larger than intended, necessitating further optimization. There were no observed behavioral complications after sonication and no hMSCs localization in non-pulsed regions demonstrating precise localization and no off-target delivery. CONCLUSION The global hurdle of systemic therapy due to the BBB makes access of therapeutics, let alone cellular therapy to the brain parenchyma, nearly impossible. This study investigates for the first time the utility of FUS to non-destructively permeabilize the BBB by creating a transient pore big enough for hMSC access.
s vi266NEURO-ONCOLOGY • NOVEMBER 2017to co-localize in cells with detectable levels of gag, a viral structural protein.CD protein expression by IHC was assessed in tissue from locations that corresponded with samples positive for CD by PCR and ranged from 1.16% to 10.4% area of the field. These data show that intravenous delivery of Toca 511 results in appreciable deposition of vector in the tumor. Further, we have observed an inverse correlation between T cell infiltrate in the tumor microenvironment and clinical benefit in a complementary Phase I study in which Toca 511 was solely delivered into the resection cavity. Therefore, the nature of the study design described herein, which uses IV delivery of Toca 511, provides a unique opportunity to assess the spatial relationship between CD protein expression and histological features of the tumor. Immunohistochemical assessment to determine spatial correlates between CD protein and T cells, T regulatory cells, and immunosuppressive myeloid cells will be presented. Updated clinical response data will also be presented.
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