Ali Alawieh

Revisiting leishmaniasis in the time of war: the Syrian conflict and the Lebanese outbreak

BACKGROUND Leishmaniasis is a neglected tropical disease, endemic in many worldwide foci including the Middle East. Several outbreaks have occurred in the Middle East over the past decades, mostly related to war-associated population migration. With the start of the Syrian war, the frequency and magnitude of these outbreaks increased alarmingly. We describe the epidemiology of Leishmania infection in Lebanon and the most recent outbreak relevant to the Syrian war. METHODS We reviewed all leishmaniasis cases reported to the Epidemiologic Surveillance Department at the Lebanese Ministry of Public Health between 2001 and the first quarter of 2014. The demographics and distribution of Syrian refugees in Lebanon were linked to reports of new Leishmania cases. RESULTS In total, 1033 new cases of leishmaniasis were reported in 2013 compared to a previous annual number in the range of 0-6 cases. The majority of cases reported in 2013 involved Syrian refugees and their relevant areas of concentration. CONCLUSIONS This new outbreak of leishmaniasis in Lebanon is the first of its kind for more than a decade. The sudden increase in Leishmania cases in Lebanon in 2013 is attributed to the increasing numbers and wide distribution of Syrian refugees in Lebanon. This serves as an example of the risks associated with military conflicts and the ability of communicable diseases to cross borders.

Systems Biology, Bioinformatics, and Biomarkers in Neuropsychiatry

Although neuropsychiatric (NP) disorders are among the top causes of disability worldwide with enormous financial costs, they can still be viewed as part of the most complex disorders that are of unknown etiology and incomprehensible pathophysiology. The complexity of NP disorders arises from their etiologic heterogeneity and the concurrent influence of environmental and genetic factors. In addition, the absence of rigid boundaries between the normal and diseased state, the remarkable overlap of symptoms among conditions, the high inter-individual and inter-population variations, and the absence of discriminative molecular and/or imaging biomarkers for these diseases makes difficult an accurate diagnosis. Along with the complexity of NP disorders, the practice of psychiatry suffers from a “top-down” method that relied on symptom checklists. Although checklist diagnoses cost less in terms of time and money, they are less accurate than a comprehensive assessment. Thus, reliable and objective diagnostic tools such as biomarkers are needed that can detect and discriminate among NP disorders. The real promise in understanding the pathophysiology of NP disorders lies in bringing back psychiatry to its biological basis in a systemic approach which is needed given the NP disorders’ complexity to understand their normal functioning and response to perturbation. This approach is implemented in the systems biology discipline that enables the discovery of disease-specific NP biomarkers for diagnosis and therapeutics. Systems biology involves the use of sophisticated computer software “omics”-based discovery tools and advanced performance computational techniques in order to understand the behavior of biological systems and identify diagnostic and prognostic biomarkers specific for NP disorders together with new targets of therapeutics. In this review, we try to shed light on the need of systems biology, bioinformatics, and biomarkers in neuropsychiatry, and illustrate how the knowledge gained through these methodologies can be translated into clinical use providing clinicians with improved ability to diagnose, manage, and treat NP patients.

Complement in the Homeostatic and Ischemic Brain

The complement system is a component of the immune system involved in both recognition and response to pathogens, and it is implicated in an increasing number of homeostatic and disease processes. It is well documented that reperfusion of ischemic tissue results in complement activation and an inflammatory response that causes post-reperfusion injury. This occurs following cerebral ischemia and reperfusion and triggers secondary damage that extends beyond the initial infarcted area, an outcome that has rationalized the use of complement inhibitors as candidate therapeutics after stroke. In the central nervous system, however, recent studies have revealed that complement also has essential roles in synaptic pruning, neurogenesis, and neuronal migration. In the context of recovery after stroke, these apparent divergent functions of complement may account for findings that the protective effect of complement inhibition in the acute phase after stroke is not always maintained in the subacute and chronic phases. The development of effective stroke therapies based on modulation of the complement system will require a detailed understanding of complement-dependent processes in both early neurodegenerative events and delayed neuro-reparatory processes. Here, we review the role of complement in normal brain physiology, the events initiating complement activation after cerebral ischemia-reperfusion injury, and the contribution of complement to both injury and recovery. We also discuss how the design of future experiments may better characterize the dual role of complement in recovery after ischemic stroke.

Assessment of Serum UCH-L1 and GFAP in Acute Stroke Patients

A rapid and reliable diagnostic test to distinguish ischemic from hemorrhagic stroke in patients presenting with stroke-like symptoms is essential to optimize management and triage for thrombolytic therapy. The present study measured serum concentrations of ubiquitin C-terminal hydrolase (UCH-L1) and glial fibrillary astrocytic protein (GFAP) in acute stroke patients and healthy controls and investigated their relation to stroke severity and patient characteristics. We also assessed the diagnostic performance of these markers for the differentiation of intracerebral hemorrhage (ICH) from ischemic stroke (IS). Both UCH-L1 and GFAP concentrations were significantly greater in ICH patients than in controls (p < 0.0001). However, exclusively GFAP differed in ICH compared with IS (p < 0.0001). GFAP yielded an AUC of 0.86 for differentiating between ICH and IS within 4.5hrs of symptom onset with a sensitivity of 61% and a specificity of 96% using a cut-off of 0.34ng/ml. Higher GFAP levels were associated with stroke severity and history of prior stroke. Our results demonstrate that blood UCH-L1 and GFAP are increased early after stroke and distinct biomarker-specific release profiles are associated with stroke characteristics and type. We also confirmed the potential of GFAP as a tool for early rule-in of ICH, while UCH-L1 was not clinically useful.

Injury site-specific targeting of complement inhibitors for treating stroke

Cumulative evidence indicates a role for the complement system in both pathology and recovery after ischemic stroke. Here, we review the current understanding of the dual role of complement in poststroke injury and recovery, and discuss the challenges of anti‐complement therapies. Most complement directed therapeutics currently under investigation or development systemically inhibit the complement system, but since complement is important for immune surveillance and is involved in various homeostatic activities, there are potential risks associated with systemic inhibition. Depending on the target within the complement pathway, other concerns are high concentrations of inhibitor required, low efficacy and poor bioavailability. To overcome these limitations, approaches to target complement inhibitors to specific sites have been investigated. Here, we discuss targeting strategies, with a focus on strategies developed in our lab, to specifically localize complement inhibition to sites of tissue injury and complement activation, and in particular to the postischemic brain. We discuss various injury site‐specific targeted complement inhibitors as potential therapeutic agents for the treatment of ischemic stroke treatment, as well as their use as investigative tools for probing complement‐dependent pathophysiological processes.

Post-Genomics Nanotechnology Is Gaining Momentum: Nanoproteomics and Applications in Life Sciences

The post-genomics era has brought about new Omics biotechnologies, such as proteomics and metabolomics, as well as their novel applications to personal genomics and the quantified self. These advances are now also catalyzing other and newer post-genomics innovations, leading to convergences between Omics and nanotechnology. In this work, we systematically contextualize and exemplify an emerging strand of post-genomics life sciences, namely, nanoproteomics and its applications in health and integrative biological systems. Nanotechnology has been utilized as a complementary component to revolutionize proteomics through different kinds of nanotechnology applications, including nanoporous structures, functionalized nanoparticles, quantum dots, and polymeric nanostructures. Those applications, though still in their infancy, have led to several highly sensitive diagnostics and new methods of drug delivery and targeted therapy for clinical use. The present article differs from previous analyses of nanoproteomics in that it offers an in-depth and comparative evaluation of the attendant biotechnology portfolio and their applications as seen through the lens of post-genomics life sciences and biomedicine. These include: (1) immunosensors for inflammatory, pathogenic, and autoimmune markers for infectious and autoimmune diseases, (2) amplified immunoassays for detection of cancer biomarkers, and (3) methods for targeted therapy and automatically adjusted drug delivery such as in experimental stroke and brain injury studies. As nanoproteomics becomes available both to the clinician at the bedside and the citizens who are increasingly interested in access to novel post-genomics diagnostics through initiatives such as the quantified self, we anticipate further breakthroughs in personalized and targeted medicine.

Biomarkers in psychiatry: how close are we?

A commentary on Systems biology, bioinformatics and biomarkers in neuropsychiatry by Alawieh, A., Zaraket, F., Li, J., Mondello, S., Nokkari, A., Razafsha, M., et al. (2012). Front. Neurosci. 6:187. doi: 10.3389/fnins.2012.00187 Until recently, there has been an ongoing worldwide quest in search for disease-specific molecular biomarkers in medicine. These biological molecules can allow for: a reliable and accurate disease diagnosis and prognosis, better understanding of pathogenesis and pathophysiological mechanisms, and for predicting disease progression and monitoring therapy. Furthermore, biomarkers can provide major opportunities for drug target identification which can ultimately translate into new therapeutic strategies with disease-modifying effects. Notably, all of these conditions are inherent characteristics of neuropsychiatric diseases. Biomarker research has achieved great success in various clinical fields such as cardiovascular disease, hepatic disorders, neurotrauma leading to key markers including the discovery of troponin as marker for myocardial infarction, and 14-3-3 protein for Creuzfolt-Jacob Disease, S100β/UCH-L1/αII-spectrin for brain trauma (Hayes et al., 2011; Kobeissy et al., 2011; Mondello et al., 2011). However, in psychiatry this field is still lagging since no putative biomarker has yet made its way into clinical application (Schulenborg et al., 2006; Lescuyer et al., 2007). Biological psychiatry research has been introduced as an attempt to draw psychiatry back to its biological roots in order to improve injury mechanisms and disease processes and its components. It has been well-understood today in clinical medicine that no promising accurate and definite disease diagnosis, therapy, and prognosis can be established without drawing back the clinical manifestation of the disease. Therefore, biological psychiatry is now focusing on the use of all available advanced molecular techniques that can allow for biomarker detection assisted by the afore-employed imaging and analysis techniques. Such approaches include the utilization of high throughput omics approaches such as: epigenetics, genomics, proteomics, lipidomics, and metabolomics studies (Robeva, 2010; Westerhoff, 2011). In addition, these methodologies rely on sophisticated computational-multi disciplinary field of systems biology utilizing advanced bioinformatics processing tools that can interpret the high throughput molecular omics data relevant to neuropsychiatric research. Among the ultimate aims of such discipline is the identification of novel sensitive and disease-specific biomarker(s). The promise that systems biology can lead a progress in biological psychiatry returns to the very complex nature of psychiatric disorders. Such disorders involve multifactorial genetic and environmental interactions together with the dynamic nature of protein alterations affecting both cellular as well as structural changes on the neuronal levels. Therefore, assessing psychiatric disorders cannot be targeted at a single behavioral or cellular level but rather would require a holistic global approach that can assess different components of such disorders (Fang and Casadevall, 2011; Westerhoff, 2011). This can lead the inquiry into the roots of such disorders and identify new diagnostic and assessment biomarkers. However, the need for biomarker discovery and the implementation of systems biology techniques is not just because of the complexity of the disease. It is also an attempt to surmount the available diagnostic techniques such as DSM IV and ICD-10 that involve “subjective” checklist analysis of signs and symptoms of these diseases that causes frustration among most psychiatric practitioners (Linden, 2012; Tretter and Gebicke-Haerter, 2012). Having been said, there has been a pronounced worldwide joint effort in the advancing of biomarker studies that is evident by the surge of research and review articles focusing on the application of systems biology, bioinformatics, and biomarkers in neuropsychiatry. These studies have included the use of high-throughput genomic, epigenetics, proteomic, metabolomics, and other—bioinformatic computational algorithms tools as well as the use of animal models, in vitro and in vivo tissue cultures and in silico models. These techniques have been applied on different aspects of neuropsychiatric disorders spanning: drug abuse, eating disorders, and other psychiatric disorders involving schizophrenia, bipolar disorder, and major depressive disorder etc. (Kobeissy et al., 2008; Avena, 2011). The application of these techniques has provided several disease models of psychiatric diseases (Tretter and Gebicke-Haerter, 2012) that have moved research and therapy forward as with the dopamine agonist model of schizophrenia that we reviewed in a separate publication (Alawieh et al., 2012). However, success reported by using such techniques is still in its infancy due to the aforementioned complexity of psychiatric diseases as well as for other reasons. These include, on one hand, the limitations associated with these techniques coupled with “mindset” related to scientists and researchers that emphasizes on data discovery rather than data analysis and validation. This resulted in massive amount of data—majorly non-replicable and non-validated—with very low biological significance and clinical impact (Kraemer et al., 2002; Staner, 2006; Martins-De-Souza et al., 2011). Therefore, there is now an uprising need for the integrative and predictive analysis as well as validation of the available data collected to infer the biological significance relevant to psychiatry. Finally, the field of biomarker discovery in psychiatry, taking advantage of systems biology approach and the available bioinformatics tools, is believed to yield several advantages including early diagnosis that is critical to psychiatric diseases and accurate criteria for disease, diagnosis, classification, and stratification. It can also allow for advanced personalized therapy and can act, if appropriately, validated as surrogate end points that can eliminate several limitations and greatly advance clinical research (Biomarkers Definitions Working Group, 2001; Zhang et al., 2010).

The golden 35 min of stroke intervention with ADAPT: effect of thrombectomy procedural time in acute ischemic stroke on outcome

Introduction In acute ischemic stroke (AIS), extending mechanical thrombectomy procedural times beyond 60 min has previously been associated with an increased complication rate and poorer outcomes. Objective After improvements in thrombectomy methods, to reassess whether this relationship holds true with a more contemporary thrombectomy approach: a direct aspiration first pass technique (ADAPT). Methods We retrospectively studied a database of patients with AIS who underwent ADAPT thrombectomy for large vessel occlusions. Patients were dichotomized into two groups: ‘early recan’, in which recanalization (recan) was achieved in ≤35 min, and ‘late recan’, in which procedures extended beyond 35 min. Results 197 patients (47.7% women, mean age 66.3 years) were identified. We determined that after 35 min, a poor outcome was more likely than a good (modified Rankin Scale (mRS) score 0–2) outcome. The baseline National Institutes of Health Stroke Scale (NIHSS) score was similar between ‘early recan’ (n=122) (14.7±6.9) and ‘late recan’ patients (n=75) (15.9±7.2). Among ‘early recan’ patients, recanalization was achieved in 17.8±8.8 min compared with 70±39.8 min in ‘late recan’ patients. The likelihood of achieving a good outcome was higher in the ‘early recan’ group (65.2%) than in the ‘late recan’ group (38.2%; p<0.001). Patients in the ‘late recan’ group had a higher likelihood of postprocedural hemorrhage, specifically parenchymal hematoma type 2, than those in the ‘early recan’ group. Logistic regression analysis showed that baseline NIHSS, recanalization time, and atrial fibrillation had a significant impact on 90-day outcomes. Conclusions Our findings suggest that extending ADAPT thrombectomy procedure times beyond 35 min increases the likelihood of complications such as intracerebral hemorrhage while reducing the likelihood of a good outcome.

Biomarker identification in psychiatric disorders: from neuroscience to clinical practice

Patients with psychiatric disorders exhibit several neurobehavioral and neuropsychological alterations compared to healthy controls. However, signature endpoints of these behavioral manifestations have not yet been translated into clinical tests for diagnosis and follow-up measures. Recently, neuroproteomic approaches have been utilized to identify unique signature markers indicative of these disorders. Development of reliable biomarkers has the potential to revolutionize the diagnosis, classification, and monitoring of clinical responses in psychiatric diseases. However, the lack of biological gold standards, the evolving nosology of psychiatric disorders, and the complexity of the nervous system are among the major challenges that have hindered efforts to develop reliable biomarkers in the field of neuropsychiatry and drug abuse. While biomarkers currently have a limited role in the area of neuropsychiatry, several promising biomarkers have been proposed in conditions such as dementia, schizophrenia, depression, suicide, and addiction. One of the primary objectives of this review is to discuss the role of proteomics in the development of biomarkers specific to neuropsychiatry. We discuss and evaluate currently available biomarkers as well as those that are under research for clinical use in the future. (Journal of Psychiatric Practice 2015;21:37–48)

Identifying the Role of Complement in Triggering Neuroinflammation after Traumatic Brain Injury

The complement system is implicated in promoting acute secondary injury after traumatic brain injury (TBI), but its role in chronic post-traumatic neuropathology remains unclear. Using various injury-site targeted complement inhibitors that block different complement pathways and activation products, we investigated how complement is involved in neurodegeneration and chronic neuroinflammation after TBI in a clinically relevant setting of complement inhibition. The current paradigm is that complement propagates post-TBI neuropathology predominantly through the terminal membrane attack complex (MAC), but the focus has been on acute outcomes. Following controlled cortical impact in adult male mice, we demonstrate that although inhibition of the MAC (with CR2-CD59) reduces acute deficits, inhibition of C3 activation is required to prevent chronic inflammation and ongoing neuronal loss. Activation of C3 triggered a sustained degenerative mechanism of microglial and astrocyte activation, reduced dendritic and synaptic density, and inhibited neuroblast migration several weeks after TBI. Moreover, inhibiting all complement pathways (with CR2-Crry), or only the alternative complement pathway (with CR2-fH), provided similar and significant improvements in chronic histological, cognitive, and functional recovery, indicating a key role for the alternative pathway in propagating chronic post-TBI pathology. Although we confirm a role for the MAC in acute neuronal loss after TBI, this study shows that upstream products of complement activation generated predominantly via the alternative pathway propagate chronic neuroinflammation, thus challenging the current concept that the MAC represents a therapeutic target for treating TBI. A humanized version of CR2fH has been shown to be safe and non-immunogenic in clinical trials. SIGNIFICANCE STATEMENT Complement, and specifically the terminal membrane attack complex, has been implicated in secondary injury and neuronal loss after TBI. However, we demonstrate here that upstream complement activation products, generated predominantly via the alternative pathway, are responsible for propagating chronic inflammation and injury following CCI. Chronic inflammatory microgliosis is triggered by sustained complement activation after CCI, and is associated with chronic loss of neurons, dendrites and synapses, a process that continues to occur even 30 d after initial impact. Acute and injury-site targeted inhibition of the alternative pathway significantly improves chronic outcomes, and together these findings modify the conceptual paradigm for targeting the complement system to treat TBI.