Simvastatin is part of the pharmacotherapeutic group of HMG-CoA reductase inhibitors (ATC-Code: C10A A01). Simvastatin is licensed within the EU for hypercholesterolemia and cardiovascular prevention but for this trial its use will be outside its licensed indication. Oral Simvastatin will be taken 40mg daily (one tablet in the evening) for 4 weeks and then at week 4 up titrated to 80mg daily (two tablets in the evening.

Matched Placebo (one tablet in the evening) for 4 weeks and then at week 4 up titrated to two tablets daily in the evening.

Secondary Progressive Multiple Sclerosis

Simvastatin 40mg for first 4 weeks and 80mg (if tolerated) thereafter up to 17 weeks

Simvastatin

Department of Neuroinflammation, UCL Institute of Neurology

Simvastatin in Secondary Progressive Multiple Sclerosis

A Double-blind, Randomised, Placebo-controlled Single-site Study of High Dose Simvastatin Treatment for Secondary Progressive Multiple Sclerosis: Impact on Vascular Perfusion and Oxidative Damage

compared between patients on simvastatin or placebo using multiple linear regressions. ASL is an MRI method that allows non-invasive measurement of CBF using inversion of arterial water spins as a tracer.The aim is to explore whether subtlechangesinCBFoccur over time between placebo and simvastatin treated patients, including potential waning of the effects of the drug over time.

To explore whether statin treatment reduces glutamate levels. These will be measured applying an advanced MRI technique called spectroscopy which detects biochemical changes in the brain.

To establish if Adaptive Optics Scanning Laser Ophthalmoscope (AOSLO) measurements of blood flow are useful correlates for cerebral blood flow measurement on and off treatment.

To establish whether Arterial Spin Labelling (ASL) measurements of blood flow are useful correlates for cerebral blood flow measurement on and off treatment. The cerebral arterial hemodynamic measure bolus arrival time will be measured, as the time from labeling of blood in feeding arteries to its first arrival in the capillary network of the voxel of interest. This will be supported by a questionnaire investigating factors that influence brain perfusion (related to lifestyle and health, mental state, personality and cognition and use of caffeine and recreational drugs) to improve the accuracy and to facilitate the interpretation of perfusion-derived parameters.

To explore whether statin reduce the rate of brain atrophy, including grey matter volumes, on MRI (excluding the effect of pseudo-atrophy, which is a temporary response to the drug rather than an actual loss of tissue). The MRI images will be analysed using softwares developed at UCL to quantify the amount of brain tissue loss over time.

Clinician observed expanded disability status score (EDSS) is a method of quantifying disability in MS and records changes in disability over time. The EDSS scale ranges from 0 (no disability) to 10 (death due to MS) in 0.5 unit increments that represent higher levels of disability. Scoring is based on an examination by a neurologist and encompasses pyramidal, cerebellar, brainstem, sensory, bowel/bladder function in addition to visual, cerebral and other functions. Changes in score (including no changes) will be recorded to determine progression of disability.

Multiple Sclerosis Function Composite (MSFC) includes the 25 foot timed foot walk (25TFW), which involves marking a 25-foot distance in an unobstructed hallway; an assistive device (if needed) may be used by the participant and recorded. Their speed is then timed up to a time limit of 3 mins in both directions. Changes in scores will be recorded over the time-points described.

Multiple Sclerosis Function Composite (MSFC) includes the 9 hole peg test (9HPT). The 9-HPT is a quantitative measure of upper extremity (arm and hand) function. Both the dominant and non-dominant hands are tested twice (two consecutive trials of the dominant hand, followed immediately by two consecutive trials of the non-dominant hand). It is important that the 9-HPT be administered on a solid table (not a rolling hospital bedside table) and that the 9-HPT apparatus be anchored (e.g., with Dycem). The pegs are selected one at a time, using one hand only, and put into the holes as quickly as possible in any order until all the holes are filled. Then, without pausing, the pegs are removed one at a time and returned to the container. This is timed and recorded at the time-points described.

Patient reported multiple sclerosis impact scale version 2 (MSIS-29v2) is a self-administered questionnaire covering 29 items that asks to what degree MS has impacted the person physically and mentally over the past two weeks.

Patient reported Multiple Sclerosis Walking Score version 2 (MSWSv2) is a 12 item self-administered questionnaire that measures walking performance over the previous two weeks. Each items is summed to generate a total score which is then transformed to a scale ranging from 0 to 100. Higher scores indicate greater impact on walking. Changes in scores will be recorded over the time-points described.

The EuroQol Health Related Quality of Life (EQ5d5L) is a five-item questionnaire that assesses mobility, self-care, pain/discomfort, anxiety/depression and a person's usual activities. It incorporates an additional visual analogue scale (VAS) which enables a calculation of quality of life years (QALY) so health economic analyses can be performed. Each item of the EQ5D5L is responded to on a scale as follows: no problems, slight problems, moderate problems, severe problems and extreme problems. Changes in scores will be recorded over the time-points described.

Blood samples from these patients will be taken at baseline and at weeks 4, 16 and 20 to investigate the effect of statins on vascular leakage and free radical damage. Biomarkers will be determined as follows: (i) For RNA/DNA oxidative damage serum levels of 8-hydroxyguanosine (8-OHG)/8-hydroxydeoxyguanosine (8-OHdG); (ii) Protein oxidative damage will be determined by assaying plasma proteins for nitrotyrosine and carbonyl content; and (iii) Detection of lipid oxidative damage by assaying for the advanced lipid peroxidation end products 4-hydroxynonenal (4-HNE or HNE), malondialdehyde (MDA), 8-iso-prostaglandin F2α and thiobarbituric acid reactive substances (TBARS) (Miller et al., 2012).

Frontal Assessment Battery (FAB). The FAB is a brief tool that can be used at the bedside or in a clinic setting to assist in discriminating between dementias with a frontal dysexecutive phenotype and Dementia of Alzheimer‟s Type (DAT).
The FAB has validity in distinguishing Fronto-temporal type dementia from DAT in mildly demented patients (MMSE > 24). Total score is from a maximum of 18, higher scores indicating better performance. Changes in scores will be recorded over the time-points described.

Symbol Digit Modalities Test (SDMT) is measure of cognitive impairment. The subject is asked to match single digits to symbols using a key as a guide that pairs the numbers to the symbols. They are presented with a page headed by a key that pairs the single digits 1-9 with nine symbols and they then write or orally report their responses in a scoring form. It can be administered in oral and written form and is timed and guided by a trained examiner ie. suitably qualified member of the research team. Changes in scores will be recorded over the time-points described.

Oxygen saturation of retinal vessels will be measured using the Oxymap T1. The device measures oxygen saturation quickly and non-invasively by taking two simultaneous images of the retina using two different wavelengths to determine the amount of oxygen bound haemoglobin in the blood.

Density of retinal vessels will be measured using optical coherence tomography angiography (OCTA). OCTA is a method of retinal imaging which is non-invasive and involves the patient holding their head still and staring at a dim light while imaging takes place.

Inner retinal thickness will be measured using optical coherence tomography (OCT). OCT is a method of retinal imaging which is non-invasive and involves the patient holding their head still and staring at a dim light while imaging takes place.

To assess changes in axonal parameters, such as fiber orientation dispersion and axonal densities occurring over time using NODDI, an advanced MRI technique that reflects the microstructural complexity of dendrites and axons in vivo.

To assess whether patients develop new lesions or pre-existing lesions enlarge over time as surrogate markers for the inflammatory process.

No identifiable patient information will be supplied to other researchers external to the organisation.

University College, London

MS Society

Relapsing Remitting Multiple Sclerosis

Modified Atkins diet

University of Virginia

Utilization of the Ketogenic Diet in Patient With Relapsing Remitting MS

The Effect of the Ketogenic Diet on Patients With Relapsing Remitting Multiple Sclerosis

Determine if patients are able to adhere to (number of days patient able to demonstrate ketosis) and tolerate a strict diet over an extended period of time as reported in urinary ketone analysis.

Determine the benefits, if any, of the ketogenic diet in RRMS subjects physically, emotionally, and clinically as reported in patient reported outcome surveys. Survey responses are evaluated on a scale of 0-10 with 0 being no affect and 10 being highly affected by the disease.

Assessment of height and weight to calculate subject BMI throughout the study. This will be compared with survey on physical activity to see if scores (no disease impact to high disease impact on activity) correspond with changes in BMI.

J. Nicholas Brenton, MD

Assistant Professor of Neurology and Pediatrics

Pediatric patients, aged 0-5 years, diagnosed with hydrocephalus undergoing a surgical (non-bedside) shunting procedure with general anesthesia. Pts will receive a standardized general anesthetic with isoflurane.

Pediatric patients, aged 0-5 years, diagnosed with hydrocephalus undergoing a surgical (non-bedside) shunting procedure with general anesthesia. Pts will receive a standardized general anesthetic with dexmedetomidine and remifentanil infusions..

Otherwise healthy pediatric patients, aged 0-5 years, undergoing MRI with general anesthesia for evaluation of non-neurologic disease. Patients will receive a standardized general anesthetic with isoflurane.

Pediatric patients, aged 0-5 years, diagnosed with hydrocephalus undergoing a surgical (non-bedside) shunting procedure with general anesthesia. Pts will receive a standardized general anesthetic with isoflurane.
Isoflurane

Isoflurane Arm

Pediatric patients, aged 0-5 years, diagnosed with hydrocephalus undergoing a surgical (non-bedside) shunting procedure with general anesthesia. Pts will receive a standardized general anesthetic with dexmedetomidine and remifentanil infusions..
Dexmedetomidine

Dexmedetomidine/Remifentanil Arm

MRI Control Arm

Total

Sex: Female, Male

Race (NIH/OMB)

Weight

Anesthetic Time

Previous Anesthesia

ASA 1: Normal healthy patient
ASA 2: Patients with mild systemic disease
ASA 3: Patients with severe systemic disease
ASA 4: Patients with severe systemic disease that is a constant threat to life
ASA 5: Moribund patients who are not expected to survive without the operation
ASA 6: A declared brain-dead patient whose organs are being removed for donor purposes

American Society of Anesthesiologists (ASA) Physical Status classification

Surgery subjects will have blood collected once at the start of surgery, once at the end of surgery, and once in the PACU. MRI patients will have blood collected once prior to the start of the MRI and once at the completion of the MRI.

Change in Serum Cytokine Levels

Overall Study

Joseph D. Tobias, MD

Toxicity

Hydrocephalus

Isoflurane

Dexmedetomidine

Isoflurane-induced Neuroinflammation in Children With Hydrocephalus

Isoflurane-induced Neuroinflammation in Children With Hydrocephalus: A Bench-to-bedside, Translational Study of Molecular Pathways and Therapeutic Approaches

Joseph D. Tobias

Chairman of Anesthesiology & Pain Medicine

Nationwide Children's Hospital

Ohio State University

Healthy

Adm 100 U/kg sc 1 hour before completing exercise in protocol

encephalomyelitis/hypoxia

Simvastatin in Secondary Progressive Multiple Sclerosis

Utilization of the Ketogenic Diet in Patient With Relapsing Remitting MS

Isoflurane-induced Neuroinflammation in Children With Hydrocephalus

Can Erythropoietin Protect the Cerebral Blood Flow and Oxygenation During Simulated Dive?

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