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With which cancers has the loss of SMARCB1 been associated? | Genotyping cancer-associated genes in chordoma identifies mutations in oncogenes and areas of chromosomal loss involving CDKN2A, PTEN, and SMARCB1 Loss of SMARCB1/INI1 expression is considered to be a hallmark for childhood chordomas (CCs) | The molecular mechanisms underlying chordoma pathogenesis are unknown. We
therefore sought to identify novel mutations to better understand chordoma
biology and to potentially identify therapeutic targets. Given the relatively
high costs of whole genome sequencing, we performed a focused genetic analysis
using matrix-assisted laser desorption/ionization-time of flight mass
spectrometer (Sequenom iPLEX genotyping). We tested 865 hotspot mutations in 111
oncogenes and selected tumor suppressor genes (OncoMap v. 3.0) of 45 human
chordoma tumor samples. Of the analyzed samples, seven were identified with at
least one mutation. Six of these were from fresh frozen samples, and one was
from a paraffin embedded sample. These observations were validated using an
independent platform using homogeneous mass extend MALDI-TOF (Sequenom hME
Genotyping). These genetic alterations include: ALK (A877S), CTNNB1 (T41A), NRAS
(Q61R), PIK3CA (E545K), PTEN (R130), CDKN2A (R58*), and SMARCB1 (R40*). This
study reports on the largest comprehensive mutational analysis of chordomas
performed to date. To focus on mutations that have the greatest chance of
clinical relevance, we tested only oncogenes and tumor suppressor genes that
have been previously implicated in the tumorigenesis of more common
maligcies. We identified rare genetic changes that may have functional
significance to the underlying biology and potential therapeutics for chordomas.
Mutations in CDKN2A and PTEN occurred in areas of chromosomal copy loss. When
this data is paired with the studies showing 18 of 21 chordoma samples
displaying copy loss at the locus for CDKN2A, 17 of 21 chordoma samples
displaying copy loss at PTEN, and 3 of 4 chordoma samples displaying deletion at
the SMARCB1 locus, we can infer that a loss of heterozygosity at these three
loci may play a significant role in chordoma pathogenesis. |
Where do centromeres locate according to the Rabl orientation of eukaryotic nuclei? | The Rabl orientation is an example of the non-random arrangement of chromosomes, centromeres are grouped in a limited area near the nuclear periphery and telomeres are located apart from centromeres. | Specific chromosome domains in interphase nuclei of neurons and glia were
studied by three-dimensional (3-D) reconstruction of serial optical sections
from in situ hybridized human CNS tissue. Overall patterns of centromere
organization, delineated with alphoid repeats, were comparable to those seen in
mouse, and are clearly conserved in mammalian evolution. Cloned probes from
other individual chromosome domains were used to define interphase organization
more precisely. Homologous chromosomes were spatially separated in nuclei. In
large neurons, probes specific for 9q12, or 1q12 showed that at least one
homolog was always compartmentalized together with centromeres on the nucleolus,
while the second signal either abutted the nucleolus or was on the nuclear
membrane. A telomeric Yq12 sequence also localized together with perinucleolar
centromeres in a completely non-Rabl orientation. In astrocytes, these three
chromosome regions were on the membrane and not necessarily associated with
nucleoli. Therefore there are different patterns of interphase chromosome
organization in functionally distinct cell types. In contrast to the above
domains, a 1p36.3 telomeric sequence embedded in a large Alu-rich and early
replicating chromosome region, was always found in an interior euchromatic
nuclear compartment in both neurons and glial cells. In double hybridizations
with 1q12 and 1p36.3 probes, 1p arms were clearly separated in all cells, and
arms projected radially into the interior nucleoplasm with non-Rabl
orientations. There was no absolute or rigid position for each 1p arm with
respect to each other or to the major dendrite, indicating that individual
chromosome arms may be dynamically positioned even in highly differentiated cell
types. We suggest that centromeric and other highly repeated non-transcribed
sequence domains may act as general organizing centers for cell type specific
interphase patterns that are conserved in mammalian evolution. Such centers
would allow selected groups of chromosome arms to extend into (and contract
from) an interior, presumably transcriptionally active, nuclear compartment. During interphase in the budding yeast, Saccharomyces cerevisiae, centromeres
are clustered near one pole of the nucleus as a rosette with the spindle pole
body at its hub. Opposite to the centromeric pole is the nucleolus. Chromosome
arms extend outwards from the centromeric pole and are preferentially directed
towards the opposite pole. Centromere clustering is reduced by the ndc10
mutation, which affects a kinetochore protein, and by the microtubule poison
nocodazole. This suggests that clustering is actively maintained or enforced by
the association of centromeres with microtubules throughout interphase. Unlike
the Rabl-orientation known from many higher eukaryotes, centromere clustering in
yeast is not only a relic of anaphase chromosome polarization, because it can be
reconstituted without the passage of cells through anaphase. Within the rosette,
homologous centromeres are not arranged in a particular order that would suggest
somatic pairing or genome separation. Chromosomes are not packed randomly in the nucleus. The Rabl orientation is an
example of the non-random arrangement of chromosomes, centromeres are grouped in
a limited area near the nuclear periphery and telomeres are located apart from
centromeres. This orientation is established during mitosis and maintained
through subsequent interphase in a range of species. We report that a Rabl-like
configuration can be formed de novo without a preceding mitosis during the
transition from the sexual phase to the vegetative phase of the life cycle in
fission yeast. In this process, each of the dispersed centromeres is often
associated with a novel Sad1-containing body that is contacting a cytoplasmic
microtubule laterally (Sad1 is a component of the spindle pole body (SPB)). The
Sad1-containing body was colocalized with other known SPB components, Kms1 and
Spo15 but not with Cut12, indicating that it represents a novel SPB-related
complex. The existence of the triplex structure (centromere-microtubule-Sad1
body) suggests that the clustering of centromeres is controlled by a cytoplasmic
microtubular system. Accordingly, when microtubules are destabilized, clustering
is markedly reduced. There are several reports of a closer-than-random colocalization of homologous
chromosomes in the vegetative nuclei of diploid budding yeast. Here, we studied
by fluorescence in situ hybridization (FISH) the nuclear distribution of
chromosomes and found a slight tendency toward closer proximity between
homologous (allelic) loci than between any nonhomologous chromosomal regions. We
show that most of this preferential association is not due to vegetative (also
known as somatic) pairing but is caused by the polar orientation of interphase
chromosomes (Rabl orientation). We quantified the occasional loss of detectable
fluorescence signals that is inherent to the FISH method. Signal loss leads to
the occurrence of a single signal that may be misinterpreted as the close
association of two homologous chromosomal sites. The nuclear distribution of
homologous loci, when corrected for the influence of nuclear architecture and
methodological faults, was not different or was only marginally different from a
random relative positioning as predicted by computer simulation. We discuss here
several possibilities for the residual homologous proximity that do not invoke
homology-dependent vegetative pairing, and we conclude that, in diploid budding
yeast, constitutive vegetative pairing is a negligible factor for the
organization of the interphase nucleus. Biologists have been fascinated for more than 2 centuries about how the nucleus
in eukaryotes is organised. Certain of the component parts are well known, but
the overall picture is blurred and often confusing. Small genome species have
chromosomes in their interphase nuclei disposed in diffuse chromosome
territories, without any Rabl arrangement, while in large genomes the
chromosomes run string-like through the nucleus with a Rabl orientation
following through the cell cycle. What happens in genomes of intermediate size
is either a bit of both, depending on the tissue being studied, or still remains
to be determined. The centromeres are the most dynamic and least well understood
part of the nucleus, subject to rapid evolutionary change and with an epigenetic
mark based on a special form of histone CENH3. Nonetheless, the centromere
epigenetic mark has been inherited for millions of years by a process that is a
complete mystery. Centromeres are involved with the dynamic interactions between
chromosomes and other parts of the nuclear environment, such as the nuclear
matrix and inner nuclear membrane, and they also engage with the spindle when
the order within the nucleus changes during its division. The nucleolus
organizer regions have likewise posed tantalising problems about their massive
amplification of rDNA sequences, and how they are regulated and expressed. Some
of these issues are now becoming clearer with advances in the science and the
ongoing development of new molecular tools. These developments are discussed in
this contribution, with particular reference to the centromere and the nucleolus
organizer. Measurements of distances between telocentric chromosomes, either homologous or
representing the opposite arms of a metacentric chromosome (complementary
telocentrics), were made at metaphase in root tip cells of common wheat carrying
two homologous pairs of complementary telocentrics of chromosome 1 B or 6 B
(double ditelosomic 1 B or 6 B). The aim was to elucidate the relative locations
of the telocentric chromosomes within the cell. The data obtained strongly
suggest that all four telocentrics of chromosome 1 B or 6 B are spacially and
simultaneously co-associated. In plants carrying two complementary (6 B (S) and
6 B (L)) and a non-related (5 B (L)) telocentric, only the complementary
chromosomes were found to be somatically associated. It is thought, therefore,
that the somatic association of chromosomes may involve more than two
chromosomes in the same association and, since complementary telocentrics are as
much associated as homologous, that the homology between centromeres (probably
the only homologous region that exists between complementary telocentrics) is a
very important condition for somatic association of chromosomes. The spacial
arrangement of chromosomes was studied at anaphase and prophase and the polar
orientation of chromosomes at prophase was found to resemble anaphase
orientation. This was taken as good evidence for the maintece of the
chromosome arrangement - the Rabl orientation - and of the peripheral location
of the centromere and its association with the nuclear membrane. Within this
general arrangement homologous telocentric chromosomes were frequently seen to
have their centromeres associated or directed towards each other. The role of
the centromere in somatic association as a spindle fibre attachment and
chromosome binder is discussed. It is suggested that for non-homologous
chromosomes to become associated in root tips, the only requirement needed
should be the homology of centromeres such as exists between complementary
telocentrics, or, as a possible alternative, common repeated sequences of DNA
molecules around the centromere region. |
What is the function of STAR elements in yeast telomeres? | Subtelomeres also contain Sub-Telomeric Anti-silencing Regions (STARs). We also show that the deletion of Histone-Acetyltransferase genes reduce the silencing activity of an ACS proto-silencer, but also reduce the anti-silencing activity of a STAR. The telomere-proximal portion of either X or Y' dampened silencing when located between the telomere and the reporter gene. These elements were named STARs, for subtelomeric anti-silencing regions. STARs can also counteract silencer-driven repression at the mating-type HML locus. When two STARs bracket a reporter gene, its expression is no longer influenced by surrounding silencing elements, although these are still active on a second reporter gene. | In budding yeast, the telomeric DNA is flanked by a combination of two
subtelomeric repetitive sequences, the X and Y' elements. We have investigated
the influence of these sequences on telomeric silencing. The telomere-proximal
portion of either X or Y' dampened silencing when located between the telomere
and the reporter gene. These elements were named STARs, for subtelomeric
anti-silencing regions. STARs can also counteract silencer-driven repression at
the mating-type HML locus. When two STARs bracket a reporter gene, its
expression is no longer influenced by surrounding silencing elements, although
these are still active on a second reporter gene. In addition, an intervening
STAR uncouples the silencing of neighboring genes. STARs thus display the
hallmarks of insulators. Protection from silencing is recapitulated by
multimerized oligonucleotides representing Tbf1p- and Reb1p-binding sites, as
found in STARs. In contrast, sequences located more centromere proximal in X and
Y' elements reinforce silencing. They can promote silencing downstream of an
insulated expressed domain. Overall, our results suggest that the silencing
emanating from telomeres can be propagated in a discontinuous manner via a
series of subtelomeric relay elements. Silencing at native yeast telomeres, in which the subtelomeric elements are
intact, is different from silencing at terminal truncations. The repression of
URA3 inserted in different subtelomeric positions at several chromosome ends was
investigated. Many ends exhibit very little silencing close to the telomere,
while others exhibit substantial repression in limited domains. Silencing at
native ends is discontinuous, with maximal repression found adjacent to the ARS
consensus sequence in the subtelomeric core X element. The level of repression
declines precipitously towards the centromere. Mutation of the ARS sequence or
an adjacent Abf1p-binding site significantly reduces silencing. The subtelomeric
Y' elements are resistant to silencing along their whole length, yet silencing
can be re-established at the proximal X element. Deletion of PPR1, the
transactivator of URA3, and SIR3 overexpression do not increase repression or
extend spreading of silencing to the same extent as with terminally truncated
ends. sir1Delta causes partial derepression at X-ACS, in contrast to the lack of
effect seen at terminal truncations. orc2-1 and orc5-1 have no effect on natural
silencing yet cause derepression at truncated ends. X-ACS silencing requires the
proximity of the telomere and is dependent on SIR2, SIR3, SIR4 and HDF1. The
structures found at native yeast telomeres appear to limit the potential of
repressive chromatin. Telomere Position Effect (TPE) is governed by strong repression signals emitted
by telomeres via the Sir2/3/4 Histone Deacetylase complex. These signals are
then relayed by weak proto-silencers residing in the subtelomeric core X and Y'
elements. Subtelomeres also contain Sub-Telomeric Anti-silencing Regions
(STARs). In this study we have prepared telomeres built of different
combinations of core X, Y' and STARs and have analyzed them in strains lacking
Histone-Acetyltransferase genes as well as in cdc6-1 and Δrif1 strains. We show
that core X and Y' dramatically reduce both positive and negative variations in
TPE, that are caused by these mutations. We also show that the deletion of
Histone-Acetyltransferase genes reduce the silencing activity of an ACS
proto-silencer, but also reduce the anti-silencing activity of a STAR. We
postulate that core X and Y' act as epigenetic "cushioning" cis-elements. Chromatin boundary elements serve as cis-acting regulatory DNA signals required
to protect genes from the effects of the neighboring heterochromatin. In the
yeast genome, boundary elements act by establishing barriers for heterochromatin
spreading and are sufficient to protect a reporter gene from transcriptional
silencing when inserted between the silencer and the reporter gene. Here we
dissected functional topography of silencers and boundary elements within
circular minichromosomes in Saccharomyces cerevisiae. We found that both HML-E
and HML-I silencers can efficiently repress the URA3 reporter on a multi-copy
yeast minichromosome and we further showed that two distinct heterochromatin
boundary elements STAR and TEF2-UASrpg are able to limit the heterochromatin
spreading in circular minichromosomes. In surprising contrast to what had been
observed in the yeast genome, we found that in minichromosomes the
heterochromatin boundary elements inhibit silencing of the reporter gene even
when just one boundary element is positioned at the distal end of the URA3
reporter or upstream of the silencer elements. Thus the STAR and TEF2-UASrpg
boundary elements inhibit chromatin silencing through an antisilencing activity
independently of their position or orientation in S. cerevisiae minichromosomes
rather than by creating a position-specific barrier as seen in the genome. We
propose that the circular DNA topology facilitates interactions between the
boundary and silencing elements in the minichromosomes. Human mesenchymal stem cells (hMSCs) have attracted much attention for tissue
repair and wound healing because of their self-renewal capacity and
multipotentiality. In order to mediate an effective therapy, substantial numbers
of cells are required, which necessitates extensive sub-culturing and expansion
of hMSCs. Throughout ex vivo expansion, the cells undergo telomere shortening,
and critically short telomeres can trigger loss of cell viability. Telomeres are
nucleoprotein structures that cap the ends of chromosomes, and serve to protect
the DNA from the degradation which occurs due to the end-replication problem in
all eukaryotes. As hMSCs have only a finite ability for self-renewal like most
somatic cells, assaying for telomere length in hMSCs provides critical
information on the replicative capacity of the cells, an important criterion in
the selection of hMSCs for therapy. Telomere length is generally quantified by
Southern blotting and fluorescence in situ hybridization, and more recently by
PCR-based methods. Here we describe the quantification of hMSC telomere length
by real-time PCR; our results demonstrate the effect of telomere shortening on
the proliferation and clonogenicity of hMSCs. Thus, this assay constitutes a
useful tool for the determination of relative telomere length in hMSCs. |
Name the phase 3 clinical trials for tofacitinib in colitis. | There are three phase 3, randomized, double-blind, placebo-controlled trials of tofacitinib therapy in adults with ulcerative colitis: OCTAVE Induction 1, OCTAVE Induction 2, OCTAVE Sustain. | BACKGROUND: Tofacitinib, an oral, small-molecule Janus kinase inhibitor, was
shown to have potential efficacy as induction therapy for ulcerative colitis in
a phase 2 trial. We further evaluated the efficacy of tofacitinib as induction
and maintece therapy.
METHODS: We conducted three phase 3, randomized, double-blind,
placebo-controlled trials of tofacitinib therapy in adults with ulcerative
colitis. In the OCTAVE Induction 1 and 2 trials, 598 and 541 patients,
respectively, who had moderately to severely active ulcerative colitis despite
previous conventional therapy or therapy with a tumor necrosis factor antagonist
were randomly assigned to receive induction therapy with tofacitinib (10 mg
twice daily) or placebo for 8 weeks. The primary end point was remission at 8
weeks. In the OCTAVE Sustain trial, 593 patients who had a clinical response to
induction therapy were randomly assigned to receive maintece therapy with
tofacitinib (either 5 mg or 10 mg twice daily) or placebo for 52 weeks. The
primary end point was remission at 52 weeks.
RESULTS: In the OCTAVE Induction 1 trial, remission at 8 weeks occurred in 18.5%
of the patients in the tofacitinib group versus 8.2% in the placebo group
(P=0.007); in the OCTAVE Induction 2 trial, remission occurred in 16.6% versus
3.6% (P<0.001). In the OCTAVE Sustain trial, remission at 52 weeks occurred in
34.3% of the patients in the 5-mg tofacitinib group and 40.6% in the 10-mg
tofacitinib group versus 11.1% in the placebo group (P<0.001 for both
comparisons with placebo). In the OCTAVE Induction 1 and 2 trials, the rates of
overall infection and serious infection were higher with tofacitinib than with
placebo. In the OCTAVE Sustain trial, the rate of serious infection was similar
across the three treatment groups, and the rates of overall infection and herpes
zoster infection were higher with tofacitinib than with placebo. Across all
three trials, adjudicated nonmelanoma skin cancer occurred in five patients who
received tofacitinib and in one who received placebo, and adjudicated
cardiovascular events occurred in five who received tofacitinib and in none who
received placebo; as compared with placebo, tofacitinib was associated with
increased lipid levels.
CONCLUSIONS: In patients with moderately to severely active ulcerative colitis,
tofacitinib was more effective as induction and maintece therapy than
placebo. (Funded by Pfizer; OCTAVE Induction 1, OCTAVE Induction 2, and OCTAVE
Sustain ClinicalTrials.gov numbers, NCT01465763 , NCT01458951 , and NCT01458574
, respectively.). |
What is the mode of action of the drug Prolia? | Prolia, also known as denosumab is an anti-RANKL agent for the treatment of osteoporosis. It works by preventing the development of osteoclasts which are cells that break down bone. | Since the introduction of bisphosphonates to treat diseases that affect
remodelling of bone, increasing numbers of patients with bisphosphonate-related
osteonecrosis of the jaws have been reported; the number is currently unknown.
Recently anti-RANKL agents (receptor activator of nuclear factor-kappaB ligand)
such as denosumab (Prolia, Amgen Inc., California, USA) that have a similar mode
of action to bisphosphonates have been introduced to treat such diseases. We
report a case of osteonecrosis that was induced by anti-RANKL therapy. To our
knowledge this is the first case to have been induced by these agents. Denosumab (Prolia) is a fully human monoclonal antibody directed against
receptor activator of nuclear factor-κB ligand (RANKL), which interferes with
the formation, activation, and survival of osteoclasts. It was approved by the
Food and Drug Administration in June 2010 as a new treatment for postmenopausal
osteoporosis in women who are at high risk for fracture. Given its mechanism of
action, it is an antiresorptive therapy that is administered as a 60-mg
subcutaneous injection every 6 months. It is the first biologic antiresorptive
therapy for osteoporosis, and the first osteoporosis therapy to show efficacy
and safety in patients with renal impairment. AIM: To evaluate the efficacy and safety of Denosumab (Prolia), a first-line
osteoporosis (OP) medication that is a fully human monoclonal antibody to the
receptor activator of nuclear factor xB ligand (RANKL), within an open-label
observational study.
SUBJECTS AND METHODS: Patients aged 50 years or older with postmenopausal OP,
who were treated with Prolia in clinical practice, were examined. The
concentrations of the bone resorption (BR) marker of C-terminal telopeptide and
other laboratory indicators (total serum calcium, total alkaline phosphatase,
and creatinine) were measured following 3 months. Adverse drug reactions were
recorded.
RESULTS: Three months after initiation of the investigation, there was a
significant decrease in the BR marker C-terminal telopeptide (by 89%; p<0.0001).
There were rare adverse reactions: hypocalcemia in 3 (5.9%) patients,
arthralgias in 2 (3.9%), and eczema in 1 (1.9%). There were neither serious
adverse events nor study withdrawal cases.
CONCLUSION: The preliminary results of the open-label study of Prolia in
postmenopausal OP suggest that the significantly lower BR activity determines
the efficacy of this drug and its high safety. |
How does parathyroid hormone affect circulating levels of periostin? | Parathyroid hormone can upregulate periostin levels. | Periostin is a 90 kDa secreted protein, originally identified in murine
osteoblast-like cells, with a distribution restricted to collagen-rich tissues
and certain tumors. In this paper, we first analyzed the expression of periostin
mRNA and protein in human fetal osteoblasts (hFOB) and human osteosarcoma (hOS)
cell lines by RT real-time PCR and Western blot, respectively. The hFOB 1.19 and
three hOS (MHM, KPDXM and Eggen) showed highly variable periostin mRNA levels
and protein. Second, we showed that the expression of periostin mRNA was
inversely related to the cells' abilities to differentiate and mineralize. Then,
we investigated the regulation of periostin mRNA in hFOB after siRNA treatment
and in mouse primary osteoblasts (mOB) treated with PTH. Knock-down of periostin
mRNA, down-regulated PTHrP, but did not affect the expression of other important
markers of differentiation such as RUNX2. In addition, periostin mRNA was
transiently up-regulated in osteoblasts by PTH. Finally, the localization of
periostin and its partially co-localization with collagen 1a1 mRNA and protein
was studied in mouse embryos and postnatal pups using in situ hybridization and
immunohistochemistry, respectively. In conclusion, the present study provides
novel observations related to the expression, distribution and regulation of
periostin in bone cells and extracellular matrix. |
What is MINDY (motif interacting with Ub-containing novel DUB family)? | MINDY-1 is a member of an evolutionarily conserved and structurally distinct new family of deubiquitinating enzymes. | Deubiquitinating enzymes (DUBs) remove ubiquitin (Ub) from Ub-conjugated
substrates to regulate the functional outcome of ubiquitylation. Here we report
the discovery of a new family of DUBs, which we have named MINDY (motif
interacting with Ub-containing novel DUB family). Found in all eukaryotes,
MINDY-family DUBs are highly selective at cleaving K48-linked polyUb, a signal
that targets proteins for degradation. We identify the catalytic activity to be
encoded within a previously unotated domain, the crystal structure of which
reveals a distinct protein fold with no homology to any of the known DUBs. The
crystal structure of MINDY-1 (also known as FAM63A) in complex with
propargylated Ub reveals conformational changes that realign the active site for
catalysis. MINDY-1 prefers cleaving long polyUb chains and works by trimming
chains from the distal end. Collectively, our results reveal a new family of
DUBs that may have specialized roles in regulating proteostasis. |
Has the proteome of mice hippocampus been analysed? | Yes, numerous proteomic studies of mice hippcampi has been performed. | N-Methyl-d-aspartate receptors (NMDARs) are major targets of both acute and
chronic alcohol, as well as regulators of plasticity in a number of brain
regions. Aberrant plasticity may contribute to the treatment resistance and high
relapse rates observed in alcoholics. Recent work suggests that chronic alcohol
treatment preferentially modulates both the expression and subcellular
localization of NMDARs containing the GluN2B subunit. Signaling through synaptic
and extrasynaptic GluN2B-NMDARs has already been implicated in the
pathophysiology of various other neurological disorders. NMDARs interact with a
large number of proteins at the glutamate synapse, and a better understanding of
how alcohol modulates this proteome is needed. We employed a discovery-based
proteomic approach in subcellular fractions of hippocampal tissue from chronic
intermittent alcohol (CIE)-exposed C57Bl/6J mice to gain insight into
alcohol-induced changes in GluN2B signaling complexes. Protein enrichment
analyses revealed changes in the association of post-synaptic proteins,
including scaffolding, glutamate receptor and PDZ-domain binding proteins with
GluN2B. In particular, GluN2B interaction with metabotropic glutamate (mGlu)1/5
receptor-dependent long-term depression (LTD)-associated proteins such as Arc
and Homer 1 was increased, while GluA2 was decreased. Accordingly, we found a
lack of mGlu1/5 -induced LTD while α1 -adrenergic receptor-induced LTD remained
intact in hippocampal CA1 following CIE. These data suggest that CIE
specifically disrupts mGlu1/5 -LTD, representing a possible connection between
NMDAR and mGlu receptor signaling. These studies not only demonstrate a new way
in which alcohol can modulate plasticity in the hippocampus but also emphasize
the utility of this discovery-based proteomic approach to generate new
hypotheses regarding alcohol-related mechanisms. Deletions on chromosome 22q11.2 are a strong genetic risk factor for development
of schizophrenia and cognitive dysfunction. We employed shotgun liquid
chromatography-mass spectrometry (LC-MS) proteomic and metabonomic profiling
approaches on prefrontal cortex (PFC) and hippocampal (HPC) tissue from
Df(16)A+/- mice, a model of the 22q11.2 deletion syndrome. Proteomic results
were compared with previous transcriptomic profiling studies of the same brain
regions. The aim was to investigate how the combined effect of the 22q11.2
deletion and the corresponding miRNA dysregulation affects the cell biology at
the systems level. The proteomic brain profiling analysis revealed PFC and HPC
changes in various molecular pathways associated with chromatin remodelling and
RNA transcription, indicative of an epigenetic component of the 22q11.2DS.
Further, alterations in glycolysis/gluconeogenesis, mitochondrial function and
lipid biosynthesis were identified. Metabonomic profiling substantiated the
proteomic findings by identifying changes in 22q11.2 deletion syndrome
(22q11.2DS)-related pathways, such as changes in ceramide phosphoethanolamines,
sphingomyelin, carnitines, tyrosine derivates and panthothenic acid. The
proteomic findings were confirmed using selected reaction monitoring mass
spectrometry, validating decreased levels of several proteins encoded on
22q11.2, increased levels of the computationally predicted putative miR-185
targets UDP-N-acetylglucosamine-peptide N-acetylglucosaminyltransferase 110 kDa
subunit (OGT1) and kinesin heavy chain isoform 5A and alterations in the
non-miR-185 targets serine/threonine-protein phosphatase 2B catalytic subunit
gamma isoform, neurofilament light chain and vesicular glutamate transporter 1.
Furthermore, alterations in the proteins associated with mammalian target of
rapamycin signalling were detected in the PFC and with glutamatergic signalling
in the hippocampus. Based on the proteomic and metabonomic findings, we were
able to develop a schematic model summarizing the most prominent molecular
network findings in the Df(16)A+/- mouse. Interestingly, the implicated pathways
can be linked to one of the most consistent and strongest proteomic candidates,
(OGT1), which is a predicted miR-185 target. Our results provide novel insights
into system-biological mechanisms associated with the 22q11DS, which may be
linked to cognitive dysfunction and an increased risk to develop schizophrenia.
Further investigation of these pathways could help to identify novel drug
targets for the treatment of schizophrenia. BACKGROUND: Tuberous sclerosis complex (TSC) is a rare monogenic disorder
characterized by benign tumors in multiple organs as well as a high prevalence
of epilepsy, intellectual disability and autism. TSC is caused by inactivating
mutations in the TSC1 or TSC2 genes. Heterozygocity induces hyperactivation of
mTOR which can be inhibited by mTOR inhibitors, such as rapamycin, which have
proven efficacy in the treatment of TSC-associated symptoms. The aim of the
present study was (1) to identify molecular changes associated with social and
cognitive deficits in the brain tissue of Tsc1+/- mice and (2) to investigate
the molecular effects of rapamycin treatment, which has been shown to ameliorate
genotype-related behavioural deficits.
METHODS: Molecular alterations in the frontal cortex and hippocampus of Tsc1+/-
and control mice, with or without rapamycin treatment, were investigated. A
quantitative mass spectrometry-based shotgun proteomic approach (LC-MSE) was
employed as an unbiased method to detect changes in protein levels. Changes
identified in the initial profiling stage were validated using selected reaction
monitoring (SRM). Protein Set Enrichment Analysis was employed to identify
dysregulated pathways.
RESULTS: LC-MSE analysis of Tsc1+/- mice and controls (n = 30) identified 51
proteins changed in frontal cortex and 108 in the hippocampus. Bioinformatic
analysis combined with targeted proteomic validation revealed several
dysregulated molecular pathways. Using targeted assays, proteomic alterations in
the hippocampus validated the pathways "myelination", "dendrite," and "oxidative
stress", an upregulation of ribosomal proteins and the mTOR kinase. LC-MSE
analysis was also employed on Tsc1+/- and wildtype mice (n = 34) treated with
rapamycin or vehicle. Rapamycin treatment exerted a stronger proteomic effect in
Tsc1+/- mice with significant changes (mainly decreased expression) in 231 and
106 proteins, respectively. The cellular pathways "oxidative stress" and
"apoptosis" were found to be affected in Tsc1+/- mice and the cellular
compartments "myelin sheet" and "neurofilaments" were affected by rapamycin
treatment. Thirty-three proteins which were altered in Tsc1+/- mice were
normalized following rapamycin treatment, amongst them oxidative stress related
proteins, myelin-specific and ribosomal proteins.
CONCLUSIONS: Molecular changes in the Tsc1+/- mouse brain were more prominent in
the hippocampus compared to the frontal cortex. Pathways linked to myelination
and oxidative stress response were prominently affected and, at least in part,
normalized following rapamycin treatment. The results could aid in the
identification of novel drug targets for the treatment of cognitive, social and
psychiatric symptoms in autism spectrum disorders. Similar pathways have also
been implicated in other psychiatric and neurodegenerative disorders and could
imply similar disease processes. Thus, the potential efficacy of mTOR inhibitors
warrants further investigation not only for autism spectrum disorders but also
for other neuropsychiatric and neurodegenerative diseases. |
Was saracatinib being considered as a treatment for Alzheimer's disease in November 2017? | Yes, saracatinib is being studied as a treatment against Alzheimer's Disease. A clinical Phase Ib study has been completed, and a clinical Phase IIa study is ongoing. | INTRODUCTION: Despite significant progress, a disease-modifying therapy for
Alzheimer's disease (AD) has not yet been developed. Recent findings implicate
soluble oligomeric amyloid beta as the most relevant protein conformation in AD
pathogenesis. We recently described a signaling cascade whereby oligomeric
amyloid beta binds to cellular prion protein on the neuronal cell surface,
activating intracellular Fyn kinase to mediate synaptotoxicity. Fyn kinase has
been implicated in AD pathophysiology both in in vitro models and in human
subjects, and is a promising new therapeutic target for AD. Herein, we present a
Phase Ib trial of the repurposed investigational drug AZD0530, a Src family
kinase inhibitor specific for Fyn and Src kinase, for the treatment of patients
with mild-to-moderate AD.
METHODS: The study was a 4-week Phase Ib multiple ascending dose, randomized,
double-blind, placebo-controlled trial of AZD0530 in AD patients with
Mini-Mental State Examination (MMSE) scores ranging from 16 to 26. A total of 24
subjects were recruited in three sequential groups, with each randomized to
receive oral AZD0530 at doses of 50 mg, 100 mg, 125 mg, or placebo daily for
4 weeks. The drug:placebo ratio was 3:1. Primary endpoints were safety,
tolerability, and cerebrospinal fluid (CSF) penetration of AZD0530. Secondary
endpoints included changes in clinical efficacy measures (Alzheimer's Disease
Assessment Scale - cognitive subscale, MMSE, Alzheimer's Disease Cooperative
Study - Activities of Daily Living Inventory, Neuropsychiatric Inventory, and
Clinical Dementia Rating Scale - Sum of Boxes) and regional cerebral glucose
metabolism measured by fluorodeoxyglucose positron emission tomography.
RESULTS: AZD0530 was generally safe and well tolerated across doses. One subject
receiving 125 mg of AZD0530 was discontinued from the study due to the
development of congestive heart failure and atypical pneumonia, which were
considered possibly related to the study drug. Plasma/CSF ratio of AZD0530 was
0.4. The 100 mg and 125 mg doses achieved CSF drug levels corresponding to brain
levels that rescued memory deficits in transgenic mouse models. One-month
treatment with AZD0530 had no significant effect on clinical efficacy measures
or regional cerebral glucose metabolism.
CONCLUSIONS: AZD0530 is reasonably safe and well tolerated in patients with
mild-to-moderate AD, achieving substantial central nervous system penetration
with oral dosing at 100-125 mg. Targeting Fyn kinase may be a promising
therapeutic approach in AD, and a larger Phase IIa clinical trial of AZD0530 for
the treatment of patients with AD has recently launched.
TRIAL REGISTRATION: ClinicalTrials.gov: NCT01864655. Registered 12 June 2014. |
Are mouse chromosomes acrocentric? | yes | The mouse genome contains a major and a minor satellite DNA family of repetitive
DNA sequences. The use of 5-azacytidine has allowed us to demonstrate that these
satellite DNAs are organized in two separate domains at the centromeres of mouse
chromosomes. The minor satellite is closer to the short arms of the acrocentric
chromosomes than the major satellite. The major satellite is farther away,
flanking the minor satellite and adjacent to the euchromatic long arm of each
mouse chromosome. At the level of resolution afforded by the in situ
hybridization technique it would appear that the organization of the centromeric
domain of the mouse is similar to that in man. That is, both contain two
repetitive DNA sequence families arranged in major blocks. We have assigned the gene (B2m) coding for murine beta 2-microglobulin (B2M) to
mouse chromosome 2 by using a novel panel of Chinese hamster-mouse somatic cell
hybrid clones. Because of 35 independent primary hybrids used in this study were
derived from two types of feral mice, each with a different combination of
Robertsonian translocation chromosomes, as well as from mice with a normal
complement of acrocentric chromosomes, analysis of 16 selected mouse enzyme
markers provided data on the segregation of all 20 mouse chromosomes in these
hybrids. Mouse B2M was identified in cell hybrids by immunoprecipitation with a
species-specific anti-mouse B2M antiserum followed by two-dimensional
polyacrylamide gel electrophoresis of the immunoprecipitated polypeptides.
Enzyme analysis of the segregant clones excluded all chromosomes for B2m
assignment except mouse chromosome 2, and karyotype analysis of nine informative
hybrid clones confirmed the assignment of B2m to this chromosome. These results
demonstrate that, in the mouse, as in man, B2m is not linked to the major
histocompatibility or immunoglobulin loci. Physical gene mapping by in situ hybridization is a difficult task in an
all-acrocentric mouse karyotype, because all of the chromosomes are
morphologically very similar. These difficulties can be overcome by using the
many different metacentric Robertsonian translocation (Rb) chromosomes derived
from wild mice. Here we describe the establishment of two Moloney murine
leukemia virus-transformed suspension cell lines, WMP-1 and WMP-2, derived from
wild mice of the strain WMP/WMP. These mice carry nine pairs of metacentric Rb
chromosomes containing chromosomes 1 to 18. Chromosome 19 and the sex
chromosomes are the only acrocentric chromosomes. Furthermore, a heterozygous
reciprocal translocation between chromosomes 13 and 17 involved in two Rb
chromosomes is present in this stock and provides additional marker chromosomes.
The chromosome designation of these mice is Rb(10.17)9Mpl Rb(13.15)10Mpl
T(13.17)1Lub. Genome mapping in the dog is in its early stages. Here we illustrate an approach
to combined physical and linkage mapping of type 1 anchor (gene) loci in the dog
using information on syntenic homology from human and mouse, an interbreed
cross/backcross, and a strategy for isolation of dog genomic clones containing
both gene-specific sequences and simple sequence repeat polymorphisms. Eleven
gene loci from human chromosome 17q (HSA17q) were mapped to the centromeric
two-thirds of dog chromosome 9 (CFA9), an acrocentric chromosome of medium size:
P4HB, GALK1, TK1, GH1, MYL4, BRCA1, RARA, THRA1, MPO, NF1, and CRYBA1. Eight of
these were also positioned on a linkage map spanning 38.6 cM. Based on combined
fluorescence in situ hybridization and linkage mapping, the gene order on CFA9
is similar to that of the homologous genes on HSA17q and mouse chromosome 11
(MMU11), but in the dog the gene order is inverted with respect to the
centromere. Canine loci, GALK1, TK1, GH1, MYL4, THRA1, and RARA constitute a
closely linked group near the centromeric end of CFA9, spanning a genetic
distance of only 4.7 cM. Canine NF1 and CRYBA1 lie distally, near the lower
border of the Giemsa band adjacent to the distal one-third of CFA9. NF1 and
CRYBA1 are loosely linked to the more centromeric group (31.2 cM). No HSA17
genes were found on the telomeric one-third of CFA9. Painting of dog chromosomes
with a human whole chromosome 17 probe showed hybridization with only the
proximal two-thirds of CFA9, consistent with the conclusion that the distal
one-third corresponds to a segment or segments of other human chromosomes. Two
loci, GLUT4 and PMP22, located on HSA17p, were mapped by FISH to dog chromosome
5 in a region also identified by the whole human chromosome 17 paint, indicating
disruption of HSA17 syntenic homology at the centromere. |
Is overproduction of transthyretin is associated with amyloidosis associated neuropathy? | Yes, an overproduction of transthyretin is associated with amyloidosis associated neuropathy. | BACKGROUND: Hereditary transthyretin amyloidosis (ATTR) is usually characterised
by a progressive peripheral and autonomic neuropathy often with associated
cardiac failure and is due to domitly inherited transthyretin mutations
causing accelerated amyloid deposition. The UK population is unique in that the
majority of patients have the T60A missense mutation in ATTR where tyrosine is
replaced by adenine at position 60. This has been traced to a single founder
mutation from north-west Ireland. The neuropathy phenotype is less well
described than the cardiac manifestations in this group.
METHODS: We present the findings from an observational cohort study of patients
with ATTR attending the National Hospital Inherited Neuropathy Clinic between
2009 and 2013. Detailed clinical neurological and electrophysiological data were
collected on all patients alongside correlating autonomic and cardiac
assessments. Follow-up data were available on a subset.
RESULTS: Forty-four patients with genetically confirmed ATTR were assessed; 37
were symptomatic; mean age at onset=62 years, range=38-75 years; 75.7% male.
T60A was the most common mutation (17/37), followed by V30M (5/37). A severe,
rapidly progressive, predomitly length dependent axonal sensorimotor
neuropathy was the predomit phenotype. T60A patients were distinguished by
earlier and more frequent association with carpal tunnel syndrome; a
predomice of negative sensory symptoms at onset; significant vibration
deficits; and a non-length dependent progression of motor deficit. Progression
of the neuropathy was observed over a relatively short follow-up period (2
years) in 20 patients with evidence of clinically measurable annual change in
Medical Research Council (MRC) sum score (-1.5 points per year) and Charcot
Marie Tooth Neuropathy Score (CMTNS:2.7 points per year), and a congruent trend
in the electrophysiological measures used.
CONCLUSION: The description of the ATTR neuropathy phenotype, especially in the
T60A patients, should aid early diagnosis as well as contribute to the
understanding of its natural history. INTRODUCTION AND OBJECTIVE: Transthyretin-associated familial amyloid
polyneuropathy (TTR-FAP) is a disease caused by the deposit of abnormal
transthyretin on tissues, mainly nerves. Small nerve fibers are altered earlier
during the course of the disease; hence, detection of their involvement may have
serious consequences on the natural history of disease.
METHODS: A cross-sectional, observational study, was carried out on symptomatic
patients, involving the conduct of several tests for small nerve fibers:
Vibration, Touch Pressure (TP) and Heat Pain (HP). Results were compared with
those obtained during a conventional neurological examination carried out on a
group of healthy individuals.
RESULTS: Fifteen symptomatic patients were recruited at an early stage of the
disease (60% stage 1), along with 13 healthy individuals, with both patient
groups having similar epidemiological characteristics in terms of gender, age,
weight, height or BMI. A comparison carried out between the neuropsychological
tests performed revealed statistically significant differences: Vibration
(P<.05), TP (P<.05) and HP (P<.05, except volar forearm).
CONCLUSIONS: The neurophysiological tests performed revealed significant
differences between both groups, allowing for an earlier detection of
neurological injuries compared to conventional neurological examinations. OBJECTIVE: To determine the utility of skin biopsies as a biomarker of disease
severity in subjects with amyloid neuropathy.
METHODS: Five groups of patients were studied: (1) transthyretin (TTR) familial
amyloidotic polyneuropathy (FAP; n = 20), (2) TTR mutation carriers without
peripheral neuropathy (TTR-noPN; n = 10), (3) healthy controls (n = 20), (4)
diabetic neuropathy disease controls (n = 20), and (5) patients with light-chain
(AL) amyloid (n = 2). All subjects underwent neurological examination and 3mm
skin biopsies. Sections were stained with anti-PGP9.5, anti-TTR, and Congo red.
Intraepidermal (IENFD), sweat gland (SGNFD), and pilomotor nerve fiber densities
(PMNFD) were measured. Correlations between the amount of amyloid present
(amyloid burden), fiber subtype, and Neuropathy Impairment Score in the Lower
Limbs (NIS-LL) were evaluated.
RESULTS: IENFD, SGNFD, and PMNFD were all significantly reduced in TTR-FAP
patients versus healthy controls, whereas TTR-noPN subjects had intermediate
reductions. Lower nerve fiber densities were associated with NIS-LL (p < 0.001).
Congo red staining revealed brilliant red amyloid deposits confirmed by
apple-green birefringence within dermal collagen, sweat glands, and arrector
pili that engulfed axons. The diagnostic sensitivity and specificity to detect
amyloid in skin were 70% and 100%. Both AL amyloidosis and 2 of 10 TTR-noPN
subjects were Congo red-positive. Amyloid burden correlated with IENFD
(r = -0.63), SGNFD (r = -0.67), PMNFD (r = -0.50), and NIS-LL (r = -0.57).
Wild-type TTR staining was less prominent in TTR-FAP patients.
INTERPRETATION: Cutaneous amyloid was detected in 70% of TTR-FAP and 20% of
TTR-noPN subjects. Amyloid burden correlated strongly with reductions in IENFD,
SGNFD, PMNFD, and NIS-LL. Skin is an attractive tissue to establish an amyloid
diagnosis, and amyloid burden has potential as a biomarker to detect treatment
effect in TTR-FAP drug trials. Ann Neurol 2017;82:44-56. We report a new transthyretin (ATTR) gene c.272C>G mutation and variant protein,
p.Leu32Val, in a kindred of Bolivian origin with a rapid progressive peripheral
neuropathy and cardiomyopathy. Three individuals from a kindred with peripheral
nerve and cardiac amyloidosis were examined. Analysis of the TTR gene was
performed by Sanger direct sequencing. Neuropathologic examination was obtained
on the index patient with mass spectrometry study of the ATTR deposition. Direct
DNA sequence analysis of exons 2, 3, and 4 of the TTR gene demonstrated a c.272
C>G mutation in exon 2 (p.L32V). Sural nerve biopsy revealed massive amyloid
deposition in the perineurium, endoneurium and vasa nervorum. Mass spectrometric
analyses of ATTR immunoprecipitated from nerve biopsy showed the presence of
both wild-type and variant proteins. The observed mass results for the wild-type
and variant proteins were consistent with the predicted values calculated from
the genetic analysis data. The ATTR L32V is associated with a severe course.
This has implications for treatment of affected individuals and counseling of
family members. Abnormal deposition of aggregated wild-type (WT) human transthyretin (TTR) and
its pathogenic variants is responsible for cardiomyopathy and neuropathy related
to TTR amyloidosis. The tryptophan (Trp) fluorescence measurements typically
used to study structural changes of TTR do not yield site-specific information
on the two Trp residues per TTR protomer. To obtain such information, tryptophan
labeled with fluorine at the 5 and 6 positions (5FW and 6FW) was incorporated
into TTR. Fluorescence of 5FW and 6FW-labeled WT-TTR (WT-5FW and WT-6FW) and a
single-Trp mutant W41Y showed that the photophysics of incorporated fluoro-Trp
is consistent with site-specific solvation of the indole ring of W41 and W79.
19F-NMR showed that solvent accessibility depends on both the location of the
Trp and the position of the fluorine substituent in the indole ring.
Unexpectedly, differences were observed in the rates of aggregation, with WT-6FW
aggregating more rapidly than WT-5FW or WT-TTR. Real-time 19F-NMR urea unfolding
experiments revealed that WT-5FW is kinetically more stable than WT-6FW,
consistent with the aggregation assay. In addition, structural perturbations of
residues distant from either Trp site are more extensive in WT-6FW. Notably,
residues in the dimer interfaces are perturbed by 6FW at residue 79; pathogenic
mutations in these regions are associated with reduced tetramer stability and
amyloidogenesis. The differences in behavior that arise from the replacement of
a fluorine at the 5-position of a tryptophan with one at the adjacent 6-position
emphasize the delicate balance of stability in the TTR tetramer. Transthyretin (TTR), normally a plasma circulating protein, can become misfolded
and aggregated, ultimately leading to extracellular deposition of amyloid
fibrils usually targeted to heart or nerve tissues. Referred to as
TTR-associated amyloidoses (ATTR), this group of diseases is frequently life
threatening and fatal if untreated. ATTR, caused by amyloid-forming variant TTR
proteins (ATTRm) that arise from point mutations in the TTR gene, were
classically referred to as familial amyloid cardiomyopathy (FAC) or familial
amyloid polyneuropathy (FAP), reflecting the clinical phenotype. FAC and FAP are
pathologies that can be challenging to diagnose as there are no definitive
biomarkers of disease; moreover, disease-specific measures of progression are
lacking, and treatment options are limited. Thus, the discovery of sensitive and
specific indicators of disease has the potential to improve recognition, enable
accurate measurement of amyloid progression and response to treatment, and
reveal key information regarding FAC and FAP pathobiological mechanisms. In this
study, the goal was to investigate serum proteomic features unique to FAC and
FAP types of ATTRm. Multiple-reaction monitoring mass spectrometry (MRM-MS), a
powerful technique in profiling proteomes, was used to measure the serum
concentrations of 160 proteins in samples from FAC and FAP patients. Results
were compared to data from healthy control sera obtained from individuals
matched to age (≥60 years), gender (male), and race (Caucasian). Proteomic
analyses of ATTRm (FAC and FAP) and control samples showed significant
concentration differences in 107 of 192 (56%) of the serum proteins that were
studied. In comparing FAC to FAP, differences in concentrations as well as
interactions and functions of several proteins were identified as unique to each
disease; significantly lower levels of TTR were specific to FAC, but not to FAP.
Annotated functional clustering identified extracellular region, signal, and
signal peptide as terms common to FAC and FAP. Conversely, disulfide bond was
unique to FAC; secreted, glycosylation site: N-linked, glycosylation,
glycoprotein, polymorphism, and sequence variant were associated solely with
FAP. Predicted protein-protein associations in FAC were seen for reaction,
binding, and activation processes; no associations were found in FAP. This study
demonstrates significant proteomic differences between ATTRm patient and control
sera, as well as ATTRm phenotype-associated variations in the circulating levels
of several proteins including TTR. The identification of serum proteins unique
to FAC and FAP may have diagnostic and prognostic utility and could possibly
provide important clues about disease mechanisms. |
What is cebocephaly | Cebocephaly is a developmental anomaly of the head characterized by a small head, with a defective small, flattened nose with a single nostril or absent nose and closely set eyes. | Cebocephaly (hypotelorism, single-nostril nose) and ethmocephaly (hypotelorism,
interorbital proboscis) lie in the middle of the spectrum of craniofacial
changes associated with holoprosencephaly. Because these defects and thorough
anatomic studies of them are rare, knowledge concerning morphologic as well as
pathogenetic relationships is lacking. We report the autopsy findings and
anatomic features of the dried skull of a 31 week fetus with cebocephaly and the
craniofacial dissection of a 36 week fetus with ethmocephaly. Both manifested
dysplastic changes of the ethmoid bone and anterior portion of the sphenoid
bone, with concomitant hypotelorism and defects of the medial orbital walls.
Through these latter defects, the eyes were joined in the ethmocephalic fetus
(synophthalmia). Other changes of bone (single optic foramen, approximated
maxillae, choanal atresia, thickened palate) and soft tissue (eccentric or fused
extraocular muscles, single optic nerve) in both fetuses resembled those
reported in other cases of cebocephaly and ethmocephaly, as well as cyclopia. In
the 19th century, both cebocephaly and ethmocephaly were classified as two-orbit
variants of cyclopia, a view supported by the present study. Cebocephaly is a very rare congenital anomaly combining a severe midline facial
malformation and holoprosencephaly. Here we report on first case of cebocephaly
with semilobar holoprosencephaly, hypotelorism, and a single nostril due to
intrauterine TORCH infection (Toxoplasmosis, other [syphilis, varicella-zoster,
parvovirus B19], Rubella, Cytomegalovirus [CMV], and Herpes infections) in the
English language literature. Chromosomal analysis showed normal karyotyping. Cebocephaly is a very rare congenital midline facial anomaly characterized by a
blind-ended single nostril and ocular hypotelorism, and is usually combined with
alobar holoprosencephaly. We report here a case of alobar holoprosencephaly with
cebocephaly and craniosynostosis. Chromosomal analysis revealed normal
karyotyping. The facial dysmorphism was characterized by the single nostril,
hypotelorism, absence of philtrum and small head girth. The failure of cleavage
of the prosencephalon and the fusion of all cranial sutures except for the
sagittal suture were documented by computed tomography (CT) and magnetic
resoce image (MRI). Early detection by the prenatal ultrasound examination is
important because of poor prognosis of alobar holoprosencephaly. We report a case of alobar holoprosencephaly (HPE) and cebocephaly associated
with uncontrolled maternal type 1 (insulin-dependent) diabetes mellitus. Alobar
HPE is the most severe form of HPE. Patients with cebocephaly have ocular
hypotelorism and a proboscis with a single, blind-ended nostril. Shortly after
our patient was born, we were consulted for airway management, as the parents'
goal was to bring their child home. A tracheostomy tube was placed, and choanal
atresia repair was eventually performed. The infant was never decannulated,
however, and she died at the age of 9 months of acute respiratory distress
syndrome secondary to an upper respiratory infection. To the best of our
knowledge, this case represents the longest reported survival of an infant with
alobar HPE and cebocephaly. Decisions regarding the care of these infants should
be made in a collaborative, multidisciplinary fashion, with special attention
paid to the primary caregivers' goals of care. |
How can network assortativity be applied in the three-dimensional analysis of the genome? | Chromatin assortativity is a way to integrate the epigenomic landscape of a specific cell type with its chromatin interaction network and thus investigate which proteins or chromatin marks mediate genomic contacts. | Many developmental, physiological, and behavioral processes depend on the
precise expression of genes in space and time. Such spatiotemporal gene
expression phenotypes arise from the binding of sequence-specific transcription
factors (TFs) to DNA, and from the regulation of nearby genes that such binding
causes. These nearby genes may themselves encode TFs, giving rise to a
transcription factor network (TFN), wherein nodes represent TFs and directed
edges denote regulatory interactions between TFs. Computational studies have
linked several topological properties of TFNs - such as their degree
distribution - with the robustness of a TFN's gene expression phenotype to
genetic and environmental perturbation. Another important topological property
is assortativity, which measures the tendency of nodes with similar numbers of
edges to connect. In directed networks, assortativity comprises four distinct
components that collectively form an assortativity signature. We know very
little about how a TFN's assortativity signature affects the robustness of its
gene expression phenotype to perturbation. While recent theoretical results
suggest that increasing one specific component of a TFN's assortativity
signature leads to increased phenotypic robustness, the biological context of
this finding is currently limited because the assortativity signatures of
real-world TFNs have not been characterized. It is therefore unclear whether
these earlier theoretical findings are biologically relevant. Moreover, it is
not known how the other three components of the assortativity signature
contribute to the phenotypic robustness of TFNs. Here, we use publicly available
DNaseI-seq data to measure the assortativity signatures of genome-wide TFNs in
41 distinct human cell and tissue types. We find that all TFNs share a common
assortativity signature and that this signature confers phenotypic robustness to
model TFNs. Lastly, we determine the extent to which each of the four components
of the assortativity signature contributes to this robustness. |
Which phase III clinical trials for rheumatoid arthritis involve baricitinib? (November 2017) | The phase 3 clinical trials of baricitinib in rheumatoid arthritis patients are: RA-BEACON, RA-BUILD, RA-BEAM. | BACKGROUND: Baricitinib is an oral, reversible, selective Janus kinase 1 and 2
inhibitor.
METHODS: In this phase III, double-blind 24-week study, 684 biologic
disease-modifying antirheumatic drug (DMARD)-naïve patients with rheumatoid
arthritis and inadequate response or intolerance to ≥1 conventional synthetic
DMARDs were randomly assigned 1:1:1 to placebo or baricitinib (2 or 4 mg) once
daily, stratified by region and the presence of joint erosions. Endpoint
measures included American College of Rheumatology 20% response (ACR20, primary
endpoint), Disease Activity Score (DAS28) and Simplified Disease Activity Index
(SDAI) score ≤3.3.
RESULTS: More patients achieved ACR20 response at week 12 with baricitinib 4 mg
than with placebo (62% vs 39%, p≤0.001). Compared with placebo, statistically
significant improvements in DAS28, SDAI remission, Health Assessment
Questionnaire-Disability Index, morning joint stiffness, worst joint pain and
worst tiredness were observed. In a supportive analysis, radiographic
progression of structural joint damage at week 24 was reduced with baricitinib
versus placebo. Rates of adverse events during the treatment period and serious
adverse events (SAEs), including serious infections, were similar among groups
(SAEs: 5% for baricitinib 4 mg and placebo). One patient had an adverse event of
tuberculosis (baricitinib 4 mg); one patient had an adverse event of
non-melanoma skin cancer (baricitinib 4 mg). Two deaths and three major adverse
cardiovascular events occurred (placebo). Baricitinib was associated with a
decrease in neutrophils and increases in low-density and high-density
lipoprotein.
CONCLUSIONS: In patients with rheumatoid arthritis and an inadequate response or
intolerance to conventional synthetic DMARDs, baricitinib was associated with
clinical improvement and inhibition of progression of radiographic joint damage.
TRIAL REGISTRATION NUMBER: NCT01721057; Results. OBJECTIVES: To assess baricitinib on patient-reported outcomes (PROs) in
patients with moderately to severely active rheumatoid arthritis, who had
insufficient response or intolerance to ≥1 tumour necrosis factor inhibitors
(TNFis) or other biological disease-modifying antirheumatic drugs (bDMARDs).
METHODS: In this double-blind phase III study, patients were randomised to
once-daily placebo or baricitinib 2 or 4 mg for 24 weeks. PROs included the
Short Form-36, EuroQol 5-D, Functional Assessment of Chronic Illness
Therapy-Fatigue (FACIT-F), Health Assessment Questionnaire-Disability Index
(HAQ-DI), Patient's Global Assessment of Disease Activity (PtGA), patient's
assessment of pain, duration of morning joint stiffness (MJS) and Work
Productivity and Activity Impairment Questionnaire-Rheumatoid Arthritis.
Treatment comparisons were performed with logistic regression for categorical
measures or analysis of covariance for continuous variables.
RESULTS: 527 patients were randomised (placebo, 176; baricitinib 2 mg, 174;
baricitinib 4 mg, 177). Both baricitinib-treated groups showed statistically
significant improvements versus placebo in most PROs. Improvements were
generally more rapid and of greater magnitude for patients receiving baricitinib
4 mg than 2 mg and were maintained to week 24. At week 24, more
baricitinib-treated patients versus placebo-treated patients reported normal
physical functioning (HAQ-DI <0.5; p≤0.001), reductions in fatigue (FACIT-F
≥3.56; p≤0.05), improvements in PtGA (p≤0.001) and pain (p≤0.001) and reductions
in duration of MJS (p<0.01).
CONCLUSIONS: Baricitinib improved most PROs through 24 weeks compared with
placebo in this study of treatment-refractory patients with previously
inadequate responses to bDMARDs, including at least one TNFi. PRO results
aligned with clinical efficacy data for baricitinib.
TRIAL REGISTRATION NUMBER: NCT01721044; Results. |
Which disease risk can be estimated with the Stop-Bang questionnaire? | Stop-Bang questionnaire is used to predict risk of obstructive sleep apnea (OSA). | BACKGROUND: As many as 80% of patients with asthma suffer from allergic rhinitis
(AR), and rhinitis symptoms are associated with sleep complaints The aim of this
cross-sectional study was to assess the prevalence of obstructive sleep apnea
syndrome risk in patients with asthma and to explore the association between
comorbid rhinitis and obstructive sleep apnea syndrome risk.
METHODS: Subjects with asthma were recruited by general practitioners during a
control visit. Physicians compiled a questionnaire that assessed the presence of
AR according to ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines and
factors influencing the risk of obstructive sleep apnea syndrome
(gastroesophageal reflux disease, obesity, smoking). Subjects completed a
questionnaire evaluating the presence and severity of AR and the STOP-BANG
questionnaire (snoring, tiredness during daytime, observed apnea, high blood
pressure, body mass index, age, neck circumference, gender), a validated
screening method to identify obstructive sleep apnea syndrome risk. Physicians
were blinded to the subjects' questionnaires, ensuring objectivity of the
method.
RESULTS: The analyses were conducted on 1,941 subjects (males 58%, mean age 48.2
± 15.2 y): 740 with asthma alone and 1,201 with asthma and AR. STOP-BANG
revealed that 52.6% of the subjects were at increased risk of obstructive sleep
apnea syndrome: 47.3% of subjects with asthma alone and 55.9% of patients with
asthma and AR. Rhinitis was associated with a 1.44 times higher odds ratio for
having obstructive sleep apnea syndrome risk. Rhinitis duration and severity
were associated with obstructive sleep apnea syndrome risk, although the latter
deserved greater importance. The results showed that, once a correction for each
of these factors was performed, subjects with AR with an odds ratio of 1.99 were
reported to be at risk of obstructive sleep apnea syndrome.
CONCLUSIONS: The probable increased risk of obstructive sleep apnea syndrome is
associated with the concomitant presence of rhinitis, independent of obesity and
other contributors to risk of obstructive sleep apnea syndrome. STUDY OBJECTIVE: To determine if a high score (≥ 3) on the STOP-Bang screening
questionnaire for obstructive sleep apnea (OSA) predicts whether obese patients
are at high risk for OSA and increased risk of difficult airway.
DESIGN: Prospective, questionnaire-based clinical assessment.
SETTING: University-affiliated hospital.
PATIENTS: 127 ASA physical status 2 and 3 patients, who were scheduled for
elective bariatric surgery.
INTERVENTIONS: Patients were allocated to three groups. Group 1 patients had a
previous history of OSA, Group 2 patients had no history of OSA but did have a
high STOP-Bang score (≥ 3), and Group 3 patients had no history of OSA but did
have a low STOP-Bang score (< 3). Groups 2 and 3 only were assessed using the
STOP-Bang questionnaire. After induction and intubation of the patient, an
anesthesiologist who was blinded to the three study group allocations completed
an airway questionnaire on the three study groups.
MEASUREMENTS: The frequency of difficult airway, difficult mask ventilation with
or without muscle relaxation, poor visualization of the vocal cords, difficulty
in blade insertion, and difficult intubation were compared.
MAIN RESULTS: The group of patients with high STOP-Bang scores (Group 2) and
those patients previously diagnosed with OSA (Group1) showed a higher risk for
difficult airway than the patients with low STOP-Bang scores (Group 3; P <
0.001).
CONCLUSION: The STOP-Bang score may be used as an effective predictor of
difficult airway in obese patients. Obese surgical patients with
unknown/undiagnosed OSA status should be evaluated using the STOP-Bang
questionnaire score. BACKGROUND: The present study validates and evaluates the sensitivity and
specificity of four internationally popular questionnaires, translated into
Chinese, for assessing suspected obstructive sleep apnea (OSA) patients, namely,
the Berlin questionnaire, the ASA checklist, the STOP questionnaire and the
STOP-BANG questionnaire. Their predictive values in OSA risks in patients
presenting with OSA symptoms are examined. Questionnaires may be helpful in
prioritizing polysomnography (PSG) and in treatment for the more severe cases.
METHODS: All patients attending our sleep laboratory for overnight PSG were
recruited. They were asked to complete three questionnaires (Berlin, ASA
checklist and STOP) 2 weeks before and on the same night as the PSG. STOP-BANG
questionnaire, an extended STOP with demographic data, 'B'-body mass index
(BMI), 'A'-age, 'N'-neck circumference and 'G'-gender was completed by our
technologists using the patient's completed STOP.
RESULTS: A number of 141 patients were recruited. The sensitivities and
specificities for STOP-BANG with cutoffs at PSG's RDI=5, RDI=15 and RDI=30 were
81% to 86% and 34% to 57%, respectively. The high-risk group patients identified
by STOP-BANG had significantly higher respiratory disturbance index and lower
minimum oxygen saturation than the low-risk group patients.
CONCLUSION: Among the four questionnaires studied, STOP-BANG, with only eight
questions and the highest sensitivity, is the best questionnaire of the four for
OSA screening. This can potentially assist in prioritizing PSG and can be
helpful in clinical or self-evaluation by the general public. PURPOSE: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder
that is underdiagnosed. OSA is usually diagnosed by polysomnography (PSG) and,
if untreated, could lead to life-threatening complications. Many screening
questionnaires have been developed to screen and identify patients at high risk
for OSA. This study aimed to evaluate and validate the Arabic version of
Stop-Bang questionnaire as a screening tool for patients with OSA symptoms
referred to a sleep clinic.
METHODS: All referred Arabic-speaking adult patients presenting to a Sleep
Disorders Specialized Clinic in Al Ain for PSG were requested to complete an
Arabic STOP-Bang questionnaire. A score of 3 or more out of a possible 8 was
taken to indicate high risk for presence of OSA. These scores were then
evaluated versus results from the overnight, monitored PSG. Apnea/hypopnea index
(AHI) of ≥5/h was considered for diagnosis of OSA.
RESULTS: One hundred ninety-three sleep clinic patients were enrolled in this
study. PSG was positive (AHI ≥5) in 85 % of the studied population. STOP-Bang
questionnaire was positive (≥3) in 87 % of the population. Reproducibility of
STOP-Bang questionnaire was tested, and the intraclass correlation coefficient
of the total score of STOP-Bang questionnaire was 0.931 (95 % CI 0.834-0.972).
The sensitivities of the STOP-Bang screening tool for an AHI of ≥5, ≥15, and ≥30
were 90, 96.75, and 99.70 %, respectively, with negative predictive values
(NPVs) of 36, 84, and 92 %, respectively. ROC curve was 0.77.
CONCLUSION: The Arabic version of STOP-Bang questionnaire is an easy-to-use tool
that can be implemented as a reliable, quick screening tool for OSA in patients
referred to sleep clinic. It demonstrated high sensitivity and NPV especially
for patients with moderate to severe OSA. We believe that this tool will help
physicians to earlier identify cases at risk of OSA. STUDY OBJECTIVE: The aims of this study were to (1) explore the incidence of
right-sided heart dysfunction (RHD) and STOP-Bang questionnaire responses
consistent with obstructive sleep apnea (OSA) and (2) assess the relationship
between patients with STOP-Bang questionnaire responses consistent with OSA and
echocardiographic findings suggestive of RHD.
DESIGN: Observational study.
SETTING: Tertiary academic center preoperative clinic.
PATIENTS: Two hundred patients presenting for elective surgery to the University
of Utah preoperative clinic.
INTERVENTION: Abbreviated transthoracic right-sided echocardiogram and STOP-Bang
questionnaire.
MEASUREMENTS: Tricuspid annular plane systolic excursion, tissue Doppler-derived
tricuspid lateral annular systolic velocity (S'), and the tricuspid inflow E
wave to tricuspid annular tissue Doppler e' wave ratio (E/e') for the presence
of RHD, as well as responses to STOP-Bang questionnaire.
MAIN RESULTS: A total of 140 echocardiograms were analyzed after exclusion of
participants with incomplete STOP-Bang questionnaires and inadequate images.
Thirty-five patients (25%) reported 5 or more positive responses to the
STOP-Bang questionnaire. Forty-six patients (35%) had abnormal right-sided heart
measurements. Of the 35 patients with STOP-Bang scores 5 or greater, 11 (31%)
had evidence of RHD. No correlation was observed between STOP-Bang scores and
the echocardiography metrics of RHD.
CONCLUSIONS: This preliminary study suggests that there are numerous sources of
RHD, among one of which is sleep apnea, and/or the STOP-Bang questionnaire is
not a sensitive tool for predicting RHD. We conclude that although the STOP-Bang
questionnaire is easy to implement in a preoperative clinical setting, it is not
useful in identifying patients at risk for RHD. BACKGROUND: Diagnosing obstructive sleep apnea (OSA) is clinically relevant
because untreated OSA has been associated with increased morbidity and
mortality. The STOP-Bang questionnaire is a validated screening tool for OSA. We
conducted a systematic review and meta-analysis to determine the effectiveness
of STOP-Bang for screening patients suspected of having OSA and to predict its
accuracy in determining the severity of OSA in the different populations.
METHODS: A search of the literature databases was performed. Inclusion criteria
were: 1) Studies that used STOP-Bang questionnaire as a screening tool for OSA
in adult subjects (>18 years); 2) The accuracy of the STOP-Bang questionnaire
was validated by polysomnography--the gold standard for diagnosing OSA; 3) OSA
was clearly defined as apnea/hypopnea index (AHI) or respiratory disturbance
index (RDI) ≥ 5; 4) Publications in the English language. The quality of the
studies were explicitly described and coded according to the Cochrane Methods
group on the screening and diagnostic tests.
RESULTS: Seventeen studies including 9,206 patients met criteria for the
systematic review. In the sleep clinic population, the sensitivity was 90%, 94%
and 96% to detect any OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥15), and
severe OSA (AHI ≥30) respectively. The corresponding NPV was 46%, 75% and 90%. A
similar trend was found in the surgical population. In the sleep clinic
population, the probability of severe OSA with a STOP-Bang score of 3 was 25%.
With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the
probability rose proportionally to 35%, 45%, 55% and 75%, respectively. In the
surgical population, the probability of severe OSA with a STOP-Bang score of 3
was 15%. With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the
probability increased to 25%, 35%, 45% and 65%, respectively.
CONCLUSION: This meta-analysis confirms the high performance of the STOP-Bang
questionnaire in the sleep clinic and surgical population for screening of OSA.
The higher the STOP-Bang score, the greater is the probability of
moderate-to-severe OSA. AIMS AND OBJECTIVES: This study aimed to compare the efficiency of the STOP-BANG
and Berlin Obstructive Sleep Apnoea Syndrome questionnaires for evaluating
potential respiratory complications during the perioperative period.
BACKGROUND: Questionnaires that are used to determine obstructive sleep apnoea
risk are not widely used for surgical patients. Among the questionnaires that
are commonly used for obstructive sleep apnoea screening, it remains unclear
whether the STOP-BANG or Berlin Obstructive Sleep Apnoea Syndrome questionnaire
is more effective in terms of ease of use, usage period and diagnosis of
surgical patients with obstructive sleep apnoea risk.
DESIGN: This study was designed as a descriptive and prospective study.
METHODS: The study included 126 patients over 18 years of age who were American
Society of Anesthesiologists classification class I-II and underwent
laparoscopic cholecystectomy. To determine the potential obstructive sleep
apnoea syndrome risk, the STOP-BANG and Berlin questionnaires were administered.
Respiratory complications were then observed during the perioperative period.
RESULTS: During intubation and extubation, we observed statistically significant
differences in difficult intubation, difficult facemask ventilation and
desaturation frequency between the high- and low-risk groups for obstructive
sleep apnoea syndrome, as determined by the STOP-BANG questionnaire. During
extubation, statistically significant differences in coughing, breath-holding
and desaturation frequency were observed between the high-risk and low-risk
groups, according to the Berlin questionnaire. In the post-anaesthesia care
unit, both questionnaires found statistically significant differences between
the low- and high-risk groups.
CONCLUSION: Obstructive sleep apnoea syndrome screening questionnaires
administered during the preoperative period are useful for predicting
perioperative respiratory complications. It may be most useful to administer the
STOP-BANG questionnaire as the initial evaluation.
RELEVANCE TO CLINICAL PRACTICE: Questionnaires may be used to determine the risk
of obstructive sleep apnoea syndrome, which could impact the anaesthetisation of
surgical patients. Questionnaires for determining the risk of obstructive sleep
apnoea syndrome should be used regularly for surgical patients, and these
questionnaires should be used to improve clinical protocols for anaesthesia and
postanaesthesia care. Background. The STOP-BANG questionnaire has been used to identify surgical
patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying
patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG
score ≥ 3. Few studies have examined whether postoperative complications are
increased in HR patients and none have been described in oncologic patients.
Objective. This retrospective study examined if HR patients experience increased
complications evidenced by an increased length of stay (LOS) in the
postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and
the frequency of oxygen desaturation (<93%) in cancer patients who were given
the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an
ambulatory surgery center. Results. The majority of patients in our study were
men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m(2) (88.4%).
STOP-BANG results were obtained on 404 patients. Cumulative incidence of the
time to discharge between HR and the LR groups was plotted. By 8 hours, LR
patients showed a higher cumulative probability of being discharged early (80%
versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA
based on the STOP-BANG questionnaire were less likely to be discharged early
from the PACU compared to LR patients. Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder; however, it
remains underdiagnosed and undertreated. Although screening tools such as the
Berlin questionnaire (BQ), STOP-BANG questionnaire (SBQ), STOP questionnaire
(STOP), and Epworth sleepiness scale (ESS) are widely used for OSA, the findings
regarding their diagnostic accuracy are controversial. Therefore, this
meta-analysis investigated and compared the summary sensitivity, specificity,
and diagnostic odds ratio (DOR) among the BQ, SBQ, STOP, and ESS according to
the severity of OSA. Electronic databases, namely the Embase, PubMed, PsycINFO,
ProQuest dissertations and theses A&I databases, and China knowledge resource
integrated database, were searched from their inception to July 15, 2016. We
included studies examining the sensitivity and specificity of the BQ, SBQ, STOP,
and ESS against the apnea-hypopnea index (AHI) or respiratory disturbance index
(RDI). The revised quality assessment of diagnostic accuracy studies was used to
evaluate the methodological quality of studies. A random-effects bivariate model
was used to estimate the summary sensitivity, specificity, and DOR of the tools.
We identified 108 studies including a total of 47 989 participants. The summary
estimates were calculated for the BQ, SBQ, STOP, and ESS in detecting mild
(AHI/RDI ≥ 5 events/h), moderate (AHI/RDI ≥ 15 events/h), and severe OSA
(AHI/RDI ≥ 30 events/h). The performance levels of the BQ, SBQ, STOP, and ESS in
detecting OSA of various severity levels are outlined as follows: for mild OSA,
the pooled sensitivity levels were 76%, 88%, 87%, and 54%; pooled specificity
levels were 59%, 42%, 42%, and 65%; and pooled DORs were 4.30, 5.13, 4.85, and
2.18, respectively. For moderate OSA, the pooled sensitivity levels were 77%,
90%, 89%, and 47%; pooled specificity levels were 44%, 36%, 32%, and 621%; and
pooled DORs were 2.68, 5.05, 3.71, and 1.45, respectively. For severe OSA, the
pooled sensitivity levels were 84%, 93%, 90%, and 58%; pooled specificity levels
were 38%, 35%, 28%, and 60%; and pooled DORs were 3.10, 6.51, 3.37, and 2.10,
respectively. Therefore, for mild, moderate, and severe OSA, the pooled
sensitivity and DOR of the SBQ were significantly higher than those of other
screening tools (P < .05); however, the specificity of the SBQ was lower than
that of the ESS (P < .05). Moreover, age, sex, body mass index, study sample
size, study populations, presence of comorbidities, PSG or portable monitoring
performance, and risk of bias in the domains of the index test and reference
standard were significant moderators of sensitivity and specificity (P < .05).
Compared with the BQ, STOP, and ESS, the SBQ is a more accurate tool for
detecting mild, moderate, and severe OSA. Sleep specialists should use the SBQ
to conduct patient interviews for the early diagnosis of OSA in clinical
settings, particularly in resource-poor countries and sleep clinics where PSG is
unavailable. OBJECTIVE: The STOP-Bang questionnaire was developed as a quick and simple
screening tool for obstructive sleep apnea (OSA) in preoperative clinics. We
aimed to evaluate the validity of the STOP-Bang questionnaire to predict
moderate-to-severe and severe OSA in the general population.
METHODS: A sample of 242 subjects selected from a population-based cohort in
Singapore completed home-based sleep testing with a type 3 monitor. Subjects
were asked to complete the STOP questionnaire while body mass index (BMI), age,
neck circumference, and sex were recorded. A score of ≥3 on the questionnaire
indicated high risk of OSA.
RESULTS: A total of 68 subjects (28.1%) and 26 subjects (10.7%) had an
apnea-hypopnea index (AHI) of ≥15 and ≥30 events per hour, respectively. Of the
subjects, 89 (36.8%) were classified as high risk based on the questionnaire.
The sensitivity of a STOP-Bang score of ≥3 was 66.2% to detect AHI ≥15 and 69.2%
to detect AHI ≥30. The specificities were 74.7% and 67.1%, respectively. The
negative predictive values were 85% for moderate-to-severe OSA and 94.8% for
severe OSA. The corresponding positive predictive values were 50.6% and 20.2%,
respectively. Using BMI cutoffs of 30 and 27.5 for Asians compared to the
original cutoff of 35 did not improve the questionnaire performance
significantly.
CONCLUSION: The STOP-Bang questionnaire can be used as a screening tool in the
general population in view of its moderate sensitivity and high negative
predictive value for subjects with moderate-to-severe and severe OSA. The cutoff
of BMI >35 can be used in Asians, as lower BMI cutoffs did not improve
questionnaire performance. STUDY OBJECTIVE: The aim of this study is to evaluate whether adding the item of
"apple body type" to the STOP-BANG questionnaire enhances diagnostic performance
of the questionnaire for detecting obstructive sleep apnea (OSA).
DESIGN: Cross-sectional study.
SETTING: Sleep center setting.
PATIENTS: Two hundred and eight subjects who were referred for an evaluation of
possible OSA at Tulane Comprehensive Sleep Center. The exclusion criteria were
age<18years old, incomplete or absent questionnaire, incomplete body type
identification, polysomnography (PSG) refusal, and pregt women.
INTERVENTIONS: STOP-BANG items and body type data were collected on the initial
clinic visit. An overnight PSG was performed on every participant.
MEASUREMENTS: Descriptive analyses of the demographic data and PSG variables
were performed. The predictive parameters of STOP and STOP-BANG without and with
body type score (STOP-Apple and STOPBANG-Apple) were compared.
MAIN RESULTS: The STOP questionnaire's sensitivity/specificity/positive
likelihood ratio (+LR) (cut-off=2) was 96%/11%/1.1, respectively whereas the
STOP-Apple questionnaire (cut-off=3) was 88%/39%/1.5. The STOP-BANG's
sensitivity/specificity/+LR (cut-off=3) was 96%/19%/1.2, respectively whereas
the STOP-BANG-Apple questionnaire (cut-off=4) was 90%/39%/1.5. The area under
the Receiver Operating Characteristic (ROC) curve of STOP-Apple was comparable
to the STOP-BANG (P=0.25). The addition of the apple body type item to the
STOP-BANG questionnaire in participants with a score≥3 led to increased
specificity (67.4%), increased the odds ratio of having OSA of 2.5 (95% CI,
1.2-5.3) and odds ratio of having moderate-severe OSA of 4.7 (95% CI, 2.5-8.7).
CONCLUSION: In the sleep center setting, adding the body type item to the
STOP-BANG questionnaire improves not only clinical prediction for PSG confirmed
OSA but also predicts moderate to severe of OSA. BACKGROUND: An accurate, clinical screening tool for obstructive sleep apnea
(OSA) that identifies patients for further diagnostic testing would assist in
the diagnosis of this comorbidity. One example, the STOP-BANG questionnaire
(SBQ), has been validated as a screening tool with high sensitivity. However,
its specificity may result in a high false-positive rate. The aim of this study
to determine if addition of the Modified Mallampati score to the SBQ improves
its specificity.
METHODS: The authors studied 162 patients referred to the Sleep Disorders Clinic
at Yedikule Chest Disease Education and Research Hospital. All patients were
prospectively screened for risk of OSA using the SBQ, their oral anatomy was
assessed by Modified Mallampati scoring, and sleep quality characterized by
polysomnography. Polysomnography results were reviewed when available and the
predictive performance of the SBQ and the modified SBQ scoring models were
compared.
RESULTS: In the authors' study an SBQ score ≥3 yielded sensitivities of 0.85,
0.86, and 0.91 for Apnea-Hypopnea Index (AHI) ≥5/h, AHI ≥15/h, and AHI ≥30/h,
respectively, and specificities of 0.09, 0.10, and 0.18. The modified SBQ with a
cutoff of ≥4 (>3) points for AHI levels of >5, >15, and >30 yielded respective
sensitivities of 0.84, 0.86, and 0.91 and specificities of 0.25, 0.26, and 0.27.
CONCLUSIONS: The author's results from indicated the modified SBQ with a cutoff
of >3 points in this study was more specific than the standard SBQ but no less
sensitive, and may be used in identifying OSA patients for further diagnostic
evaluation or avoiding unnecessary testing. PURPOSE: Several questionnaires are available for the screening of obstructive
sleep apnea (OSA). Herein, we compare the performance characteristics of nine
available questionnaires for assessing the likelihood of OSA.
METHODS: Consecutive subjects who underwent polysomnography at the sleep
laboratory of the unit were included. Subjects with obstructive events and apnea
hypopnea index (AHI) ≥5 were considered to have OSA. The likelihood ratios (LRs)
and other performance characteristics were calculated for the following nine
questionnaires: Berlin, modified Berlin, STOP, STOP-Bang and OSA50
questionnaires, sleep apnea clinical score (SACS), Epworth sleepiness scale
(ESS), American Society of Anesthesiologists (ASA) checklist, and the elbow sign
questionnaire.
RESULTS: Two-hundred and ten subjects (mean age, 46.5 years; mean body mass
index [BMI], 31.9 kg/m2; 27.1% women) were included. OSA was diagnosed in 78.1%
of patients; 49.5% had severe OSA (AHI ≥30). The SACS questionnaire had the
highest positive LR (LR+, 5.6) and positive predictive value (95.2%). The
modified Berlin questionnaire had the best negative LR (LR-, 0.2) and the
highest negative predictive value (57.1%). The STOP-Bang questionnaire also had
an LR- of 0.2 if BMI threshold of 25 kg/m2 (like that in the modified Berlin
questionnaire) was used. Among individual items of various sleep questionnaires,
the highest LR+ was obtained for neck circumference >43 cm (LR+, 4.9), while the
best LR- was obtained for snoring and BMI >25 kg/m2 (LR-, 0.2).
CONCLUSIONS: The SACS and the STOP-Bang questionnaires (BMI threshold of
25 kg/m2) were found to provide the best positive and negative LRs,
respectively, for the prediction of OSA. We believe that information from these
questionnaires may help in prioritizing patients for sleep studies in
high-volume centers. |
List indications for palivizumab for treatment of RSV-induced bronchiolitis. | According to guidelines palivizumab is available for treatment of RSV-induced bronchiolitis in high-risk infants: born before 29 weeks' gestation, infants with chronic lung disease of prematurity, and infants and children with hemodynamically significant heart disease. Palivizumab reduces the burden of bronchiolitis but does not prevent infection. | BACKGROUND: Respiratory syncytial virus (RSV) is a common pathogen that is the
leading cause of lower respiratory tract infections in young children. High-risk
children are at risk of severe infection, which may require hospitalisation. RSV
is also associated with a high risk for respiratory morbidity and mortality,
which may have long-term clinical and economic consequences.
OBJECTIVE: To assess the cost effectiveness of palivizumab, a humanised
monoclonal antibody, used as prevention against severe respiratory syncytial
virus (RSV) infection requiring hospitalisation, in the indication of preterm
infants and infants with preterm/bronchopulmonary dysplasia and in the second
indication of children with congenital heart disease in the Dutch healthcare
setting.
METHODS: A decision-tree model was used to estimate the cost effectiveness of
palivizumab, used as a preventative treatment against severe respiratory
syncytial virus (RSV) infection, in high-risk groups of children in the
Netherlands. The analysis was based on a lifetime follow-up period in order to
capture the impact of palivizumab on long-term morbidity and mortality resulting
from an RSV infection. Data sources included published literature, the
palivizumab pivotal trials, official price/tariff lists and national population
statistics. The study was conducted from the perspective of society in the
Netherlands.
RESULTS: The use of palivizumab results in undiscounted incremental
cost-effectiveness ratios of €12,728/QALY and €4,256/QALY in
preterm/bronchopulmonary dysplasia and congenital heart disease indications,
respectively. Inclusion of indirect costs leads to even more favourable
cost-effectiveness outcomes. The study is limited by a number of conservative
assumptions. It was assumed that palivizumab only affects the occurrence of RSV
hospitalisation and does not influence the severity of the RSV infection.
Another assumption was that international clinical trial data and data on
utilities could be applied to the Dutch healthcare setting.
CONCLUSION: Palivizumab provides cost-effective prophylaxis against RSV in
high-risk infants. The use of palivizumab in these children results in positive
short- and long-term health-economic benefits. Bronchiolitis is the leading cause of hospitalization of infants and young
children worldwide. Respiratory syncytial virus (RSV) is the most common cause
of bronchiolitis in infants. Studies conducted using molecular diagnostic assays
confirmed that RSV accounts for over 50% of bronchiolitis in young children
requiring hospitalization. Those studies demonstrate that it is common to
identify RSV in association with a second viral agent but it is yet unclear
whether the simultaneous detection of two or even three viruses is associated
with increased disease severity. Despite extensive efforts, a vaccine for
prevention of RSV infection is not yet available. Palivizumab a humanized
monoclonal antibody directed against the F protein of RSV is the only agent
licensed to prevent severe RSV disease in high-risk children. Among the new
antivirals being developed for treatment of RSV infections, an RNA-interference
based agent has demonstrated promising results for treatment of lung transplant
recipients with acute RSV infection. In 2014, the American Academy of Pediatrics (AAP) updated their recommendations
for palivizumab prophylaxis for children who are at high risk for severe
respiratory syncytial virus (RSV) infection. To investigate the potential impact
of the more restrictive 2014 criteria on the eligibility for palivizumab
prophylaxis, we applied the 2012 and 2014 AAP recommendations for palivizumab
prophylaxis to a multicenter cohort of 2207 US children hospitalized for
bronchiolitis. According to the 2012 AAP recommendations, 215 children (9.7%)
were eligible for palivizumab prophylaxis, while 140 children (6.3%) would have
been eligible based on the 2014 updated recommendations (34.9% relative
decrease; 95%CI: 28.5-41.7%). The decrease was largely driven by the restriction
of eligibility to preterm infants with gestational age <29 weeks. Further
development of and refinement of cost-effective approaches for the prevention of
severe RSV infection are needed. BACKGROUND: RSV causes considerable morbidity and mortality in children. In
cystic fibrosis (CF) viral infections are associated with worsening respiratory
symptoms and bacterial colonization. Palivizumab is effective in reducing RSV
hospitalization in high risk patient groups. Evidence regarding its
effectiveness and safety in CF is inconclusive. CF screening in N. Ireland
enabled timely palivizumab prophylaxis, becoming routine in 2002.
OBJECTIVES: To determine the effect of palivizumab on RSV-related
hospitalization and compare lung function and bacterial colonization at age 6
years for those born pre- and post-introduction of palivizumab prophylaxis.
METHODS: A retrospective audit was conducted for all patients diagnosed with CF
during the period from 1997 to 2007 inclusive. RSV-related hospitalization, time
to Pseudomonas aeruginosa (PA) 1st isolate, lung function and growth parameters
were recorded. Comparisons were made for outcomes pre- and post-introduction of
routine palivizumab administration in 2002. A cost evaluation was also
performed.
RESULTS: Ninety-two children were included; 47 pre- and 45 post-palivizumab
introduction. The overall RSV-positive hospitalization rate was 13%. The
relative risk of RSV infection in palivizumab non-recipients versus recipients
was 4.78 (95%CI: 1.1-20.7), P = 0.027. Notably, PA 1st isolate was significantly
earlier in the palivizumab recipient cohort versus non-recipient cohort (median
57 vs. 96 months, P < 0.025) with a relative risk of 2.5. Chronic PA infection
at 6 years remained low in both groups, with similar lung function and growth
parameters. Total costs were calculated at £96,127 ($151,880) for the
non-recipient cohort versus £137,954 ($217,967) for the recipient cohort.
CONCLUSION: Palivizumab was effective in reducing RSV-related hospitalization
infection in CF patients. Surprisingly, we found a significantly earlier time to
1st isolate of PA in palivizumab recipients which we could not explain by
altered or improved diagnostic tests. Respiratory syncytial virus (RSV) infection is ubiquitous with almost all
infants having been infected by 2 years of age and lifelong repeated infections
common. It is the second largest cause of mortality, after malaria, in infants
outside the neonatal period and causes up to 200,000 deaths per year worldwide.
RSV results in clinical syndromes that include upper respiratory tract
infections, otitis media, bronchiolitis (up to 80% of cases) and lower
respiratory tract disease including pneumonia and exacerbations of asthma or
viral-induced wheeze. For the purposes of this review we will focus on RSV
bronchiolitis in infants in whom the greatest disease burden lies. For infants
requiring hospital admission, the identification of the causative respiratory
virus is used to direct cohorting or isolation and infection control procedures
to minimize nosocomial transmission. Nosocomial RSV infections are associated
with poorer clinical outcomes, including increased mortality, the need for
mechanical ventilation and longer length of hospital stay. Numerous clinical
guidelines for the management of infants with bronchiolitis have been published,
although none are specific for RSV bronchiolitis. Ribavirin is the only licensed
drug for the specific treatment of RSV infection but due to drug toxicity and
minimal clinical benefit it has not been recommended for routine clinical use.
There is currently no licensed vaccine to prevent RSV infection but passive
immunoprophylaxis using a monoclonal antibody, palivizumab, reduces the risk of
hospitalization due to RSV infection by 39-78% in various high-risk infants
predisposed to developing severe RSV disease. The current management of RSV
bronchiolitis is purely supportive, with feeding support and oxygen
supplementation until the infant immune system mounts a response capable of
controlling the disease. The development of a successful treatment or
prophylactic agent has the potential to revolutionize the care and outcome for
severe RSV infections in the world's most vulnerable infants. BACKGROUND: Respiratory syncytial virus (RSV) is a common reason for
hospitalization of infants. In clinical trials, palivizumab reduced RSV
hospitalization rates for premature infants. The 2014 American Academy of
Pediatrics clinical practice guideline advised against use of palivizumab for
otherwise healthy infants ≥29 weeks' gestation. The aim of this study was to
determine the effect of palivizumab administration on hospitalization rates for
RSV and bronchiolitis without RSV diagnosis among infants 29 to 36 weeks'
gestation who do not have chronic illness.
METHODS: Claims data were extracted from databases of 9 Texas Medicaid managed
care programs. Eligible infants were 29 to 36 weeks' gestation, without claims
suggesting chronic illness, and who were born between April 1 and December 31 of
2012, 2013, and 2014.
RESULTS: A total of 2031 eligible infants of 29 to 32 weeks' gestation and
12 066 infants of 33 to 36 weeks' gestation were identified; 41.5% of the
infants 29 to 32 weeks' gestation and 3.7% of the infants 33 to 36 weeks'
gestation had paid claims for dispensing of ≥1 palivizumab doses. Among the
infants of 29 to 32 weeks' gestation, palivizumab dispensing was associated with
reduced RSV hospitalization rates (3.1% vs 5.0%, P = .04) but increased
hospitalizations for bronchiolitis without RSV diagnosis (3.3% vs 1.9%, P =
.05). There were no significant differences by palivizumab administration status
for the infants of 33 to 36 weeks' gestation.
CONCLUSIONS: Among infants 29 to 32 weeks' gestation without chronic illness,
palivizumab use was associated with reduced RSV hospitalizations but increased
hospitalizations for bronchiolitis without RSV diagnosis. Respiratory syncytial virus (RSV) is the leading cause of acute respiratory
infections in children, yet no vaccine is available. The sole licensed
preventive treatment against RSV is composed of a monoclonal neutralizing
antibody (palivizumab), which targets a conformational epitope located on the
fusion protein (F). Palivizumab reduces the burden of bronchiolitis but does not
prevent infection. Thus, the development of RSV vaccines remains a priority. We
previously evaluated orings formed by RSV nucleoprotein (N) as an RSV
vaccine, as well as an immunostimulatory carrier for heterologous antigens.
Here, we linked the palivizumab-targeted epitope (called FsII) to N, to generate
N-FsII-orings. Intranasal N-FsII immunization elicited anti-F antibodies in
mice that were non-neutralizing in vitro. Nevertheless, RSV-challenged animals
were better protected against virus replication than mice immunized with
N-orings, especially in the upper airways. In conclusion, an N-FsII-focused
vaccine is an attractive candidate combining N-specific cellular immunity and
F-specific antibodies for protection. Bronchiolitis is a common lower respiratory tract infection in infants and young
children, and respiratory syncytial virus (RSV) is the most common cause of this
infection. RSV is transmitted through contact with respiratory droplets either
directly from an infected person or self-inoculation by contaminated secretions
on surfaces. Patients with RSV bronchiolitis usually present with two to four
days of upper respiratory tract symptoms such as fever, rhinorrhea, and
congestion, followed by lower respiratory tract symptoms such as increasing
cough, wheezing, and increased respiratory effort. In 2014, the American Academy
of Pediatrics updated its clinical practice guideline for diagnosis and
management of RSV bronchiolitis to minimize unnecessary diagnostic testing and
interventions. Bronchiolitis remains a clinical diagnosis, and diagnostic
testing is not routinely recommended. Treatment of RSV infection is mainly
supportive, and modalities such as bronchodilators, epinephrine,
corticosteroids, hypertonic saline, and antibiotics are generally not useful.
Evidence supports using supplemental oxygen to maintain adequate oxygen
saturation; however, continuous pulse oximetry is no longer required. The other
mainstay of therapy is intravenous or nasogastric administration of fluids for
infants who cannot maintain their hydration status with oral fluid intake.
Educating parents on reducing the risk of infection is one of the most important
things a physician can do to help prevent RSV infection, especially early in
life. Children at risk of severe lower respiratory tract infection should
receive immunoprophylaxis with palivizumab, a humanized monoclonal antibody, in
up to five monthly doses. Prophylaxis guidelines are restricted to infants born
before 29 weeks' gestation, infants with chronic lung disease of prematurity,
and infants and children with hemodynamically significant heart disease. |
List factors that promote lymphangiogenesis. | VEGF-C
VEGF-D
VEGF-R3 | BACKGROUND: The anti-cancer mechanism of neo-adjuvant hormonal therapy (NHT) is
not well understood. Lymphangiogenesis plays an important role in cancer
progression and is regulated by a complex mechanism that includes vascular
endothelial growth factor (VEGF) signaling. However, there is little information
regarding relationship between lymphangiogenesis and androgen deprivation. The
aim of this study was to clarify changes in lymphangiogenesis and VEGF
expression induced by androgen deprivation in prostate cancer in vivo and in
vitro.
METHODS: Patients who had undergone a radical prostatectomy were enrolled in the
study (NHT, n = 60 and non-NHT, n = 64). Lymph vessels were identified by D2-40
immunoreactivity and lymph vessel density and lymph vessel area (LVD and LVA,
respectively) were measured from micrographs. The expression of VEGF-A, -B, -C,
and -D was evaluated by immunohistochemistry. The prognostic value of LVD and
LVA for biochemical recurrence was also investigated.
RESULTS: Mean LVD ± SD was higher in the NHT than in the non-NHT group
(11.3 ± 3.0 vs. 7.1 ± 3.4 per high power field; P < 0.001). LVA was larger in
the NHT than in the non-NHT group (512.8 ± 174.9 vs. 202.7 ± 72.8 µm2 ;
P < 0.001). VEGF-A expression was lower whereas VEGF-C and -D levels were higher
in the NHT than in the non-NHT group. VEGF-B expression in specimens with NHT
was lower than that in biopsy specimens at diagnosis. These results were
confirmed by in vitro studies used androgen-sensitive prostate cancer cell line.
LVA was found to be an independent predictor of biochemical recurrence in
patients who received NHT.
CONCLUSIONS: Our results demonstrate that NHT stimulates lymphangiogenesis via
upregulation of VEGF-C and -D, which may increase LVA and affect the outcome of
prostate cancer patients. This findings were supported by in vitro data of
prostate cancer cell. Prostate 77:255-262, 2017. © 2016 The Authors. The
Prostate Published by Wiley Periodicals, Inc. Although bronchial angiogenesis has been well documented in allergic asthma,
lymphangiogenesis has not been widely studied. Therefore, we evaluated changes
in lung lymphatics in a rat model of allergen-induced asthma using house dust
mite (Der p 1; 100 μg/challenge). Additionally, properties of isolated lung
lymphatic endothelial cells (CD45-, CD141+, LYVE-1+, Prox-1+) were studied in
vitro. Three weeks after the onset of intranasal allergen exposure
(twice-weekly), an increase in the number of lung lymphatic vessels was measured
(34% increase) by lung morphometry. New lymphatic structures were seen
predomitly in the peribronchial and periarterial interstitial space but also
surrounding large airways. Isolated lymphatic endothelial cells from sensitized
lungs showed enhanced proliferation (% Ki67+), chemotaxis, and tube formation
(number and length) compared to lymphatic endothelial cells isolated from naive
rat lungs. This hyper-proliferative lymphangiogenic phenotype was preserved
through multiple cell passages (2-8). Lymphatic endothelial cells isolated from
naive and HDM-sensitized rats produced similar in vitro levels of VEGF-C,
VEGF-D, and VEGFR3 protein, each recognized as critical lymphangiogenic factors.
Inhibition with anti-VEGFR (axitinib, 0.1 μM) blocked proliferation and
chemotaxis. Results suggest that in vivo sensitization causes fundamental
changes to lymphatic endothelium, which are retained in vitro, and may relate to
VEGFR downstream signaling. Vascular endothelial growth factors (VEGFs) control angiogenesis and
lymphangiogenesis during development and in pathological conditions. In the
zebrafish trunk, Vegfa controls the formation of intersegmental arteries by
primary angiogenesis and Vegfc is essential for secondary angiogenesis, giving
rise to veins and lymphatics. Vegfd has been largely thought of as dispensable
for vascular development in vertebrates. Here, we generated a zebrafish vegfd
mutant by genome editing. vegfd mutants display significant defects in facial
lymphangiogenesis independent of vegfc function. Strikingly, we find that vegfc
and vegfd cooperatively control lymphangiogenesis throughout the embryo,
including during the formation of the trunk lymphatic vasculature.
Interestingly, we find that vegfd and vegfc also redundantly drive artery
hyperbranching phenotypes observed upon depletion of Flt1 or Dll4. Epistasis and
biochemical binding assays suggest that, during primary angiogenesis, Vegfd
influences these phenotypes through Kdr (Vegfr2) rather than Flt4 (Vegfr3).
These data demonstrate that, rather than being dispensable during development,
Vegfd plays context-specific indispensable and also compensatory roles during
both blood vessel angiogenesis and lymphangiogenesis. Lymphatic vessels are vital for the trafficking of immune cells from the
interstitium to draining lymph nodes during inflammation. Hypertension is
associated with renal infiltration of activated immune cells and inflammation;
however, it is unknown how renal lymphatic vessels change in hypertension. We
hypothesized that renal macrophage infiltration and inflammation would cause
increased lymphatic vessel density in hypertensive rats. Spontaneously
hypertensive rats (SHR) that exhibit hypertension and renal injury (SHR-A3
strain) had significantly increased renal lymphatic vessel density and
macrophages at 40 wk of age compared with Wistar-Kyoto (WKY) controls. SHR rats
that exhibit hypertension but minimal renal injury (SHR-B2 strain) had
significantly less renal lymphatic vessel density compared with WKY rats. The
signals for lymphangiogenesis, VEGF-C and its receptor VEGF-R3, and
proinflammatory cytokine genes increased significantly in the kidneys of SHR-A3
rats but not in SHR-B2 rats. Fischer 344 rats exhibit normal blood pressure but
develop renal injury as they age. Kidneys from 24-mo- and/or 20-mo-old Fischer
rats had significantly increased lymphatic vessel density, macrophage
infiltration, VEGF-C and VEGF-R3 expression, and proinflammatory cytokine gene
expression compared with 4-mo-old controls. These data together demonstrate that
renal immune cell infiltration and inflammation cause lymphangiogenesis in
hypertension- and aging-associated renal injury. Lymphatic dysfunction is associated with the progression of many cardiovascular
disorders due to their role in maintaining tissue fluid homeostasis. Promoting
new lymphatic vessels (lymphangiogenesis) is a promising strategy to reverse
these cardiovascular disorders via restoring lymphatic function. Vascular
endothelial growth factor (VEGF) members VEGF-C and VEGF-D are both potent
candidates for stimulating lymphangiogenesis, though maintaining spatial and
temporal control of these factors represents a challenge to developing efficient
therapeutic lymphangiogenic applications. Injectable alginate hydrogels have
been useful for the controlled delivery of many angiogenic factors, including
VEGF-A, to stimulate new blood vasculature. However, the utility of these
tunable hydrogels for delivering lymphangiogenic factors has never been closely
examined. Thus, the objective of this study was to utilize ionically
cross-linked alginate hydrogels to deliver VEGF-C and VEGF-D for potential
lymphangiogenic applications. We demonstrated that lymphatic endothelial cells
(LECs) are sensitive to temporal presentation of VEGF-C and VEGF-D but with
different responses between the factors. The greatest LEC mitogenic and
sprouting response was observed for constant concentrations of VEGF-C and a high
initial concentration that gradually decreased over time for VEGF-D.
Additionally, alginate hydrogels provided sustained release of radiolabeled
VEGF-C and VEGF-D. Finally, VEGF-C and VEGF-D released from these hydrogels
promoted a similar number of LEC sprouts as exogenously added growth factors and
new vasculature in vivo via a chick chorioallantoic membrane (CAM) assay.
Overall, these findings demonstrate that alginate hydrogels can provide
sustained and bioactive release of VEGF-C and VEGF-D which could have
applications for therapeutic lymphangiogenesis. |
Which siRNA based drug is in clinical trials for the treatment of pancreatic cancer? | siG12D-LODERTM has been tested in a phase 1/2a clinical trial of patients with pancreatic cancer. | PURPOSE: The miniature biodegradable implant siG12D-LODER™ was inserted into a
tumor and released a siRNA drug against KRAS(G12D) along four months. This novel
siRNA based drug was studied, in combination with chemotherapy, as targeted
therapy for Locally Advanced Pancreatic Cancer (LAPC).
METHODS: An open-label Phase 1/2a study in the first-line setting of patients
with non-operable LAPC was initiated. In this study patients were assigned to
receive a single dose of siG12D-LODERs, in three escalating dose cohorts
(0.025mg, 0.75mg and 3.0mg). Gemcitabine was given on a weekly basis, following
the siG12D-LODERTM insertion, until disease progression. The recommended dose
was further examined with modified FOLFIRINOX. The follow up period was eight
weeks and survival until death.
RESULTS: Fifteen patients with LAPC were enrolled. Among the 15 treated
patients, the most frequent adverse events observed were grade 1or 2 in severity
(89%); five patients experienced serious adverse events (SAEs). In 12 patients
analyzed by CT scans, none showed tumor progression, the majority (10/12)
demonstrated stable disease and two showed partial response. Decrease in tumor
marker CA19-9 was observed in 70% (7/10) of patients. Median overall survival
was 15.12 months; 18 month survival was 38.5%.
CONCLUSIONS: The combination of siG12D-LODER™ and chemotherapy is well
tolerated, safe and demonstrated a potential efficacy in patients with LAPC.
NCT01188785. Conventional chemotherapy treatments for pancreatic cancer are mainly
palliative. RNA interference (RNAi)-based drugs present the potential for a new
targeted treatment. LOcal Drug EluteR (LODER(TM)) is a novel biodegradable
polymeric matrix that shields drugs against enzymatic degradation and releases
small interfering RNA (siRNA) against G12D-mutated KRAS (siG12D). siG12D-LODER
has successfully passed a phase 1/2a clinical trial. Such a formulation
necessitates biocompatibility and safety studies. We describe the safety and
toxicity studies with siG12D-LODER in 192 Hsd:Sprague Dawley rats, after
repeated subcutaneous administrations (days 1, 14, and 28). Animals were
sacrificed on days 29 and 42 (recovery phase). In all groups, no adverse effects
were noted, and all animals showed favorable local and systemic tolerability.
Histopathologically, LODER implantation resulted in the expected capsule
formation, composed of a thin fibrotic tissue. On the interface between the
cavity and the capsule, a single layer composed of macrophages and
multinucleated giant cells was observed. No difference was noted between the
placebo and siG12D-LODER groups. These findings provide valuable information for
future preclinical studies with siRNA-bearing biodegradable polymers and for the
safety aspects of RNAi-based drugs as a targeted therapy. |
How is CTCF activated post-translationally? | The chromatin insulator protein CTCF carries a post-translational modification: poly(ADP-ribosyl)ation. | Chromatin insulators demarcate expression domains by blocking the cis effects of
enhancers or silencers in a position-dependent manner. We show that the
chromatin insulator protein CTCF carries a post-translational modification:
poly(ADP-ribosyl)ation. Chromatin immunoprecipitation analysis showed that a
poly(ADP-ribosyl)ation mark, which exclusively segregates with the maternal
allele of the insulator domain in the H19 imprinting control region, requires
the bases that are essential for interaction with CTCF. Chromatin
immunoprecipitation-on-chip analysis documented that the link between CTCF and
poly(ADP-ribosyl)ation extended to more than 140 mouse CTCF target sites. An
insulator trap assay showed that the insulator function of most of these CTCF
target sites is sensitive to 3-aminobenzamide, an inhibitor of poly(ADP-ribose)
polymerase activity. We suggest that poly(ADP-ribosyl)ation imparts chromatin
insulator properties to CTCF at both imprinted and nonimprinted loci, which has
implications for the regulation of expression domains and their demise in
pathological lesions. Our previous data have shown that in L929 mouse fibroblasts the control of
methylation pattern depends in part on poly(ADP-ribosyl)ation and that
ADP-ribose polymers (PARs), both present on poly(ADP-ribosyl)ated PARP-1 and/or
protein-free, have an inhibitory effect on Dnmt1 activity. Here we show that
transient ectopic overexpression of CCCTC-binding factor (CTCF) induces PAR
accumulation, PARP-1, and CTCF poly(ADP-ribosyl)ation in the same mouse
fibroblasts. The persistence in time of a high PAR level affects the DNA
methylation machinery; the DNA methyltransferase activity is inhibited with
consequences for the methylation state of genome, which becomes diffusely
hypomethylated affecting centromeric minor satellite and B1 DNA repeats. In
vitro data show that CTCF is able to activate PARP-1 automodification even in
the absence of nicked DNA. Our new finding that CTCF is able per se to activate
PARP-1 automodification in vitro is of great interest as so far a burst of
poly(ADP-ribosyl)ated PARP-1 has generally been found following introduction of
DNA strand breaks. CTCF is unable to inhibit DNMT1 activity, whereas
poly(ADP-ribosyl)ated PARP-1 plays this inhibitory role. These data suggest that
CTCF is involved in the cross-talk between poly(ADP-ribosyl)ation and DNA
methylation and underscore the importance of a rapid reversal of PARP activity,
as DNA methylation pattern is responsible for an important epigenetic code. CCCTC-binding factor (CTCF) is a ubiquitous Zn-finger-containing protein with
numerous recognized functions, including, but not limited to, gene activation
and repression, enhancer-blocking, X-chromosome inactivation, and gene
imprinting. It is believed that the protein performs such a variety of functions
by interacting with an array of very diverse proteins. In addition, CTCF
undergoes several post-translational modifications, including
poly(ADP-ribosyl)ation. The PARylated form of CTCF has recently been implicated
in two important functions: gene imprinting and control of ribosomal gene
transcription. Here, we summarize and critically discuss the available data on
the interplay between CTCF and poly(ADP-ribosyl)ation in these two processes. We
consider the newly described phenomena in the broader context of PARP's
activities, including the crucial role of protein PARylation in the regulation
of the genome methylation pattern. The interaction of DNA with proteins in the context of chromatin has to be
tightly regulated to achieve so different tasks as packaging, transcription,
replication and repair. The very rapid and transient post-translational
modification of proteins by poly(ADP-ribose) has been shown to take part in all
four. Originally identified as immediate cellular answer to a variety of
genotoxic stresses, already early data indicated the ability of this highly
charged nucleic acid-like polymer to modulate nucleosome structure, the basic
unit of chromatin. At the same time the enzyme responsible for synthesizing
poly(ADP-ribose), the zinc-finger protein poly(ADP-ribose) polymerase-1 (PARP1),
was shown to control transcription initiation as basic factor TFIIC within the
RNA-polymerase II machinery. Later research focused more on PARP-mediated
regulation of DNA repair and cell death, but in the last few years,
transcription as well as chromatin modulation has re-appeared on the scene. This
review will discuss the impact of PARP1 on transcription and transcription
factors, its implication in chromatin remodeling for DNA repair and probably
also replication, and its role in controlling epigenetic events such as DNA
methylation and the functionality of the insulator protein CCCTC-binding factor. |
What is the HPG pore? | The use of nanopore technologies is expected to spread in the future because they are portable and can sequence long fragments of DNA molecules without prior amplification. The first nanopore sequencer available, the MinION™ from Oxford Nanopore Technologies, is a USB-connected, portable device that allows real-time DNA analysis. In addition, other new instruments are expected to be released soon, which promise to outperform the current short-read technologies in terms of throughput. Despite the flood of data expected from this technology, the data analysis solutions currently available are only designed to manage small projects and are not scalable. HPG pore is a toolkit for exploring and analysing nanopore sequencing data. HPG Pore can run on both individual computers and in the Hadoop distributed computing framework, which allows easy scale-up to manage the large amounts of data expected to result from extensive use of nanopore technologies in the future. | BACKGROUND: The use of opore technologies is expected to spread in the future
because they are portable and can sequence long fragments of DNA molecules
without prior amplification. The first opore sequencer available, the MinION™
from Oxford Nanopore Technologies, is a USB-connected, portable device that
allows real-time DNA analysis. In addition, other new instruments are expected
to be released soon, which promise to outperform the current short-read
technologies in terms of throughput. Despite the flood of data expected from
this technology, the data analysis solutions currently available are only
designed to manage small projects and are not scalable.
RESULTS: Here we present HPG Pore, a toolkit for exploring and analysing
opore sequencing data. HPG Pore can run on both individual computers and in
the Hadoop distributed computing framework, which allows easy scale-up to manage
the large amounts of data expected to result from extensive use of opore
technologies in the future.
CONCLUSIONS: HPG Pore allows for virtually unlimited sequencing data
scalability, thus guaranteeing its continued management in near future
scenarios. HPG Pore is available in GitHub at http://github.com/opencb/hpg-pore. |
SGOT is an abbreviation for an enzyme other wise known as alanine amino transferase, yes or no? | patients with aspartate amino transferase (SGOT), alanine amino transferase (SGPT), | The usefulness of blood enzyme determinations as markers of liver necrosis was
tested in 100 alcoholics who underwent biopsy during clinical investigation.
Mean values of glutamate dehydrogenase (GDH), serum aspartate and alanine
transferase (SGOT and SGPT), ornithine carbamoyltransferase (OCT), and
gamma-glutamyltranspeptidase (gamma-GTP) tended to rise with increasing liver
cell necrosis, though values of SGOT, SGPT, OCT, and gamma-GTP showed
considerable overlap between the 32 patients with histologically proved
hepatitis and the 68 without. By contrast, GDH values showed virtually no
overlap between patients with and without hepatitis, and a value of two and a
half times the normal value discriminated between the two groups. Because of its
easy determination and its reliable reflection of liver cell necrosis the GDH
concentration should be estimated routinely in alcoholic patients. Palamneus gravimanus envenomated rats showed dose-dependent alterations in serum
biochemical parameters. Sub lethal doses of 100, 200, and 400 microg/kg of P.
gravimanus venom were injected intramuscularly into rats. Blood samples were
collected by heart puncture before and 4 h after crude venom administration.
Serum was analyzed for glucose, blood urea nitrogen (BUN), uric acid, total
protein, cholesterol, sodium, potassium, inorganic phosphorus, alkaline
phosphatase, aspartate aminotransferase (AST-SGOT), alanine amino-transferase
(ALT-SGPT), lactate dehydrogenase (LDH), and creatinine phosphokinase (CPK).
Statistically significant increases in serum levels of glucose, creatinine, AST,
ALT, BUN, CPK, and LDH and significant decreases in serum levels of total
protein, uric acid, cholesterol, calcium, and potassium 4 h after venom
administration could be due to the toxic action of P. gravimanus venom on
certain organs in rats. BACKGROUND: Generation of novel spontaneous ER positive mammary tumor animal
model from heterozygous NIH nude mice.
METHODS: Using brother-sister mating with pedigree expansion system, we derived
a colony of heterozygous breeding females showing ER-Positive tumors around the
age of 6 months. Complete blood picture, differential leukocyte count, and serum
levels of Estrogen, Alanine amino transferase (SGPT), Aspartate amino
transferase (SGOT), total protein and albumin were estimated. Aspiration
biopsies and microbiology were carried out. Gross pathology of the tumors and
their metastatic potential were assessed. The tumors were excised and further
characterized using histopathology, cytology, electron microscopy (EM),
molecular markers and Mouse mammary Tumor Virus - Long Terminal Repeats (MMTV
LTR) specific RT-PCR.
RESULTS: The tumors originated from 2nd or 5th or both the mammary glands and
were multi-nodulated with variable central necrosis accompanied with an
accumulation of inflammatory exudate. Significant increases in estrogen, SGPT,
SGOT and neutrophils levels were noticed. Histopathologically, invasive nodular
masses of pleomorphic tubular neoplastic epithelial cells invaded fibro-vascular
stroma, adjacent dermis and subcutaneous tissue. Metastatic spread through
hematogenous and regional lymph nodes, into liver, lungs, spleen, heart and
dermal lymphatics was observed. EM picture revealed no viral particles and
MMTV-negativity was confirmed through MMTV LTR-specific RT-PCR. High expression
of ER alpha, moderate to high expression of proliferating cell nuclear antigen
(PCNA), moderate expression of vimentin and Cytokeratin 19 (K19) and low
expression of p53 were observed in tumor sections, when compared with that of
the normal mammary gland.
CONCLUSION: Since 75% of human breast cancer were classified ER-positive and as
our model mimics (in most of the characteristics, such as histopathology,
metastasis, high estrogen levels) the ER-positive luminal epithelial-like human
breast cancer, this model will be an attractive tool to understand the biology
of estrogen-dependant breast cancer in women. To our knowledge, this is the
first report of a spontaneous mammary model displaying regional lymph node
involvement with both hematogenous and lymphatic spread to liver, lung, heart,
spleen and lymph nodes. OBJECTIVE: Comparison of gamma glutamyltransferase in normal and type 2
diabetics.
METHODS: In a cross-sectional study, 100 apparently normal healthy subjects and,
47 type 2 diabetic subjects were selected from either sex with ages between
18-65 years. Subjects were measured for waist/hip ratio, BMI and serum levels of
ALT, AST, Alk phosphatase and glutamyl transferase (GGT). The study excluded by
screening for AntiHCV, HBsAg and patients with aspartate amino transferase
(SGOT), alanine amino transferase (SGPT), GGT levels more than three times the
normal and subject with a total leukocyte count more than 10,000/microl.
RESULTS: The levels of GGT levels were found to be most significant among all
the liver enzymes (P = 0.001). The levels of GGT compared with type 2 diabetics
was found to be significantly increased when compared with BMI,
waist/circumference, cholesterol, triglycerides (TG), high density lipoprotein
(HDL), low density lipoprotein (LDL), fasting blood sugar level and blood
pressure (P = 0.001). The pearson regression analysis showed a positive relation
with systolic, diastolic blood pressure and fasting blood sugar.
CONCLUSION: These results indicate that levels of GGT were raised with increased
waist girth, BMI, blood pressure TG and low HDL, all of these are the features
of metabolic syndrome according to ATP III criteria. Hence, serum GGT may be an
important investigation for diabetes and metabolic syndrome. |
Is patisiran currently (November 2017) in clinical phase II trials? | No, patisiran is in phase 3 clinical studies. | Ten years after Fire and Melo's Nobel Prize for discovery of gene silencing by
double-stranded RNA, a remarkable progress was achieved in RNA interference
(RNAi). Changes in the chemical structure of synthetic oligonucleotides make
them more stable and specific, and new delivery strategies became progressively
available. The attention of pharmaceutical industry rapidly turned to RNAi, as
an opportunity to explore new drug targets. This review addresses nine
small-interfering RNAs (siRNAs) and one unique microRNA (miRNA) inhibitor, which
entered the phase 2-3 clinical trials. The siRNAs in focus are PF-04523655,
TKM-080301, Atu027, SYL040012, SYL1001, siG12D-LODER (phase 2), QPI-1002,
QPI-1007, and patisiran (phase 3). Regarding miRNAs, their content can be down-
or up-regulated, by using miRNA inhibitors (AntimiRs) or miRNA mimics.
Miravirsen is an AntimiR-122 for hepatitis C virus infection. The flexibility of
RNAi technology is easily understood taking into account: (i) the different drug
targets (i.e. p53, caspase 2, PKN3, β2-adrenergic receptor, mutated KRAS,
microRNAs); (ii) therapeutic conditions, including ophthalmic diseases, kidney
injury, amyloidosis, pancreatic cancer, viral hepatitis; and (iii) routes of
administration (ocular, intravenous, subcutaneous, intratumoral). Although some
issues are still matters of concern (delivery, toxicity, cost, and biological
barriers), RNAi definitively opens a wide avenue for drug development. BACKGROUND: Patisiran is an investigational RNA interference (RNAi) therapeutic
in development for the treatment of hereditary ATTR (hATTR) amyloidosis, a
progressive disease associated with significant disability, morbidity, and
mortality.
METHODS: Here we describe the rationale and design of the Phase 3 APOLLO study,
a randomized, double-blind, placebo-controlled, global study to evaluate the
efficacy and safety of patisiran in patients with hATTR amyloidosis with
polyneuropathy. Eligible patients are 18-85 years old with hATTR amyloidosis,
investigator-estimated survival of ≥2 years, Neuropathy Impairment Score (NIS)
of 5-130, and polyneuropathy disability score ≤IIIb. Patients are randomized 2:1
to receive either intravenous patisiran 0.3 mg/kg or placebo once every 3 weeks.
The primary objective is to determine the efficacy of patisiran at 18 months
based on the difference in the change in modified NIS+7 (a composite measure of
motor strength, sensation, reflexes, nerve conduction, and autonomic function)
between the patisiran and placebo groups. Secondary objectives are to evaluate
the effect of patisiran on Norfolk-Diabetic Neuropathy quality of life
questionnaire score, nutritional status (as evaluated by modified body mass
index), motor function (as measured by NIS-weakness and timed 10-m walk test),
and autonomic symptoms (as measured by the Composite Autonomic Symptom Score-31
questionnaire). Exploratory objectives include assessment of cardiac function
and pathologic evaluation to assess nerve fiber innervation and amyloid burden.
Safety of patisiran will be assessed throughout the study.
DISCUSSION: APOLLO represents the largest randomized, Phase 3 study to date in
patients with hATTR amyloidosis, with endpoints that capture the multisystemic
nature of this disease.
TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov ( NCT01960348
); October 9, 2013. |
Which R/Bioconductor package has been developed for cancer subtype identification? | Identifying molecular cancer subtypes from multi-omics data is an important step in the personalized medicine. CancerSubtypes is an R/Bioconductor package for molecular cancer subtype identification, validation and visualization. CancerSubtypes integrates four main computational methods which are highly cited for cancer subtype identification and provides a standardized framework for data pre-processing, feature selection, and result follow-up analyses, including results computing, biology validation and visualization. The input and output of each step in the framework are packaged in the same data format, making it convenience to compare different methods. | SUMMARY: Identifying molecular cancer subtypes from multi-omics data is an
important step in the personalized medicine. We introduce CancerSubtypes, an R
package for identifying cancer subtypes using multi-omics data, including gene
expression, miRNA expression and DNA methylation data. CancerSubtypes integrates
four main computational methods which are highly cited for cancer subtype
identification and provides a standardized framework for data pre-processing,
feature selection, and result follow-up analyses, including results computing,
biology validation and visualization. The input and output of each step in the
framework are packaged in the same data format, making it convenience to compare
different methods. The package is useful for inferring cancer subtypes from an
input genomic dataset, comparing the predictions from different well-known
methods and testing new subtype discovery methods, as shown with different
application scenarios in the Supplementary Material.
AVAILABILITY AND IMPLEMENTATION: The package is implemented in R and available
under GPL-2 license from the Bioconductor website
(http://bioconductor.org/packages/CancerSubtypes/).
CONTACT: [email protected] or [email protected].
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. |
Is Solanezumab effective for Alzheimer's Disease? | No. Solanezumab, a humanized monoclonal antibody that binds amyloid, failed to improve cognition or functional ability in patients with Alzheimer's Disease. | BACKGROUND: Alzheimer's disease is characterized by amyloid-beta plaques,
neurofibrillary tangles, gliosis, and neuronal loss. Solanezumab, a humanized
monoclonal antibody, preferentially binds soluble forms of amyloid and in
preclinical studies promoted its clearance from the brain.
METHODS: In two phase 3, double-blind trials (EXPEDITION 1 and EXPEDITION 2), we
randomly assigned 1012 and 1040 patients, respectively, with mild-to-moderate
Alzheimer's disease to receive placebo or solanezumab (administered
intravenously at a dose of 400 mg) every 4 weeks for 18 months. The primary
outcomes were the changes from baseline to week 80 in scores on the 11-item
cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog11;
range, 0 to 70, with higher scores indicating greater cognitive impairment) and
the Alzheimer's Disease Cooperative Study-Activities of Daily Living scale
(ADCS-ADL; range, 0 to 78, with lower scores indicating worse functioning).
After analysis of data from EXPEDITION 1, the primary outcome for EXPEDITION 2
was revised to the change in scores on the 14-item cognitive subscale of the
Alzheimer's Disease Assessment Scale (ADAS-cog14; range, 0 to 90, with higher
scores indicating greater impairment), in patients with mild Alzheimer's
disease.
RESULTS: Neither study showed significant improvement in the primary outcomes.
The modeled difference between groups (solanezumab group minus placebo group) in
the change from baseline was -0.8 points for the ADAS-cog11 score (95%
confidence interval [CI], -2.1 to 0.5; P=0.24) and -0.4 points for the ADCS-ADL
score (95% CI, -2.3 to 1.4; P=0.64) in EXPEDITION 1 and -1.3 points (95% CI,
-2.5 to 0.3; P=0.06) and 1.6 points (95% CI, -0.2 to 3.3; P=0.08), respectively,
in EXPEDITION 2. Between-group differences in the changes in the ADAS-cog14
score were -1.7 points in patients with mild Alzheimer's disease (95% CI, -3.5
to 0.1; P=0.06) and -1.5 in patients with moderate Alzheimer's disease (95% CI,
-4.1 to 1.1; P=0.26). In the combined safety data set, the incidence of
amyloid-related imaging abnormalities with edema or hemorrhage was 0.9% with
solanezumab and 0.4% with placebo for edema (P=0.27) and 4.9% and 5.6%,
respectively, for hemorrhage (P=0.49).
CONCLUSIONS: Solanezumab, a humanized monoclonal antibody that binds amyloid,
failed to improve cognition or functional ability. (Funded by Eli Lilly;
EXPEDITION 1 and 2 ClinicalTrials.gov numbers, NCT00905372 and NCT00904683.). INTRODUCTION: EXPEDITION and EXPEDITION2 were identically designed
placebo-controlled phase 3 studies assessing effects of solanezumab, an
antiamyloid monoclonal antibody binding soluble amyloid-β peptide, on cognitive
and functional decline over 80 weeks in patients with mild-to-moderate
Alzheimer's disease (AD). Primary findings for both studies have been published.
METHODS: Secondary analyses of efficacy, biomarker, and safety endpoints in the
pooled (EXPEDTION + EXPEDITION2) mild AD population were performed.
RESULTS: In the mild AD population, less cognitive and functional decline was
observed with solanezumab (n = 659) versus placebo (n = 663), measured by
Alzheimer's Disease Assessment Scale Cognitive subscale, Mini-Mental State
Examination, and Alzheimer's Disease Cooperative Study-Activities of Daily
Living functional scale Instrumental ADLs. Baseline-to-endpoint changes did not
differ between treatment groups for Alzheimer's Disease Cooperative
Study-Activities of Daily Living functional scale, basic items of the ADCS-ADL,
and Clinical Dementia Rating Sum of Boxes. Plasma/cerebrospinal fluid biomarker
findings indicated target engagement by solanezumab. Solanezumab demonstrated
acceptable safety. Efficacy findings for the moderate AD population are also
provided.
DISCUSSION: These findings describe solanezumab effects on efficacy/safety
measures in a mild AD population. Another phase 3 study, EXPEDITION3, will
investigate solanezumab's effects in a mild AD population. Passive anti-beta-amyloid (Aß) immunotherapy has been shown to clear brain Aß
deposits. Results from phase III clinical trials in mild-to-moderate Alzheimer's
disease (AD) patients with two monoclonal antibodies bapineuzumab and
solanezumab and intravenous immunoglobulin have been disappointing. Subsequent
analysis of pooled data from both phase III trials with solanezumab showed a
reduction in cognitive decline in patients with mild AD. Solanezumab and new
monoclonal antibodies are being tested in patients with prodromal and
preclinical AD in search for a disease-modifying treatment. Pharmaceutical companies and the NIH have invested heavily in a variety of
potential disease-modifying therapies for Alzheimer's disease (AD) but
unfortunately all double-blind placebo-controlled Phase III studies of these
drugs have failed to show statistically significant results supporting their
clinical efficacy on cognitive measures. These negative results are surprising
as most of these medications have the capability to impact the biomarkers which
are associated with progression of Alzheimer's disease. Areas covered: This
contradiction prompted us to review all study phases of Intravenous
Immunoglobulin (IVIG), Bapineuzumab, Solanezumab, Avagacestat and Dimebolin to
shed more light on these recent failures. We critically analyzed these studies,
recommending seven lessons from these failures which should not be overlooked.
Expert commentary: We suggest a new methodology for future treatment research in
Alzheimer's disease considering early intervention with more focus on cognitive
decline as a screening tool, more sophisticated exclusion criteria with more
reliance on biomarkers, stratification of subjects based on the rate of
cognitive decline aiming less heterogeneity, and a longer study duration with
periodic assessment of cognition and activities of daily living during the study
and also after a washout period. Alzheimer's disease (AD) is a common, chronic expensive debilitating
neurodegenerative disease with no current treatments to prevent the physical
deterioration of the brain and the consequent cognitive deficits. The current
pathophysiology of Alzheimer's disease is the accumulation of neurofibrillary
tangles (NFTs) of hyperphosphorylated tau protein and amyloid-beta (Aβ) plaques.
Antibody therapy of Tau and Amyloid beta, vaccines and other methods to decrease
Tau and or Amyloid have not been successful after considerable pharmaceutical
and biotech efforts. For example, Eli Lilly announced a major change to its
closely watched clinical trial for the Alzheimer's drug solanezumab which failed
to reach statistical significance. Recently, a report on animal models using
photomodulation with near infrared light to treat AD pathology in K369I tau
transgenic model (K3) l engineered to develop neurofibrillary tangles, and the
APPs/PSEN1dE9 transgenic model (APP/PS1) to develop amyloid plaques. Mice were
treated with NIR 20 times over a four-week period and NIR treatment (600-1000
nm) was associated with a reduction in the size and number of amyloid-β plaques
in the neocortex and hippocampus. We now report a small pilot double blind,
placebo-controlled trial (n=11) 6 active, 3 controls and 2 dropouts assessing
the effect of 28 consecutive, sixminute transcranial sessions of near infrared
(NIR) stimulation using 1060-1080 nm light emitting diodes. Subjects were
independently diagnosed with dementia conducted in an outpatient behavioral
healthcare clinic. IRB approval was obtained through the Quietmind Foundation's
institutional review Board (IRB). Results showed changes in executive
functioning; clock drawing, immediate recall, praxis memory, visual attention
and task switching (Trails A&B) as well as a trend of improved EEG amplitude and
connectivity measures. Neuroplasticity has also been reported with NIR light
stimulation and mitochondrial enhancement. Protein aggregation is a pathological hallmark of and may play a central role in
the neurotoxicity in age-associated neurodegenerative diseases, such as
Alzheimer's disease and Parkinson's disease. Accordingly, inhibiting aggregation
of amyloidogenic proteins, including amyloid β and α-synuclein, has been a main
therapeutic target for these disorders. Among various strategies, amyloid β
immunotherapy has been extensively investigated in Alzheimer's disease, followed
by similar studies of α-synuclein in Parkinson's disease. Notably, a recent
study of solanezumab, an amyloid β monoclonal antibody, raises hope for the
further therapeutic potential of immunotherapy, not only in Alzheimer's disease,
but also for other neurodegenerative disorders, including Parkinson's disease.
Thus, it is expected that further refinement of immunotherapy against
neurodegenerative diseases may lead to increasing efficacy. Meanwhile, type II
diabetes mellitus has been associated with an increased risk of
neurodegenerative disease, such as Alzheimer's disease and Parkinson's disease,
and studies have shown that metabolic dysfunction and abnormalities surrounding
insulin signaling may underlie disease progression. Naturally, "anti-insulin
resistance" therapy has emerged as a novel paradigm in the therapy of
neurodegenerative diseases. Indeed, incretin agonists, which stimulate
pancreatic insulin secretion, reduce dopaminergic neuronal loss and suppress
Parkinson's disease disease progression in clinical trials. Similar studies are
ongoing also in Alzheimer's disease. This paper focuses on critical issues in
"immunotherapy" and "anti-insulin resistance" therapy in relation to therapeutic
strategies against neurodegenerative disease, and more importantly, how they
might merge mechanistically at the point of suppression of protein aggregation,
raising the possibility that combined immunotherapy and "anti-insulin
resistance" therapy may be superior to either monotherapy. |
Are organisms in the genus Morexella associated with sepsis? | Moraxella species may cause neonatal sepsis | BACKGROUND: Neonatal sepsis is characterised by bacteraemia and clinical
symptoms caused by microorganisms and their toxic products. Gram negative
bacteria are the commonest causes of neonatal Sepsis. The resistance to the
commonly used antibiotics is alarmingly high. The major reason for emerging
resistance against antibiotics is that doctors often do not take blood cultures
before starting antibiotics. We have carried out this study to find out various
bacteria causing neonatal sepsis and their susceptibility to antibiotics for
better management of neonatal sepsis.
METHODS: A total of 130 neonates with sepsis who were found to be blood culture
positive were taken in this study. Culture/sensitivity was done, isolated
organisms identified and their sensitivity/resistance was noted against
different antibiotics. Data were arranged in terms of frequencies and
percentage.
RESULTS: Out of 130 culture proven cases of neonatal sepsis, gram negative
bacteria were found in 71 (54.6%) cases and gram positive bacteria in 59 (45.4%)
cases. Staphylococcus aureus was the most common bacteria found in 35 (26.9%)
cases followed by Escherichia coli in 30 (23.1%) cases. Acinetobacter species,
Staphylococcus epidermidis, Klebseila, Streptococci, Enterobacter cloacae and
Morexella species were found in 17 (13.1%), 17 (13.1%), 13 (10%), 7 (5.4%), 6
(4.6%), and 5 (3.8%) cases respectively. In most of the cases causative
organisms were found to be resistant to commonly used antibiotics like
ampicillin, amoxicillin, cefotaxime, and ceftriaxone (77.7%, 81.5%, 63.1%, and
66.9% respectively). There was comparatively less (56.9%) resistance to
ceftazidime. Gentamicin had resistance in 55.1% cases, while amikacin and
tobramycin had relatively less resistance (17.4% and 34.8% cases respectively).
Quinolones and imipenem had relatively less resistance. Vancomycin was found to
be effective in 100% cases of Staphylococcus group.
CONCLUSION: Staphylococcus aureus are the most common gram positive bacteria and
Escherichia coli are the most common gram negative bacteria causing neonatal
sepsis. Resistance to commonly used antibiotics is alarmingly increasing.
Continued surveillance is mandatory to assess the resistance pattern at a
certain level. |
Are there mammalian promoters with distal enhancer functions? | Yes. Several studies have suggested that some promoters might have enhancer functions. By exploiting a high-throughput enhancer reporter assay, scientists have unraveled a set of mammalian promoters displaying enhancer activity. These promoters have distinct genomic and epigenomic features and frequently interact with other gene promoters. Extensive CRISPR-Cas9 genomic manipulation demonstrated the involvement of these promoters in the cis regulation of expression of distal genes in their natural loci. | Gene expression in mammals is precisely regulated by the combination of
promoters and gene-distal regulatory regions, known as enhancers. Several
studies have suggested that some promoters might have enhancer functions.
However, the extent of this type of promoters and whether they actually function
to regulate the expression of distal genes have remained elusive. Here, by
exploiting a high-throughput enhancer reporter assay, we unravel a set of
mammalian promoters displaying enhancer activity. These promoters have distinct
genomic and epigenomic features and frequently interact with other gene
promoters. Extensive CRISPR-Cas9 genomic manipulation demonstrated the
involvement of these promoters in the cis regulation of expression of distal
genes in their natural loci. Our results have important implications for the
understanding of complex gene regulation in normal development and disease. |
What gene is mutated in Familial Mediterranean Fever? | The MEFV gene which encodes the pyrin protein is mutated in Familial Mediterranean Fever(FMF). | BACKGROUND: Familial Mediterranean fever is a recessively inherited disorder
characterized by episodes of fever with abdominal pain, pleurisy, or arthritis.
The familial Mediterranean fever gene, designated MEFV, was recently cloned, and
at least three missense mutations (M6801, M694V, and V726A) that account for a
large percentage of patients with this disease were identified.
OBJECTIVE: To establish a diagnostic test for familial Mediterranean fever.
DESIGN: Cross-sectional study of a convenience sample of patients attending
familial Mediterranean fever clinics.
SETTING: Tertiary referral hospitals.
PATIENTS: 107 patients with familial Mediterranean fever, their family members,
and controls.
MEASUREMENTS: Mutations in the 107 samples were assessed by amplifying genomic
DNA with use of primers that selectively amplify the normal or altered DNA
sequence of the 3 MEFV mutations (amplification refractory mutation system
[ARMS]). Mutations were independently assessed by automated sequencing of
genomic DNA amplified by polymerase chain reaction to evaluate the sensitivity
and specificity of the ARMS assay.
RESULTS: The ARMS assay correctly identified M6801, M694V, and V726A mutations
in 82 persons with mutations documented by DNA sequencing (21 homozygotes, 2
compound heterozygotes, and 59 simple heterozygotes). Of 7 persons known from
family studies to be noncarriers and 18 unrelated persons who were negative for
these mutations by sequencing, none had MEFV mutations according to ARMS.
CONCLUSION: The ARMS assay is a rapid, cost-effective, and accurate method for
detecting three common mutations in familial Mediterranean fever. Familial Mediterranean fever (FMF) is a recessively inherited disorder
characterized by recurrent, self-limited attacks of fever and serositis and by
infiltration of affected tissues by large numbers of neutrophils. A candidate
gene for FMF was identified by positional cloning and named "MEFV." The
corresponding protein was named "pyrin." To elucidate the currently unknown
function of pyrin, we characterized its tissue distribution, regulation of
expression during hematopoietic differentiation, and subcellular localization.
Reverse transcription-polymerase chain reaction analysis, followed by
hybridization with an internal oligonucleotide, demonstrated expression of MEFV
in different populations of peripheral blood cells. Among hematopoietic cell
lines, MEFV was almost exclusively expressed in cells of the myeloid lineage.
Furthermore, MEFV messenger RNA was strongly expressed within 24 hours of
dimethyl sulfoxide-induced granulocytic differentiation of HL-60 cells. Analysis
of complementary DNA from human solid tumor-derived cell lines revealed
expression of MEFV in several cell lines derived from colon and prostate
cancers. Expression of MEFV fused to enhanced green fluorescent protein showed
that pyrin localized in distinct patches in the cytoplasm, forming a perinuclear
cap. Taken together, MEFV is predomitly expressed in myeloid cells and
upregulated during myeloid differentiation, and the corresponding protein,
pyrin, is expressed in the cytoplasm. (Blood. 2000;95:1451-1455) Identification of the genes involved in hereditary periodic fever syndromes has
led to the recognition of a new pathophysiological category, the
autoinflammatory disorders. The main non-hereditary autoinflammatory disease in
childhood is systemic juvenile idiopathic arthritis (sJIA), others being the
chronic infantile neurological cutaneous arthropathy (CINCA) syndrome and the
periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA)
syndrome. Familial Mediterranean fever (FMF) has been traced to mutations in the
MEFV gene. Mutations in the MVK gene, encoding the enzyme mevalonate kinase,
cause the hyper-IgD periodic fever syndrome (HIDS). The tumour necrosis
factor(TNF)-receptor-associated periodic syndromes (TRAPS) have been linked to
mutations in theTNFRSF1A gene, encoding a TNF-alpha receptor, and the CIAS1 gene
is mutated in familial cold autoinflammatory syndrome. We discuss how this
knowledge has influenced diagnosis and treatment of these rare genetic disorders
and how it might change our approach to the more common rheumatic diseases. Familial Mediterranean fever (FMF) is an autosomal recessive disorder
characterized by recurrent attacks of fever, serositis, and a risk for AA
amyloidosis. FMF is caused by mutations in the Mediterranean fever gene (MEFV),
which is expressed in blood cells of the myelomonocytic differentiation pathway.
We identified a novel mutation S1791 in exon 2 of MEFV in two members of a
family of Turkish origin. In both cases, S1791 was in compound heterozygosity
with MEFV mutation M694V, and the characteristic clinical syndrome of FMF
including amyloidosis was found. The location of S1791 in exon 2 is of interest
because (1) amyloidosis in FMF has previously been found to be strongly
associated with compound exon 10 mutations and (2) it supports the notion that
the mechanism causing FMF is connected to the cytoplasmic rather than nuclear
function of the molecule. OBJECTIVE: To investigate the expression of the familial Mediterranean fever
(FMF) gene (MEFV) in human synovial fibroblasts.
METHODS: MEFV messenger RNA in synovial fibroblasts, chondrocytes, and
peripheral blood leukocytes (PBLs) was analyzed by semiquantitative and
real-time polymerase chain reaction and ribonuclease protection assay. The
subcellular localization of pyrin, the MEFV product, was determined in
transfected synovial fibroblasts and HeLa cells with plasmids encoding pyrin
isoforms. Native pyrin was detected with an antipyrin antibody.
RESULTS: MEFV was expressed in synovial fibroblasts, but not in chondrocytes.
Four alternatively spliced transcripts were identified: an extension of exon 8
(exon 8ext) resulting in a frameshift that predicts a truncated protein lacking
exons 9 and 10, the addition of an exon (exon 4a) predicting a truncated protein
at exon 5, the in-frame substitution of exon 2a for exon 2, and the previously
described removal of exon 2 (exon 2Delta). Exon 8ext transcripts represented 27%
of the total message population in synovial fibroblasts. All other alternatively
spliced transcripts were rare. Consensus and alternatively spliced transcripts
were induced by lipopolysaccharide in synovial fibroblasts and PBLs. In
transfected cells, the proteins encoded by all highly expressed splice forms
were cytoplasmic. In contrast, native pyrin was predomitly nuclear in
synovial fibroblasts, neutrophils, and dendritic cells, but was cytoplasmic in
monocytes.
CONCLUSION: Several MEFV transcripts are expressed and inducible in synovial
fibroblasts. A prominent isoform lacks the C-terminal domain that contains the
majority of mutations found in patients with FMF. While recombit forms of all
major pyrin isoforms are cytoplasmic, native pyrin is nuclear in several cell
types. Thus, mechanisms in addition to splicing patterns must control pyrin's
subcellular distribution. Familial Mediterranean fever (FMF) is the most frequent hereditary inflammatory
disease characterized by self-limited recurrent attacks of fever and serositis.
It is transmitted in an autosomal recessive pattern and affects certain ethnic
groups mainly Jews, Turks, Arabs, and Armenians. FMF is caused by mutations in
MEFV gene, which encodes pyrin. This protein is expressed mainly in
myeloid/monocytic cells and modulates IL-1beta processing, NF-kappaB activation,
and apoptosis. A mutated pyrin probably results in uncontrolled inflammation.
The most devastating complication of FMF is amyloidosis, leading to chronic
renal failure. M694V homozygocity, male gender and the alpha/alpha genotype of
serum amyloid A1 gene are the currently established risk factors for development
of amyloidosis. Daily colchicine is the mainstay of the therapy for the disease,
resulting in complete remission or marked reduction in the frequency and
duration of attacks in most patients. It is also effective in preventing and
arresting renal amyloidosis. BACKGROUND: Asthma is an inflammatory airway disease caused by interaction
between susceptibility genes and diverse environmental factors. In Israel,
asthma seems to be familial and more severe in patients of Iraqi Jewish descent.
On the other hand, asthma is less frequent in individuals with familial
Mediterranean fever, an autoinflammatory disease prevalent in the Iraqi Jewish
community and linked to mutations in the familial Mediterranean fever gene,
designated MEFV.
OBJECTIVES: To explore a possible role for mutated MEFV in the reduced
susceptibility to asthma and to determine its expression in Israeli subjects of
Iraqi origins.
METHODS: Using a case-control approach, we studied the presence of the 3 most
common MEFV mutations (M694V, V726A, and E148Q) in DNA samples from 75 patients
with asthma and 45 asymptomatic first-degree relatives, all of Iraqi Jewish
origin. The severity of asthma was evaluated using a published severity score.
RESULTS: Eleven patients with asthma and 14 of their relatives carried 1 or 2
mutations in the MEFV gene, a carrier rate significantly lower in patients with
asthma than in their first-degree relatives and in ethnically matched healthy
individuals (P < .03 and P < .003, respectively). Carriers of MEFV mutations had
less severe disease, compared with noncarriers (P < .002).
CONCLUSION: These findings suggest that MEFV mutations may have a protective
effect in the pathogenesis of asthma. The aim of this study was to determine the relationship between clinical
findings and the most common mutated alleles of MEFV gene in a childhood
population and to determine the sensitivity of the 12-mutation-strip assay test
in familial Mediterranean fever (FMF). Records of 452 FMF children living in
western Anatolia, Turkey, (12.3 ± 4.7 years mean) were retrospectively reviewed.
Of the 408 patients who met the Tel-Hashomer criteria, 364 were classified into
two main groups (two-mutant/one-mutant allele) either of which had three
subgroups. The two-mutant allele frequency was 51% and one-mutant allele 38%; 1%
had complex-mutant alleles and 10% no mutant-alleles. The mean severity score
was 8.3 ± 2.5. Most common clinical features were fever (81.9%), abdominal pain
(86.3%) and myalgia (58.8%), and the least common ones: diarrhea (1.7%),
protracted febrile myalgia (1.2%) and acute orchitis (1.5%). We detected 33
different genotypes of the MEFV gene: the most common mutant allele was M694V
followed by symptomatic allele mutation of E148Q. Although not significantly
associated with clinical findings, P369S mutation was not rare (7.5%).
Phenotype-genotype correlation revealed that patients with two-allele mutations
had more severe clinical presentation and high constipation rate (22.5%); 32.6%
of patients with M694V/M694V had splenomegaly. Acute orchitis and protracted
febrile myalgia as rare clinical findings were more common in M694V homozygotes.
Comparisons of clinical findings among patients with one-mutation allele were
made for the first time, but no significant association was found. Positive
predictive value of strip assay screening for 12 mutations was recorded as 89%.
We suggest that whole sequence analysis for supportive diagnosis of FMF should
be performed for selected patients only. Familial Mediterranean fever is a recessive autoinflammatory disease that is
frequent in Armenians, Jews, Arabs, and Turks. The MEFV gene is responsible for
this disease. We looked for MEFV gene variations (polymorphism and mutations) in
a population that resides in Central Anatolia, Turkey. DNA was extracted from
peripheral blood leukocytes of 802 familial Mediterranean fever patients. The
DNA sequence data were examined for approximately 150 different mutations and
polymorphisms, including single nucleotide polymorphisms in different exons of
the MEFV gene. The male:female ratio of these patients was 1.44:1. Mutations
were detected in 48.1% of the patients; 7.5% were homozygous, 11.1% were
compound heterozygous and 31.5% had only one identifiable mutant allele. No
mutations were detected in 51.9% of the patients. The main clinical
characteristics of the patients were: abdominal pain in 20.6%, arthritis in
22.9% and amyloidosis in 4.6%. Sixty-six percent of patients had a family
history of familial Mediterranean fever; 19.4% of the patients were found to
have parental consanguinity. We conclude that the genetics of familial
Mediterranean fever is more complex than has previously been reported;
heterozygous patients presenting a severe phenotype should be further analyzed
for less common secondary MEFV mutations, using gene sequencing. OBJECTIVES: To define in patients affected by familial Mediterranean fever (FMF)
whether or not interleukin (IL)-1β secretion (1) is enhanced, (2) correlates
with the type of MEFV mutation and (3) is mediated by NLRP3.
METHODS: Freshly isolated monocytes from 21 patients with FMF (12 homozygous and
9 heterozygous), 14 MEFV healthy carriers and 30 healthy donors (HDs),
unstimulated or after lipopolysaccharide (LPS)-induced activation, were analysed
for redox state (production of reactive oxygen species (ROS) and antioxidant
responses) and IL-1β and IL-1 receptor antagonist (IL-1Ra) secretion. NLRP3
down-modulation was induced by in vitro silencing of the NLRP3 gene.
RESULTS: LPS-stimulated monocytes from patients with FMF displayed enhanced
IL-1β secretion, which correlated with number and penetrance of MEFV mutations.
Silencing of NLRP3 consistently inhibited IL-1β secretion. As in other
autoinflammatory diseases, FMF monocytes produced more ROS than genetically
negative cells from HDs. Unlike in cryopyrin-associated periodic fever syndromes
(CAPS), however, they were characterised by a conserved and sustained
antioxidant response. Consistent with this finding, activated MEFV-mutated
monocytes did not exhibit the functional indicators of oxidative stress observed
in CAPS, including accelerated IL-1β secretion and deficient production of
IL-1Ra.
CONCLUSIONS: MEFV-mutated monocytes display enhanced IL-1β secretion, which
correlates with number of high-penetrance mutations and level of endogenous ROS.
Unlike NLRP3-mutated cells, monocytes carrying MEFV mutations withstand
oxidative stress and preserve IL-1Ra production, thereby limiting inflammation.
Finally, in contrast with that found in the animal model, the increased
secretion of IL-1β by LPS-stimulated FMF monocytes is NLRP3-dependent. Familial Mediterranean fever (FMF) is a recessive inherited autoinflammatory
syndrome. Patients with FMF have symptoms such as recurrent fever and abdominal
pain, sometimes accompanied by arthralgia. Biopsy specimens have revealed
substantial neutrophil infiltration into synovia. FMF patients have a mutation
in the Mediterranean fever gene, encoding pyrin, which is known to regulate the
inflammasome, a platform for processing interleukin (IL)-1β. FMF patients
heterozygous for E148Q mutation, heterozygous for M694I mutation, or combined
heterozygous for E148Q and M694I mutations, which were found to be major
mutations in an FMF study group in Japan, suffer from arthritis, the severity of
which is likely to be lower than in FMF patients with M694V mutations.
Expression plasmids of wild-type (WT) pyrin and mutated pyrin, such as E148Q,
M694I, M694V, and E148Q+M694I, were constructed, and SW982 synovial sarcoma
cells were transfected with these expression plasmids. IL-8 and IL-6 were
spontaneously secreted from the culture supernatant of SW982 cells without any
stimulation, whereas IL-1β and TNF-α could not be detected even when stimulated
with lipopolysaccharide. Notably, two inflammasome components, ASC and
caspase-1, could not be detected in SW982 cells by Western blotting. IL-8 but
not IL-6 secretion from SW982 cells was largely suppressed by WT pyrin, but less
suppressed by mutated pyrin, which appeared to become weaker in the order of
E148Q, M694I, E148Q+M694I, and M694V mutations. As for IL-8 and IL-6, similar
results were obtained using stable THP-1 cells expressing the WT pyrin or
mutated pyrins, such as M694V or E148Q, when stimulated by LPS. In addition,
IL-8 secretion from mononuclear cells of FMF patients was significantly higher
than that of healthy volunteers when incubated on a culture plate. Thus, our
results suggest that IL-8 secretion from SW982 synovial sarcoma cells suppressed
by pyrin independently of inflammasome is affected by pyrin mutations, which may
reflect the activity in FMF arthritis. OBJECTIVE: Cardiovascular diseases (CVD) are very common in the general
population. Atherosclerosis is the main pathogenesis. Familial Mediterranean
fever (FMF) is an autosomal recessive disease. The gene causing FMF, designated
MEFV, encodes a protein called pyrin or marenostrin that is expressed mainly in
myeloid bone marrow precursors, neutrophils and monocytes. We herein aimed to
determine the prevalence of MEFV mutations (all exon 2, 10 mutations) in
patients with early coronary heart disease (early CHD) and coronary heart
disease (CHD) with multiple risk factors and among the healthy subjects as
controls.
METHODS: A total of 197 patients and 119 healthy subjects were recruited and
enrolled into three groups in terms of inclusion criteria. Ninety-one patients
diagnosed with early CHD enrolled into group one (men < 45 years of age, women
< 40 years of age), 106 patients with CHD (men > 50 years of age) to group two
and 119 healthy controls enrolled into group three. None of patients was
diagnosed with FMF. The diagnosis of CHD was established on electrocardiographic
changes, echocardiography and coronary angiography.
RESULTS: Thirty-eight patients (41.8%) with early CHD, 17 patients (16%) with
CHD and 24 healthy controls (20.2%) carried at least one mutated MEFV allele.
Young patients with CHD have different risk factor profiles, clinical
presentations and prognoses than older patients. Young patients with CHD usually
have multiple risk factors.
CONCLUSION: This study suggests that MEFV mutations in early CHD patients had
significantly increased in contrast to CHD patients and healthy controls. BACKGROUND: Familial Mediterranean Fever (FMF), characterized by recurrent fever
and inflammation of serous membranes, is an autosomal recessive disease caused
by mutations in the Mediterranean fever (MEFV) gene. Around 296 mutations have
been reported to date.
METHODS: Two two-generation Turkish families with a total of four members
diagnosed with FMF clinically were screened with DNA sequencing performed on
exon 2 and exon 10 of the MEFV genes. Then, complete exome sequencing analysis
of MEFV gene was done for four patients in whom novel mutation was detected.
RESULTS: A novel single base Guanine (G) insertion mutation in the coding region
of MEFV gene, named c.2330dupG (p.Gln778Serfs*4 or Q778SfsX4) resulting in a
mutated Pyrin/Marenostrin protein was identified.
CONCLUSIONS: This is the first report of a new mutation in exon 10 of the MEFV
gene in two Turkish families. This novel pattern of insertion mutation may
provide important information for further studies on FMF pathogenesis. The causative mutations for familial Mediterranean fever (FMF) are located in
the MEFV gene, which encodes pyrin. Pyrin modulates the susceptibility to
apoptosis via its PYD domain, but how the mutated versions of pyrin affect
apoptotic processes are poorly understood. Spontaneous and induced rates of
systemic neutrophil apoptosis as well as the levels of proteins involved in
apoptosis were investigated ex vivo in patients with FMF using flow cytometry
and RT-qPCR. The freshly collected neutrophils from the patients in FMF
remission displayed a significantly larger number of cells spontaneously
entering apoptosis compared to control (6.27 ± 2.14 vs. 1.69 ± 0.18%). This
elevated ratio was retained after 24 h incubation of neutrophils in the growth
medium (32.4 ± 7.41 vs. 7.65 ± 1.32%). Correspondingly, the mRNA level for
caspase-3 was also significantly increased under these conditions. In response
to the inducing agents, the neutrophils from FMF patients also displayed
significantly elevated apoptotic rates compared to control. The elevated rates,
however, can be largely explained by the higher basal ratio of apoptotic cells
in the former group. Monitoring of several proteins involved in apoptosis has
not revealed any conventional mechanisms contributing to the enhanced apoptotic
rate of neutrophils in FMF. Although the exact molecular mechanisms of
accelerated neutrophil apoptosis in FMF remain unknown, it may provide a
protection against excessive inflammation and tissue damage due to a massive
infiltration of neutrophils in the acute period of the disease. Familial Mediterranean fever (FMF) is the most common monogenic periodic fever
syndrome and characterized by recurrent episodes of fever, serositis, arthritis,
dermal manifestations, and long-term renal complications. The MEFV gene was
described in 1997 as the gene responsible for FMF and is inherited in autosomal
recessive manner. It encodes mutated protein pyrin, an important player in the
innate immune system and the component of inflammasome which leads to
exaggerated inflammatory response through uncontrolled production of
interleukin-1. The recent progress in molecular genetics and understanding of
pathogenesis showed a more complicated picture of FMF inheritance, penetrance,
and pathogenesis. The pathogenesis is not completely understood although the
gene responsible for FMF has been identified. Whether the pyrin mutation effect
in FMF is due to a loss of function or a gain of function is still
controversial. The diagnosis is mainly clinical and the genetic testing is
indicated to support it. Colchicine remains the mainstay of treatment of FMF
since 1972. It decreases the attacks, improves quality of life, and prevents
amyloidosis. The recent advances in genetic testing and molecular studies has
led to the development of new therapies of interleukin-1 inhibitors; anakinra,
canakinumab, and rilonacept. |
Which R/bioconductor package has been developed to aid in epigenomic analysis? | DeepBlueR is a package that allows for large-scale epigenomic analysis in R. | MOTIVATION: While large amounts of epigenomic data are publicly available, their
retrieval in a form suitable for downstream analysis is a bottleneck in current
research. The DeepBlue Epigenomic Data Server provides a powerful interface and
API for filtering, transforming, aggregating and downloading data from several
epigenomic consortia.
RESULTS: To make public epigenomic data conveniently available for analysis in
R, we developed an R/Bioconductor package that connects to the DeepBlue
Epigenomic Data Server, enabling users to quickly gather and transform
epigenomic data from selected experiments for analysis in the Bioconductor
ecosystem.
AVAILABILITY AND IMPLEMENTATION: http://deepblue.mpi-inf.mpg.de/R .
REQUIREMENTS: R 3.3, Bioconductor 3.4.
CONTACT: [email protected] or [email protected].
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. |
Is autosomal dominant inheritanced form of Osteogenesis imperfecta caused by mutations in the genes associated with collagen production? | Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. The autosomal dominant form of the disease is cause by a mutation in the COL1A1 or COL1A2 genes which produce type I collagen. | Most individuals with osteogenesis imperfecta (OI) are heterozygous for domit
mutations in one of the genes that encode the chains of type I collagen. Each of
the more than 30 mutations characterized to date has been unique to the affected
member(s) of the family. We have determined that two individuals with a
progressive deforming variety of OI, OI type III, have the same new domit
mutation [alpha 1(I)gly154 to arg] and that two unrelated infants with perinatal
lethal OI, OI type II, share a second new domit mutation [alpha 1(I)gly1003
to ser]. These mutations occurred at CpG dinucleotides, in a manner consistent
with deamination of a methylated cytosine residue, and raise the possibility
that CpG dinucleotides are common sites of recurrent mutations in collagen
genes. Further, these findings confirm that the OI type-III phenotype,
previously thought to be inherited in an autosomal recessive manner, can result
from new domit mutations in the COL1A1 gene of type-I collagen. Autosomal domit osteogenesis imperfecta is caused by mutations in the COL1A2
and COL1A1 genes of type I collagen. In a family with OI type IV genetically
linked to the COL1A2 gene, we attempted prenatal diagnosis in a pregcy at
risk by genotyping the DNA of the fetus for a COL1A2 gene associated RFLP. Our
results showed that the fetus inherited the normal COL1A2 allele from her
affected parent. Linkage analysis can thus be used in the prenatal diagnosis of
domitly inherited osteogenesis imperfecta. Osteogenesis imperfecta (OI) type I is characterized by bone fragility without
significant deformity, osteopenia, normal stature, blue sclerae, and autosomal
domit inheritance. Dermal fibroblasts from most affected individuals produce
about half the expected amount of type I collagen, suggesting that the OI type I
phenotype results from a variety of mutations which alter the apparent
expression of either COL1A1 or COL1A2, the genes encoding the chains of type I
collagen. Short-pulse labeling of dermal fibroblasts with [3H]proline from
affected individuals in 19 families indicates that most have alterations in the
expected 2:1 synthetic ratio of pro alpha 1(I): pro alpha 2(I), with most having
decreased production of pro alpha 1(I). Ratios of COL1A1:COL1A2 mRNA from these
individuals, using slot-blot hybridization, indicate that they fall into
different groups, but that most have decreased COL1A1 mRNA levels, compared with
controls. These data suggest that most of our OI I families have COL1A1
mutations. Copy number and size of the COL1A1 gene by restriction endonuclease
analysis of genomic DNA from affected individuals are normal in the families
examined. We have identified one 3 generation family in which all affected
members have one normal COL1A1 allele and another with a 5 base-pair deletion
near the 3' end of the gene. The deletion creates a shift in the translational
reading-frame and predicts the synthesis of an elongated pro alpha 1(I) chain.
In a second family, a father and a son have a single exon deletion that results
from a splicing mutation. Chemical cleavage analysis of amplified cDNA from
affected individuals in different regions of the COL1A1 gene, including the
promoter, suggests that several individuals have point mutations within the
coding region of the gene, while one individual may have a small deletion within
the alpha 1(I) carboxyl-terminal propeptide region. Our data provide evidence
for significant molecular heterogeneity within the OI type I phenotype and
indicate that a variety of mutations can result in decreased synthesis of type I
collagen. Osteogenesis imperfecta (OI), commonly known as "brittle bone disease", is a
domit autosomal disorder characterized by bone fragility and abnormalities of
connective tissue. Biochemical and molecular genetic studies have shown that the
vast majority of affected individuals have mutations in either the COL1A1 or
COL1A2 genes that encode the chains of type I procollagen. OI is associated with
a wide spectrum of phenotypes varying from mild to severe and lethal conditions.
The mild forms are usually caused by mutations which inactivate one allele of
COL1A1 gene and result in a reduced amount of normal type I collagen, while the
severe and lethal forms result from domit negative mutations in COL1A1 or
COL1A2 which produce structural defects in the collagen molecule. The most
common mutations are substitutions of glycine residues, which are crucial to
formation and function of the collagen triple helix, by larger amino acids.
Although type I collagen is the major structural protein of both bone and skin,
the mutations in type I collagen genes cause a bone disease. Some reports showed
that the mutant collagen can be expressed differently in bone and in skin. Since
most mutations identified in OI are domit negative, the gene therapy requires
a fundamentally different approach from that used for genetic-recessive
disorders. The antisense therapy, by reducing the expression of mutant genes, is
able to change a structural mutation into a null mutation, and thus convert
severe forms of the disease into mild OI type I. Autosomal domit osteogenesis imperfecta (OI) is caused by mutations in the
genes (COL1A1 or COL1A2) encoding the chains of type I collagen. Recently,
dysregulation of hydroxylation of a single proline residue at position 986 of
both the triple-helical domains of type I collagen alpha1(I) and type II
collagen alpha1(II) chains has been implicated in the pathogenesis of recessive
forms of OI. Two proteins, cartilage-associated protein (CRTAP) and
prolyl-3-hydroxylase-1 (P3H1, encoded by the LEPRE1 gene) form a complex that
performs the hydroxylation and brings the prolyl cis-trans isomerase
cyclophilin-B (CYPB) to the unfolded collagen. In our screen of 78 subjects
diagnosed with OI type II or III, we identified three probands with mutations in
CRTAP and 16 with mutations in LEPRE1. The latter group includes a mutation in
patients from the Irish Traveller population, a genetically isolated community
with increased incidence of OI. The clinical features resulting from CRTAP or
LEPRE1 loss of function mutations were difficult to distinguish at birth.
Infants in both groups had multiple fractures, decreased bone modeling
(affecting especially the femurs), and extremely low bone mineral density.
Interestingly, "popcorn" epiphyses may reflect underlying cartilaginous and bone
dysplasia in this form of OI. These results expand the range of CRTAP/LEPRE1
mutations that result in recessive OI and emphasize the importance of
distinguishing recurrence of severe OI of recessive inheritance from those that
result from parental germline mosaicism for COL1A1 or COL1A2 mutations. Osteogenesis imperfecta is a systemic heritable disorder of connective tissue
whose cardinal manifestation is bone fragility. In approximately 90% of
individuals with osteogenesis imperfecta, mutations in either of the genes
encoding the pro-alpha1 or pro-alpha2 chains of type I collagen (COL1A1 or
COL1A2) can be identified. Of those without collagen mutations, a number of them
will have mutations involving the enzyme complex responsible for
posttranslational hydroxylation of the position 3 proline residue of COL1A1. Two
of the genes encoding proteins involved in that enzyme complex, LEPRE1 and
cartilage-associated protein, when mutated have been shown to cause autosomal
recessive osteogenesis imperfecta, which has a moderate to severe clinical
phenotype, often indistinguishable from osteogenesis imperfecta types II or III.
Mutations in COL1A1 or COL1A2 which result in an abnormal protein still capable
of forming a triple helix cause a more severe phenotype than mutations that lead
to decreased collagen production as a result of the domit negative effect
mediated by continuous protein turnover. The current standard of care includes a
multidisciplinary approach with surgical intervention when necessary, proactive
physiotherapy, and consideration for the use of bisphosphonates all in attempts
to improve quality of life. Osteogenesis imperfecta (OI) is a heterogeneous group of inherited disorders of
bone formation, resulting in low bone mass and an increased propensity to
fracture. It exhibits a broad spectrum of clinical severity, ranging from
multiple fractures in utero and perinatal death, to normal adult stature and low
fracture incidence. Extra-skeletal features of OI include blue sclera, hearing
loss, skin hyperlaxity, joint hyperextensibility, and dentinogenesis imperfecta.
The proα1(I) and proα2(I) chains of collagen 1 are encoded by the COL1A1 and
COL1A2 genes, respectively; quantitative or qualitative defects in type I
collagen synthesis usually manifest as types of OI or some sub-types of EDS. The
majority of patients (about 90%) with a clinical diagnosis of OI have a mutation
in the COL1A1 or COL1A2 genes, which shows an autosomal domit pattern of
inheritance. Six other genes, CRTAP, LEPRE1, FKBP10, PP1B, SP7/Osterix (OSX),
and SERPINH1, are associated with autosomal recessive forms of OI. However,
other, rare phenotypes have also been described. There are many differential
diagnoses of the short, syndromic child, including chromosomal, single gene, and
multifactorial causes. However, one condition of particular relevance in the
context of this report is the Russell-Silver syndrome (RSS). As originally
described, the RSS is a very specific condition. However, it has subsequently
become an umbrella term for a heterogeneous group of conditions presenting with
short stature and triangular shape to the face. A significant proportion of
these are now believed to be due to imprinting defects at 11p15. However, the
cause in many cases remains unknown. We describe two cases with a phenotypic
overlap between OI and RSS who both have COL1A1 mutations. Thus, a type 1
collagenopathy should be considered in the differential diagnosis of syndromic
short stature. Domit inheritance of osteogenesis imperfecta (OI) is caused by mutations in
COL1A1 or COL1A2, the genes that encode type I collagen, and CRTAP, LEPRE1,
PPIB, FKBP10, SERPINH1, and SP7 mutations were recently detected in a minority
of patients with autosomal recessive OI. However, these findings have been
mostly restricted to Western populations. The proportion of mutations and the
correlations between genotype and phenotype in Chinese patients with OI are
completely unknown. In this study, mutation analyses were performed for COL1A1,
COL1A2, CRTAP, and LEPRE1 in a cohort of 58 unrelated Chinese patients with OI;
the relationship between collagen type I mutations and clinical features was
examined. A total of 56 heterozygous mutations were identified in COL1A1 and
COL1A2, including 43 mutations in COL1A1 and 13 mutations in COL1A2. Among the
56 causative COL1A1 and COL1A2 mutations, 24 novel mutations were found, and 25
(44.6%) resulted in the substitution of a glycine within the Gly-X-Y triplet
domain of the triple helix. Compared with COL1A1 haploinsufficiency (n = 23),
patients with mutations affecting glycine residues had a severe skeletal
phenotype. In patients 18 years of age or older, on average patients with COL1A1
haploinsufficiency were taller and had higher femoral neck bone mineral density
than with patients with helical mutations. Interestingly, we found two novel
compound heterozygous mutations in the LEPRE1 gene in two unrelated families
with autosomal recessive OI. Although the genotype-phenotype correlation is
still unclear, our findings are useful to understand the genetic basis of
Chinese patients with OI. Osteogenesis imperfecta (OI) is a clinically and genetically heterogeneous
disorder associated with bone fragility and susceptibility to fractures after
minimal trauma. OI type V has an autosomal-domit pattern of inheritance and
is not caused by mutations in the type I collagen genes COL1A1 and COL1A2. The
most remarkable and pathognomonic feature, observed in ~65% of affected
individuals, is a predisposition to develop hyperplastic callus after fractures
or surgical interventions. To identify the molecular cause of OI type V, we
performed whole-exome sequencing in a female with OI type V and her unaffected
parents and searched for de novo mutations. We found a heterozygous de novo
mutation in the 5'-untranslated region of IFITM5 (the gene encoding Interferon
induced transmembrane protein 5), 14 bp upstream of the annotated translation
initiation codon (c.-14C>T). Subsequently, we identified an identical
heterozygous de novo mutation in a second individual with OI type V by Sanger
sequencing, thereby confirming that this is the causal mutation for the
phenotype. IFITM5 is a protein that is highly enriched in osteoblasts and has a
putative function in bone formation and osteoblast maturation. The mutation
c.-14C>T introduces an upstream start codon that is in frame with the reference
open-reading frame of IFITM5 and is embedded into a stronger Kozak consensus
sequence for translation initiation than the annotated start codon. In vitro,
eukaryotic cells were able to recognize this start codon, and they used it
instead of the reference translation initiation signal. This suggests that five
amino acids (Met-Ala-Leu-Glu-Pro) are added to the N terminus and alter IFITM5
function in individuals with the mutation. OBJECTIVE: To investigate mutation of COL1A1 gene and analyze the relationship
between genotype and clinical phenotype in a family with osteogenesis imperfecta
(OI).
METHODS: The family history of an OI pedigree, along with clinical data, was
collected. Blood samples from the proband and his families, as well as 50 normal
controls, were collected. Mutation of COL1A1 gene was screened using PCR-high
resolution melting (PCR-HRM) and validated by sequencing.
RESULTS: PCR HRM method showed an abnormal result in proband COL1A133_34 exons,
which Tm was 87.7℃, in contrast to the normal control (wt) Tm of 87.9±0.06℃.
There was a significant difference between the proband and the normal control
with the standardization curve and the difference curves. DNA sequencing showed
that Y9COL1A1 gene exons 33_34 has lost a C base (c.2321delC), which resulted in
a frameshift mutation and caused an premature termination codon (UAA) at amino
acid 334, i.e., p.Pro774LeufsX334 The father and grandfather of the proband,
both suffered from OI, were verified to be heterozygous for the same mutation.
The same mutation was not found in 50 normal controls. Database search confirmed
this to be a novel mutation. Pedigree analysis suggested that it has an
autosomal domit inheritance. The proband and patients from the family were
clinically diagnosed as OI type I.
CONCLUSION: The study has identified a novel mutation of COL1A1 gene,
c.2321delC. This frameshift mutation has caused a premature stop codon and
reduced collagen type synthesis, characterized by a lighter OI clinical
phenotype. BACKGROUND: Osteogenesis imperfecta (OI) is a group of hereditary disorders
characterized by low bone mass and recurrent fractures. Most OI cases follow an
autosomal domit pattern of inheritance and are attributed to mutations in
genes encoding type I collagen (COL1A1/COL1A2). Genomic structural variations
involving type I collagen genes are extremely rare in OI.
CASE REPORT: In this study, we characterized a de novo balanced translocation of
t(5;7)(q32;q21.3) that caused an extremely rare type of OI in a patient from a
non-consanguineous family. The clinical phenotypes of this OI included recurrent
fractures, low bone mass, macrocephaly, blue sclera and failure to thrive.
Next-generation sequencing was used to identify the translocation, and Sanger
sequencing was used to validate and map the breakpoints. The breakpoint on
chromosome 7 disrupted the COL1A2 gene in the 17th exon, presumed to affect type
I collagen production and give rise to OI. The breakpoint on chromosome 5
disrupted the protein phosphatase 2 regulatory subunit B, beta gene (PPP2R2B)
within the first intron.
CONCLUSIONS: This is the first report of a copy-neutral structural variant
involving COL1A2 that leads to a rare type of OI. This study expands the
genotypic spectrum of OI and demonstrates the effectiveness of targeted
sequencing for breakpoint mapping. Osteogenesis imperfecta (OI) is a genetic disorder characterised by low bone
mineral density resulting in fractures. 85-90% of patients with OI carry a
variant in the type 1 collagen genes, COL1A1 and COL1A2, which follows an
autosomal domit pattern of inheritance. However, within the last two decades,
there have been growing number of variants identified in genes that follow an
autosomal recessive pattern of inheritance. Our proband is a child born in
Mexico with multiple fractures of ribs, minimal calvarial mineralisation,
platyspondyly, marked compression and deformed long bones. He also presented
with significant hydranencephaly, requiring ventilatory support from birth, and
died at 8days of age. A homozygous c.338_357delins22 variant in exon 2 of
SERPINH1 was identified. This gene encodes heat shock protein 47, a
collagen-specific chaperone which binds to the procollagen triple helix and is
responsible for collagen stabilisation in the endoplasmic reticulum. There is
minimal literature on the mechanism of action for variants in SERPINH1 resulting
in osteogenesis imperfecta. Here we discuss this rare, previously unreported
variant, and expand on the phenotypic presentation of this novel variant
resulting in a severe, lethal phenotype of OI in association with
hydranencephaly. BACKGROUND: Osteogenesis imperfecta (OI) is a heterogeneous bone disorder
characterized by recurrent fractures. Although most cases of OI have
heterozygous mutations in COL1A1 or COL1A2 and show autosomal domit
inheritance, during the last years there has been an explosion in the number of
genes responsible for both recessive and domit forms of this condition.
Herein, we have analyzed a cohort of patients with OI, all offspring of
unaffected parents, to determine the spectrum of variants accounting for these
cases. Twenty patients had nonrelated parents and were sporadic, and 21 were
born to consanguineous relationships.
METHODS: Mutation analysis was performed using a next-generation sequencing gene
panel, homozygosity mapping, and whole exome sequencing (WES).
RESULTS: Patients offspring of nonconsanguineous parents were mostly identified
with COL1A1 or COL1A2 heterozygous changes, although there were also a few cases
with IFITM5 and WNT1 heterozygous mutations. Only one sporadic patient was a
compound heterozygote for two recessive mutations. Patients offspring of
consanguineous parents showed homozygous changes in a variety of genes including
CRTAP,FKBP10,LEPRE1,PLOD2,PPIB,SERPINF1,TMEM38B, and WNT1. In addition, two
patients born to consanguineous parents were found to have de novo COL1A1
heterozygous mutations demonstrating that causative variants in the collagen I
structural genes cannot be overlooked in affected children from consanguineous
couples. Further to this, WES analysis in probands lacking mutations in OI genes
revealed deleterious variants in SCN9A,NTRK1, and SLC2A2, which are associated
with congenital indifference to pain (CIP) and Fanconi-Bickel syndrome (FBS).
CONCLUSION: This work provides useful information for clinical and genetic
diagnosis of OI patients with no positive family history of this disease. Our
data also indicate that CIP and FBS are conditions to be considered in the
differential diagnosis of OI and suggest a positive role of SCN9A and NTRK1 in
bone development. BACKGROUND: Osteogenesis imperfecta (OI) is a heterogeneous hereditary
connective tissue disorder clinically hallmarked by increased susceptibility to
bone fractures.
METHODS: We analyzed a cohort of 77 diagnosed OI patients from 49 unrelated
Palestinian families. Next-generation sequencing technology was used to screen a
panel of known OI genes.
RESULTS: In 41 probands, we identified 28 different disease-causing variants of
9 different known OI genes. Eleven of the variants are novel. Ten of the 28
variants are located in COL1A1, five in COL1A2, three in BMP1, three in FKBP10,
two in TMEM38B, two in P3H1, and one each in CRTAP, SERPINF1, and SERPINH1. The
absence of disease-causing variants in the remaining eight probands suggests
further genetic heterogeneity in OI. In general, most OI patients (90%) harbor
mainly variants in type I collagen resulting in an autosomal domit
inheritance pattern. However, in our cohort almost 61% (25/41) were affected
with autosomal recessive OI. Moreover, we document a 21-kb genomic deletion in
the TMEM38B gene identified in 29% (12/41) of the tested probands, making it the
most frequent OI-causing variant in the Palestinian population.
CONCLUSION: This is the first genetic screening of an OI cohort from the
Palestinian population. Our data are important for genetic counseling of OI
patients and families in highly consanguineous populations. |
Is Apremilast effective for Behcet’s syndrome? | Yes. Apremilast was proven to be effective for treatment of Behcet’s syndrome. | Apremilast (Otezla(®)), an oral small molecule inhibitor of type-4 cyclic
nucleotide phosphodiesterase (PDE-4), is under development with Celgene
Corporation for the treatment of psoriatic arthritis, psoriasis, ankylosing
spondylitis, Behçet's syndrome, atopic dermatitis, and rheumatoid arthritis.
Apremilast is indicated for the treatment of active psoriatic arthritis in
adults. Apremilast has received its first global approval for this indication in
the USA. Regulatory submissions for approval in this indication are under review
in Canada and Europe. Regulatory filings have also been submitted for apremilast
in the treatment of plaque psoriasis in the USA and Europe. This article
summarizes the milestones in the development of apremilast leading to its first
approval for the treatment of psoriatic arthritis. BACKGROUND: Oral ulcers, the hallmark of Behçet's syndrome, can be resistant to
conventional treatment; therefore, alternative agents are needed. Apremilast is
an oral phosphodiesterase-4 inhibitor that modulates several inflammatory
pathways.
METHODS: We conducted a phase 2, multicenter, placebo-controlled study in which
111 patients with Behçet's syndrome who had two or more oral ulcers were
randomly assigned to receive 30 mg of apremilast twice daily or placebo for 12
weeks. This regimen was followed by a 12-week extension phase in which the
placebo group was switched to apremilast and a 28-day post-treatment
observational follow-up phase. The patients and clinicians were unaware of the
study assignments throughout the trial. The primary end point was the number of
oral ulcers at week 12. Secondary outcomes included pain from these ulcers
(measured on a 100-mm visual-analogue scale, with higher scores indicating worse
pain), the number of genital ulcers, overall disease activity, and quality of
life.
RESULTS: The mean (±SD) number of oral ulcers per patient at week 12 was
significantly lower in the apremilast group than in the placebo group (0.5±1.0
vs. 2.1±2.6) (P<0.001). The mean decline in pain from oral ulcers from baseline
to week 12 was greater with apremilast than with placebo (-44.7±24.3 mm vs.
-16.0±32.5 mm) (P<0.001). Nausea, vomiting, and diarrhea were more common in the
apremilast group (with 22, 9, and 12 incidents, respectively, among 55 patients)
than in the placebo group (with 10, 1, and 2 incidents, respectively, among 56
patients), findings that were similar to those in previous studies of
apremilast. There were two serious adverse events in patients receiving
apremilast.
CONCLUSIONS: Apremilast was effective in treating oral ulcers, which are the
cardinal manifestation of Behçet's syndrome. This preliminary study was neither
large enough nor long enough to assess long-term efficacy, the effect on other
manifestations of Behçet's syndrome, or the risk of uncommon serious adverse
events. (Funded by Celgene; ClinicalTrials.gov number, NCT00866359.). Several studies were published last year which focused on the epidemiology,
immunopathogenesis, genetics, clinical manifestations and management of Behçet's
syndrome. Recent epidemiologic studies support the earlier contention that the
frequency of BS increases from North to South in Europe, BS is rare in
Sub-Saharan Africa, it follows a more severe course among young men, especially
if the disease onset is at a young age and that in European countries, the
frequency is higher among immigrants from BS prevalent countries compared to
locals living in the same environment. The relationship between HLA-B51 and
Behçet's was re-emphasised and a functional role affecting cellular cytotoxicity
was proposed. Innate immunity was explored and TLR7 copy number variations and
nucleic acid sensors of varying inflammasome pathways were studied. Vascular
relapse risk is decreased when BS patients are treated with immunosuppressives
with or without anti-coagulation rather than anti-coagulation alone. Although
rare in the Far East, the clinical picture of the vascular involvement was quite
similar to the previously published reports. Interestingly a female predomice
among those with cerebral vein thrombosis was noted. Venous claudication is a
frequent and severe symptom among BS patients with lower extremity DVT.
Budd-Chiari syndrome associated with BS is usually associated with IVC
thrombosis. Silent cases exist and have a better prognosis. The mortality rate
among the patients symptomatic for liver disease remains high. Methotrexate
seems to be effective in the treatment of chronic progressive neuro-Behçet's
disease. Renal involvement is an uncommon disorder in BS. Suicidal thoughts are
increased among BS patients with severe organ involvement. Work-related
disability in BS is high and under-appreciated. Apremilast, an inhibitor of
phosphodiesterase-4, was effective in a phase 2, double blind,
placebo-controlled study. Adalimumab seems to be effective in severe uveitis of
BS even after failure of infliximab. New cytokine inhibitors targeting IL-1 and
IL-6 appear to be effective especially for uveitis and CNS involvement
refractory to anti TNF agents. PURPOSE OF REVIEW: Current trends in the management of Behçet's syndrome will be
reviewed in this article.
RECENT FINDINGS: Biologic agents have gained increasing importance over the
years in the management of Behçet's syndrome. Long-term results of observational
studies have shown that anti-tumor necrosis factor agents may be effective in
Behçet's syndrome patients with refractory eye involvement. Case series
reporting about use of anti-tumor necrosis factor agents in vascular and
gastrointestinal involvement have also shown good results. Caution is required
for infectious complications with these agents. Apremilast is an
immunomodulatory agent that works through phosphodiesterase 4 inhibition. A
randomized controlled trial has shown that it is effective for the management of
oral and genital ulcers and is generally well tolerated.
SUMMARY: The outcome of Behçet's syndrome with major organ involvement has
improved with more effective management strategies, especially with the use of
biologic agents in severe cases. Controlled trials are needed to guide
physicians in making treatment decisions. INTRODUCTION: Behçet's syndrome (BS) is a systemic inflammatory disorder
characterized by a wide range of potential clinical manifestations with no
gold-standard therapy. However, the recent classification of BS at a crossroads
between autoimmune and autoinflammatory syndromes has paved the way to new
further therapeutic opportunities in addition to anti-tumor necrosis factor
agents.
AREAS COVERED: This review provides a digest of all current experience and
evidence about pharmacological agents recently described as having a role in the
treatment of BS, including interleukin (IL)-1 inhibitors, tocilizumab,
rituximab, alemtuzumab, ustekinumab, interferon-alpha-2a, and apremilast.
EXPERT OPINION: IL-1 inhibitors currently represent the most studied agents
among the latest treatment options for BS, proving to be effective, safe and
with an acceptable retention on treatment. However, since BS is a peculiar
disorder with clinical features responding to certain treatments that in turn
can worsen other manifestations, identifying new treatment options for patients
unresponsive to the current drug armamentarium is of great relevance. A number
of agents have been studied in the last decade showing changing fortunes in some
cases and promising results in others. The latter will potentially provide their
contribution for better clinical management of BS, improving patients' quality
of life and long-term outcome. |
Are splicing speckles associated with transcription? | Speckles contain little detectable transcriptional activity. | The NHPX protein is a nucleolar factor that binds directly to a conserved RNA
target sequence found in nucleolar box C/D snoRNAs and in U4 snRNA. Using
enhanced yellow fluorescent protein (EYFP)- and enhanced cyan fluorescent
protein-NHPX fusions, we show here that NHPX is specifically accumulated in both
nucleoli and Cajal bodies (CBs) in vivo. The fusion proteins display identical
localization patterns and RNA binding specificities to the endogenous NHPX.
Analysis of a HeLa cell line stably expressing EYFP-NHPX showed that the
nucleolar accumulation of NHPX was preceded by its transient accumulation in
splicing speckles. Only newly expressed NHPX accumulated in speckles, and the
nucleolar pool of NHPX did not interchange with the pool in speckles, consistent
with a unidirectional pathway. The transient accumulation of NHPX in speckles
prior to nucleoli was observed in multiple cell lines, including primary cells
that lack CBs. Inhibitor studies indicated that progression of newly expressed
NHPX from speckles to nucleoli was dependent on RNA polymerase II transcription,
but not on RNA polymerase I activity. The data show a specific temporal pathway
involving the sequential and directed accumulation of NHPX in distinct
subnuclear compartments, and define a novel mechanism for nucleolar
localization. "Splicing speckles" are major nuclear domains rich in components of the splicing
machinery and polyA(+) RNA. Although speckles contain little detectable
transcriptional activity, they are found preferentially associated with specific
mRNA-coding genes and gene-rich R bands, and they accumulate some unspliced
pre-mRNAs. RNA polymerase II transcribes mRNAs and is required for splicing,
with some reports suggesting that the inactive complexes are stored in splicing
speckles. Using ultrathin cryosections to improve optical resolution and
preserve nuclear structure, we find that all forms of polymerase II are present,
but not enriched, within speckles. Inhibition of polymerase activity shows that
speckles do not act as major storage sites for inactive polymerase II complexes
but that they contain a stable pool of polymerase II phosphorylated on serine(2)
residues of the C-terminal domain, which is transcriptionally inactive and may
have roles in spliceosome assembly or posttranscriptional splicing of pre-mRNAs.
Paraspeckle domains lie adjacent to speckles, but little is known about their
protein content or putative roles in the expression of the speckle-associated
genes. We find that paraspeckles are transcriptionally inactive but contain
polymerase II, which remains stably associated upon transcriptional inhibition,
when paraspeckles reorganize around nucleoli in the form of caps. The mechanisms of long-term adaptation to low oxygen environment are quite well
studied, but little is known about the sensing of oxygen shortage, the signal
transduction and the shortterm effects of hypoxia in plant cells. We have found
that an RNA helicase eIF4A-III, a putative component of the Exon Junction
Complex, rapidly changes its pattern of localisation in the plant nucleus under
hypoxic conditions. In normal cell growth conditions GFPeIF4A-III was mainly
nucleoplasmic, but in hypoxia stress conditions it moved to the nucleolus and
splicing speckles. This transition occurred within 15-20 min in Arabidopsis
culture cells and seedling root cells, but took more than 2 h in tobacco BY-2
culture cells. Inhibition of respiration, transcription or phosphorylation in
cells and ethanol treatment had similar effects to hypoxia. The most likely
consequence is that a certain mRNA population will remain bound to the eIF4A-III
and other mRNA processing proteins, rather than being transported from the
nucleus to the cytoplasm, and thus its translation will be suspended. Despite being densely packed with chromatin, nuclear bodies and a nucleoskeletal
network, the nucleus is a remarkably dynamic organelle. Chromatin loops form and
relax, RNA transcripts and transcription factors move diffusively, and nuclear
bodies move. We show here that RNA splicing speckled domains (splicing speckles)
fluctuate in constrained nuclear volumes and remodel their shapes. Small
speckles move in a directed way toward larger speckles with which they fuse.
This directed movement is reduced upon decreasing cellular ATP levels or
inhibiting RNA polymerase II activity. The random movement of speckles is
reduced upon decreasing cellular ATP levels, moderately reduced after inhibition
of SWI/SNF chromatin remodeling and modestly increased upon inhibiting RNA
polymerase II activity. To define the paths through which speckles can
translocate in the nucleus, we generated a pressure gradient to create flows in
the nucleus. In response to the pressure gradient, speckles moved along
curvilinear paths in the nucleus. Collectively, our results demonstrate a new
type of ATP-dependent motion in the nucleus. We present a model where recycling
splicing factors return as part of small sub-speckles from distal sites of RNA
processing to larger splicing speckles by a directed ATP-driven mechanism
through interchromatin spaces. |
What is miravirsen? | Miravirsen is the first miRNA-targeting drug for the treatment of hepatitis C. | BACKGROUND: MicroRNA-122 (miR-122) is an important host factor for hepatitis C
virus replication. Administration of miravirsen, an anti-miR-122
oligonucleotide, resulted in a dose dependent and prolonged decrease in HCV RNA
levels in chronic hepatitis C patients.
AIM: To assess the plasma level of various miRNAs in patients dosed with
miravirsen.
METHODS: We included 16 of 36 chronic hepatitis C patients who received five
injections of either 3 mg/kg (n = 4), 5 mg/kg (n = 4), 7 mg/kg (n = 4)
miravirsen or placebo (n = 4) over a 4-week period in a double-blind, randomised
phase 2a study. Plasma levels of 179 miRNAs were determined by qPCR and compared
between patients dosed with miravirsen or placebo.
RESULTS: Median plasma miR-122 level at baseline in patients receiving
miravirsen was 3.9 × 10(3) compared to 1.3 × 10(4) copies/4 μL in placebo-dosed
patients (P = 0.68). At week 1, 4, 6 and 10/12, patients dosed with miravirsen
had respectively a median 72-fold, 174-fold, 1109-fold and 552-fold lower
expression of miR-122 than at baseline (P = 0.001, as compared to patients
receiving placebo). At week 4 of dosing, miRNA-profiling demonstrated a
significant lower expression of miR-210 and miR-532-5p compared to baseline (3.0
and 4.7-fold lower respectively). However, subsequent longitudinal analysis
showed no significant differences in miR-210 and miR-532-5p plasma levels
throughout the study period.
CONCLUSIONS: We demonstrated a substantial and prolonged decrease in plasma
miR-122 levels in patients dosed with miravirsen. Plasma levels of other miRNAs
were not significantly affected by antagonising miR-122. Normothermic ex vivo liver perfusion (NEVLP) offers the potential to optimize
graft function prior to liver transplantation (LT). Hepatitis C virus (HCV) is
dependent on the presence of miRNA(microRNA)-122. Miravirsen, a locked-nucleic
acid oligonucleotide, sequesters miR-122 and inhibits HCV replication. The aim
of this study was to assess the efficacy of delivering miravirsen during NEVLP
to inhibit miR-122 function in a pig LT model. Pig livers were treated with
miravirsen during NEVLP or cold storage (CS). Miravirsen absorption, miR-122
sequestration, and miR-122 target gene derepression were determined before and
after LT. The effect of miravirsen treatment on HCV infection of hepatoma cells
was also assessed. NEVLP improved miravirsen uptake versus CS. Significant
miR-122 sequestration and miR-122 target gene derepression were seen with NEVLP
but not with CS. In vitro data confirmed miravirsen suppression of HCV
replication after established infection and prevented HCV infection with
pretreatment of cells, analogous to the pretreatment of grafts in the transplant
setting. In conclusion, miravirsen delivery during NEVLP is a potential strategy
to prevent HCV reinfection after LT. This is the first large-animal study to
provide "proof of concept" for using NEVLP to modify and optimize liver grafts
for transplantation. Only 20 years after the discovery of small non-coding, single-stranded
ribonucleic acids, so-called microRNAs (miRNAs), as post-transcriptional gene
regulators, the first miRNA-targeting drug Miravirsen for the treatment of
hepatitis C has been successfully tested in clinical Phase II trials. Addressing
miRNAs as drug targets may enable the cure, or at least the treatment of
diseases, which presently seems impossible. However, due to miRNAs' chemical
structure, generation of potential drug molecules with necessary pharmacokinetic
properties is still challenging and requires a re-thinking of the drug discovery
process. Therefore, this chapter highlights the potential of miRNAs as drug
targets, discusses the challenges, and tries to give a complete overview of
recent strategies in miRNA drug discovery. Ten years after Fire and Melo's Nobel Prize for discovery of gene silencing by
double-stranded RNA, a remarkable progress was achieved in RNA interference
(RNAi). Changes in the chemical structure of synthetic oligonucleotides make
them more stable and specific, and new delivery strategies became progressively
available. The attention of pharmaceutical industry rapidly turned to RNAi, as
an opportunity to explore new drug targets. This review addresses nine
small-interfering RNAs (siRNAs) and one unique microRNA (miRNA) inhibitor, which
entered the phase 2-3 clinical trials. The siRNAs in focus are PF-04523655,
TKM-080301, Atu027, SYL040012, SYL1001, siG12D-LODER (phase 2), QPI-1002,
QPI-1007, and patisiran (phase 3). Regarding miRNAs, their content can be down-
or up-regulated, by using miRNA inhibitors (AntimiRs) or miRNA mimics.
Miravirsen is an AntimiR-122 for hepatitis C virus infection. The flexibility of
RNAi technology is easily understood taking into account: (i) the different drug
targets (i.e. p53, caspase 2, PKN3, β2-adrenergic receptor, mutated KRAS,
microRNAs); (ii) therapeutic conditions, including ophthalmic diseases, kidney
injury, amyloidosis, pancreatic cancer, viral hepatitis; and (iii) routes of
administration (ocular, intravenous, subcutaneous, intratumoral). Although some
issues are still matters of concern (delivery, toxicity, cost, and biological
barriers), RNAi definitively opens a wide avenue for drug development. |
Centor criteria are used for which disease? | Centor criteria were developed to diagnose streptococcal pharyngitis. | STUDY OBJECTIVE: We evaluate the test characteristics and test for spectrum bias
of a rapid antigen test for group A beta-hemolytic streptococcal (GABHS)
pharyngitis among adults.
METHODS: Medical record and laboratory results of consecutive adult patients
receiving a rapid antigen test for GABHS in the emergency department or urgent
care clinic of an urban teaching hospital between August 1999 and December 1999
were analyzed. Patients were stratified according to the number of clinical
features present using the following modified Centor criteria: history of fever,
absence of cough, presence of pharyngeal exudate, and cervical lymphadenopathy.
The sensitivity of the rapid antigen test was defined as the number of patients
with positive rapid antigen test results divided by the number of patients with
either positive rapid antigen test results or negative rapid antigen test
results and positive throat culture results.
RESULTS: In the study sample of 498 patient visits, the prevalence of GABHS
pharyngitis was 28% (95% confidence interval [CI] 24% to 32%). The prevalence of
GABHS pharyngitis increased as modified Centor scores increased: 0 or 1=14%,
2=20%, 3=43%, and 4=52%. An increased number of modified Centor criteria (0 or
1, 2, 3, 4) was associated with increased rapid antigen test sensitivity (61%,
76%, 90%, and 97%, respectively) (Mantel-Haenszel trend test; P =.001).
CONCLUSION: The sensitivity of the rapid antigen test for GABHS is not a fixed
value but varies with the spectrum of disease. Among adults with 3 or 4 clinical
criteria for GABHS pharyngitis, further study may reveal that culture
confirmation of negative rapid antigen test results are not necessary. BACKGROUND: Rapid antigen detection testing (RADT) is often performed for
diagnosis of group A beta-hemolytic streptococcal (GABHS) pharyngitis among
children. Among adults, the sensitivity of this test varies on the basis of
disease severity (spectrum bias). A similar phenomenon may occur when this test
is used in a pediatric population, which may affect the need for culture
confirmation of all negative RADT results.
OBJECTIVES: To assess the performance of a clinical scoring system and to
determine whether RADT spectrum bias is present among children who are evaluated
for GABHS pharyngitis.
METHODS: Laboratory and clinical records for a consecutive series of pediatric
patients who underwent RADT at the Marshfield Clinic between January 2002 and
March 2002 were reviewed retrospectively. Patients were stratified according to
the number of clinical features present by using modified Centor criteria, ie,
history of fever, absence of cough, presence of pharyngeal exudates, and
cervical lymphadenopathy. The sensitivity of the RADT was defined as the number
of patients with positive RADT results divided by the number of patients with
either positive RADT results or negative RADT results but positive throat
culture results.
RESULTS: RADT results were positive for 117 of 561 children (21%), and culture
results were positive for 35 of 444 children (8%) with negative RADT results.
The overall prevalence of GABHS pharyngitis was 27% (95% confidence interval:
23-31%). The prevalence of GABHS pharyngitis was 18% among patients with 0
Centor criteria, 16% among those with 1 criterion, 32% among those with 2
criteria, and 50% among those with 3 or 4 criteria. Spectrum bias was present,
inasmuch as RADT sensitivity increased with Centor scores, ie, 47% sensitivity
among children with 0 Centor criteria, 65% among those with 1 criterion, 82%
among those with 2 criteria, and 90% among those with 3 or 4 criteria.
CONCLUSIONS: The sensitivity of RADT for GABHS pharyngitis is not a fixed value
but varies with the severity of disease. However, even among pediatric patients
with > or =3 Centor criteria for GABHS pharyngitis, the sensitivity of RADT is
still too low to support the use of RADT without culture confirmation of
negative results. OBJETIVO: Determinamos la validez de la técnica antigénica rápida (TAR) OSOM
StrepA Genzyme en el diagnóstico de la faringitis aguda causada por estreptococo
betahemolítico del grupo A (EBHGA).
DISEÑO: Estudio de pruebas diagnósticas.
EMPLAZAMIENTO: Equipo urbano de atención primaria.
PARTICIPANTES: Todos los pacientes mayores de 14 años atendidos en 6 consultas
con síntomas de odinofagia y 2 o más de los criterios de Centor (exudado
faringoamigdalar, adenopatías laterocervicales dolorosas, ausencia de tos y/o
historia o presencia de fiebre).
MEDICIONES PRINCIPALES: A todos los pacientes se les tomó una muestra
faringoamigdalar con 2 hisopos, uno para TAR y otro que fue remitido al servicio
de microbiología para realizar cultivo.
RESULTADOS: Fueron evaluables 182 sujetos, con una edad media de 30,6 ± 12,1
años, 116 mujeres (63,7%). Presentaron 2, 3 y 4 criterios de Centor 63, 83 y 36
sujetos, respectivamente. El cultivo fue positivo en 102 casos (56%),
observándose infección por EBHGA en 40 pacientes (22%; intervalo de confianza
[IC] del 95%, 21,2-22,8); en 26 casos se aisló estreptococo del grupo C (14,3%).
La infección por EBHGA presentó una mayor prevalencia entre los pacientes con 4
criterios (un 38,9% frente a un 25,3% observado con 3 criterios y frente al 7,9%
con 2 criterios; p < 0,001). La TAR tuvo una sensibilidad del 95%, una
especificidad del 93%, un valor predictivo positivo del 79,2% y un valor
predictivo negativo del 98,5%.
CONCLUSIONES: Estos resultados demuestran la utilidad de la TAR para el
diagnóstico de la faringitis estreptocócica. Su uso debería extenderse a todas
las consultas de atención primaria. The European Society for Clinical Microbiology and Infectious Diseases
established the Sore Throat Guideline Group to write an updated guideline to
diagnose and treat patients with acute sore throat. In diagnosis, Centor
clinical scoring system or rapid antigen test can be helpful in targeting
antibiotic use. The Centor scoring system can help to identify those patients
who have higher likelihood of group A streptococcal infection. In patients with
high likelihood of streptococcal infections (e.g. 3-4 Centor criteria)
physicians can consider the use of rapid antigen test (RAT). If RAT is
performed, throat culture is not necessary after a negative RAT for the
diagnosis of group A streptococci. To treat sore throat, either ibuprofen or
paracetamol are recommended for relief of acute sore throat symptoms. Zinc
gluconate is not recommended to be used in sore throat. There is inconsistent
evidence of herbal treatments and acupuncture as treatments for sore throat.
Antibiotics should not be used in patients with less severe presentation of sore
throat, e.g. 0-2 Centor criteria to relieve symptoms. Modest benefits of
antibiotics, which have been observed in patients with 3-4 Centor criteria, have
to be weighed against side effects, the effect of antibiotics on microbiota,
increased antibacterial resistance, medicalisation and costs. The prevention of
suppurative complications is not a specific indication for antibiotic therapy in
sore throat. If antibiotics are indicated, penicillin V, twice or three times
daily for 10 days is recommended. At the present, there is no evidence enough
that indicates shorter treatment length. INTRODUCTION: Centor criteria (fever >38.5°C, swollen, tender anterior cervical
lymph nodes, tonsillar exudate and absence of cough) are an algorithm to assess
the probability of group A β haemolytic Streptococcus (GABHS) as the origin of
sore throat, developed for adults. We wanted to evaluate the correlation between
Centor criteria and presence of GABHS in children with sore throat admitted to
our paediatric emergency department (PED).
DESIGN: Retrospective cohort study.
SETTING: The emergency department of a large tertiary university hospital in
Brussels, with over 20 000 yearly visits for children below age 16.
PARTICIPANTS: All medical records (from 2008 to 2010) of children between ages 2
and 16, who were diagnosed with pharyngitis, tonsillitis or sore throat and
having a throat swab culture for GABHS. Children with underlying chronic
respiratory, cardiac, haematological or immunological diseases and children who
had already received antibiotics (AB) prior to the PED consult were excluded.
Only records with a full disease history were selected. Out of a total 2118
visits for sore throats, 441 met our criteria. The children were divided into
two age groups, 2-5 and 5-16 years.
RESULTS: The prevalence of GABHS was higher in the older children compared to
the preschoolers (38.7 vs 27.6; p=0.01), and the overall prevalence was 32%.
There was no significant difference in the prevalence of GABHS for all different
Centor scores within an age group. Likelihood ratios (LR) demonstrate that none
of the individual symptoms or a Centor score of ≥3 seems to be effective in
ruling in or ruling out GABHS. Pooled LR (CI) for Centor ≥3 was 0.67 (CI 0.50 to
0.90) for the preschoolers and 1.37 (CI 1.04 to 1.79) for the older children.
CONCLUSIONS: Our results confirm the ineffectiveness of Centor criteria as a
predicting factor for finding GABHS in a throat swab culture in children. BACKGROUND: Diagnosing GABHS (Group A-beta Hemolytic Streptococcus)
tonsillopharyngitis by clinical scoring is a recommended approach in developed
countries, but there is still much controversy for low resource settings.
AIM: We aimed to assess the impact of Centor criteria with the support of
practical laboratory tests.
METHODS: We prospectively included patients complaining sore throat (N = 282).
We evaluated them in terms of Centor scoring and performed white blood cell
count (WBC), C-reactive protein (CRP), rapid antigen detecting test, and throat
culture.
RESULTS: In GABHS cases (N = 32, 11·3%), two of the criteria were observed to be
positive in more than half of the cases (N = 19, 59·3%), while 13 (40·7%) cases
met three/four criteria. The specificity of having two criteria was found to be
65·5% and increased to 91·5% after including CRP and WBC.
CONCLUSION: Centor criteria could be safely used to reduce unnecessary
antibiotic usage for tonsillopharyngitis in developing countries. BACKGROUND: Excessive antibiotics use increases the risk of resistance. Previous
studies have shown that the Centor score combined with Rapid Antigen Detection
Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic
prescribing in patients with sore throat. According to the former Swedish
guidelines RADT was recommended with 2-4 Centor criteria present and antibiotics
were recommended if the test was positive. C- reactive protein (CRP) was not
recommended for sore throats. Inappropriate use of RADT and CRP has been
reported in several studies.
METHODS: From a larger project 16 general practitioners (GPs) who stated
management of sore throats not according to the guidelines were identified.
Half-hour long semi-structured interviews were conducted. The topics were the
management of sore throats and the use of near-patient tests. Qualitative
content analysis was used.
RESULTS: The use of the near-patient test interplayed with the clinical
assessment and the perception that all infections caused by bacteria should be
treated with antibiotics. The GPs expressed a belief that the clinical picture
was sufficient for diagnosis in typical cases. RADT was not believed to be
relevant since it detects only one bacterium, while CRP was considered as a
reliable numerical measure of bacterial infection.
CONCLUSIONS: Inappropriate use of near-patient test can partly be understood as
remts of outdated knowledge. When new guidelines are introduced the
differences between them and the former need to be discussed more explicitly. OBJECTIVE: History, clinical examination and throat culture may be inadequate to
rule in or out the presence of group A streptococci (GAS) infection in patients
with sore throat in a remote location. We correlated the diagnostic accuracy for
guiding antibiotic prescription of clinical decision and physiological scoring
systems to a rapid diagnostic point of care (POC) test result in paediatric
patients presenting with sore throat.
METHODS: Prospective diagnostic accuracy study conducted between 30 June 2014
and 27 February 2015 in a remote Australian ED using a convenience sample. Among
paediatric patients presenting with sore throat, the Centor criteria and
clinical decision were documented. Simultaneously, patients without sore throat
or respiratory tract infection were tested to determine the number of carriers.
A throat swab on all patients was tested using a POC test (Alere TestPack +Plus
Strep A with on board control), considered as reference standard to detect GAS
infection.
RESULTS: A total of 101 patients with sore throat were tested with 26 (25.7%)
positive for GAS. One hundred and forty-seven patients without sore throat were
tested with one positive POC test result (specificity 99%; 95% CI 96-100).
Positive predictive value for clinician decision-making for a positive GAS swab
(bacterial infection) was 29% (95% CI 17-43), negative predictive value 78% (95%
CI 63-88). Area under ROC for the Centor score was 0.70 (95% CI 0.58-0.81).
CONCLUSION: Clinician judgement and Centor score are inadequate tools for
clinical decision-making for children presenting with sore throat. Adjunctive
POC testing provides sufficient accuracy to guide antibiotic prescription on
first presentation. OBJECTIVES: The UK 5 year antimicrobial resistance strategy recognizes the role
of point-of-care diagnostics to identify where antimicrobials are required, as
well as to assess the appropriateness of the diagnosis and treatment. A sore
throat test-and-treat service was introduced in 35 community pharmacies across
two localities in England during 2014-15.
METHODS: Trained pharmacy staff assessed patients presenting with a sore throat
using the Centor scoring system and patients meeting three or all four of the
criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield
group A streptococci. Patients with a positive throat swab test were offered
antibiotic treatment.
RESULTS: Following screening by pharmacy staff, 149/367 (40.6%) patients were
eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive
for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all
patients accessing the service. Just under half of patients that were not
showing signs of a bacterial infection (60/123, 48.8%) would have gone to their
general practitioner if the service had not been available.
CONCLUSIONS: This study has shown that it is feasible to deliver a
community-pharmacy-based screening and treatment service using point-of-care
testing. This type of service has the potential to support the antimicrobial
resistance agenda by reducing unnecessary antibiotic use and inappropriate
antibiotic consumption. Background Inappropriate use of antibiotic treatment for pharyngitis by
community pharmacists is prevalent in developing countries. Little is known
about how the pharmacists identify patients with bacterial pharyngitis.
Objective To ascertain the appropriateness of diagnosis of streptococcal
pharyngitis among Thai community pharmacists according to the Centor criteria
and to identify factors related to antibiotic dispensing. Setting 1040 Thai
community pharmacists. Method A cross-sectional survey of community pharmacists
was conducted in November 2012 to March 2013. The self-administered
questionnaires were mailed to 57 % of community pharmacists in the south of
Thailand (n = 1040). The survey included questions on diagnosis of streptococcal
pharyngitis, knowledge on pharyngitis, and attitudes and control beliefs
regarding antibiotic dispensing. Main outcome measure The appropriateness of
diagnosis of streptococcal pharyngitis according to the original and modified
Centor criteria and determits of antibiotic dispensing including demographic
characteristics of pharmacists, knowledge on pharyngitis, and attitudes and
control beliefs on antibiotic dispensing. Results Approximately 68 % completed
the questionnaires (n = 703). Compared to the pharmacists who reported not
dispensing antibiotics in the hypothetical case with common cold, those reported
dispensing antibiotics were more likely to consider the following
conditions-presence of cough, mild sore throat and patients with age >60 years
as cues for diagnosis of streptococcal pharyngitis (p < 0.05). The use of fewer
scores of the clinical prediction rules for diagnosis was observed in antibiotic
dispensers, compared to who did not do so (p < 0.005). Antibiotic dispensing was
positively associated with period of dispensing experience (>5 years) [odds
ratio (OR) 1.52; 95 % confidence interval (CI) 1.03-2.23], belief that
antibiotics could shorten duration of pharyngitis (OR 1.48; 95 % CI 1.11-1.99),
belief that antibiotics could prevent the complications (OR 1.44; 95 % CI
1.09-1.91) and belief that dispensing antibiotics could satisfy the patients (OR
1.31; 95 % CI 1.01-1.71). Nonetheless, antibiotic dispensing was negatively
associated with knowledge about pharyngitis (OR 0.83; 95 % CI 0.75-0.93).
Conclusion Pharmacists who are knowledgeable on the Centor criteria are more
likely to appropriately diagnose streptococcal pharyngitis and less likely to
dispense antibiotics in such case. Acute sore throat is a common presentation in primary care settings. We aimed to
improve our compliance with national antibiotic guidelines for sore throat
symptoms to 90% in 3 months' time period. The national guidelines are based on
Centor criteria. A retrospective audit of 102 patient records with sore throat
symptoms presenting between 1 January to 30 December 2015 showed that over 50%
were given antibiotics. Those who were prescribed antibiotics, 27% did not meet
NICE criteria and 85% of patients were given immediate antibiotic prescription.
Centor criteria was documented in just 2% of cases. Compliance with correct
antibiotic course length was 15%. Antibiotic choice and dose was correct in 94%
and 92% of cases respectively. Antibiotic frequency was correctly prescribed in
100% of patients. We introduced interventions that included oral and poster
presentations to multidisciplinary team, dissemination of guidelines through
internal e-mail and systemic changes to GP electronic patient record system
EMIS. This involved creating an automated sore throat template and information
page. On re-auditing of 71 patients, after two PDSA cycles, compliance with NICE
criteria was 87% with a significant reduction in immediate prescribing (66%).
Centor criteria documentation was 42%. Correct antibiotic course length was
prescribed in over 30% of cases. Other antibiotic regimen parameters (choice,
dose and frequency) were correct in 100% of cases. The initial results
demonstrated that significant changes were needed. In particular, reducing the
amount of antibiotics prescribed by increasing compliance with NICE criteria and
ensuring all parameters of antibiotic prescription were correct. We showed that
significant sustainable improvement is achievable through carefully devised
automated systemic changes that provides critical information in readily
accessible format, and does not solely rely on prescribers' knowledge and
initiative. The outcome of these interventions are a decrease in immediate
antibiotic prescription, significant increase in Centor criteria documentation
and an increase in compliance with the correct course length of antibiotics. All
these measures would contribute to reduction in antimicrobial resistance and
improvement in patient care in the community. Future work must focus on
improving compliance with correct antibiotic course length. The increased use of antibiotics for acute tonsillitis is a public health
problem. 80% of the antibiotic prescriptions for acute tonsillitis are done in
the Primary Care practice (PCP). The inappropriate use of the antibiotic causes
bacterial resistance and treatment failure. Only patients with acute tonsillitis
caused by Group A beta-hemolytic streptococcus (GAS) have benefit of the
antibiotic treatment, which is a predict cause in 5-20%. In order to assess the
antibiotic prescribing for acute tonsillitis by the doctors in the PCP in
Macedonia we use the data from the national project about antibiotic prescribing
for acute respiratory tract infections which was conducted in November 2014
during a period of 4 weeks as part of the E-quality program sponsored by the
IPCRG. 86 general practitioners from Macedonia have participated. The group of
1768 patients, from 4 months to 88 years of age, with diagnosis of acute
tonsillitis was analyzed. The antibiotic prescriptions according to the Centor
score criteria were compared to the Cochran's guidelines which are translated
and recommended as national guidelines. 88.8% of the patients with acute
tonsillitis were treated with antibiotics, of which 52.9% with Centor score 0 to
2 were treated inappropriate. The diagnosis is mostly made based on the clinical
picture and the symptoms. Only (23.6%) of the patients were treated with
antibiotics (Penicillin V and cephalexin) according to the guidelines. We
concluded that there is a low adherence to the national guidelines. The clinical
assessment is not accurate in determining the etiology. Also, there is a high
nonadherence in prescribing the first choice of antibiotics. We emphasize the
need to change the general practitioners' prescription behavior according to the
guidelines. INTRODUCTION: Both non-Group A streptococcal (non-GAS) pharyngitis and Group A
streptococcal (GAS) pharyngitis are commonly found in patients with sore throat.
It is not known whether or not they present with similar signs and symptoms
compared to patients with non-streptococcal pharyngitis.
METHODS: MEDLINE was searched for prospective studies that reported throat
culture for both GAS and non-GAS as a reference standard, and reported at least
one sign, symptom, or the Centor score. Summary estimates of sensitivity,
specificity, likelihood ratios (LR+ and LR-), and diagnostic odds ratios (DOR)
were calculated using a bivariate random effects model. Summary receiver
operating characteristic (ROC) curves were created for key signs and symptoms.
RESULTS: Eight studies met our inclusion criteria. Tonsillar exudate had the
highest LR+ for both GAS and non-GAS pharyngitis (1.53 versus 1.71). The
confidence intervals of sensitivity, LR+, LR-, and DOR for all signs, symptoms,
and the Centor score between two groups overlapped, with the relative difference
between sensitivities within 15% for arthralgia or myalgia, fever, injected
throat, tonsillar enlargement, and tonsillar exudate. Larger differences in
sensitivities were observed for sore throat, cervical adenopathy, and lack of a
cough, although the difference for lack of a cough largely due to a single
outlier.
DISCUSSION: Signs and symptoms of patients with GAS and non-GAS pharyngitis are
generally similar. No signs or symptoms clearly distinguish GAS from non-GAS
infection. Further work is needed to determine whether Group C streptococcus is
a pathogen that should be treated. |
Does Enzastaurin improve survival of glioblastoma patients? | No. Treatment with enzastaurin does not improve survival of glioblastoma patients. | PURPOSE: This phase III open-label study compared the efficacy and safety of
enzastaurin versus lomustine in patients with recurrent glioblastoma (WHO grade
4).
PATIENTS AND METHODS: Patients were randomly assigned 2:1 to receive 6-week
cycles of enzastaurin 500 mg/d (1,125-mg loading dose, day 1) or lomustine (100
to 130 mg/m(2), day 1). Assuming a 45% improvement in progression-free survival
(PFS), 397 patients were required to provide 80% power to achieve statistical
significance at a one-sided level of .025.
RESULTS: Enrollment was terminated at 266 patients (enzastaurin, n = 174;
lomustine, n = 92) after a planned interim analysis for futility. Patient
characteristics were balanced between arms. Median PFS (1.5 v 1.6 months; hazard
ratio [HR] = 1.28; 95% CI, 0.97 to 1.70), overall survival (6.6 v 7.1 months; HR
= 1.20; 95% CI, 0.88 to 1.65), and 6-month PFS rate (P = .13) did not differ
significantly between enzastaurin and lomustine, respectively. Stable disease
occurred in 38.5% and 35.9% of patients and objective response occurred in 2.9%
and 4.3% of patients, respectively. Time to deterioration of physical and
functional well-being and symptoms did not differ between arms (HR = 1.12; P =
.54). Four patients discontinued enzastaurin because of drug-related serious
adverse events (AEs). Eleven patients treated with enzastaurin died on study
(four because of AEs; one was drug-related). All four deaths that occurred in
patients receiving lomustine were disease-related. Grade 3 to 4 hematologic
toxicities were significantly higher with lomustine (46 events) than with
enzastaurin (one event; P < or = .001).
CONCLUSION: Enzastaurin was well tolerated and had a better hematologic toxicity
profile but did not have superior efficacy compared with lomustine in patients
with recurrent glioblastoma. INTRODUCTION: Antiangiogenic approaches are currently the dominating
experimental therapeutic strategy in glioblastoma. First enthusiasm was provoked
by promising radiological response rates and an apparent clinical benefit with
some of these agents. Major limitations include the modest number of durable
responses, the lack of cytotoxic antitumor activity, of synergy when combined
with chemotherapy and of an overall survival benefit.
AREAS COVERED: We review the rationale as well as preclinical and clinical
evidence for the future development of antiangiogenic agents in glioblastoma.
The most prominent approach targets VEGF and includes agents such as the VEGF
antibody bevacizumab, the VEGF receptor fusion protein aflibercept or the
tyrosine kinase inhibitors cediranib and XL-184. Inhibition of angiogenic
pathways by small molecules, for example, enzastaurin, or anti-integrin-based
approaches, for example, cilengitide, represent alternative strategies.
EXPERT OPINION: Enzastaurin and cediranib failed in randomized Phase III trials
in recurrent glioblastoma, aflibercept in Phase II. By contrast, bevacizumab was
conditionally approved in many countries. Recently completed Phase III trials
for bevacizumab and cilengitide in the first-line setting will define the future
role of these agents. This intense clinical trial activity reflects the hope
that antiangiogenic agents will become part of the limited therapeutic options
for glioblastoma. BACKGROUND: This study's primary objective was evaluation of the
progression-free survival rate at 6 months (PFS-6) in patients with newly
diagnosed glioblastoma without O(6)-methylguanine-DNA-methyltransferase (MGMT)
promoter hypermethylation postsurgically treated with enzastaurin before and
concomitantly with radiation therapy, followed by enzastaurin maintece
therapy. PFS-6 of at least 55% was set to be relevant compared with the data of
the EORTC 26981/22981 NCIC CE.3 trial.
METHODS: Adult patients with a life expectancy of at least 12 weeks who were
newly diagnosed with a histologically proven supratentorial glioblastoma without
MGMT promoter hypermethylation were eligible. Patients were treated with
enzastaurin prior to, concomitantly with, and after standard partial brain
radiotherapy. Here we report on a multicenter, open-label, uncontrolled phase II
study of patients with newly diagnosed glioblastoma without MGMT promoter
hypermethylation treated with enzastaurin and radiation therapy within 4 study
periods.
RESULTS: PFS-6 was 53.6% (95% confidence interval [CI]: 39.8-65.6). The median
overall survival was 15.0 months (95% CI: 11.9-17.9) for all patients, 3.9
months (95% CI: 0.8-9.0) for patients with biopsy, 15.4 months (95% CI:
10.1-17.9) for patients with partial resection, and 18.9 months (95% CI:
13.9-28.5) for patients with complete resection. The safety profile in this
study was as expected from previous trials, and the therapy was well tolerated.
CONCLUSIONS: PFS-6 missed the primary planned outcome of 55%. The secondary
exploratory analysis according to resection status of the different subgroups of
patients with biopsies, partial resection, and complete resection demonstrates
the strong prognostic influence of resection on overall survival. We evaluated the efficacy of combination enzastaurin (LY317615) and bevacizumab
for recurrent maligt gliomas and explored serologic correlates. We enrolled
81 patients with glioblastomas (GBM, n = 40) and anaplastic gliomas (AG,
n = 41). Patients received enzastaurin as a loading dose of 1125 mg, followed by
500 or 875 mg daily for patients on non-enzyme-inducing or enzyme-inducing
antiepileptics, respectively. Patients received bevacizumab 10 mg/kg
intravenously biweekly. Clinical evaluations were repeated every 4 weeks.
Magnetic resoce imaging was obtained at baseline and every 8 weeks from
treatment onset. Phosphorylated glycogen synthase kinase (GSK)-3 levels from
peripheral blood mononuclear cells (PBMCs) were checked with each MRI. Median
overall survival was 7.5 and 12.4 months for glioblastomas and anaplastic glioma
cohorts, with median progression-free survivals of 2.0 and 4.4 months,
respectively. Of GBM patients, 3/40 (7.5 %) were not evaluable, while 8/37
(22 %) had partial or complete response and 20/37 (54 %) had stable disease for
2+ months. Of the 39 evaluable AG patients, 18 (46 %) had an objective response,
and 16 (41 %) had stable disease for 2+ months. The most common grade 3+
toxicities were lymphopenia (15 %), hypophosphatemia (8.8 %) and thrombotic
events (7.5 %). Two (2.5 %) GBM patients died suddenly; another death (1.3 %)
occurred from intractable seizures. Phosphorylated GSK-3 levels from PBMCs did
not correlate with treatment response. A minimally important improvement in
health-related quality of life was self-reported in 7-9/24 (29.2-37.5 %). Early
response based on Levin criteria was significantly associated with significantly
longer progression free survival for glioblastomas. Enzastaurin (LY317615) in
combination with bevacizumab for recurrent maligt gliomas is well-tolerated,
with response and progression-free survival similar to bevacizumab monotherapy. INTRODUCTION: Glioblastoma, the most common maligt brain tumor, exhibits a
poor prognosis with little therapeutic progress in the last decade. Novel
treatment strategies beyond the established standard of care with
temozolomide-based radiotherapy are urgently needed.
AREAS COVERED: We reviewed the literature on glioblastoma with a focus on phase
III trials for pharmacotherapies and/or innovative concepts until December 2015.
EXPERT OPINION: In the last decade, phase III trials on novel compounds largely
failed to introduce efficacious pharmacotherapies beyond temozolomide in
glioblastoma. So far, inhibition of angiogenesis by compounds such as
bevacizumab, cediranib, enzastaurin or cilengitide as well as alternative dosing
schedules of temozolomide did not prolong survival, neither at primary diagnosis
nor at recurrent disease. Promising strategies of pharmacotherapy currently
under evaluation represent targeting epidermal growth factor receptor (EGFR)
with biomarker-stratified patient populations and immunotherapeutic concepts
including checkpoint inhibition and vaccination. The clinical role of the
medical device delivering 'tumor-treating fields' in newly diagnosed
glioblastoma which prolonged overall survival in a phase III study has remained
controversial. After failure of several phase III trials with previously
promising agents, improvement of concepts and novel compounds are urgently
needed to expand the still limited therapeutic options for the treatment of
glioblastoma. BACKGROUND: glioblastomas are highly vascularized tumors and various
antiangiogenic drugs have been investigated in clinical trials showing unclear
results. We performed a systematic review and a meta-analysis to clarify and
evaluate their effectiveness in glioblastoma patients.
PATIENTS AND METHODS: we searched relevant published and unpublished randomized
clinical trials analyzing antiangiogenic drugs versus chemotherapy in
glioblastoma patients from January 2006 to January 2016 in MEDLINE, WEB of
SCIENCE, ASCO, ESMO and SNO databases.
RESULTS: fourteen randomized clinical trials were identified (7 with
bevacizumab, 2 cilengitide, 1 enzastaurin, 1 dasatinib, 1 vandetanib, 1
temsirolimus, 1 cediranib) including 4330 patients. Antiangiogenic drugs showed
no improvement in overall survival with a pooled HR of 1.00, a trend for an
inferior outcome, in terms of overall survival, was observed in the group of
patients receiving antiangiogenic drug alone compared to cytotoxic drug alone
(HR=1.24, p=0.056). Bevacizumab did not improve overall survival. Twelve trials
(4113 patients) were analyzed for progression-free survival. Among
antiangiogenic drugs, only bevacizumab demonstrated an improvement of
progression-free survival (HR=0.63, p<0.001), both alone (HR=0.60, p=0.003) or
in combination to chemotherapy (HR=0.63; p<0.001), both as first-line treatment
(HR=0.70, p<0.001) or in recurrent disease (HR=0.52, p<0.001).
CONCLUSIONS: antiangiogenic drugs did not improve overall survival in
glioblastoma patients, either as first or second-line treatment, and either as
single agent or in combination with chemotherapy. Among antiangiogenic drugs,
only bevacizumab improved progression-free survival regardless of treatment
line, both as single agent or in combination with chemotherapy. |
Is Tofacitinib effective for Ulcerative Colitis? | Yes. Tofacitinib, an oral small-molecule Janus kinase inhibitor, is effective in the treatment of moderate-severe ulcerative colitis. It is also effective treatment of rheumatoid arthritis and autoimmune encephalomyelitis. | BACKGROUND: Ulcerative colitis is a chronic inflammatory disease of the colon
for which current treatments are not universally effective. One additional
treatment may be tofacitinib (CP-690,550), an oral inhibitor of Janus kinases 1,
2, and 3 with in vitro functional specificity for kinases 1 and 3 over kinase 2,
which is expected to block signaling involving gamma chain-containing cytokines
including interleukins 2, 4, 7, 9, 15, and 21. These cytokines are integral to
lymphocyte activation, function, and proliferation.
METHODS: In a double-blind, placebo-controlled, phase 2 trial, we evaluated the
efficacy of tofacitinib in 194 adults with moderately to severely active
ulcerative colitis. Patients were randomly assigned to receive tofacitinib at a
dose of 0.5 mg, 3 mg, 10 mg, or 15 mg or placebo twice daily for 8 weeks. The
primary outcome was a clinical response at 8 weeks, defined as an absolute
decrease from baseline in the score on the Mayo scoring system for assessment of
ulcerative colitis activity (possible score, 0 to 12, with higher scores
indicating more severe disease) of 3 or more and a relative decrease from
baseline of 30% or more with an accompanying decrease in the rectal bleeding
subscore of 1 point or more or an absolute rectal bleeding subscore of 0 or 1.
RESULTS: The primary outcome, clinical response at 8 weeks, occurred in 32%,
48%, 61%, and 78% of patients receiving tofacitinib at a dose of 0.5 mg
(P=0.39), 3 mg (P=0.55), 10 mg (P=0.10), and 15 mg (P<0.001), respectively, as
compared with 42% of patients receiving placebo. Clinical remission (defined as
a Mayo score ≤2, with no subscore >1) at 8 weeks occurred in 13%, 33%, 48%, and
41% of patients receiving tofacitinib at a dose of 0.5 mg (P=0.76), 3 mg
(P=0.01), 10 mg (P<0.001), and 15 mg (P<0.001), respectively, as compared with
10% of patients receiving placebo. There was a dose-dependent increase in both
low-density and high-density lipoprotein cholesterol. Three patients treated
with tofacitinib had an absolute neutrophil count of less than 1500.
CONCLUSIONS: Patients with moderately to severely active ulcerative colitis
treated with tofacitinib were more likely to have clinical response and
remission than those receiving placebo. (Funded by Pfizer; ClinicalTrials.gov
number, NCT00787202.). The inflammatory diseases ulcerative colitis and Crohn's disease constitute the
two main forms of inflammatory bowel disease (IBD). They are characterized by
chronic, relapsing inflammation of the gastrointestinal tract, significantly
impacting on patient quality of life and often requiring prolonged treatment.
Existing therapies for IBD are not effective for all patients, and an unmet need
exists for additional therapies to induce and maintain remission. Here we
describe the mechanism of action of the Janus kinase (JAK) inhibitor,
tofacitinib, for the treatment of IBD and the effect of JAK inhibition on the
chronic cycle of inflammation that is characteristic of the disease. The
pathogenesis of IBD involves a dysfunctional response from the innate and
adaptive immune system, resulting in overexpression of multiple inflammatory
cytokines, many of which signal through JAKs. Thus JAK inhibition allows
multiple cytokine signaling pathways to be targeted and is expected to modulate
the innate and adaptive immune response in IBD, thereby interrupting the cycle
of inflammation. Tofacitinib is an oral, small molecule JAK inhibitor that is
being investigated as a targeted immunomodulator for IBD. Clinical development
of tofacitinib and other JAK inhibitors is ongoing, with the aspiration of
providing new treatment options for IBD that have the potential to deliver
prolonged efficacy and clinically meaningful patient benefits. Cytokines orchestrate immune and inflammatory responses involved in the
pathogenesis of ulcerative colitis (UC). Protein kinases are essential for
signal transduction in eukaryotic cells. Janus kinases (JAKs) are a family of
protein tyrosine kinases that play a pivotal role in cytokine receptor
signaling. Indeed, a major subgroup of cytokines use Type I and II cytokine
receptors which signal via the activation of JAKs. Tofacitinib is an oral JAK
inhibitor that has been studied in autoimmune pathologies, including UC and
rheumatoid arthritis with good overall efficacy and acceptable safety profile.
This literature review was performed with the goal of summarizing the knowledge
on JAK inhibitors in UC treatment. BACKGROUND: Esophageal Crohn's disease is reported as a rare manifestation,
although its prevalence may be underestimated because upper endoscopies are not
routinely performed in asymptomatic adults. Tofacitinib, an oral janus kinase
inhibitor, is a new biologic that has shown promise in the treatment of
ulcerative colitis and may be effective in the treatment of Crohn's disease
according to phase 2 trials. We report the first case of esophageal Crohn's
disease successfully treated with tofacitinib in a patient with worsening
symptoms despite maintece therapy with a tumor necrosis factor-α inhibitor.
CASE PRESENTATION: A 67-year-old Caucasian woman presented with new dysphagia
and had findings of esophageal Crohn's disease on endoscopy. The dosage of her
current biologic therapy-adalimumab-was increased in frequency, without
improvement. Our patient was started on tofacitinib and demonstrated an
improvement in symptoms, with a repeat endoscopy showing resolution of the
previous lesions.
CONCLUSION: Esophageal Crohn's disease is likely underdiagnosed but is an
important consideration in a patient with new symptoms of dysphagia and known
Crohn's disease. Tofacitinib, while a novel agent, could have a role in the
treatment of esophageal Crohn's disease that does not improve with
intensification of the current biologic therapy. It provides a different
mechanism in patients who become refractory to maintece therapy. Recently, several medical treatments for ulcerative colitis (UC) have been
developed, including 5-aminosalicylic acids (5-ASAs), corticosteroids,
thiopurine, calcineurin inhibitors, and anti-tumor necrosis factor (TNF) α
treatments. Treatment options including calcineurin inhibitors and anti-TNF
treatment for refractory UC are discussed in this article. Furthermore, upcoming
treatments are introduced, such as golimumab, vedolizumab, AJM300, tofacitinib.
Budesonide foamwill be used as one treatment option in patients with distal
colitis. Herbal medicine, such as Qing-Dai is also effective for active UC and
may be useful for patients who are refractory to anti-TNFα treatments. In the
near future, physicians will able to use many different treatments for UC
patients. However, we should not forget 5-ASA and corticosteroids as the
fundamental treatments for UC patients. BACKGROUND: Tofacitinib, an oral, small-molecule Janus kinase inhibitor, was
shown to have potential efficacy as induction therapy for ulcerative colitis in
a phase 2 trial. We further evaluated the efficacy of tofacitinib as induction
and maintece therapy.
METHODS: We conducted three phase 3, randomized, double-blind,
placebo-controlled trials of tofacitinib therapy in adults with ulcerative
colitis. In the OCTAVE Induction 1 and 2 trials, 598 and 541 patients,
respectively, who had moderately to severely active ulcerative colitis despite
previous conventional therapy or therapy with a tumor necrosis factor antagonist
were randomly assigned to receive induction therapy with tofacitinib (10 mg
twice daily) or placebo for 8 weeks. The primary end point was remission at 8
weeks. In the OCTAVE Sustain trial, 593 patients who had a clinical response to
induction therapy were randomly assigned to receive maintece therapy with
tofacitinib (either 5 mg or 10 mg twice daily) or placebo for 52 weeks. The
primary end point was remission at 52 weeks.
RESULTS: In the OCTAVE Induction 1 trial, remission at 8 weeks occurred in 18.5%
of the patients in the tofacitinib group versus 8.2% in the placebo group
(P=0.007); in the OCTAVE Induction 2 trial, remission occurred in 16.6% versus
3.6% (P<0.001). In the OCTAVE Sustain trial, remission at 52 weeks occurred in
34.3% of the patients in the 5-mg tofacitinib group and 40.6% in the 10-mg
tofacitinib group versus 11.1% in the placebo group (P<0.001 for both
comparisons with placebo). In the OCTAVE Induction 1 and 2 trials, the rates of
overall infection and serious infection were higher with tofacitinib than with
placebo. In the OCTAVE Sustain trial, the rate of serious infection was similar
across the three treatment groups, and the rates of overall infection and herpes
zoster infection were higher with tofacitinib than with placebo. Across all
three trials, adjudicated nonmelanoma skin cancer occurred in five patients who
received tofacitinib and in one who received placebo, and adjudicated
cardiovascular events occurred in five who received tofacitinib and in none who
received placebo; as compared with placebo, tofacitinib was associated with
increased lipid levels.
CONCLUSIONS: In patients with moderately to severely active ulcerative colitis,
tofacitinib was more effective as induction and maintece therapy than
placebo. (Funded by Pfizer; OCTAVE Induction 1, OCTAVE Induction 2, and OCTAVE
Sustain ClinicalTrials.gov numbers, NCT01465763 , NCT01458951 , and NCT01458574
, respectively.). As our medical armamentarium for IBD continues to expand, it is essential that
clinicians understand both optimizing and sequencing of individual and
combination therapeutic approaches with available medications. Areas covered:
This review summarizes dosing strategies and therapeutic drug monitoring for
pharmacologic optimization in IBD. Aminosalicylates remain first-line therapies
for mild-to-moderate UC but have limited evidence of efficacy in CD. Budesonide
provides an alternative to aminosalicylates when targeted to appropriate sites
in the distal small bowel and colon, as do conventional corticosteroids when
applied rectally. Systemic steroids are highly efficacious but burdened by
toxicity. Thiopurines or methotrexate can be utilized as steroid-sparing agents.
Biologic agents targeting TNF remain important for steroid-sparing therapy in
moderate-to-severe UC and CD. Newer biologics targeting lymphocyte trafficking
and lymphocyte activation are also efficacious for moderate-to-severe IBD. Near
future conventional drug options include oral agents such as tofacitinib and
mongersen. Expert commentary: Positioning therapies according to the location,
phenotypes, and severity, as well as the use of therapeutic and clinical
targets, will improve outcomes and minimize toxicities and therapeutic
futilities. Future IBD treatment should focus on personalized therapy plans
based on genetic determits, targeted mechanisms of action, and pharmacologic
optimization. OBJECTIVES: Various investigational medicinal products have been developed for
ulcerative colitis (UC). Our aim was to systematically evaluate novel
pharmacological therapeutic agents for the treatment of UC.
MATERIAL AND METHODS: Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) recommendations were followed. A search of the medical
literature was conducted in the MEDLINE database for original research papers
published between 01 January 2010 and 31 October 2014.
RESULTS: Twenty one studies, including 11,524 adults were analyzed. Thirteen
different novel therapeutic drug options were identified. Vedolizumab and
golimumab were superior to placebo as induction and maintece therapy.
Tofacitinib showed dose related efficacy for induction therapy. Etrolizumab
showed higher clinical remission rates compared to placebo. Phosphatidylcholine
led to an improved clinical activity index. HMPL-004 may become a mesalamine
alternative for mild to moderate UC. PF00547,659 was well tolerated. Statins
were not beneficial for acute exacerbations of UC. Abatacept, rituximab and
visilizumab did not lead to improved outcomes compared to placebo. Higher
concentration of BMS 936557 was associated with improved efficacy compared to
placebo. Basiliximab did not enhance corticosteroid efficacy.
CONCLUSIONS: Patients with UC might achieve clinical response or remission by
utilizing some of these agents with a favorable side effect profile. Further
studies are needed to evaluate their short- and long-term efficacy and safety. Atherosclerosis is a chronic inflammatory cardiovascular disease with high
mortality worldwide. Tofacitinib (CP-690,550), an oral small-molecule Janus
kinase inhibitor, has been shown to be effective in the treatment of rheumatoid
arthritis, autoimmune encephalomyelitis and ulcerative colitis. However, its
protective effect against atherosclerosis remains poorly understood. The aim of
the present study was to evaluate the effects of Tofacitinib on atherogenic diet
(ATD)-induced atherosclerosis using apolipoprotein E deficient (apoE-/-) mice.
Atherosclerosis-prone apoE-/- mice were fed with ATD and treated with or without
Tofacitinib through intragastrical administration (10 mg kg-1 day-1) for 8
weeks. Our results showed that Tofacitinib did not change plasma lipids, while
significantly reduced the levels of plasma pro-inflammatory cytokines IL-6 and
TNF-α. It also significantly attenuated atherosclerotic plaque lesion in the
aortic root and macrophages contained in plaque as shown with Mac2
immuno-staining. Peritoneal macrophages (PMC) were separated from apoE-/- mice
fed with 8-week ATD, and then subjected to inflammation tests. Flow cytometry
analysis of F4/80 and CD206 and mRNA levels of M1 and M2 macrophages markers
showed that M1 macrophages decreased while M2 macrophages increased in
Tofacitinib treated group. Expressions of other inflammatory genes also
indicated an anti-inflammatory status in mice treated with Tofacitinib. Ox-LDL
was used to induce foam cell formation from PMC in wild type mice, and the
results displayed a reduced formation of foam cells and decreased inflammation
in mice with Tofacitinib administration (1 μM). The mRNA and protein levels of
ATP binding cassette subfamily A member 1 (ABCA1), a key gene involved in
cholesterol efflux, remarkably increased, while it was absence of alterations in
scavenger receptors expression. Therefore, we demonstrated that Tofacitinib
could attenuate atherosclerosis and foam cells formation by inhibiting
inflammation and upregulating ABCA1 expression. Tofacitinib, a non-selective Janus kinase (JAK) inhibitor, is effective in
inducing clinical and endoscopic remission in patients with active ulcerative
colitis (UC). Tofacitinib inhibits cytokine signalling through blockade of JAK1,
JAK2, JAK3 and tyrosine kinase 2 (TYK2). Adverse events including neutropenia
and anaemia resulting from JAK2 inhibition have been observed in actively
treated patients. By selectively targeting JAK1, such adverse events could be
expected to be avoided. This open label study was designed to enrol 15 patients
with UC, however the trial was discontinued after two inclusions due to safety
concerns with the agent in a parallel trial for systemic lupus erythematosus.
GSK2586184 was administered in two patients with moderate-to-severe UC. The JAK1
selective inhibitor GSK2586184 was well tolerated and induced clinical and
endoscopic response in two patients with moderate-to-severe UC. In addition,
treatment with GSK2586184 decreased histology scores and faecal calprotectin
levels at early withdrawal. |
Which are the main transcriptional activators of circadian oscillations? | Mammalian CLOCK and BMAL1 are two members of bHLH-PAS-containing family of transcription factors that represent the positive elements of circadian autoregulatory feedback loop. | Transcriptional regulation appears to be fundamental to circadian oscillations
of clock gene expression. These oscillations are believed to control output
rhythms. The transcriptional feedback loop and a model of interlocked loops have
been proposed as the basis for these oscillations. We characterized the genomic
structure of the mouse Bmal1 gene (mBmal1) and defined the mBmal1 promoter
region. Transcription of mBmal1 was activated by CRY1, CRY2, and PER2, and was
repressed by BMAL1-CLOCK dimers. Therefore, CRY, PER2, and BMAL1-CLOCK play
bidirectional roles in transcription when they are at high levels by late day
and midnight, respectively. This underlies the opposite phase of BMAL1 compared
to CRY and PER. We propose that a BMAL1 negative feedback loop interlocks with
the CRY and PER2 negative feedback loop by inter-activation, forming a third
positive forward loop. This transcriptional model suggests a molecular basis for
the maintece of stability, persistence, and period of circadian rhythms. The
transcriptional potency of CRY is predomit within the mammalian clock,
suggesting a clearance mechanism for CRY in period maintece. (c)2002 Elsevier
Science (USA). Mammalian CLOCK and BMAL1 are two members of bHLH-PAS-containing family of
transcription factors that represent the positive elements of circadian
autoregulatory feedback loop. In the form of a heterodimer, they drive
transcription from E-box enhancer elements in the promoters of responsive genes.
We have examined abundance, posttranslational modifications, cellular
localization of endogenous and ectopically expressed CLOCK and BMAL1 proteins.
Nuclear/cytoplasm distribution of CLOCK was found to be under circadian
regulation. Analysis of subcellular localization of CLOCK in embryo fibroblasts
of mice carrying different germ-line circadian mutations showed that circadian
regulation of nuclear accumulation of CLOCK is BMAL1-dependent. Formation of
CLOCK/BMAL1 complex following ectopic coexpression of both proteins is followed
by their codependent phosphorylation, which is tightly coupled to CLOCK nuclear
translocation and degradation. This binding-dependent coregulation is specific
for CLOCK/BMAL1 interaction, as no other PAS domain protein that can form a
complex with either CLOCK or BMAL1 was able to induce similar effects.
Importantly, all posttranslational events described in our study are coupled
with active transactivation complex formation, which argues for their
significant functional role. Altogether, these results provide evidence for an
additional level of circadian system control, which is based on regulation of
transcriptional activity or/and availability of CLOCK/BMAL1 complex. BACKGROUND: The circadian expression of the mammalian clock genes is based on
transcriptional feedback loops. Two basic helix-loop-helix (bHLH) PAS (for
Period-Arnt-Sim) domain-containing transcriptional activators, CLOCK and BMAL1,
are known to regulate gene expression by interacting with a promoter element
termed the E-box (CACGTG). The non-canonical E-boxes or E-box-like sequences
have also been reported to be necessary for circadian oscillation.
RESULTS: We report a new cis-element required for cell-autonomous circadian
transcription of clock genes. This new element consists of a canonical E-box or
a non-canonical E-box and an E-box-like sequence in tandem with the latter with
a short interval, 6 base pairs, between them. We demonstrate that both E-box or
E-box-like sequences are needed to generate cell-autonomous oscillation. We also
verify that the spacing nucleotides with constant length between these 2
E-elements are crucial for robust oscillation. Furthermore, by in silico
analysis we conclude that several clock and clock-controlled genes possess a
direct repeat of the E-box-like elements in their promoter region.
CONCLUSION: We propose a novel possible mechanism regulated by double E-box-like
elements, not to a single E-box, for circadian transcriptional oscillation. The
direct repeat of the E-box-like elements identified in this study is the minimal
required element for the generation of cell-autonomous transcriptional
oscillation of clock and clock-controlled genes. In the vertebrate circadian feedback loop, CLOCK:BMAL heterodimers induce the
expression of Cry genes. The CRY proteins in turn inhibit CLOCK:BMAL-mediated
transcription closing the negative feedback loop. Four CRYs, which all inhibit
CLOCK:BMAL-mediated transcription, exist in zebrafish. Although these zebrafish
Crys (zCry1a, 1b, 2a, and 2b) show a circadian pattern of expression, previous
studies have indicated that the circadian oscillation of zCry1a could be
CLOCK:BMAL-independent. Here we show that abrogation of CLOCK:BMAL-dependent
transcription in zebrafish cells by the domit negative zCLOCK3-DeltaC does
not affect the circadian oscillation of zCry1a. Moreover, we provide several
lines of evidence indicating that the extracellular signal-regulated kinase
(ERK) signaling cascade modulates the circadian expression of zCry1a gene in
constant darkness. Taken together, our data strongly support the notion that
circadian oscillation of zCry1a is CLOCK:BMAL-independent and further indicate
that mechanisms involving non-canonical clock genes could contribute to the
circadian expression of zCry1a gene in a cell autonomous manner. The mammalian circadian oscillator is composed of interacting positive and
negative transcription events. The clock proteins PER1 and PER2 play essential
roles in a negative limb of the feedback loop that generates the circadian
rhythm in mammals. In addition, the proteins CLOCK and BMAL1 (also known as
ARNTL) form a heterodimer that drives the Per genes via the E-box consensus
sequences within their promoter regions. In the present study, we demonstrate
that Id2 is involved in stabilization of the amplitudes of the circadian
oscillations by suppressing transcriptional activation of clock genes Clock and
Bmal1. Id2 shows dynamic oscillation in the SCN, with a peak in the late
subjective night. Under constant dark conditions (DD), Id2(-/-) mice showed no
apparent difference in locomotor activity, however, under constant light
conditions (LL), Id2(-/-) mice exhibit aberrant locomotor activity, with lower
circadian oscillation amplitudes, although the free running periods in Id2(-/-)
mice show no differences from those in either wild type or heterozygous mice.
Id2(-/-) animals also exhibit upregulation of Per1 in constant light, during
both the subjective night and day. In wild type mice, Id2 is upregulated by
constant light exposure during the subjective night. We propose that Id2
expression in the SCN contributes to maintece of dynamic circadian
oscillations. |
Is CREB a key memory protein? | The creb protein is associated with memory | One of the key issues pertaining to the control of memory is to respond to a
consistently changing environment or microbial niche present in it. Human cyclic
AMP response element binding protein (CREB) transcription factor which plays a
crucial role in memory has a homolog in C. elegans, crh-1. crh-1 appears to
influence memory processes to certain extent by habituation of the host to a
particular environment. The discrimination between the pathogen and a
non-pathogen is essential for C. elegans in a microbial niche which determines
its survival. Training the nematodes in the presence of a virulent pathogen (S.
aureus) and an opportunistic pathogen (P. mirabilis) separately exhibits a
different behavioural paradigm. This appears to be dependent on the CREB
transcription factor. Here we show that C. elegans homolog crh-1 helps in memory
response for a short term against the interacting pathogens. Following
conditioning of the nematodes to S. aureus and P. mirabilis, the wild type
nematodes exhibited a positive response towards the respective pathogens which
diminished slowly after 2h. By contrast, the crh-1 deficient nematodes had a
defective memory post conditioning. The molecular data reinforces the importance
of crh-1 gene in retaining the memory of nematode. Our results also suggest that
involvement of neurotransmitters play a crucial role in modulating the memory of
the nematode with the assistance of CREB. Therefore, we elucidate that CREB is
responsible for the short term memory response in C. elegans against bacterial
pathogens. Author information:
(1)Departament de Farmacología, Toxicología I Química Terapéutica, Facultat de
Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona,
Spain.
(2)Departament de Bioquímica, Facultat de Medicina i Ciències de la Salut,
Universitat Rovira i Virgili, Reus, Spain.
(3)Biomedical Research Networking Center in Neurodegenerative Diseases
(CIBERNED), Madrid, Spain.
(4)Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain.
(5)Unitat de Farmacia, Tecnologia Farmacèutica i Fisico-química, Facultat de
Farmàcia, Universitat de Barcelona, Barcelona, Spain.
(6)Institute of Nanoscience and Nanotechnology (IN2UB), University of Barcelona,
Barcelona, Spain.
(7)Department of Biological Sciences, Kent State University, Kent, OH, USA.
(8)Departamento de Biología Celular y Molecular, Laboratorio de Regeneración y
Desarrollo Neural, Instituto de Neurobiología, CUCBA, Mexico.
(9)Neuroscience Group, Instituto de Investigacion Hospital 12 de Octubre,
Madrid, Spain.
(10)Departament de Biologia Cel•lular, Fisiologia i Immunologia, Facultat de
Biologia, Universitat de Barcelona, Barcelona, Spain.
(11)Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud,
Universidad Autónoma de Chile, Talca, Chile.
(12)Departament de Farmacología, Toxicología I Química Terapéutica, Facultat de
Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona, Barcelona,
Spain. [email protected].
(13)Biomedical Research Networking Center in Neurodegenerative Diseases
(CIBERNED), Madrid, Spain. [email protected].
(14)Institut de Neurociències, Universitat de Barcelona, Barcelona, Spain.
[email protected].
(15)Unitat de Farmacologia i Farmacognosia, Facultat de Farmàcia i Ciències de
l'Alimentació, Universitat de Barcelona, Barcelona, Spain. Av. Joan XXIII s/n,
E-08028, Barcelona, Spain. [email protected]. |
Which clinical trials for psoriasis involved tofacitinib? (November 2017) | Four phase 3 clinical trials have been performed to assess tofacitinib in psoriasis patients: OPT Retreatment, OPT Pivotal 1, OPT Pivotal 2, OPT Compare | BACKGROUND: Tofacitinib is an oral Janus kinase inhibitor that is being
investigated for psoriasis. Psoriasis impacts on physical and psychological
well-being; improvements in health-related quality of life (HRQoL) with
etanercept in psoriasis are well documented.
OBJECTIVE: To evaluate HRQoL with tofacitinib, vs. placebo or etanercept, in the
Phase 3, randomized, placebo-controlled, non-inferiority, Oral-treatment
Psoriasis Trial (OPT) Compare Study (NCT01241591).
METHODS: Adults with moderate to severe chronic plaque psoriasis were randomized
3:3:3:1 to tofacitinib 10 or 5 mg twice daily (BID), etanercept 50 mg twice
weekly or placebo, for 12 weeks. Patient-reported outcomes (PROs) included
Dermatology Life Quality Index (DLQI), Itch Severity Item and Patient Global
Assessment of psoriasis.
RESULTS: At baseline, 83.4% (911/1092) of patients had a DLQI score ranging
between 6 and 30, indicating a substantial burden of disease. By Week 12, 47.3%,
43.6% and 30.9% of patients in the tofacitinib 10 mg BID, etanercept and
tofacitinib 5 mg BID groups, respectively, had a DLQI score of 0 or 1 (no effect
of psoriasis on QoL) vs. 7.8% for placebo (all P < 0.0001). Tofacitinib
significantly reduced itch vs. placebo (P < 0.05 both doses) and etanercept (P <
0.0001 both doses) within 1 day of starting treatment. Furthermore, reductions
in itch were greater with tofacitinib 10 mg BID, vs. etanercept, at Weeks 2-12
(all time points P < 0.05). At Week 2, an Itch Severity Item score of 'little or
no itch' was more frequent with tofacitinib 10 mg (68.6%) vs. etanercept (57.4%)
and placebo (12.2%), and the PtGA response rate was significantly greater with
tofacitinib 10 mg vs. placebo (P < 0.05).
CONCLUSION: Oral tofacitinib provided significant improvements across multiple
PROs by Week 12. Improvements with tofacitinib 10 mg BID were comparable to
etanercept, and improvements in itch were greater and more rapid with
tofacitinib 10 mg BID. BACKGROUND: Tofacitinib is an oral Janus kinase inhibitor being investigated for
psoriasis. A Phase 3 withdrawal/re-treatment study (NCT01186744; OPT
Retreatment) showed tofacitinib re-treatment was effective in patients with
chronic plaque psoriasis.
OBJECTIVES: To describe the effects of tofacitinib withdrawal/re-treatment on
health-related quality of life (HRQoL) and disease symptoms measured by
patient-reported outcomes (PROs).
METHODS: The study was divided into initial treatment, treatment withdrawal, and
re-treatment periods. Initial treatment: patients were randomized to receive
tofacitinib 5 (n = 331) or 10 mg (n = 335) BID for 24 weeks. Treatment
withdrawal: patients who achieved both ≥ 75% reduction in Psoriasis Area and
Severity Index (PASI) score from baseline and Physician's Global Assessment of
'clear'/'almost clear' at Week (W)24 received placebo (withdrawal) or the
previous dose (continuous treatment). Re-treatment: at relapse (> 50% loss of
W24 PASI response) or at W40, patients received their initial tofacitinib dose.
PROs included: Dermatology Life Quality Index (DLQI), Itch Severity Item (ISI),
Short Form-36 (SF-36) and Patient's Global Assessment (PtGA).
RESULTS: After initial treatment with tofacitinib 5 and 10 mg BID, substantial
and significant improvements were reported for mean DLQI (baseline: 12.6 and
12.6; W24: 5.1 and 2.6) and ISI (baseline: 6.7 and 6.9; W24: 2.9 and 1.6).
Patients continuously treated with tofacitinib 5 and 10 mg BID maintained those
improvements through Week 56 (DLQI: 3.0 and 2.1; ISI: 2.3 and 1.4). By W40,
patients withdrawn from tofacitinib 5 and 10 mg BID showed worsening in DLQI
(5.0 and 6.2) and ISI (3.7 and 4.0) scores; improvements were regained upon
re-treatment (W56, DLQI: 3.4 and 2.4; ISI: 2.2 and 1.6). Similar results were
reported for PtGA and SF-36.
CONCLUSION: Continuous tofacitinib treatment provided sustained improvement in
HRQoL and disease symptoms. Patients randomized to treatment withdrawal lost
initial improvements. Upon re-treatment, improvements were recaptured to levels
comparable to those seen with continuous treatment. BACKGROUND: Tofacitinib is an oral Janus kinase inhibitor. Efficacy and safety
of tofacitinib in patients with moderate-to-severe plaque psoriasis have been
demonstrated.
OBJECTIVE: We sought to assess the efficacy of tofacitinib for the treatment of
nail psoriasis over a period of 52 weeks.
METHODS: In 2 identical phase 3 studies (OPT Pivotal 1 and 2), patients were
randomized 2:2:1 to receive tofacitinib 5 mg, tofacitinib 10 mg, or placebo,
twice daily. At week 16, placebo-treated patients were re-randomized to
tofacitinib. This post hoc analysis of patients with existing nail psoriasis
assessed the Nail Psoriasis Severity Index (NAPSI) score and proportions of
patients achieving ≥50% reduction in NAPSI from baseline (NAPSI50), NAPSI75, or
NAPSI100.
RESULTS: Baseline mean NAPSI scores for patients treated with tofacitinib
5 mg (N = 487), tofacitinib 10 mg (N = 476), and placebo (N = 233) twice daily
were 27.0, 27.3, and 26.9, respectively. At week 16, significantly (all P < .05)
more patients receiving tofacitinib 5 mg and tofacitinib 10 mg versus placebo
twice daily achieved NAPSI50 (32.8%, 44.2% vs 12.0%), NAPSI75 (16.9%, 28.1% vs
6.8%), and NAPSI100 (10.3%, 18.2% vs 5.1%), respectively. Improvements were
sustained to week 52.
LIMITATIONS: Limitations include discontinuation of clinical nonresponders at
week 28.
CONCLUSIONS: Tofacitinib treatment resulted in improvements in nail psoriasis
versus placebo at week 16; improvements were maintained over 52 weeks
[NCT01276639; NCT01309737]. |
Which two interleukins are inhibited by Ustekinumab? | Ustekinumab, a monoclonal antibody that binds to the shared p40 subunit of interleukin-12 and interleukin-23, is approved in the USA and Europe for moderate to severe plaque psoriasis. | BACKGROUND: Interleukins 12 and 23 have important roles in the pathophysiology
of psoriasis. We assessed ustekinumab, a human monoclonal antibody directed
against these cytokines, for the treatment of psoriasis.
METHODS: In this phase III, parallel, double-blind, placebo-controlled study,
766 patients with moderate-to-severe psoriasis were randomly assigned to receive
ustekinumab 45 mg (n=255) or 90 mg (n=256) at weeks 0 and 4 and then every 12
weeks; or placebo (n=255) at weeks 0 and 4, with subsequent crossover to
ustekinumab at week 12. Patients who were initially randomised to receive
ustekinumab at week 0 who achieved long-term response (at least 75% improvement
in psoriasis area and severity index [PASI 75] at weeks 28 and 40) were
re-randomised at week 40 to maintece ustekinumab or withdrawal from treatment
until loss of response. Both randomisations were done with a minimisation method
via a centralised interactive voice response system. The primary endpoint was
the proportion of patients achieving PASI 75 at week 12. Analyses were by
intention to treat. This study is registered with ClinicalTrials.gov, number
NCT00267969.
FINDINGS: All randomised patients were included in the efficacy analysis. 171
(67.1%) patients receiving ustekinumab 45 mg, 170 (66.4%) receiving ustekinumab
90 mg, and eight (3.1%) receiving placebo achieved PASI 75 at week 12
(difference in response rate vs placebo 63.9%, 95% CI 57.8-70.1, p<0.0001 for 45
mg and 63.3%, 57.1-69.4, p<0.0001 for 90 mg). At week 40, long-term response had
been achieved by 150 patients in the 45 mg group and 172 patients in the 90 mg
group. Of these, 162 patients were randomly assigned to maintece ustekinumab
and 160 to withdrawal. PASI 75 response was better maintained to at least 1 year
in those receiving maintece ustekinumab than in those withdrawn from
treatment at week 40 (p<0.0001 by log-rank test). During the placebo-controlled
phase, adverse events occurred in 278 (54.5%) of the 510 patients receiving
ustekinumab and 123 (48.2%) of the 255 receiving placebo. Serious adverse events
occurred in six (1.2%) of 510 patients receiving ustekinumab and in two (0.8%)
of 255 receiving placebo in this phase. The pattern of adverse events was much
the same in the placebo crossover and randomised withdrawal phases as it was in
the placebo-controlled phase.
INTERPRETATION: Ustekinumab seems to be efficacious for the treatment of
moderate-to-severe psoriasis; dosing every 12 weeks maintains efficacy for at
least a year in most patients. BACKGROUND: Repeated subcutaneous injections of a monoclonal antibody against
the p40 subunit of interleukins 12 and 23, ustekinumab, were used to treat
patients with relapsing-remitting multiple sclerosis (RRMS) to assess the drug's
safety, efficacy, and pharmacokinetics.
METHODS: In this phase II, multicentre, randomised, double-blind,
placebo-controlled study, 249 patients with RRMS, aged 18-65 years, were
eligible to be assigned equally (by a central randomisation procedure based on
study site and presence or absence of gadolinium-enhancing T1-weighted lesions
at baseline) to one of five groups that received placebo or four different
ustekinumab dosages at weeks 0, 1, 2, 3, 7, 11, 15, and 19. Ustekinumab doses
were 27 mg, 90 mg q8w, 90 mg, or 180 mg; the 90 mg q8w dosage group received
placebo substitute at weeks 7 and 15. The primary endpoint was the cumulative
number of new gadolinium-enhancing T1-weighted lesions on serial cranial MRI
through week 23. Patients were followed up through week 37. Analysis was by
intention to treat. This trial is registered with ClinicalTrials.gov, number
NCT00207727.
FINDINGS: From August, 2004, to December, 2006, 249 patients underwent
randomisation (49 for placebo; 50 for each ustekinumab group). Ustekinumab
treatment did not show a significant reduction in the primary endpoint for any
dosage groups versus placebo. At week 37, adverse events occurred in 38 (78%)
placebo-treated patients and 170 (85%) ustekinumab-treated patients, with
infections most commonly reported. Serious adverse events occurred in one (2%)
placebo-treated patient and six (3%) ustekinumab-treated patients. Maligt
diseases were reported in two patients shortly after the initiation of
ustekinumab treatment; both patients were withdrawn from the trial and given
appropriate treatment, which resulted in complete remission. No serious
infections, cardiovascular events, or exacerbation of demyelinating events
occurred. A dose-dependent increase in serum concentrations of ustekinumab was
recorded.
INTERPRETATION: Ustekinumab is generally well tolerated but does not show
efficacy in reducing the cumulative number of gadolinium-enhancing T1-weighted
lesions in multiple sclerosis. Ustekinumab is a fully human monoclonal antibody that binds with high
specificity and affinity to the cytokines interleukin (IL)-12 and IL-23, thereby
suppressing IL-12- and IL-23-mediated inflammation associated with psoriasis. In
two large, phase III trials in patients with moderate to severe plaque
psoriasis, significantly more subcutaneous ustekinumab 45 or 90 mg recipients
(administered as two injections 4 weeks apart) than placebo recipients achieved
a 75% improvement on the Psoriasis Area and Severity Index (PASI 75) score at 12
weeks. Other efficacy measures, including the physician's global assessment of
clinical response at week 12, also favored ustekinumab over placebo. Psoriatic
symptom control was maintained during ustekinumab maintece therapy
(administered once every 12 weeks) for up to 76 weeks. In a phase II trial in
patients with active plaque psoriasis and psoriatic arthritis, signs and
symptoms of arthritis and psoriatic symptom control were improved to a greater
extent with ustekinumab than with placebo at 12 weeks, based on the proportion
of patients achieving a 20% improvement in American College of Rheumatology
response criteria (arthritis) or PASI 75 (skin symptoms). Health-related quality
of life, assessed using the Dermatology Life Quality Index and the Health
Assessment Questionnaire disability index, was improved to a significantly
greater extent with ustekinumab than with placebo at week 12. Subcutaneous
ustekinumab was generally well tolerated in clinical trials, with most
treatment-emergent adverse events being of mild severity. (1) For adults with plaque psoriasis, after failure of topical symptomatic
treatments and PUVA therapy, several systemic immunosuppressive agents are
acceptable for severe disease: methotrexate, then ciclosporin, and possible a
TNF alpha antagonist (etanercept, etc.); (2) Ustekinumab is an inhibitor of
interleukins 12 and 23, which are believed to be implicated in the onset of
psoriasis. It is authorized in the European Union for patients who fail to
respond to conventional systemic treatments; (3) In one trial with a low level
of evidence (single-blind), 2 subcutaneous injections of ustekinumab at an
interval of 4 weeks appeared to be statistically more effective than
twice-weekly subcutaneous injections of etanercept for 12 weeks. More patients
achieved a 75% reduction in the score most widely used to evaluate the extent
and intensity of plaque psoriasis lesions (PASI score): about 71% versus 57%.
The results beyond this period have not been reported; (4) Two randomised,
double-blind, placebo-controlled trials in a total of 1996 patients showed that
at least two-thirds of patients treated with ustekinumab achieved at least a 75%
reduction in their PASI score versus fewer than 4% with placebo; (5) In animal
studies, interleukin 12 and 23 inhibitors cause cancer. There is therefore a
high risk of cancer developing during prolonged treatment with ustekinumab; (6)
The main adverse effects identified in clinical trials include infections,
injection-site reactions, psychological disorders and development of
anti-ustekinumab antibodies; (7) There is insufficient follow-up to evaluate the
cardiac risks associated with ustekinumab; (8) As maintece therapy,
ustekinumab is administered as one subcutaneous injection every 12 weeks. This
practical advantage compared to TNF alpha antagonists must be weighed against
the risks inherent in prolonged immunosuppression; (9) In summary, for
symptomatic relief of patients whose psoriasis poses major problems despite
treatment with methotrexate or ciclosporin, in the absence of a better
alternative, it is better to use a TNF alpha antagonist and to avoid exposing
patients to the risks associated with ustekinumab, particularly its carcinogenic
risk. Ustekinumab, a human immunoglobulin G1 kappa (IgG1k) monoclonal antibody that
binds with high affinity to human interleukin-12 and interleukin-23, has
demonstrated efficacy in patients with psoriasis. The objective of this study
was to perform exposure-response modeling to increase the understanding of
reduction in disease severity following treatment with ustekinumab in patients
with moderate to severe psoriasis who participate in two phase III studies
(PHOENIX 1 and PHOENIX 2). Patients were randomly assigned to receive
ustekinumab 45 mg or 90 mg (n = 1312; 11,624 Psoriasis Area and Severity Index
[PASI] scores) or placebo (n = 665; 3278 PASI scores). Disease severity was
assessed using PASI scores. A population mechanism-based exposure-response model
of ustekinumab using NONMEM was developed using serum ustekinumab concentrations
and PASI scores. The pharmacodynamic response effect was the reduction in PASI
score. The placebo effect, although minor, was also integrated into the model.
None of the covariate factors evaluated (eg, demographics, baseline disease
characteristics, comorbidities) significantly contributed to the between-subject
variability in the pharmacodynamic parameters. The developed exposure-response
model can serve as a basis to support future alternative dosing regimens for
ustekinumab in patients with moderate to severe plaque psoriasis. A robust
exposure-response relationship has been confirmed for ustekinumab in psoriasis. BACKGROUND: Biologic agents offer a range of new therapeutic options for
patients with psoriasis; however, the relative benefit-risk profiles of such
therapies are not well known. We compared two biologic agents, ustekinumab (an
interleukin-12 and interleukin-23 blocker) and etanercept (an inhibitor of tumor
necrosis factor alpha), for the treatment of psoriasis.
METHODS: We randomly assigned 903 patients with moderate-to-severe psoriasis to
receive subcutaneous injections of either 45 or 90 mg of ustekinumab (at weeks 0
and 4) or high-dose etanercept (50 mg twice weekly for 12 weeks). The primary
end point was the proportion of patients with at least 75% improvement in the
psoriasis area-and-severity index (PASI) at week 12; a secondary end point was
the proportion with cleared or minimal disease on the basis of the physician's
global assessment. Assessors were unaware of the treatment assignments. The
efficacy and safety of a crossover from etanercept to ustekinumab were evaluated
after week 12.
RESULTS: There was at least 75% improvement in the PASI at week 12 in 67.5% of
patients who received 45 mg of ustekinumab and 73.8% of patients who received 90
mg, as compared with 56.8% of those who received etanercept (P=0.01 and P<0.001,
respectively). Similarly, 65.1% of patients who received 45 mg of ustekinumab
and 70.6% of patients who received 90 mg of ustekinumab had cleared or minimal
disease according to the physician's global assessment, as compared with 49.0%
of those who received etanercept (P<0.001 for both comparisons). Among patients
who did not have a response to etanercept, 48.9% had at least 75% improvement in
the PASI within 12 weeks after crossover to ustekinumab. One or more adverse
events occurred through week 12 in 66.0% of patients who received 45 mg of
ustekinumab and 69.2% of patients who received 90 mg of ustekinumab and in 70.0%
who received etanercept; 1.9%, 1.2%, and 1.2%, respectively, had serious adverse
events. Safety patterns were similar before and after crossover from etanercept
to ustekinumab.
CONCLUSIONS: The efficacy of ustekinumab at a dose of 45 or 90 mg was superior
to that of high-dose etanercept over a 12-week period in patients with
psoriasis. (ClinicalTrials.gov number, NCT00454584.) BACKGROUND: Ustekinumab, a fully human immunoglobulin (Ig) G1K monoclonal
antibody directed against the p40 subunit of interleukin (IL)-12/23, has
demonstrated efficacy in patients with moderate-to-severe psoriasis.
OBJECTIVE: To evaluate the effect of IL-12/23 inhibition on immunocompetency by
antigen-recall response in a preclinical multiple-dose toxicology study and
three single-dose, phase 1 studies.
METHODS: Cynomolgus monkeys (Mauritius; n = 32) treated with subcutaneous (s.c.)
placebo or ustekinumab 22.5 or 45 mg/kg twice weekly for 26 weeks were assessed
for antibody responsiveness to keyhole limpet hemocyanin (KLH). Patients with
psoriasis or multiple sclerosis who received a single-dose of placebo (n = 8) or
ustekinumab (n = 46) 0.09-4.5 mg/kg intravenous (i.v.) or 0.27-2.7 mg/kg s.c.
were assessed by pneumococcal and tetanus antigen challenge. Primary T-cell
response was not assessed in humans.
RESULTS: Anti-KLH antibody responses in ustekinumab-treated cynomolgus monkeys
were comparable to those observed in placebo-treated animals. A normal antibody
response (> or = two-fold increase from baseline) to pneumococcal antigen was
seen in 34/46 (73.9%) ustekinumab-treated versus 4/8 (50%) placebo-treated
patients. A normal antigen-recall response (> or = four-fold increase from
baseline) was seen in 12/20 (60%) ustekinumab- and 4/5 (80%) placebo-treated
patients following tetanus toxoid exposure. Percentages of circulating immune
cells were not affected by ustekinumab treatment.
CONCLUSION: Results in nonhuman primates and human patients suggest that
ustekinumab treatment does not significantly impair recall humoral immune system
functions. Psoriasis is a chronic, genetically determined, immune-mediated, inflammatory
skin disease affecting approximately 2% to 3% of Caucasian population. Given the
well-established role of the immuno-mediated inflammation in the pathogenesis of
psoriasis, in the past few years several key steps in the pathogenesis of this
disease have been elucidated and the increased knowledge led to the development
of specific drugs, commonly defined as "biologics" targeting one or more of
these steps. At present an anti-CD11a antibody (efalizumab), an anti-LFA3/CD2
receptor (alefacept) and 3 antitumor necrosis factor alpha agents (adalimumab,
etanercept, infliximab) are now commercially available for the treatment of both
psoriasis and psoriatic arthritis. Recent studies have demonstrated that
interleukins (IL) 12 and 23 play an important role in the pathophysiology of
psoriasis. In fact members of the IL-12 family of cytokines have the potential
to act as the next major cytokine(s) in pathogenesis and the treatment of
psoriasis. Ustekinumab (CNTO 1275, Centocor Inc, Malvern, PA, USA) is a human
monoclonal antibody that binds to the shared p40 protein subunit of human
interleukins 12 and 23 with high affinity and specificity, thereby preventing
interaction with their surface IL-12Rβ1 receptor. Different clinical studies
have been conducted to date. In particular a phase II study and two phase III
studies, PHOENIX 1 together with PHOENIX 2, show very encouraging results. This
review reports on the latest progress made in the clinical use of biologic drugs
for psoriasis focusing on the new human IL-12/23 monoclonal antibody,
ustekinumab, for psoriasis. The recognition of the roles of interleukins (IL)-12 and IL-23 in the
development of psoriasis is an important advance in the understanding, and the
subsequent management, of this chronic inflammatory disease. Two human anti-p40
monoclonal antibodies targeting both IL-12 and IL-23 via their shared p40
subunit have been developed: briakinumab and ustekinumab. Recent Phase 2 and
Phase 3 trials have illustrated the benefits of briakinumab (in Phase 3 clinical
development) and ustekinumab (approved in the EU, and also in other territories
worldwide) in the treatment of moderate to severe plaque psoriasis. Available
data indicate that a strategy targeting the IL-12 p40 subunit has considerable
advantages over targeting of tumour necrosis factor-α, offering rapid onset of
efficacy with a favourable dosing regimen (every 12 weeks for ustekinumab).
Registries incorporating rigorous pharmacovigilance are now required to further
understand the clinical profile of these drugs over long-term use. Psoriasis is a chronic inflammatory skin condition, characterized by T-helper
(Th) 1 and Th17 cell activation. Ustekinumab is a fully human immunoglobulin G1κ
monoclonal antibody that targets the common p40 subunit that is shared by both
interleukin (IL)-12 and IL-23, consequently inhibiting T-cell differentiation
along both Th1 and Th17 pathways. This is a report of two patients who developed
psoriatic arthritis during ustekinumab treatment for psoriasis. Neither patient
had a personal or family history of arthritis. Psoriasis is a T-cell-mediated autoimmune disease involving the skin. Two
cytokines, interleukin-12 (IL-12) and IL-23 have been shown to play a pivotal
role in the pathogenesis of the disease. Ustekinumab (Stelara) is a therapeutic
monoclonal antibody (mAb) targeted against the p40 shared subunit of IL-12 and
IL-23. Recently the ability of therapeutic proteins (TP) including mAbs that
target either cytokines directly (e.g., Pegasys; peginterferon α-2a) or their
respective cell surface receptors [e.g., tocilizumab (Actemra); anti IL-6R] to
desuppress cytochrome P450 (P450) enzymes in vitro and in the clinic, has been
demonstrated. In the present study the ability of IL-12 and IL-23 to suppress
multiple P450 enzymes was investigated in vitro using six separate lots of
cultured human hepatocytes. Following exposure of 10 ng/ml IL-12 and IL-23 for
48 hours, either alone or in combination, no change in CYP2B6, 2C9, 2C19, or 3A4
gene expression or functional activity was observed. None of the untreated
hepatocyte donors showed appreciable expression of the IL-12 or IL-23 receptors.
Similar results were seen with whole human liver samples. Exposure of
hepatocytes to IL-12 and/or IL-23, known P450 suppressors (IL-6 and tumor
necrosis factor-α) or known P450 inducers (β-naphthoflavone, phenobarbital, and
rifampicin) did not appreciably alter the expression of the IL-12 and IL-23
receptors either. Finally, in contrast to the positive control IL-6, expression
of the acute phase C-reactive protein was unaltered following IL-12 and/or IL-23
treatment. Together, these data suggest a negligible propensity for IL-12 or
IL-23 to directly alter P450 enzymes in human hepatocytes. INTRODUCTION: The biologic, Ustekinumab (Stelara®, Centocor, Inc., Malvern, PA,
USA), is a fully human monoclonal antibody with a high affinity for the shared
p40 subunit of interleukins 12 and 23 (IL-12 and IL-23). Approved for use in
treating moderate-to-severe psoriasis in 2009, there has been considerable
interest in the long-term safety of ustekinumab.
AREAS COVERED: This review discusses the use of ustekinumab in the treatment of
psoriasis and its potential to be an effective and well-tolerated therapy. A
literature search was performed for articles published through April 2013 to
identify any safety concerns.
EXPERT OPINION: Our results indicate that ustekinumab has demonstrated higher
efficacy rates as compared to traditional therapies; and with a favorable dosing
schedule and stable safety profile, patients with recalcitrant disease will now
have another option for treatment. Ustekinumab is a fully human monoclonal antibody directed against the p40
subunit shared by interleukin 12 and interleukin 23, two naturally occurring
protein regulators that play an important role in immune-mediated inflammatory
diseases, including psoriatic arthritis (PsA). In September of 2009, the US FDA
approved ustekinumab for the treatment of adult patients with moderate to severe
plaque psoriasis. Beginning in November of 2009, Janssen Biotech (formerly
Centocor Biotech), the developer of ustekinumab, initiated clinical trials to
investigate the efficacy of ustekinumab in the treatment of other inflammatory
disorders, including PsA. Phase II and Phase III studies showed both a good
safety profile and significant efficacy for ustekinumab in the treatment of PsA,
leading to the drug's approval in both Europe and the USA. In an immunotherapy
market currently dominated by anti-TNF-α drugs for the treatment of PsA,
ustekinumab offers an alternative option for patients with PsA, including those
unresponsive to methotrexate and the TNF-α inhibitory agents currently approved
for this potentially debilitating disease. OBJECTIVE: Evaluate ustekinumab, an anti-interleukin (IL)-12 and IL-23 antibody,
effects on radiographic progression in psoriatic arthritis (PsA).
METHODS: We conducted preplanned integrated analyses of combined radiographic
data from PSUMMIT-1 and PSUMMIT-2 phase 3, randomised, controlled trials.
Patients had active PsA despite prior conventional and/or biologic
disease-modifying antirheumatic drugs (≥5/66 swollen, ≥5/68 tender joints,
C-reactive protein ≥3.0 mg/L, documented plaque psoriasis). Patients (PSUMMIT-1,
n=615; PSUMMIT-2, n=312) were randomised to ustekinumab 45 mg, 90 mg, or
placebo, at weeks (wk) 0, 4 and every (q) 12 wks. At wk 16, patients with <5%
improvement in tender/swollen joint counts entered blinded early escape. All
other placebo patients received ustekinumab 45 mg at wk 24 and wk 28, then q 12
wks. Radiographs of hands/feet at wks 0/24/52 were assessed using PsA-modified
van der Heijde-Sharp (vdH-S) scores; combined PSUMMIT-1 and PSUMMIT-2 changes in
total vdH-S scores from wk 0 to wk 24 comprised the prespecified primary
radiographic analysis. Treatment effects were assessed using analysis of
variance on van der Waerden normal scores (factors=treatment, baseline
methotrexate usage, and study).
RESULTS: Integrated data analysis results indicated that ustekinumab-treated
patients (regardless of dose) demonstrated significantly less radiographic
progression at wk 24 than did placebo recipients (wk 0-24 total vdH-S score mean
changes: 0.4-combined/individual ustekinumab dose groups, 1.0-placebo; all
p<0.02). From wk 24 to wk 52, inhibition of radiographic progression was
maintained for ustekinumab-treated patients, and progression was substantially
reduced among initial placebo recipients who started ustekinumab at wk 16 or wk
24 (wk 24 - wk 52, total vdH-S score mean change: 0.08).
CONCLUSIONS: Ustekinumab 45 and 90 mg treatments significantly inhibited
radiographic progression of joint damage in patients with active PsA. Psoriatic arthritis (PsA) is a chronic inflammatory seronegative
spondyloarthritis associated with psoriasis. While TNF-α inhibitors have
revolutionized the treatment of rheumatic diseases, including PsA, not all
patients respond to these agents while others are unsuitable or intolerant to
them. Thus, there is a need for additional treatment modalities with a novel
mechanism of action. In the past years, the IL-23/Th17 axis has emerged as an
important mechanism in the pathogenesis of PsA. Ustekinumab, a fully human IgG1κ
monoclonal antibody that targets the common subunit p40 of IL-12 and IL-23, has
been shown in clinical trials, to be well-tolerated and effective in patients
with active PsA. It improved signs and symptoms of PsA, inhibited radiographic
progression and was effective in dactylitis, enthesitis, and skin disease, with
a safety profile consistent with the one observed in patients with psoriasis.
Moreover, it was to be effective in anti-TNF-α experienced patients, definitely
fulfilling an unmet need in the management of PsA. INTRODUCTION: Ustekinumab is a human monoclonal antibody directed against the
shared p40 subunit of interleukins 12 and 23. Ustekinumab is currently approved
for the treatment of psoriatic arthritis (PsA) and moderate to severe plaque
psoriasis, and is being evaluated in Crohn's disease (CD).
AREAS COVERED: The first evidence supporting the efficacy of ustekinumab in the
treatment of moderate to severe CD was published in 2008. Results from
subsequent phase II and phase III randomized controlled trials (RCTs) have shown
promising data on the clinical efficacy of induction and remission of moderate
to severe CD. These data and the safety profile of ustekinumab will be reviewed.
Expert commentary: As a significant proportion of individuals with CD have
ongoing symptoms and inflammation despite existing therapies, there is a
clinical need for new agents like ustekinumab directed at different targets on
the inflammatory pathway. Looking forward, more studies are needed to evaluate
dosing escalation or de-escalation in addition to timing of therapy switches. In
addition, further data is required to gauge the comparative effectiveness of
ustekinumab to the biologic agents that are currently used in the treatment of
CD. Recent advances in the therapeutics of psoriatic arthritis (PsA) have provided
more options to clinicians managing PsA. The purpose of this review is to update
the reader on treatment options for PsA using conventional synthetic disease
modifying agents (csDMARDs) and novel therapies including tumour necrosis factor
alpha inhibitors, interleukin 12/23 inhibitor (ustekinumab), the interleukin 17
antagonists including secukinumab, brodalumab, ixekizumab, and the
phosphodiesterase-4 inhibitor, apremilast. Areas covered: We reviewed published
articles on the treatment of PsA. Our main sources of data included treatment
recommendations, registry studies, systematic literature reviews, major
randomised controlled trials for more recently approved drugs, and abstracts
from the American College of Rheumatology and EULAR meetings. Expert commentary:
An overview of the evidence for the use of various pharmacotherapeutic agents
for treatment of this heterogeneous disease was compiled. Treatment options for
the various domains of PsA are also discussed. OBJECTIVE: Interleukin (IL)-12 and IL-23 have been implicated in the
pathogenesis of rheumatoid arthritis (RA). The safety and efficacy of
ustekinumab, a human monoclonal anti-IL-12/23 p40 antibody, and guselkumab, a
human monoclonal anti-IL-23 antibody, were evaluated in adults with active RA
despite methotrexate (MTX) therapy.
METHODS: Patients were randomly assigned (1:1:1:1:1) to receive placebo at weeks
0, 4 and every 8 weeks (n=55), ustekinumab 90 mg at weeks 0, 4 and every 8 weeks
(n=55), ustekinumab 90 mg at weeks 0, 4 and every 12 weeks (n=55), guselkumab
50 mg at weeks 0, 4 and every 8 weeks (n=55), or guselkumab 200 mg at weeks 0, 4
and every 8 weeks (n=54) through week 28; all patients continued a stable dose
of MTX (10-25 mg/week). The primary end point was the proportion of patients
with at least a 20% improvement in the American College of Rheumatology criteria
(ACR 20) at week 28. Safety was monitored through week 48.
RESULTS: At week 28, there were no statistically significant differences in the
proportions of patients achieving an ACR 20 response between the combined
ustekinumab group (53.6%) or the combined guselkumab group (41.3%) compared with
placebo (40.0%) (p=0.101 and p=0.877, respectively). Through week 48, the
proportions of patients with at least one adverse event (AE) were comparable
among the treatment groups. Infections were the most common type of AE.
CONCLUSIONS: Treatment with ustekinumab or guselkumab did not significantly
reduce the signs and symptoms of RA. No new safety findings were observed with
either treatment.
TRIAL REGISTRATION NUMBER: NCT01645280. Ankylosing spondylitis (AS) and axial spondyloarthritis (ax SpA) are chronic
inflammatory diseases mainly involving the axial skeleton. Pharmacological
treatments for AS and ax SpA usually include local glucocorticoid injections,
NSAIDs and anti-TNFα agents. Since around 30% to 40% of patients are non
responders or intolerant to anti-TNFα agents, we need new therapeutic options
for AS and ax SpA. Areas covered: This review describes the new biological
agents that can be used or are in development for AS or ax SpA as well as
emerging synthetic targeted drugs. Expert opinion: Based on the rationale of the
involvement of the IL-23/Th17 axis in AS, novel biological agents have been
developed and include secukinumab, an anti-IL-17A agent and ustekinumab, an
anti-IL-23 antibody. New compounds in the class of synthetic drugs are
apremilast, a PDE4 inhibitor, and inhibitors of kinase pathways. Secukinumab
gave positive results in the treatment of AS. Ustekinumab yielded promising
results in AS in an open labeled study. Apremilast is not effective in AS while
results with kinase inhibitors are preliminary. Future studies will clarify the
place of secukinumab in the therapeutic management of AS, its influence on
radiographic progression and its effects on the non radiographic form of the
disease. IMPORTANCE: Treatment of pityriasis rubra pilaris (PRP) is solely based on its
resemblance to psoriasis rather than any knowledge of its pathomechanism.
Insight into pathogenic mediators of inflammation is essential for targeted and
valid treatment options that could replace previous serendipitous therapeutic
approaches in refractory PRP.
OBJECTIVE: To determine whether blockade of the interleukin 23-helper T cell 17
(IL-23-TH17) pathway with ustekinumab represents an efficacious and, based on
its proinflammatory cytokine profile, targeted treatment option in PRP.
DESIGN, SETTING, AND PARTICIPANTS: In this case report, a patient with PRP
received outpatient treatment at a university hospital department of dermatology
with ustekinumab according to the dosing regimen approved for psoriasis.
Lesional skin biopsy samples were taken from this patient and 2 others with
refractory PRP. Messenger RNA (mRNA) expression of proinflammatory innate and
T-cell-derived cytokines were measured and compared with skin samples from
patients with psoriasis and healthy donors. From 1 patient, lesional skin
samples were taken before ustekinumab treatment and 4 and 28 weeks after
treatment initiation. Follow-up was completed after 6 months.
INTERVENTION: Subcutaneous ustekinumab, 45 mg, at weeks 0 and 4 and quarterly
thereafter.
MAIN OUTCOMES AND MEASURES: The primary outcome was to determine the changes in
expression of proinflammatory innate and T-cell-derived cytokines during
ustekinumab therapy. The secondary objective was to evaluate the clinical and
histopathologic phenotype in relation to the mRNA expression profile of
proinflammatory cytokines.
RESULTS: In lesional PRP skin samples from a single patient, upregulated
expression levels were found for most proinflammatory innate cytokines,
including tumor necrosis factor (TNF), IL-6, IL-12, IL-23, and IL-1β. Among
adaptive T-cell cytokines, an increase of TH1 cytokines and, in particular, TH17
cytokines IL-17A, IL-17F, and IL-22 was seen in PRP. The patient with PRP who
received ustekinumab showed regression of skin lesions after 2 weeks and almost
complete resolution after 1 month. Clinical and histopathologic improvement
paralleled the expression levels of TH17 cytokines but not of interferon-γ and
TNF, which lagged behind the amelioration.
CONCLUSIONS AND RELEVANCE: In this case report, a role of the IL-23-TH17-axis in
PRP was identified, suggesting a shared pathogenic inflammatory pathway with
psoriasis, despite evident clinical and histopathologic differences. In
addition, this report provides a rationale for targeting the IL-23-TH17-pathway
as a treatment option for refractory PRP. Pyoderma gangrenosum (PG) is an orphan disease. While research on such disorders
is based on only few randomized multicenter as well as retrospective studies,
most of the data comes from case series of small patient groups. Apart from
topical and intralesional therapeutic options for early stages and mild disease
courses, treatment predomitly involves systemic therapeutic agents. Besides
systemic corticosteroids and cyclosporine A (CsA), options also include
intravenous immunoglobulins (IVIG) and biologics such as the TNFα inhibitors
infliximab, adalimumab, and etanercept; the interleukin (IL) 12/23 antibody
ustekinumab; the IL-1 receptor antagonist anakinra; and the IL-1β antibody
canakinumab. The best evidence-based study data is available for CsA,
prednisolone, and infliximab; the latter especially in patients with concomitant
ulcerative colitis or Crohn's disease. A response to IVIG and canakinumab has
been reported in smaller case series. First described by Brocq almost 100 years
ago, it was soon recognized that PG did in fact require treatment. To this day,
however, such treatment remains a clinical challenge. Despite the severe -
albeit rare -clinical picture, improvement in therapeutic options may be
expected in the future, primarily due to further clinical studies - especially
with a greater number of patients, a better understanding of the
etiopathogenesis, as well as the use of modern targeted therapies with higher
efficacy and a lower rate of side effects than conventional immunosuppressants
such as prednisolone and CsA. Only limited data on laboratory parameter dynamics and safety under prolonged
biologic treatment in a "real-world" scenario are available for recommendations
on screening and monitoring. This study is a retrospective analysis of routine
parameter dynamics and laboratory adverse events (LAE) in psoriasis patients on
long-term treatment (n = 199) with tumour necrosis factor (TNF)-α-antagonists
(adalimumab, etanercept), and the interleukin (IL)12/23-antagonist ustekinumab.
Overall, neutrophil (PMN) counts (-11%) and triglycerides (+9%) changed
considerably. TNF-α-antagonists and ustekinumab differentially affected
lymphocyte counts (+13% and ±0%, respectively). Dynamics were pronounced during
the first 180 days of treatment. In 340 treatment-years, 15 Common Terminology
Criteria for Adverse Events (CTCAE) III-IV° LAE were recorded (11 involved liver
enzymes). They prompted alteration of the biologic regime in only 2 cases. Age,
sex, previous systemic treatments, and psoriatic arthritis did not significantly
predict LAE. Liver enzyme and triglyceride screening may be warranted in some
instances. Our data suggest that unguided monitoring of other routine laboratory
parameters is unnecessary under long-term biologic treatment. Ustekinumab is a monoclonal antibody directed against the p40 subunit, which is
part of interleukins IL-12 and IL-23. The efficacy of ustekinumab versus placebo
in terms of clinical response and remission of induction has been shown in
phase3 clinical trials. When used as subcutaneous maintece therapy, the
therapeutic benefit of ustekinumab over placebo has been confirmed in both
clinical response and remission in patients who have responded clinically to
induction therapy. In addition, ustekinumab has demonstrated an improvement in
mucosal healing parameters. The safety profile of the drug has been good, with
low infection rates (without reactivation of tuberculosis) and absence of tumour
reporting. The development of drug immunogenicity appears to be rare. In
summary, ustekinumab is a promising treatment option in patients with Crohn's
disease, as an alternative to anti-TNFα drugs. |
What is a potential side effect for Tymlos? | Possible bone cancer (osteosarcoma). During animal drug testing, TYMLOS caused some rats to develop a bone cancer called osteosarcoma. | Prolonged treatment with human parathyroid hormone (hPTH) in rats results in
development of bone tumors, though this finding has not been supported by
clinical experience. The PTH type 1 receptor agonist abaloparatide, selected for
its bone anabolic activity, is under clinical development to treat
postmenopausal women with osteoporosis. To determine the carcinogenic potential
of abaloparatide, Fischer (F344) rats were administered SC daily abaloparatide
at doses of 0, 10, 25, and 50 μg/kg or 30 μg/kg hPTH(1-34) as a positive control
for up to 2 years. Robust increases in bone density were achieved at all
abaloparatide doses and with hPTH(1-34). Comprehensive histopathological
analysis reflected a comparable continuum of proliferative changes in bone,
mostly osteosarcoma, in both abaloparatide and hPTH(1-34) treated rats.
Comparing the effects of abaloparatide and hPTH(1-34) at the 25 and 30 μg/kg
respective doses, representing similar exposure multiples to the human
therapeutic doses, revealed similar osteosarcoma-associated mortality, tumor
incidence, age at first occurrence, and metastatic potential. There were no
increases in the incidence of non-bone tumors with abaloparatide compared to
vehicle. Thus, near life-long treatment with abaloparatide in rats resulted in
dose and time dependent formation of osteosarcomas, with a comparable response
to hPTH(1-34) at similar exposure. Abaloparatide (Tymlos™) is a synthetic peptide analogue of human parathyroid
hormone-related protein that was developed by Radius Health as an osteoanabolic
agent for the treatment of postmenopausal osteoporosis. Abaloparatide acts
through selective activation of the parathyroid hormone type 1 receptor
signalling pathway. In April 2017, subcutaneous abaloparatide received its first
global approval, in the USA, for the treatment of postmenopausal women with
osteoporosis at high risk for fracture, defined as a history of osteoporotic
fracture, multiple risk factors for fracture, or patients who have failed or are
intolerant to other available osteoporosis therapy. A Marketing Authorization
Application for subcutaneous abaloparatide for the treatment of postmenopausal
women with osteoporosis was accepted by the European Medicines Agency and is
currently under review. Radius is also developing a transdermal formulation of
abaloparatide, with administration via a microneedle patch. This article
summarizes the milestones in the development of abaloparatide leading to this
first approval for the treatment of women with postmenopausal osteoporosis. |
Which disorder has been approved for treatment with Alk inhibitors? | Anaplastic lymphoma kinase (ALK) rearrangement is detected in 3-7% of patients with non-small-cell lung cancer. Crizotinib is an ALK inhibitor, which was approved in 2011 for the treatment of ALK-positive lung cancer. | Alectinib, an anaplastic lymphoma kinase (ALK) inhibitor, is approved for
treatment of patients with ALK+ non-small cell lung cancer who have progressed,
on or are intolerant to, crizotinib. This study assessed the effect of a
high-fat meal and the proton pump inhibitor, esomeprazole, on the
pharmacokinetics (PK) of alectinib. This was an open-label, 2-group study in
healthy subjects. In group 1 (n = 18), subjects were randomly assigned to a
2-treatment (A, fasted conditions; B, following a high-fat meal), 2-sequence (AB
or BA) crossover assessment, separated by a 10-day washout. In group 2 (n = 24),
subjects were enrolled in a 2-period, fixed-sequence crossover assessment to
evaluate the effect of esomeprazole. PK parameters were evaluated for alectinib,
its major similarly active metabolite, M4, and the combined exposure of
alectinib and M4. Administration of alectinib following a high-fat meal
substantially increased the combined exposure of alectinib and M4 to 331%
(90%CI, 279%-393%) and 311% (90%CI, 273%-355%) for Cmax and AUC0-∞ ,
respectively, versus fasted conditions. Coadministration of esomeprazole had no
clinically relevant effect on the combined exposure of alectinib and M4.
Alectinib should be administered under fed conditions to maximize its
bioavailability, whereas no restrictions are required with antisecretory agents. Activation of the EGFR pathway is one of the mechanisms inducing acquired
resistance to anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKI)
such as crizotinib and alectinib. Ceritinib is a highly selective ALK inhibitor
and shows promising efficacy in non-small cell lung cancers (NSCLC) harboring
the ALK gene rearrangement. However, the precise mechanism underlying acquired
resistance to ceritinib is not well-defined. This study set out to clarify the
mechanism in ALK-translocated lung cancer and to find the preclinical rationale
overcoming EGFR pathway-induced acquired resistance to ALK-TKIs. To this end,
ceritinib-resistant cells (H3122-CER) were established from the H3122 NSCLC cell
line harboring the ALK gene rearrangement via long-term exposure to ceritinib.
H3122-CER cells acquired resistance to ceritinib through EGFR bypass pathway
activation. Furthermore, H3122 cells that became resistant to ceritinib or
alectinib through EGFR pathway activation showed cross-resistance to other
ALK-TKIs. Ceritinib and afatinib combination treatment partially restored the
sensitivity to ceritinib.
IMPLICATIONS: This study proposes a preclinical rationale to use ALK-TKIs and
afatinib combination therapy for ALK-translocated lung cancers that have
acquired resistance to ALK-TKIs through EGFR pathway activation. Mol Cancer Res;
15(1); 106-14. ©2016 AACR. In 2007, the rearrangement of anaplastic lymphoma kinase (ALK) was identified to
be associated with the pathogenesis of a subset of patients with non-small-cell
lung cancer (NSCLC). Surprisingly, approximately 4 years after the discovery of
ALK rearrangement in lung cancer, the first-in-class ALK inhibitor (ALKi),
crizotinib, was approved for metastatic ALK-rearranged NSCLC by the US Food and
Drug Administration. Subsequently, next-generation ALKis, such as alectinib and
ceritinib, have been developed, and some of them have been applied in the
clinical setting. Furthermore, various resistance mechanisms against ALKis have
been gradually elucidated, and treatment strategies according to such resistance
have been proposed. In addition, novel ALKis exhibit good antitumor efficacy for
brain metastases. Thus, we now know much about ALK-rearranged NSCLC; however, is
it enough? Several concerns, such as the optimal sequence of ALKis, significance
of antiangiogenic therapy, immune checkpoint therapy, and cytotoxic chemotherapy
in ALK-rearranged NSCLC, should be clearly addressed, which would lead to the
establishment of optimal treatment strategies and a more prolonged survival in
patients with ALK rearrangement. Thus, we should w'ALK' into the next stage. The anaplastic lymphoma kinase (ALK) gene plays an important physiologic role in
the development of the brain and can be oncogenically altered in several
maligcies, including non-small-cell lung cancer (NSCLC) and anaplastic large
cell lymphomas (ALCL). Most prevalent ALK alterations are chromosomal
rearrangements resulting in fusion genes, as seen in ALCL and NSCLC. In other
tumors, ALK copy-number gains and activating ALK mutations have been described.
Dramatic and often prolonged responses are seen in patients with ALK alterations
when treated with ALK inhibitors. Three of these-crizotinib, ceritinib, and
alectinib-are now FDA approved for the treatment of metastatic NSCLC positive
for ALK fusions. However, the emergence of resistance is universal. Newer ALK
inhibitors and other targeting strategies are being developed to counteract the
newly emergent mechanism(s) of ALK inhibitor resistance. This review outlines
the recent developments in our understanding and treatment of tumors with ALK
alterations. Anaplastic lymphoma kinase (ALK) rearrangement is detected in 3-7% of patients
with non-small-cell lung cancer. Crizotinib is an ALK inhibitor, which was
approved in 2011 for the treatment of ALK-positive lung cancer. Despite the
initial enthusiasm, most of the patients develop resistance within the first
year of treatment. The main mechanisms are secondary mutations and bypass track
activation. Moreover, crizotinib has low penetration into the central nervous
system. The need to overcome these limitations has led to the development of
second-generation inhibitors that have better effectiveness against
crizotinib-resistant mutations and brain metastases. Ceritinib and alectinib are
the only approved drugs of this group. Many ongoing trials try to define the
most appropriate agent for the treatment of ALK-positive lung cancer depending
on the responsible mechanism. This review focuses on the current data regarding
the potential mechanisms of resistance to ALK inhibitors and the strategies to
overcome it. |
List proteins that are targeted by "immune checkpoints inhibitors". | The treatment landscape of advanced melanoma has changed significantly following the discovery and marketing authorisation of immune checkpoints inhibitors. Ipilimumab (anti-CTLA-4) was the first one to be approved, and it. demonstrated long-term survival in about 20% of patients. Subsequently, anti-programmed cell death-1 (a-PD-1) antibodies (pembrolizuamb, nivolumab), inhibitors of PD-1/programmed cell death-1 ligand (PD1-L) synapse, showed higher clinical efficacy with lower toxicity comparing to ipilimumab. | The infiltration of myeloid cells helps tumors to overcome immune surveillance
and imparts resistance to cancer immunotherapy. Thus, strategies to modulate the
effects of these immune cells may offer a potential therapeutic benefit. We
report here that tasquinimod, a novel immunotherapy which targets S100A9
signaling, reduces the immunosuppressive properties of myeloid cells in
preclinical models of bladder cancer (BCa). As single anticancer agent,
tasquinimod treatment was effective in preventing early stage tumor growth, but
did not achieve a clear antitumor effect in advanced tumors. Investigations of
this response revealed that tasquinimod induces an increase in the expression of
a negative regulator of T cell activation, Programmed-death-ligand 1 (PD-L1).
This markedly weakens its antitumor immunity, yet provokes an "inflamed" milieu
rendering tumors more prone to T cell-mediated immune attack by PD-L1 blockade.
Interestingly, the combination of tasquinimod with an Anti-PD-L1 antibody
enhanced the antitumor immune response in bladder tumors. This combination
synergistically modulated tumor-infiltrating myeloid cells, thereby strongly
affecting proliferation and activation of effector T cells. Together, our data
provide insight into the rational combination of therapies that activate both
innate and adaptive immune system, such as the association of S100A9-targeting
agents with immune checkpoints inhibitors, to improve the response to cancer
immunotherapeutic agents in BCa. The recent discovery of immune checkpoints inhibitors, especially
anti-programmed cell death protein 1 (PD-1) and anti-programmed cell death
protein ligand 1 (PD-L1) monoclonal antibodies, has opened new scenarios in the
management of non-small cell lung cancer (NSCLC) and this new class of drugs has
achieved a rapid development in the treatment of this disease. However,
considering the costs of these drugs and the fact that only a subset of patients
experience long-term disease control, the identification of predictive
biomarkers for the selection of candidates suitable for treatment has become a
priority. The research focused mainly on the expression of the PD-L1 receptor on
both tumor cells and/or immune infiltrates determined by immunohistochemistry
(IHC). However, different checkpoint inhibitors were tested, different IHC
assays were used, different targets were considered (tumor cells, immune
infiltrates or both) and different expression thresholds were employed in
clinical trials. In some trials the assay was used prospectively to select the
patients, while in other trials it was evaluated retrospectively. Some confusion
emerges, which makes it difficult to easily compare the literature data and to
translate them in practice management. This mini-review shows the possibilities
and pitfalls of the PD-L1 expression to predict the activity and efficacy of
anti PD1/PD-L1 monoclonal antibodies in the treatment of NSCLC. |
Which genes belong to the AUX/IAA family of transcription repressors in plants? | The Aux/IAA proteins are auxin-sensitive repressors that mediate diverse physiological and developmental processes in plants [1, 2]. There are 29 Aux/IAA genes in Arabidopsis that exhibit unique but partially overlapping patterns of expression Plant Stress Tolerance Requires Auxin-Sensitive Aux/IAA Transcriptional Repressors | Aux/IAA genes are early auxin response genes that encode short-lived nuclear
proteins with four conserved domains, referred to as I, II, III, and IV.
Arabidopsis Aux/IAA proteins repressed transcription on auxin-responsive
reporter genes in protoplast transfection assays. Mutations in domain II
resulted in increased repression, whereas mutations in domains I and III
partially relieved repression. Aux/IAA proteins fused to a heterologous DNA
binding domain were targeted to promoters of constitutively expressed reporter
genes and actively repressed transcription in an auxin-responsive and
dose-dependent manner. In comparison with an unfused luciferase protein,
luciferase fused to Aux/IAA proteins displayed less luciferase activity, which
further decreased in the presence of auxin in transfected protoplasts. Domain II
mutations increased and domain I mutations decreased luciferase activity with
the fusion proteins. These results suggested that Aux/IAA proteins function as
active repressors by dimerizing with auxin response factors bound to auxin
response elements and that early auxin response genes are regulated by
auxin-modulated stabilities of Aux/IAA proteins. Aux/IAA proteins are short-lived nuclear proteins that repress expression of
primary/early auxin response genes in protoplast transfection assays. Repression
is thought to result from Aux/IAA proteins dimerizing with auxin response factor
(ARF) transcriptional activators that reside on auxin-responsive promoter
elements, referred to as AuxREs. Most Aux/IAA proteins contain four conserved
domains, designated domains I, II, III, and IV. Domain II and domains III and IV
play roles in protein stability and dimerization, respectively. A clear function
for domain I had not been established. Results reported here indicate that
domain I in Aux/IAA proteins is an active repression domain that is transferable
and domit over activation domains. An LxLxL motif within domain I is
important for conferring repression. The domice of Aux/IAA repression domains
over activation domains in ARF transcriptional activators provides a plausible
explanation for the repression of auxin response genes via ARF-Aux/IAA
dimerization on auxin-responsive promoters. Recent studies of auxin response have focused on the functions of three sets of
proteins: the auxin (Aux) response factors (ARFs), the Aux/IAAs, and the F-box
protein TIR1. The ARF proteins bind DNA and directly activate or repress
transcription of target genes while the Aux/IAA proteins repress ARF function.
TIR1 is part of a ubiquitin protein ligase required for degradation of Aux/IAA
proteins. Here we report the isolation and characterization of a novel mutant of
Arabidopsis called axr5-1. Mutant plants are resistant to auxin and display a
variety of auxin-related growth defects including defects in root and shoot
tropisms. Further, the axr5-1 mutation results in a decrease in auxin-regulated
transcription. The molecular cloning of AXR5 revealed that the gene encodes the
IAA1 protein, a member of the Aux/IAA family of proteins. AXR5 is expressed
throughout plant development consistent with the pleiotropic mutant phenotype.
The axr5-1 mutation results in an amino acid substitution in conserved domain II
of the protein, similar to gain-of-function mutations recovered in other members
of this gene family. Biochemical studies show that IAA1/AXR5 interacts with TIR1
in an auxin-dependent manner. The mutation prevents this interaction suggesting
that the mutant phenotype is caused by the accumulation of IAA1/AXR5. Our
results provide further support for a model in which most members of the Aux/IAA
family are targeted for degradation by SCFTIR1 in response to auxin. Auxin/indole-3-acetic acid (Aux/IAA) proteins are transcriptional regulators
that mediate many aspects of plant responses to auxin. While functions of most
Aux/IAAs have been defined mainly by gain-of-function mutant alleles in
Arabidopsis thaliana, phenotypes associated with loss-of-function mutations have
been scarce and subtle. We report here that the downregulation of IAA9, a tomato
(Solanum lycopersicum) gene from a distinct subfamily of Aux/IAA genes, results
in a pleiotropic phenotype, consistent with its ubiquitous expression pattern.
IAA9-inhibited lines have simple leaves instead of wild-type compound leaves,
and fruit development is triggered before fertilization, giving rise to
parthenocarpy. This indicates that IAA9 is a key mediator of leaf morphogenesis
and fruit set. In addition, antisense plants displayed auxin-related growth
alterations, including enhanced hypocotyl/stem elongation, increased leaf
vascularization, and reduced apical domice. Auxin dose-response assays
revealed that IAA9 downregulated lines were hypersensitive to auxin, although
the only early auxin-responsive gene that was found to be upregulated in the
antisense lines was IAA3. The activity of the IAA3 promoter was stimulated in
the IAA9 antisense genetic background, indicating that IAA9 acts in planta as a
transcriptional repressor of auxin signaling. While no mutation in any member of
subfamily IV has been reported to date, the phenotypes associated with the
downregulation of IAA9 reveal distinct and novel roles for members of the
Aux/IAA gene family. Auxin regulates various aspects of plant growth and development. The
AUXIN/INDOLE-3-ACETIC ACID (Aux/IAA) genes encode short-lived transcriptional
repressors that are targeted by the TRANSPORT INHIBITOR RESPONSE1/AUXIN RECEPTOR
F-BOX proteins. The Aux/IAA proteins regulate auxin-mediated gene expression by
interacting with members of the AUXIN RESPONSE FACTOR protein family. Aux/IAA
function is poorly understood; herein, we report the identification and
characterization of insertion mutants in 12 of the 29 Aux/IAA family members.
The mutants show no visible developmental defects compared with the wild type.
Double or triple mutants of closely related Aux/IAA genes, such as iaa8-1 iaa9-1
or iaa5-1 iaa6-1 iaa19-1, also exhibit wild-type phenotypes. Global gene
expression analysis reveals that the molecular phenotypes of auxin-treated and
untreated light-grown seedlings are unaffected in the iaa17-6 and iaa5-1 iaa6-1
iaa19-1 mutants. By contrast, similar analysis with the gain-of-function
axr3-1/iaa17-1 mutant seedlings reveals dramatic changes in basal and
auxin-induced gene expression compared with the wild type. Expression of several
type-A ARABIDOPSIS RESPONSE REGULATOR genes and a number of genes involved in
cell wall biosynthesis and degradation is repressed in axr3-1/iaa17-1. The data
suggest extensive functional redundancy among Aux/IAA gene family members and
that enhanced stability of the AXR3/IAA17 protein severely alters the molecular
phenotype, resulting in developmental defects. The plant hormone auxin plays a central role in regulating many aspects of plant
growth and development. This largely occurs as a consequence of changes in gene
expression. The Aux/IAA genes are best characterized among the early
auxin-responsive genes, which encode short-lived transcriptional repressors. In
most plants examined, including Arabidopsis, soybean, and rice, the Aux/IAA
genes constitute a large gene family. By screening the available databases, at
least 15 expressed sequence tags (ESTs) have been identified from wheat
(Triticum aestivum), which exhibit high sequence identity with Aux/IAA
homologues in other species. One of these Aux/IAA genes, TaIAA1, harbouring all
the four conserved domains characteristic of the Aux/IAA proteins, has been
characterized in detail. The expression of TaIAA1 is light-sensitive,
tissue-specific, and is induced within 15-30 min of exogenous auxin application.
Also, the TaIAA1 transcript levels increase in the presence of a divalent
cation, Ca(2+), and this effect is reversed by the calcium-chelating agent,
EGTA. The TaIAA1 gene qualifies as the primary response gene because an increase
in its transcript levels by auxin is unaffected by cycloheximide. In addition to
auxin, the TaIAA1 gene is also induced by brassinosteroid, providing evidence
that interplay between hormones is crucial for the regulation of plant growth
and development. The plant hormone auxin (indole-3-acetic acid or IAA) regulates plant
development by inducing rapid cellular responses and changes in gene expression.
Auxin promotes the degradation of Aux/IAA transcriptional repressors, thereby
allowing auxin response factors (ARFs) to activate the transcription of
auxin-responsive genes. Auxin enhances the binding of Aux/IAA proteins to the
receptor TIR1, which is an F-box protein that is part of the E3 ubiquitin ligase
complex SCF(TIR1). Binding of Aux/IAA proteins leads to degradation via the 26S
proteasome, but evidence for SCF(TIR1)-mediated poly-ubiquitination of Aux/IAA
proteins is lacking. Here we used an Arabidopsis cell suspension-based
protoplast system to find evidence for SCF(TIR1)-mediated ubiquitination of the
Aux/IAA proteins SHY2/IAA3 and BDL/IAA12. Each of these proteins showed a
distinct abundance and repressor activity when expressed in this cell system.
Moreover, the amount of endogenous TIR1 protein appeared to be rate-limiting for
a proper auxin response measured by the co-transfected DR5::GUS reporter
construct. Co-transfection with 35S::TIR1 led to auxin-dependent degradation,
and excess of 35S::TIR1 even led to degradation of Aux/IAAs in the absence of
auxin treatment. Expression of the mutant tir1-1 protein or the related F-box
protein COI1, which is involved in jasmonate signaling, had no effect on Aux/IAA
degradation. Our results show that SHY2/IAA3 and BDL/IAA12 are
poly-ubiquitinated and degraded in response to increased auxin or TIR1 levels.
In conclusion, our data provide experimental support for the model that
SCF(TIR1)-dependent poly-ubiquitination of Aux/IAA proteins marks these proteins
for degradation by the 26S proteasome, leading to activation of auxin-responsive
gene expression. Auxin is a central hormone that exerts pleiotropic effects on plant growth
including the development of roots, shoots, flowers and fruit. The perception
and signaling of the plant hormone auxin rely on the cooperative action of
several components, among which auxin/indole-3-acetic acid (Aux/IAA) proteins
play a pivotal role. In this study, we identified and comprehensively analyzed
the entire Aux/IAA gene family in tomato (Solanum lycopersicum), a reference
species for Solanaceae plants, and the model plant for fleshy fruit development.
Functional characterization using a dedicated single cell system revealed that
tomato Aux/IAA proteins function as active repressors of auxin-dependent gene
transcription, with, however, different Aux/IAA members displaying varying
levels of repression. Phylogenetic analysis indicated that the Aux/IAA gene
family is slightly contracted in tomato compared with Arabidopsis, with a lower
representation of non-canonical proteins. Sl-IAA genes display distinctive
expression pattern in different tomato organs and tissues, and some of them
display differential responses to auxin and ethylene, suggesting that Aux/IAAs
may play a role in linking both hormone signaling pathways. The data presented
here shed more light on Sl-IAA genes and provides new leads towards the
elucidation of their function during plant development and in mediating hormone
cross-talk. Auxin plays a pivotal role in various plant growth and development processes,
including vascular differentiation. The modulation of auxin responsiveness
through the auxin perception and signaling machinery is believed to be a major
regulatory mechanism controlling cambium activity and wood formation. To gain
more insights into the roles of key Aux/IAA gene regulators of the auxin
response in these processes, we identified and characterized members of the
Aux/IAA family in the genome of Eucalyptus grandis, a tree of worldwide economic
importance. We found that the gene family in Eucalyptus is slightly smaller than
that in Populus and Arabidopsis, but all phylogenetic groups are represented.
High-throughput expression profiling of different organs and tissues highlighted
several Aux/IAA genes expressed in vascular cambium and/or developing xylem,
some showing differential expression in response to developmental (juvenile vs.
mature) and/or to environmental (tension stress) cues. Based on the expression
profiles, we selected a promising candidate gene, EgrIAA4, for functional
characterization. We showed that EgrIAA4 protein is localized in the nucleus and
functions as an auxin-responsive repressor. Overexpressing a stabilized version
of EgrIAA4 in Arabidopsis dramatically impeded plant growth and fertility and
induced auxin-insensitive phenotypes such as inhibition of primary root
elongation, lateral root emergence and agravitropism. Interestingly, the
lignified secondary walls of the interfascicular fibers appeared very late,
whereas those of the xylary fibers were virtually undetectable, suggesting that
EgrIAA4 may play crucial roles in fiber development and secondary cell wall
deposition. Auxins are the key players in plant growth development involving leaf formation,
phototropism, root, fruit and embryo development. Auxin/Indole-3-Acetic Acid
(Aux/IAA) are early auxin response genes noted as transcriptional repressors in
plant auxin signaling. However, many studies focus on Aux/ARF gene families and
much less is known about the Aux/IAA gene family in Brassica rapa (B. rapa).
Here we performed a comprehensive genome-wide analysis and identified 55 Aux/IAA
genes in B. rapa using four conserved motifs of Aux/IAA family (PF02309).
Chromosomal mapping of the B. rapa Aux/IAA (BrIAA) genes facilitated
understanding cluster rearrangement of the crucifer building blocks in the
genome. Phylogenetic analysis of BrIAA with Arabidopsis thaliana, Oryza sativa
and Zea mays identified 51 sister pairs including 15 same species (BrIAA-BrIAA)
and 36 cross species (BrIAA-AtIAA) IAA genes. Among the 55 BrIAA genes,
expression of 43 and 45 genes were verified using Genebank B. rapa ESTs and in
home developed microarray data from mature leaves of Chiifu and RcBr lines.
Despite their huge morphological difference, tissue specific expression analysis
of BrIAA genes between the parental lines Chiifu and RcBr showed that the genes
followed a similar pattern of expression during leaf development and a different
pattern during bud, flower and siliqua development stages. The response of the
BrIAA genes to abiotic and auxin stress at different time intervals revealed
their involvement in stress response. Single Nucleotide Polymorphisms between
IAA genes of reference genome Chiifu and RcBr were focused and identified. Our
study examines the scope of conservation and divergence of Aux/IAA genes and
their structures in B. rapa. Analyzing the expression and structural variation
between two parental lines will significantly contribute to functional genomics
of Brassica crops and we belive our study would provide a foundation in
understanding the Aux/IAA genes in B. rapa. A well-known physiological adaptation process of plants encountering drying soil
is to achieve water balance by reducing shoot growth and maintaining or
promoting root elongation, but little is known about the molecular basis of this
process. This study investigated the role of a drought-up-regulated Triticum
aestivum NAC69-1 (TaNAC69-1) in the modulation of root growth in wheat.
TaNAC69-1 was predomitly expressed in wheat roots at the early vegetative
stage. Overexpression of TaNAC69-1 in wheat roots using OsRSP3 (essentially
root-specific) and OsPIP2;3 (root-predomit) promoters resulted in enhanced
primary seminal root length and a marked increase in maturity root biomass.
Competitive growth analysis under water-limited conditions showed that OsRSP3
promoter-driven TaNAC69-1 transgenic lines produced 32% and 35% more
above-ground biomass and grains than wild-type plants, respectively. TaNAC69-1
overexpression in the roots down-regulated the expression of TaSHY2 and TaIAA7,
which are from the auxin/IAA (Aux/IAA) transcriptional repressor gene family and
are the homologs of negative root growth regulators SHY2/IAA3 and IAA7 in
Arabidopsis. The expression of TaSHY2 and TaIAA7 in roots was down-regulated by
drought stress and up-regulated by cytokinin treatment, which inhibited root
growth. DNA binding and transient expression analyses revealed that TaNAC69-1
bound to the promoters of TaSHY2 and TaIAA7, acted as a transcriptional
repressor and repressed the expression of reporter genes driven by the TaSHY2 or
TaIAA7 promoter. These data suggest that TaNAC69-1 is a transcriptional
repressor of TaSHY2 and TaIAA7 homologous to Arabidopsis negative root growth
regulators and is likely to be involved in promoting root elongation in drying
soil. The Aux/IAA proteins are auxin-sensitive repressors that mediate diverse
physiological and developmental processes in plants [1, 2]. There are 29 Aux/IAA
genes in Arabidopsis that exhibit unique but partially overlapping patterns of
expression [3]. Although some studies have suggested that individual Aux/IAA
genes have specialized function, genetic analyses of the family have been
limited by the scarcity of loss-of-function phenotypes [4]. Furthermore, with a
few exceptions, our knowledge of the factors that regulate Aux/IAA expression is
limited [1, 5]. We hypothesize that transcriptional control of Aux/IAA genes
plays a central role in the establishment of the auxin-signaling pathways that
regulate organogenesis, growth, and environmental response. Here, we describe a
screen for transcription factors (TFs) that regulate the Aux/IAA genes. We
identify TFs from 38 families, including 26 members of the DREB/CBF family.
Several DREB/CBF TFs directly promote transcription of the IAA5 and IAA19 genes
in response to abiotic stress. Recessive mutations in these IAA genes result in
decreased tolerance to stress conditions, demonstrating a role for auxin in
abiotic stress. Our results demonstrate that stress pathways interact with the
auxin gene regulatory network (GRN) through transcription of the Aux/IAA genes.
We propose that the Aux/IAA genes function as hubs that integrate genetic and
environmental information to achieve the appropriate developmental or
physiological outcome. Auxin is a small molecule morphogen that bridges SCFTIR1/AFB-AUX/IAA co-receptor
interactions leading to ubiquitylation and proteasome-dependent degradation of
AUX/IAA transcriptional repressors. Here, we systematically dissect auxin
sensing by SCFTIR1-IAA6 and SCFTIR1-IAA19 co-receptor complexes, and assess
IAA6/IAA19 ubiquitylation in vitro and IAA6/IAA19 degradation in vivo. We show
that TIR1-IAA19 and TIR1-IAA6 have distinct auxin affinities that correlate with
ubiquitylation and turnover dynamics of the AUX/IAA. We establish a system to
track AUX/IAA ubiquitylation in IAA6 and IAA19 in vitro and show that it occurs
in flexible hotspots in degron-flanking regions adorned with specific Lys
residues. We propose that this signature is exploited during auxin-mediated
SCFTIR1-AUX/IAA interactions. We present evidence for an evolving AUX/IAA
repertoire, typified by the IAA6/IAA19 ohnologues, that discriminates the range
of auxin concentrations found in plants. We postulate that the intrinsic
flexibility of AUX/IAAs might bias their ubiquitylation and destruction kinetics
enabling specific auxin responses. |
What is GenomeVIP? | Here, we introduce the Genome Variant Investigation Platform (GenomeVIP), an open-source framework for performing genomics variant discovery and annotation using cloud- or local high-performance computing infrastructure.GenomeVIP orchestrates the analysis of whole-genome and exome sequence data using a set of robust and popular task-specific tools, including VarScan, GATK, Pindel, BreakDancer, Strelka, and Genome STRiP, through a web interface. | Identifying genomic variants is a fundamental first step toward the
understanding of the role of inherited and acquired variation in disease. The
accelerating growth in the corpus of sequencing data that underpins such
analysis is making the data-download bottleneck more evident, placing
substantial burdens on the research community to keep pace. As a result, the
search for alternative approaches to the traditional "download and analyze"
paradigm on local computing resources has led to a rapidly growing demand for
cloud-computing solutions for genomics analysis. Here, we introduce the Genome
Variant Investigation Platform (GenomeVIP), an open-source framework for
performing genomics variant discovery and annotation using cloud- or local
high-performance computing infrastructure. GenomeVIP orchestrates the analysis
of whole-genome and exome sequence data using a set of robust and popular
task-specific tools, including VarScan, GATK, Pindel, BreakDancer, Strelka, and
Genome STRiP, through a web interface. GenomeVIP has been used for genomic
analysis in large-data projects such as the TCGA PanCanAtlas and in other
projects, such as the ICGC Pilots, CPTAC, ICGC-TCGA DREAM Challenges, and the
1000 Genomes SV Project. Here, we demonstrate GenomeVIP's ability to provide
high-confidence annotated somatic, germline, and de novo variants of potential
biological significance using publicly available data sets. |
List the ten types of conjoined twins. | Thoraco-omphalopagus: Two bodies fused from the upper chest to the lower chest. These twins usually share a heart, and may also share the liver or part of the digestive system.
Thoracopagus:Two bodies fused from the upper thorax to lower belly. The heart is always involved in these cases.
Omphalopagus: Two bodies fused at the lower abdomen. Unlike thoracopagus, the heart is never involved in these cases.
Pyopagus: joined at the buttocks with sacrum and coccyx anomalies
Rachipagus: Joined at the spine with vertebral and neural tube defects
Ischiopagus: joined at the hip from umbilicus to conjoined pelvis
Parasitic twins: Twins that are asymmetrically conjoined, resulting in one twin that is small, less formed, and dependent on the larger twin for survival.
Craniopagus: Fused skulls, but separate bodies
Cephalopagus: head but not face or foramen magnum, brains are usually separate
Dicephalus dipus dibrachius: 2 heads and one body | Magnetic resoce imaging (MRI) was used for the first time in the preoperative
planning for separation of conjoined twins. In these omphalopagus infants, MRI
showed normal biliary and cardiovascular structures and demonstrated, in detail,
a relatively avascular plane through the liver bridge, which enabled safe
separation with minimal blood loss at 3 1/2 months of age. A single MRI study
supplied information superior to that obtained with multiple previously
available imaging studies. MRI should be an essential part of the preoperative
workup of all types of conjoined twins. The descriptive epidemiology of conjoined twinning in the United States was
investigated using data from the Birth Defects Monitoring Program (BDMP), a
nationwide congenital malformations surveillance system that monitors discharge
diagnoses associated with a third of the births in the United States. This is
the largest recorded series concerning conjoined twins; data were analyzed on
7,903,000 births monitored by the BDMP in the period 1970-1977. The analysis
identified 81 sets of conjoined twins, for a crude incidence of 10.25 per
million births. The most common types of conjoined twins were
thoracoomphalopagus (28%), thoracopagus (18%), omphalopagus (10%), parasitic
twins (10%), and craniopagus (6%). Conjoined twins are more common among females
than males, and in nonwhites than whites. No maternal age effect was found.
There was no evidence of seasonal or temporal clustering of the cases. The large
number of conjoined twins who had birth defects that are not obviously linked to
the conjoining (particularly neural tube defects and orofacial clefts) may
provide insights into the pathogenesis of birth defects resulting from
disordered embryonic migration and fusion. Dicephalus is one of the rarest types of conjoined twins. In such cases, the
twins are usually stillborn or die shortly after birth. Termination of the
pregcy is recommended if conjoined twins are diagnosed early in the second
trimester. A case of dicephalic conjoined twins with cystic hygroma diagnosed
prenatally by ultrasound at 16 weeks' gestation is presented. The
ultrasonographic findings, management and pathology are discussed. BACKGROUND/PURPOSE: Conjoined twins are some of the most challenging patients
faced by surgeons. Pygopagus and ischiopagus twins present particular
gastrointestinal and genitourinary reconstructive challenges. This study reviews
the authors' experience with the perineal reconstruction of these types of
conjoined twins.
METHODS: Retrospective analysis was performed for 3 sets of female conjoined
twins undergoing separation between 1999 and 2001. Particular attention was
given to the separation and reconstruction of the distal gastrointestinal and
urogenital structures.
RESULTS: Three sets of female conjoined twins underwent successful separation 2
pygopagus, one ischiopagus tripus) with 5 surviving infants. The sixth infant
died of congenital anomalies incompatible with life. Four of the 5 surviving
infants had diverting enterostomies. Two of these enterostomies have been
closed. Perineal reconstruction consisted of anoplasty (5 of 5), vaginoplasty (4
of 5), and urethroplasty (4 of 5). Although fecal and urinary continence are not
completely measurable at this age (<3 years), all 5 survivors void
spontaneously. Three infants with intestinal continuity have apparently normal
defecation without the need of a bowel regimen.
CONCLUSIONS: With careful preoperative planning and a multidisciplinary team of
pediatric surgeons and urologists, satisfactory reconstruction and functional
outcome of the female perineum can be achieved in conjoined twins. INTRODUCTION: Attention is drawn to the spontaneous incidence of twinning, both
dizygotic and monozygotic in different mammalian species. Conjoined twinning,
however, only arises when the twinning event occurs at about the primitive
streak stage of development, at about 13-14 days after fertilisation in the
human, and is exclusively associated with the monoamniotic monochorionic type of
placentation. It is believed that the highest incidence of conjoined twinning is
encountered in the human. While monozygotic twinning may be induced
experimentally following exposure to a variety of agents, the mechanism of
induction of spontaneous twinning in the human remains unknown. All agents that
are capable of acting as a twinning stimulus are teratogenic, and probably act
by interfering with the spindle apparatus.
DISCUSSION: The incidence of the various types of conjoined twinning is
discussed. Information from the largest study to date indicates that the
spontaneous incidence is about 10.25 per million births. The most common
varieties encountered were thoraco-omphalopagus (28%), thoracopagus (18.5%),
omphalopagus (10%), parasitic twins (10%) and craniopagus (6%). Of these, about
40% were stillborn, and 60% liveborn, although only about 25% of those that
survived to birth lived long enough to be candidates for surgery. Conjoined
twinning occurs by the incomplete splitting of the embryonic axis and, with the
exception of parasitic conjoined twins, all are symmetrical and "the same parts
are always united to the same parts". Fusion of monozygotic twins is no longer
believed to be the basis of conjoined twinning. Accounts are provided of the
anatomical features of each of the commonly encountered varieties. BACKGROUND: Neurosurgeons are familiar with the challenges presented by
craniopagus twins, but other types of conjoined twins may also have
neurosurgical implications. We report our experience in the management of
ischiopagus and pygopagus conjoined twins.
METHODS: This is a retrospective review of the management of conjoined twins at
Red Cross Children's Hospital in Cape Town, South Africa.
RESULTS: Twenty-three pairs of symmetrical conjoined twins were managed over a
40-year period (1964-2003), of which 16 (70%) were separated. Of these cases, 6
are the focus of this study, namely 4 pairs of ischiopagus twins and 2 pairs of
pygopagus twins seen between 1993 and 2003. In 2 cases, there was direct
involvement of the nervous system at the site of union, with 1 pair of
ischiopagi manifesting end-to-end union of their spinal cords, while a pair of
pygopagi had back-to-back fusion of the conus. Another pair of ischiopagi had a
fused dural sac without joined neural elements, but one of these children
developed syringomyelia 2 years after separation. Neuroimaging was invaluable in
detecting these abnormalities. The one pair of ischiopagi who died before
separation were HIV positive and had severe brain atrophy and cystic
encephalmalacia at autopsy. Nine of the 12 children (75%) had bony abnormalities
of the spine remote from the area of conjunction. The most common finding was
the presence of hemivertebrae, usually in the thoracic spine. Six children
manifested scoliosis, which has already progressed in the oldest two. Technical
aspects such as timing and sequence of separation, the division of neural
tissues and reconstruction are discussed, as are the long-term complications of
their spinal abnormalities.
CONCLUSIONS: Ischiopagus and pygopagus conjoined twins manifest an interesting
array of spinal abnormalities, which present challenges, not only at the time of
separation, but also in their long-term management. Conjoined twins are rare phenomena occurring in one in 1 in 50,000 live births.
Successful surgical separation of conjoined twins is a major undertaking
requiring careful planning by a multidisciplinary team. Reports of seperation of
joined twins in developing countries like Nigeria are rare. Ten cases of
conjoined twins were separated between 1936 and January 2003 (including the
authors two new cases). There were five omphalopagus, two pygopagus, two
heterpagus and one ishiopagus twins. Three underwent emergency separation with
83.3% mortality while seven underwent elective seperation with 64.3% survival.
The overall mortality rate was 50%. Despite the absence of advanced
technological resource selected group of conjoined twins can be successfully
separated in a developing country like Nigeria. An improvement in facilities and
availability of trained personnel in likely to be associated with improved
outcome. Craniopagus twins (CPT) are an uncommon, highly fascinating accident of nature.
The clinical pathology of this complex entity is reviewed and placed in
perspective. A logical classification aids understanding of the anomaly, and is
essential to gauge outcome from separation attempts. 'Partial forms' lack
significant shared dural venous sinuses (SDVS) and 'Total forms' with SDVS also
exhibit more severe compressional brain distortion. Our classification consists
of Partial Angular (PA), Partial Vertical (PV), Total Angular (TA) and Total
Vertical (TV, formerly O'Connell Types I-III). Total vertical has a continuous
cranium, and inter-twin axial facial rotation <40 degrees (Type I), 140-180
degrees (Type II) or intermediate (Type III). The term 'Angular' denotes an
inter-twin longitudinal angle below 140 degrees , regardless of axial rotation.
Our review categorized 64 well-delineated CPT, including 41 operative separation
attempts in small children since initial success in 1952. Just over one-half
were TV, almost one-third TA, and partial forms accounted for the remaining
one-sixth. About 30% of CPT had shared or fused brain tissue, and a similar
percentage of TA twins shared a posterior fossa. Partial forms had significantly
higher birth weights, were separated at an earlier age (6 versus 11 months) and
had lower mortality and better outcome compared with Total forms. A multi-staged
surgical separation for Total CPT had a significantly better mortality than
single-staged separation. Discussion emphasizes embryological, anatomical and
clinical aspects of the malformation, with emphasis upon obstacles to a
successful outcome. Conjoined twins represent a rare form of incomplete embryonic separation. They
are classified into eight different subtypes, with 18% representing pyopagus
conjoints. History is scattered with accounts of the various types of conjoints
and it is only recently that strategies have been devised to enable surgical
separation of such twins. It is estimated that approximately 20 cases of
separation of pyopagus twins have been performed. We provide a historical look
at pyopagus conjoint twins and report our neurosurgical experience of
Australasia's first separation of pyopagus twin girls. This article provides some additions and corrections on a recently published
case report concerning a pair of di-symmetrical cephalopagus conjoined twins.
Eight different types of conjoined twins can be distinguished; one is
cephalopagus, which is fourth in rarity of occurrence. Between 17 and 24% of
cephalopagus is of the male sex. More than 30 case reports of di-symmetrical
cephalopagus can be traced in Western literature, the oldest one described and
illustrated in 1569. A hypothetical mechanism for conjoined twinning postulated by Spencer ([2003]
Developmental Malformations and Clinical Implications, Baltimore: Johns Hopkins
University Press, p 1-476) suggests that, after separation, monovular twins fuse
in one of eight predictable homologous sites. The tripus fetal specimen under
study embodies characteristics of three types therefore preventing it from
classification into a simple variant of any one of the eight twin types
described by Spencer. The aim of this study was to reveal internal structural
anomalies of the fetal specimen by using magnetic resoce imaging and
computerized tomography. Dorsally appended to the primary twin is a secondary
head mass (brain tissue and ocular globe) and two spinal columns converging at
T4/T5, suggesting rachipagus twinning. The ventral orientation of the secondary
twin's (right lateral) lower limb suggests parapagus twinning. The caudal
divergence of the spinal columns and the presence of a secondary hemipelvis,
separate from the primary pelvis, suggest cephalopagus twinning. Measurements of
the long bones indicate a gestational age of ∼20-23 weeks. Secondary
malformations of the primary fetal body include anencephaly, cleft palate, renal
agenesis, decreased left ventricular outflow, and a prematurely terminating
descending aorta. This study demonstrates the possibility of using current
imaging techniques to study very old, formalin-preserved human material for
documentation and scientific discussion without destroying the specimen, thus
keeping it intact for posterity. Objective. Conjoined twin is a rarely seen congenital anomaly together with
severe mortality and morbidity. The more common types of conjoined twins include
the thoracopagus type, where the fusion is anterior, at the chest, and involves
the heart. We are reporting one case of conjoined thoracopagus twins diagnosed
by ultrasonography at 11 weeks. Case Report. In a multigravid pregt woman who
has been admitted to our clinic with a diagnosis of conjoined twins,
thoracopagus, by ultrasonography at an 11-week gestation, termination of the
pregcy was performed. Conclusion. Making an early diagnosis with
ultrasonographic examination gives the parents a chance to elect pregcy
termination. The separation of craniopagus conjoined twins is a very rare and complex
challenge. As with many rare challenges, it presents initially as a deceptively
simple problem requiring only the most basic clinical techniques. As in many
reconstructive problems, this paradigm mandates that the neurosurgical team
performs the separation with the plastic surgeons providing closure at the end
of the separation. Historically, these approaches have included, as with the
separation of many other types of conjoined twins, the use of tissue expansion
before separation followed by separation surgery. In the best hands, at the most
capable medical centers, the mortality reported in the literature for the past
50 years is greater than 50%. Craniofacial surgery frequently demands a
coordinated effort between plastic surgery and neurosurgery and many other
specializations; separating craniopagus twins takes this coordination to a
stratospheric level. It is, however, this coordination that is of paramount
importance. Success clearly requires an understanding of the complex
interrelationship between the "separation" and the "reconstruction" and that
decisions made for 1 aspect of the surgery will have a profound impact on
another aspect of the surgery. The impact can be disastrous or, if planned well,
can be advantageous.We were contacted to evaluate craniopagus conjoined male
infant twins for separation. Radiographic studies suggested that the brains were
separate, and their medical team suggested that they were "fit for separation."
We reviewed the literature and reviewed our colleagues' experiences with similar
cases around the world. It became clear that whether separation had been
unsuccessful or successful, a variety of issues accompanied surgery as follows:
(1) massive intraoperative hemorrhage, (2) cerebral edema, (3) venous infarcts,
(4) swelling of flaps, and (5) dehiscence of repairs with cerebrospinal fluid
(CSF) leak, meningitis, or brain exposure. Although the initial plan was to
separate the twins in the same fashion as in previous cases (ie, single-stage
separation surgery preceded by tissue expansion of the scalp), it was clear that
this approach increases cerebral venous pressure during the separation component
of surgery and therefore set up a cascade of events favoring failure rather than
success. Wishing to favor success, we elected to design an open-ended
multistaged separation to improve venous collateral circulation. We believe that
this would improve venous drainage, prevent increased venous pressure, diminish
cerebral edema, and favor the integrity of the dura and flap repair that would
in turn lessen the risk of CSF leak. The stages would also allow the twins to
recover from each stage before progressing to the next stage while continuing to
receive nutritional support and physical therapy. Four major stages for 9 ½
months led to their successful separation. There has been no CSF leak or
meningitis. To our knowledge, this technique has since been applied to 2 other
sets of craniopagus with similar outcomes.A review of the pertinent literature,
our rationale, and methodology are discussed in this article. This article briefly reviews two specific types of conjoined twins, ischiopagus
and diprosopus, and discusses recent cases of such twins born in India. Some
members of the Hindu community worshiped these conjoined twins as incarnations
of Hindu deities. In discussing this phenomenon, the authors aim to elucidate
certain features of the faith tradition of Hinduism itself. The reception of
these conjoined twins as incarnations of Hindu deities can be understood by
examining two salient features of Hindu polytheism: the pictorial depiction of
Hindu deities with multiple appendages and the concept of an incarnation, or
avatar, of a Hindu deity. One of the most interesting congenital malformations to manage is a conjoined
twin. Conjoined twins are rare occurrences in obstetric/pediatric practice. More
commonly known as Siamese twins, this phenomenon is shrouded in mystery and
considered a curiosity by general public. Current technology is lending a
helping hand in the early diagnosis of these conditions. Frequently, the twins
are born dead, but there are few cases in which the twins survive. We presented
a case of dicephalus dipud conjoined twins; a rare type of conjoined twins. PURPOSE: Conjoined twins are a rare complication of 9 monozygotic twins and are
associated with high perinatal mortality. Pygopagus are one of the rare types of
conjoined twins with only a handful of cases reported in the literature. We
present the case of one-and-half month-old male pygopagus conjoined twins, who
were joined together dorsally in lower lumbar and sacral region and had spina
bifida and shared a single thecal sac with combined weight of 6.14 kg. Spinal
cord was separated at the level of the conus followed by duraplasty. They had
uneventful recovery with normal 15 months follow-up.
CONCLUSION: Separation of conjoined twins is recommended in where this is
feasible with the anticipated survival of both or one infant. Cephalopagus is a rare variety of conjoined twins. They are fused with their
heads, thoracic and upper abdominal cavities. The exact mechanism for
development of conjoined twins cannot be clearly explained. It appears that
there is an alteration in the normal developmental process of monozygotic twins,
which fail to separate from each other. We present the morphology of a
cephalothoracopagus, revealed through anatomical dissection, emphasizing the
arrangement of the viscera in the thoracic and abdominal cavities. They are
fused with their heads, thoracic and upper abdominal cavities. The lower abdomen
and pelvic cavities are free. Each twin has two upper and lower limbs, normally
shaped. Each twin has a heart and two lungs. There is a single pharynx,
esophagus and stomach, but normal lower abdominal systems. The genital and
urinary systems are apparently normal. Due to the fusion of the heads and
abnormal arrangement of the superior central nervous system, surgery is not
attempted in these cases, the prognosis being very poor. Conjoined twins are the most rare form of monozygotic twinning occurring when
there is incomplete division of the embryonic disc after day 13 post conception.
This is associated with a very high risk of perinatal morbidity and mortality.
Prognosis is dependent on the site and extent of fusion and the degree of
sharing of vital organs. Most conjoined twins die in utero or in the early
neonatal period. However less severe cases can be successfully separated. This
is a review of the types of conjoined twinning, an historical perspective and a
case of a rare form known as dicephalus dipus dibrachius (two heads and a single
body with two arms and two legs). |
Which algorithm has been developed in order to improve multiple circular sequence alignment using refined sequences? | MARS improves multiple circular sequence alignment using refined sequences. MARS was implemented in the C++ programming language as a program to compute the rotations (cyclic shifts) required to best align a set of input sequences. Experimental results, using real and synthetic data, show that MARS improves the alignments, with respect to standard genetic measures and the inferred maximum-likelihood-based phylogenies, and outperforms state-of-the-art methods both in terms of accuracy and efficiency. | BACKGROUND: A fundamental assumption of all widely-used multiple sequence
alignment techniques is that the left- and right-most positions of the input
sequences are relevant to the alignment. However, the position where a sequence
starts or ends can be totally arbitrary due to a number of reasons:
arbitrariness in the linearisation (sequencing) of a circular molecular
structure; or inconsistencies introduced into sequence databases due to
different linearisation standards. These scenarios are relevant, for instance,
in the process of multiple sequence alignment of mitochondrial DNA, viroid,
viral or other genomes, which have a circular molecular structure. A solution
for these inconsistencies would be to identify a suitable rotation (cyclic
shift) for each sequence; these refined sequences may in turn lead to improved
multiple sequence alignments using the preferred multiple sequence alignment
program.
RESULTS: We present MARS, a new heuristic method for improving Multiple circular
sequence Alignment using Refined Sequences. MARS was implemented in the C++
programming language as a program to compute the rotations (cyclic shifts)
required to best align a set of input sequences. Experimental results, using
real and synthetic data, show that MARS improves the alignments, with respect to
standard genetic measures and the inferred maximum-likelihood-based phylogenies,
and outperforms state-of-the-art methods both in terms of accuracy and
efficiency. Our results show, among others, that the average pairwise distance
in the multiple sequence alignment of a dataset of widely-studied mitochondrial
DNA sequences is reduced by around 5% when MARS is applied before a multiple
sequence alignment is performed.
CONCLUSIONS: Analysing multiple sequences simultaneously is fundamental in
biological research and multiple sequence alignment has been found to be a
popular method for this task. Conventional alignment techniques cannot be used
effectively when the position where sequences start is arbitrary. We present
here a method, which can be used in conjunction with any multiple sequence
alignment program, to address this problem effectively and efficiently. |
Which stapled peptide has been designed to target Ctf4? | The stapled Sld5 peptide was able to displace the Ctf4 partner DNA polymerase α from the replisome in yeast extracts. | |
Mutation of which gene causes arterial tortuosity syndrome? | Arterial tortuosity syndrome is an autosomal recessive connective tissue disorder caused by loss-of-function mutations in SLC2A10, which encodes facilitative glucose transporter 10 (GLUT10). | Author information:
(1)Division of Biology and Genetics, Department of Molecular and Translational
Medicine, School of Medicine, University of Brescia, Viale Europa 11, 25123,
Brescia, Italy. [email protected].
(2)Division of Biology and Genetics, Department of Molecular and Translational
Medicine, School of Medicine, University of Brescia, Viale Europa 11, 25123,
Brescia, Italy. [email protected].
(3)Division of Biology and Genetics, Department of Molecular and Translational
Medicine, School of Medicine, University of Brescia, Viale Europa 11, 25123,
Brescia, Italy. [email protected].
(4)Pediatric Cardiology, Department of Pediatrics, University of Padova, School
of Medicine, Padova, Italy. [email protected].
(5)Division of Dermatology, Department of Clinical and Experimental Sciences,
Spedali Civili University Hospital, Brescia, Italy. [email protected].
(6)Division of Biology and Genetics, Department of Molecular and Translational
Medicine, School of Medicine, University of Brescia, Viale Europa 11, 25123,
Brescia, Italy. [email protected].
(7)Unità Operativa di Genetica Medica, Ospedale Gaetano Rummo, Benevento, Italy.
[email protected].
(8)Unità Operativa di Genetica Medica, Ospedale Gaetano Rummo, Benevento, Italy.
[email protected].
(9)Pediatric Cardiology, A.O.R.N. Ospedale dei Colli, II University of Naples,
Naples, Italy. [email protected].
(10)Pediatric Cardiology, A.O.R.N. Ospedale dei Colli, II University of Naples,
Naples, Italy. [email protected].
(11)Division of Dermatology, Department of Clinical and Experimental Sciences,
Spedali Civili University Hospital, Brescia, Italy.
[email protected].
(12)Pediatric Cardiology, Department of Pediatrics, University of Padova, School
of Medicine, Padova, Italy. [email protected].
(13)Division of Biology and Genetics, Department of Molecular and Translational
Medicine, School of Medicine, University of Brescia, Viale Europa 11, 25123,
Brescia, Italy. [email protected]. Arterial tortuosity syndrome (ATS) is an autosomal recessive connective tissue
disorder caused by loss-of-function mutations in SLC2A10, which encodes
facilitative glucose transporter 10 (GLUT10). The role of GLUT10 in ATS
pathogenesis remains an enigma, and the transported metabolite(s), i.e. glucose
and/or dehydroascorbic acid, have not been clearly elucidated. To discern the
molecular mechanisms underlying the ATS aetiology, we performed gene expression
profiling and biochemical studies on skin fibroblasts. Transcriptome analyses
revealed the dysregulation of several genes involved in TGFβ signalling and
extracellular matrix (ECM) homeostasis as well as the perturbation of specific
pathways that control both the cell energy balance and the oxidative stress
response. Biochemical and functional studies showed a marked increase in
ROS-induced lipid peroxidation sustained by altered PPARγ function, which
contributes to the redox imbalance and the compensatory antioxidant activity of
ALDH1A1. ATS fibroblasts also showed activation of a non-canonical TGFβ
signalling due to TGFBRI disorganization, the upregulation of TGFBRII and
connective tissue growth factor, and the activation of the αvβ3 integrin
transduction pathway, which involves p125FAK, p60Src and p38 MAPK. Stable GLUT10
expression in patients' fibroblasts normalized redox homeostasis and PPARγ
activity, rescued canonical TGFβ signalling and induced partial ECM
re-organization. These data add new insights into the ATS dysregulated
biological pathways and definition of the pathomechanisms involved in this
disorder. PURPOSE OF REVIEW: Arterial tortuosity is emerging as a common feature in
genetically mediated thoracic aortic disease that may be prognostic. This review
will summarize recent literature on arterial tortuosity in the setting of
genetic arteriopathies.
RECENT FINDINGS: Although arterial tortuosity has been primarily described in
Loeys-Dietz syndrome due to TGFBR1 and TGFBR2 mutations and in arterial
tortuosity syndrome due to SLC210A mutations, recent studies that use
quantitative measures of tortuosity suggest that tortuosity is present in many
other genetic conditions associated with aortic dilation and dissection. The
mechanisms of the development of tortuosity in these disorders are not fully
understood, but are founded in the concept that there is abnormal, pathologic
arterial lengthening in a fixed space, resulting in more tortuous vessels.
Further studies suggest that patients with increased arterial tortuosity are at
increased risk of adverse cardiovascular events, including aortic surgery,
aortic dissection, and death.
SUMMARY: Arterial tortuosity is commonly present in genetically mediated aortic
disease. Given the suboptimal performance of aortic dimension alone in
predicting aortic dissection, quantification of tortuosity may augment the
current algorithms for determining risk in patients with aortic disease. INTRODUCTION: Arterial tortuosity syndrome (ATS) is a rare autosomal recessive
disease hallmarked by tortuosity, stenosis, and aneurysm development of large-
and medium-sized arteries. Mutations in SLC2A10, a gene that encodes the
facilitative glucose transporter GLUT10, cause ATS. Several case reports have
noted associated ophthalmic findings such as keratoconus, keratoglobus, and
myopia without detailed descriptions or standardized examinations. We report the
ophthalmic findings in a cohort of compound heterozygous ATS patients and
heterozygous carriers of SLC2A10 mutations.
METHODS: Five ATS patients and three carriers were identified through an ATS
specialty clinic at the Arkansas Children's Hospital in Little Rock, Arkansas.
Patients underwent complete eye examinations, including corneal pachymetry,
topography, and optical coherence tomography when indicated.
RESULTS: All five patients with ATS had myopia and thin corneas with an average
central corneal thickness of 426 µm, and three had corneal ectasia, two with
early keratoconus and one with keratoglobus and deep stromal corneal opacities.
One patient had bilateral high irregular astigmatism, and one had unilateral
high regular astigmatism. All carriers had myopia, one had corneal thinning, and
one developed keratectasia in one eye many years after laser-assisted in situ
keratomileusis (LASIK) surgery.
CONCLUSION: We document a spectrum of ophthalmic manifestations of ATS with
universal findings of myopia, corneal thinning, and a propensity for corneal
ectasia leading to keratoconus or keratoglobus. Heterozygous carriers may
develop keratectasia after corneal refractive surgery. Our data support regular
eye examinations for all patients carrying SLC2A10 mutations with follow-up
tailored to clinical findings. |
Fusarium oxysporum f. sp lycopersici. is a plant pathogen in plants producing what common food? | Fusarium oxysporum f. sp lycopersici.produces causes vascular wilt disease in tomatoes. | The antifungal glycoalkaloid alpha-tomatine of the tomato plant (Lycopersicon
esculentum) is proposed to protect the plant against phytopathogenic fungi.
Fusarium oxysporum f. sp. lycopersici, a vascular pathogen of tomato, produces a
tomatinase enzyme which hydrolyses the glycoalkaloid into non-fungitoxic
compounds. Detoxification of alpha-tomatine may be how this fungus avoids the
plant glycoalkaloid barrier. As an initial step to evaluate this possibility we
have studied the induction of tomatinase; (i) in fungal cultures containing
extracts from leaf, stem or root of tomato plants; and (ii) in stem and root of
tomato plants infected with the pathogen at different infection stages. The
kinetics of tomatinase induction with leaf extract (0.6% dry weight) was similar
to that observed with 20 micrograms ml-1 of alpha-tomatine. In the presence of
stem extract, tomatinase activity was less than 50% of that induced with leaf
extract, whereas in the presence of root extract tomatinase activity was very
low. In the stem of infected tomato plants tomatinase activity was higher at the
wilt stage than in previous infections stages and in root, tomatinase activity
appeared with the first symptoms and was maintained until wilting. TLC analysis
showed that the tomatinase induced in culture medium with plant extracts and in
infected tomato plants had the same mode of action as the enzyme induced with
pure alpha-tomatine, hydrolysing the glycoalkaloid into its non-fungitoxic
forms, tomatidine and beta-lycotetraose. The antisera raised against purified
tomatinase recognized in extracts of root and stem of infected tomato plants a
protein of 50000 (45000 when proteins were deglycosylated), corresponding to the
tomatinase enzyme. Therefore, it is concluded that F. oxysporum f. sp.
lycopersici express tomatinase in vivo as a result of the infection of tomato
plant. The soilborne fungus Fusarium oxysporum f. sp. radicis-lycopersici causes tomato
foot and root rot (TFRR), which can be controlled by the addition of the
nonpathogenic fungus F. oxysporum Fo47 to the soil. To improve our understanding
of the interactions between the two Fusarium strains on tomato roots during
biocontrol, the fungi were labeled using different autofluorescent proteins as
markers and subsequently visualized using confocal laser scanning microscopy.
The results were as follows. i) An at least 50-fold excess of Fo47over F.
oxysporum f. sp. radicis-lycopersici was required to obtain control of TFRR. ii)
When seedlings were planted in sand infested with spores of a single fungus,
Fo47 hyphae attached to the root earlier than those of F. oxysporum f. sp.
radicis-lycopersici. iii) Subsequent root colonization by F. oxysporum f. sp.
radicis-lycopersici was faster and to a larger extent than that by Fo47. iv)
Under disease-controlling conditions, colonization of tomato roots by the
pathogenic fungus was significantly reduced. v) When the inoculum concentration
of Fo47 was increased, root colonization by the pathogen was arrested at the
stage of initial attachment to the root. vi) The percentage of spores of Fo47
that germinates in tomato root exudate in vitro is higher than that of the
pathogen F. oxysporum f. sp. radicis-lycopersici. Based on these results, the
mechanisms by which Fo47 controls TFRR are discussed in terms of i) rate of
spore germination and competition for nutrients before the two fungi reach the
rhizoplane; ii) competition for initial sites of attachment, intercellular
junctions, and nutrients on the tomato root surface; and iii) inducing systemic
resistance. Saponin detoxification enzymes from pathogenic fungi are involved in the
infection process of their host plants. Fusarium oxysporum f. sp lycopersici, a
tomato pathogen, produces the tomatinase enzyme Tom1, which degrades
alpha-tomatine to less toxic derivates. To study the role of the tom1 gene in
the virulence of F. oxysporum, we performed targeted disruption and
overexpression of the gene. The infection process of tomato plants inoculated
with transformants constitutively producing Tom1 resulted in an increase of
symptom development. By contrast, tomato plants infected with the knockout
mutants showed a delay in the disease process, indicating that Tom1, although
not essential for pathogenicity, is required for the full virulence of F.
oxysporum. Total tomatinase activity in the disrupted strains was reduced only
25%, leading to beta(2)-tomatine as the main hydrolysis product of the saponin
in vitro. In silico analysis of the F. oxysporum genome revealed the existence
of four additional putative tomatinase genes with identities to tomatinases from
family 3 of glycosyl hydrolases. These might be responsible for the remaining
tomatinase activity in the Deltatom1 mutants. Our results indicate that
detoxification of alpha-tomatine in F. oxysporum is carried out by several
tomatinase activities, suggesting the importance of these enzymes during the
infection process. ABSTRACT Fusarium oxysporum f. sp. radicis-lycopersici, the causal agent of
Fusarium crown and root rot of tomato, and F. oxysporum f. sp. basilici, the
causal agent of Fusarium wilt in basil, are soilborne pathogens capable of
producing conspicuous masses of macroconidia along the stem. The role of the
airborne propagules in the epidemics of the disease in tomato plants was
studied. In the field, airborne propagules of F. oxysporum f. sp.
radicis-lycopersici were trapped with a selective medium and their prevalence
was determined. Plants grown in both covered and uncovered pots, detached from
the field soil, and exposed to natural aerial inoculum developed typical
symptoms (82 to 87% diseased plants). The distribution of inoculum in the growth
medium in the pots also indicated the occurrence of foliage infection. In
greenhouse, foliage and root inoculations were carried out with both tomato and
basil and their respective pathogens. Temperature and duration of high relative
humidity affected rate of colonization of tomato, but not of basil, by the
respective pathogens. Disease incidence in foliage-inoculated plants reached 75
to 100%. In these plants, downward movement of the pathogens from the foliage to
the crown and roots was observed. Wounding enhanced pathogen invasion and
establishment in the foliage-inoculated plants. The sporulation of the two
pathogens on stems, aerial dissemination, and foliage infection raise the need
for foliage protection in addition to soil disinfestation, in the framework of
an integrated disease management program. The purpose of this work was to gain an insight on the potential role of the
phytopathogenic fungus Fusarium oxysporum f. sp. lycopersici in the
translocation of metals and metalloids from soil to plant roots in tomato
(Lycopersicum esculentum). Two varieties of tomato (one susceptible and another
resistant to infection by Fusarium oxysporum f. sp. lycopersici) were challenged
with the fungus for different periods of time, and several elements (V, Cr, Mn,
Co, Cu, Zn, As, Se, Mo, Ag, Cd, Pb) were determined in roots and in soil
substrate. Additionally, phenolic plant products were also analyzed for the
evaluation of the plant response to biotic stress. In order to obtain
representative results for plants cultivated in noncontaminated environments,
the infected and control plants were grown in commercial soil with natural,
relatively low metal concentrations, partly associated with humic substances.
Using such an experimental design, a specific role of the fungus could be
observed, while possible effects of plant exposure to elevated concentrations of
heavy metals were avoided. In the infected plants of two varieties, the root
concentrations of several metals/metalloids were increased compared to control
plants; however, the results obtained for elements and for phenolic compounds
were significantly different in the two plant varieties. It is proposed that
both Lycopersicum esculentum colonization by Fusarium oxysporum f. sp.
lycopersici and the increase of metal bioavailability due to fungus-assisted
solubilization of soil humic substances contribute to element traffic from soil
to roots in tomato plant. Secreted-in-xylem (SIX) proteins of the vascular wilt pathogen Fusarium
oxysporum f. sp. lycopersici are secreted during infection of tomato and
function in virulence or avirulence. F. oxysporum formae speciales have specific
host ranges but the roles of SIX proteins in diverse hosts are unknown. We
identified homologs of F. oxysporum f. sp. lycopersici SIX1, SIX4, SIX8, and
SIX9 in the genome of Arabidopsis infecting isolate Fo5176. A SIX4 homolog
(termed Fo5176-SIX4) differed from that of F. oxysporum f. sp. lycopersici
(Fol-SIX4) by only two amino acids, and its expression was induced during
infection of Arabidopsis. Transgenic Arabidopsis plants constitutively
expressing Fo5176-SIX4 had increased disease symptoms with Fo5176. Conversely,
Fo5176-SIX4 gene knock-out mutants (Δsix4) had significantly reduced virulence
on Arabidopsis, and this was associated with reduced fungal biomass and host
jasmonate-mediated gene expression, the latter known to be essential for host
symptom development. Full virulence was restored by complementation of Δsix4
mutants with either Fo5176-SIX4 or Fol-SIX4. Thus, Fo5176-SIX4 contributes
quantitatively to virulence on Arabidopsis whereas, in tomato, Fol-SIX4 acts in
host specificity as both an avirulence protein and a suppressor of other
race-specific resistances. The strong sequence conservation for SIX4 in F.
oxysporum f. sp. lycopersici and Fo5176 suggests a recent common origin. The present study was undertaken to explore the inhibitory effect of
cyanobacterial extracts of Nostoc commune FA-103 against the tomato-wilt
pathogen, Fusarium oxysporum f. sp. lycopersici. In an optimal medium, cell
growth, antifungal activity, and antifungal compound production could be
increased 2.7-fold, 4.1-fold, and 13.4-fold, respectively. A crude algal extract
had a similar effect as mancozeb at the recommended dose, both in laboratory and
pot tests. In vitro and in vivo fungal growth, spore sporulation and fungal
infection of wilt pathogen in tomato seeds were significantly inhibited by
cyanobacterial extracts. Nostoc commune FA-103 extracts have potential for the
suppression of Fusarium oxysporum f. sp. lycopersici. Plant pathogens secrete effectors to manipulate their host and facilitate
colonization. Fusarium oxysporum f. sp. lycopersici is the causal agent of
Fusarium wilt disease in tomato. Upon infection, F. oxysporum f. sp. lycopersici
secretes numerous small proteins into the xylem sap (Six proteins). Most Six
proteins are unique to F. oxysporum, but Six6 is an exception; a homolog is also
present in two Colletotrichum spp. SIX6 expression was found to require living
host cells and a knockout of SIX6 in F. oxysporum f. sp. lycopersici compromised
virulence, classifying it as a genuine effector. Heterologous expression of SIX6
did not affect growth of Agrobacterium tumefaciens in Nicotiana benthamiana
leaves or susceptibility of Arabidopsis thaliana toward Verticillium dahliae,
Pseudomonas syringae, or F. oxysporum, suggesting a specific function for F.
oxysporum f. sp. lycopersici Six6 in the F. oxysporum f. sp. lycopersici- tomato
pathosystem. Remarkably, Six6 was found to specifically suppress I-2-mediated
cell death (I2CD) upon transient expression in N. benthamiana, whereas it did
not compromise the activity of other cell-death-inducing genes. Still, this I2CD
suppressing activity of Six6 does not allow the fungus to overcome I-2
resistance in tomato, suggesting that I-2-mediated resistance is independent
from cell death. Medicinal plant extracts of five plants; Adhatoda vasica, Eucalyptus globulus,
Lantana camara, Nerium oleander and Ocimum basilicum collected from Cairo, Egypt
were evaluated against Fusarium oxysporum f. sp. lycopersici race 3 in vitro
conditions using water and certain organic solvents. The results revealed that
cold distilled water extracts of O. basilicum and E. globulus were the most
effective ones for inhibiting the growth of F. oxysporum f. sp. lycopersici.
Butanolic and ethanolic extracts of the tested plants inhibited the pathogen
growth to a higher extent than water extracts. Butanolic extract of O. basilicum
completely inhibited the growth of F. oxysporum f. sp. lycopersici at
concentrations 1.5 and 2.0% (v/v). Butanolic extracts (2.0%) of tested plants
had a strong inhibitory effect on hydrolytic enzymes; β-glucosidase, pectin
lyase and protease of F. oxysporum f. sp. lycopersici. This study has confirmed
that the application of plant extracts, especially from O. basilicum for
controlling F. oxysporum f. sp. lycopersici is environmentally safe, cost
effective and does not disturb ecological balance. Investigations are in
progress to test the efficacy of O. basilicum extract under in vivo conditions. Fusarium oxysporum is an ascomycetous fungus that is well-known as a soilborne
plant pathogen. In addition, a large population of nonpathogenic F. oxysporum
(NPF) inhabits various environmental niches, including the phytosphere. To
obtain an insight into the origin of plant pathogenic F. oxysporum, we focused
on the tomato (Solanum lycopersicum) and its pathogenic F. oxysporum f. sp.
lycopersici (FOL). We collected F. oxysporum from wild and transition Solanum
spp. and modern cultivars of tomato in Chile, Ecuador, Peru, Mexico,
Afghanistan, Italy, and Japan, evaluated the fungal isolates for pathogenicity,
VCG, mating type, and distribution of SIX genes related to the pathogenicity of
FOL, and constructed phylogenies based on ribosomal DNA intergenic spacer
sequences. All F. oxysporum isolates sampled were genetically more diverse than
FOL. They were not pathogenic to the tomato and did not carry SIX genes. Certain
NPF isolates including those from wild Solanum spp. in Peru were grouped in FOL
clades, whereas most of the NPF isolates were not. Our results suggested that
the population of NPF isolates in FOL clades gave rise to FOL by gaining
pathogenicity. The Fusarium wilt caused by Fusarium oxysporum strains is the most devastating
disease of cucumber, baa, and tomato. The biological control of this disease
has become an attractive alternative to the chemical fungicides and other
conventional control methods. In this review, the research trends and biological
control efficiencies (BCE) of different microbial strains since 2000 are
reviewed in detail, considering types of microbial genera, inoculum application
methods, plant growth medium and conditions, inoculum application with
amendments, and co-inoculation of different microbial strains and how those
affect the BCE of Fusarium wilt. The data evaluation showed that the BCE of
biocontrol agents was higher against the Fusarium wilt of cucumber compared to
the Fusarium wilts of baa and tomato. Several biocontrol agents mainly
Bacillus, Trichoderma, Pseudomonas, nonpathogenic Fusarium, and Penicillium
strains were evaluated to control Fusarium wilt, but still this lethal disease
could not be controlled completely. We have discussed different reasons of
inconsistent results and recommendations for the betterment of BCE in the
future. This review provides knowledge of the biotechnology of biological
control of Fusarium wilt of cucumber, baa, and tomato in a nut shell that
will provide researchers a beginning line to start and to organize and plan
research for the future studies. Seventy-four Fusarium oxysporum soil isolates were assayed for known effector
genes present in an F. oxysporum f. sp. lycopersici race 3 tomato wilt strain
(FOL MN-25) obtained from the same fields in Manatee County, Florida. Based on
the presence or absence of these genes, four haplotypes were defined, two of
which represented 96% of the surveyed isolates. These two most common effector
haplotypes contained either all or none of the assayed race 3 effector genes. We
hypothesized that soil isolates with all surveyed effector genes, similar to FOL
MN-25, would be pathogenic toward tomato, whereas isolates lacking all effectors
would be nonpathogenic. However, inoculation experiments revealed that presence
of the effector genes alone was not sufficient to ensure pathogenicity on
tomato. Interestingly, a nonpathogenic isolate containing the full suite of
unmutated effector genes (FOS 4-4) appears to have undergone a chromosomal
rearrangement yet remains vegetatively compatible with FOL MN-25. These
observations confirm the highly dynamic nature of the F. oxysporum genome and
support the conclusion that pathogenesis among free-living populations of F.
oxysporum is a complex process. Therefore, the presence of effector genes alone
may not be an accurate predictor of pathogenicity among soil isolates of F.
oxysporum. In the present study, we investigated the role of Trichoderma virens
(TriV_JSB100) spores or cell-free culture filtrate in the regulation of growth
and activation of the defence responses of tomato (Solanum lycopersicum) plants
against Fusarium oxysporum f. sp. lycopersici by the development of a
biocontrol-plant-pathogen interaction system. Two-week-old tomato seedlings
primed with TriV_JSB100 spores cultured on barley grains (BGS) or with cell-free
culture filtrate (CF) were inoculated with Fusarium pathogen under glasshouse
conditions; this resulted in significantly lower disease incidence in tomato
Oogata-Fukuju plants treated with BGS than in those treated with CF. To dissect
the pathways associated with this response, jasmonic acid (JA) and salicylic
acid (SA) signalling in BGS- and CF-induced resistance was evaluated using JA-
and SA-impaired tomato lines. We observed that JA-deficient mutant def1 plants
were susceptible to Fusarium pathogen when they were treated with BGS. However,
wild-type (WT) BGS-treated tomato plants showed a higher JA level and
significantly lower disease incidence. SA-deficient mutant NahG plants treated
with CF were also found to be susceptible to Fusarium pathogen and displayed low
SA levels, whereas WT CF-treated tomato plants exhibited moderately lower
disease levels and substantially higher SA levels. Expression of the
JA-responsive defensin gene PDF1 was induced in WT tomato plants treated with
BGS, whereas the SA-inducible pathogenesis-related protein 1 acidic (PR1a) gene
was up-regulated in WT tomato plants treated with CF. These results suggest that
TriV_JSB100 BGS and CF differentially induce JA and SA signalling cascades for
the elicitation of Fusarium oxysporum resistance in tomato. |
Is cilengitide effective for treatment of glioblastoma? | No, cilengitide does not improve survival of glioblastoma (GBM) patients. Cilengitide is a cyclic pentapeptide that demonstrated efficacy for GBM treatment by targeting the integrins avβ3 and avβ5 over-expressed on GBM cells. However, randomized phase III CENTRIC and phase II CORE trials explored failed to meet their primary endpoints. However, in CORE, higher αvβ3 levels in tumor cells were associated with improved progression-free survival by central review and with improved overall survival in patients treated with cilengitide. Analysis of randomized clinical trials of antiangiogenic drugs (including cilengitide) showed no improvement in overall survival and a trend for an inferior outcome, in terms of overall survival, in patients receiving antiangiogenic drug alone compared to cytotoxic drug alone. | The integrin antagonist cilengitide has been explored as an adjunct with
anti-angiogenic properties to standard of care temozolomide chemoradiotherapy
(TMZ/RT → TMZ) in newly diagnosed glioblastoma. Preclinical data as well as
anecdotal clinical observations indicate that anti-angiogenic treatment may
result in altered patterns of tumor progression. Using a standardized approach,
we analyzed patterns of progression on MRI in 21 patients enrolled onto a phase
2 trial of cilengitide added to TMZ/RT → TMZ in newly diagnosed glioblastoma.
Thirty patients from the experimental treatment arm of the EORTC/NCIC pivotal
TMZ trial served as a reference. MRIcro software was used to map location and
extent of initial preoperative and recurrent tumors on MRI of both groups into
the same stereotaxic space which were then analyzed using an automated tool of
image analysis. Clinical and outcome data of the cilengitide-treated patients
were similar to those of the EORTC/NCIC trial except for a higher proportion of
patients with a methylated O(6)-methylguanyl-DNA-methyltransferase gene
promoter. Analysis of recurrence pattern revealed neither a difference in the
size of the recurrent tumor nor in the distance of the recurrences from the
preoperative tumor location between groups. Overall frequencies of distant
recurrences were 20 % in the reference group and 19 % (4/21 patients) in the
cilengitide group. Compared with TMZ/RT → TMZ alone, the addition of cilengitide
does not alter patterns of progression. This analysis does not support concerns
that integrin antagonism by cilengitide may induce a more aggressive phenotype
at progression, but also provides no evidence for an anti-invasive activity of
cilengitide in patients with newly diagnosed glioblastoma. Maligt gliomas especially glioblastoma (GBM) are poorly responsive to the
current treatments. Cilengitide (CGT) is a cyclic pentapeptide that demonstrated
efficacy for GBM treatment by targeting the integrins avβ3 and avβ5
over-expressed on GBM cells. However, clinical translation of this therapy has
been limited by issues including fast blood clearance, high kidney and liver
uptake, poor blood-brain barrier (BBB) penetration, low tumor specificity and
rapid washout from tumors. In this study, these issues were tackled in an
integrated manner using a multi-stage strategy combining ultrasound-targeted
microbubble destruction (UTMD) with CGT otherapy. CGT oparticles (CGT-NP)
prepared using gelatin and Poloxamer 188-grafted heparin copolymer demonstrated
significant apoptotic and cytotoxic effects in C6 GBM cells. Biodistribution
study in a rat GBM model demonstrated buildup of high CGT level in tumors
subjected to CGT-NP+UTMD combined therapy. The tumor CGT level in these animals
was increased over 3-fold, tumor retention of CGT prolonged and renal clearance
significantly reduced when compared with free CGT with or without UTMD.
CGT-NP+UTMD treatment was further shown to extend the median survival period
from less than 20days in the control and about 30days in free CGT group to about
80days. This was achieved with low CGT dosing level (2mg/kg twice weekly). In
situ monitoring of GFAP, Ki67, caspase-3, Beclin-1, and LC-3 in the tumor
samples together with TUNEL assay, transmission electron microscope imaging and
Western blot assay all demonstrated high apoptotic and autophagy activities
induced by the combined therapy. In conclusion, this study has provided
extensive preclinical data supporting the use of this combined therapy to
overcome the limitations of standard CGT treatment of gliomas. Conflict of interest statement: CONFLICTS OF INTEREST Michael Weller has
received research grants from Acceleron, Bayer, Isarna, MSD, Merck Serono, PIQUR
and Roche and honoraria for lectures or advisory board participation from
Celldex, Isarna, Magforce, MSD, Merck Serono, Pfizer, Roche and Teva. Louis Burt
Nabors serves in an uncompensated advisory board role for Merck Serono. Thierry
Gorlia reports no disclosures. Henning Leske reports no disclosures. Elisabeth
Rushing reports no disclosures. Pierre Bady reports no disclosures. Christine
Hicking is an employee and stockowner of Merck KGaA. James Perry has received
honoraria for lectures or advisory board participation from Merck, MSD,
Midatech, and Roche. Yong-Kil Hong reports no disclosures. Patrick Roth has
received honoraria for advisory boards or lectures from Roche, MSD, Novartis and
Molecular Partners. Wolfgang Wick has received research grants from Apogenix,
Boehringer Ingelheim, Eli Lilly, immatics, MSD and Roche as well as honoraria
for lectures or advisory board participation from MSD and Roche. Simon Goodman
is a Merck KGaA employee and holds patents on the integrin antibodies used in
this study. Monika Hegi has received an honorary for advisory board
participation from MSD, Merck Serono, Roche, and MDxHealth. Martin Picard is a
Merck KGaA employee. Holger Moch has received research grants from Merck Serono.
Josef Straub is a Merck KGaA employee. Roger Stupp has served on advisory boards
for Roche/Genentech, MSD and EMD-Serono/Merck. Newly diagnosed glioblastoma multiforme with unmethylated MGMT promoter has a
poor prognosis, with a median survival of 12 months. This phase II study
investigated the efficacy and safety of combining the selective integrin
inhibitor cilengitide with a combination of metronomic temozolomide and
procarbazine for these patients. Eligible patients (newly diagnosed,
histologically confirmed supratentorial glioblastoma with unmethylated MGMT
promoter) were entered into this multicentre study. Cilengitide (2000 mg IV
twice weekly) was commenced 1 week prior to radiotherapy combined with daily
temozolomide (60 mg/m(2)) and procarbazine (50 or 100 mg) and, after 4 weeks'
break, followed by six adjuvant cycles of temozolomide (50-60 mg/m(2)) and
procarbazine (50 or 100 mg) on days 1-20, every 28 days. Cilengitide was
continued for up to 12 months or until disease progression or unacceptable
toxicity. The primary endpoint for efficacy was a 12-month overall survival rate
of 65 %. Twenty-nine patients completed study treatment. Sixteen patients
survived for 12 months or more, an overall survival rate of 55 %. The median
overall survival was 14.5 months (95 % CI 11.1-19.6) and the median
progression-free survival was 7.4 months (95 % CI 6.1-8). Cilengitide combined
with metronomic temozolomide and procarbazine in MGMT-promoter unmethylated
glioblastoma did not improve survival compared with historical data and does not
warrant further investigation. Glioblastoma (GBM) is the most common primary maligt brain tumor that nearly
always results in a bad prognosis. Temozolomide plus radiotherapy (TEM+RAD) is
the most common treatment for newly diagnosed GBM. With the development of
molecularly targeted drugs, several clinical trials were reported; however, the
efficacy of the treatment remains controversial. So we attempted to measure the
dose of the molecularly targeted drug that could improve the prognosis of those
patients. The appropriate electronic databases (PubMed, MEDLINE, EMBASE, and the
Cochrane Library) were searched for relevant studies. A meta-analysis was
performed after determining which studies met the inclusion criteria. Six
randomized, controlled trials (RCTs) were identified for this meta-analysis,
comprising 2,637 GBM patients. The benefit of overall survival (OS) was hazard
ratio (HZ), 0.936 [95% confidence interval (CI), 0.852-1.028]. The benefit with
respect to progression-free survival (PFS) rate was HZ of 0.796 (95% CI,
0.701-0.903). OS benefit of cilengitide was HZ of 0.792 (95% CI, 0.642-0.977).
The adverse effects higher than grade 3 were 57.7% in the experimental group and
44.1% in the placebo group (odds ratio, 1.679; 95% CI, 1.434-1.967). The
addition of molecularly targeted drugs to TEM + RAD did not improve the OS of
patients with GBM; however, it did improve PFS in patients treated by
cilengitide who could not get improvement in OS. The rate of adverse effects was
higher in the experimental group than in the placebo group. BACKGROUND: glioblastomas are highly vascularized tumors and various
antiangiogenic drugs have been investigated in clinical trials showing unclear
results. We performed a systematic review and a meta-analysis to clarify and
evaluate their effectiveness in glioblastoma patients.
PATIENTS AND METHODS: we searched relevant published and unpublished randomized
clinical trials analyzing antiangiogenic drugs versus chemotherapy in
glioblastoma patients from January 2006 to January 2016 in MEDLINE, WEB of
SCIENCE, ASCO, ESMO and SNO databases.
RESULTS: fourteen randomized clinical trials were identified (7 with
bevacizumab, 2 cilengitide, 1 enzastaurin, 1 dasatinib, 1 vandetanib, 1
temsirolimus, 1 cediranib) including 4330 patients. Antiangiogenic drugs showed
no improvement in overall survival with a pooled HR of 1.00, a trend for an
inferior outcome, in terms of overall survival, was observed in the group of
patients receiving antiangiogenic drug alone compared to cytotoxic drug alone
(HR=1.24, p=0.056). Bevacizumab did not improve overall survival. Twelve trials
(4113 patients) were analyzed for progression-free survival. Among
antiangiogenic drugs, only bevacizumab demonstrated an improvement of
progression-free survival (HR=0.63, p<0.001), both alone (HR=0.60, p=0.003) or
in combination to chemotherapy (HR=0.63; p<0.001), both as first-line treatment
(HR=0.70, p<0.001) or in recurrent disease (HR=0.52, p<0.001).
CONCLUSIONS: antiangiogenic drugs did not improve overall survival in
glioblastoma patients, either as first or second-line treatment, and either as
single agent or in combination with chemotherapy. Among antiangiogenic drugs,
only bevacizumab improved progression-free survival regardless of treatment
line, both as single agent or in combination with chemotherapy. OBJECTIVE: New therapeutic agents in combination with the standard Stupp
protocol (a protocol about the temozolomide combined with radiotherapy treatment
with glioblastoma was research by Stupp R in 2005) were assessed to evaluate
whether they were superior to the Stupp protocol alone, to determine the optimum
treatment regimen for patients with newly diagnosed glioblastoma.
PATIENTS AND METHODS: We implemented a search strategy to identify studies in
the following databases: PubMed, Cochrane Library, EMBASE, CNKI, CBM, Wanfang,
and VIP, and assessed the quality of extracted data from the trials included.
Statistical software was used to perform network meta-analysis.
RESULTS: The use of novel therapeutic agents in combination with the Stupp
protocol were all shown to be superior than the Stupp protocol alone for the
treatment of newly diagnosed glioblastoma, ranked as follows: cilengitide
2000mg/5/week, bevacizumab in combination with irinotecan, nimotuzumab,
bevacizumab, cilengitide 2000mg/2/week, cytokine-induced killer cell
immunotherapy, and the Stupp protocol. In terms of serious adverse effects, the
intervention group showed a 29% increase in the incidence of adverse events
compared with the control group (patients treated only with Stupp protocol) with
a statistically significant difference (RR=1.29; 95%CI 1.17-1.43; P<0.001). The
most common adverse events were thrombocytopenia, lymphopenia, neutropenia,
pneumonia, nausea, and vomiting, none of which were significantly different
between the groups except for neutropenia, pneumonia, and embolism.
CONCLUSIONS: All intervention drugs evaluated in our study were superior to the
Stupp protocol alone when used in combination with it. However, we could not
conclusively confirm whether cilengitide 2000mg/5/week was the optimum regime,
as only one trial using this protocol was included in our study. BACKGROUND: Determining the expression levels of neuroglial antigen 2 (NG2) in
glioma cell lines and to evaluate the potential contribution of NG2 to
cilengitide response were aimed.
MATERIALS AND METHODS: Endogenous expression level of NG2 was determined using
quantitative reverse transcription polymerase chain reaction and immunoblotting.
Cilengitide responses of the cells were monitored to determine half maximal
inhibitory concentration values. Whether the suppression of NG2 expression
alters the response of A172 cells to cilengitide was examined.
RESULTS: The effect of cilengitide on inducing apoptosis of the cells was
determined by TUNEL staining. High mRNA and protein expression of NG2 was
detected in A172 and U-87MG cells, while T98G, M059K and M059J cells
demonstrated low levels of NG2. A172, U-87MG and positive control MG-63 were
relatively sensitive to cilengitide compared to T98G, M059K and M059J. MG-63,
A172 and U-87MG were unexpectedly found to be more susceptible to cilengitide.
In addition, NG2 knock-down showed no significant difference in cell death
between small interfering RNA (siRNA)-transfected and cilengitide-treated
groups. The results showed that cilengitide caused detachment and subsequently
initiated apoptosis. Glioma cell lines express variable levels of NG2 and differ
in their responses to cilengitide. Although increased numbers of apoptotic cells
were found in untransfected cells compared to siRNA-transfected cells upon
exposed to cilengitide, the difference was not documented to be significant
between two groups.
CONCLUSION: It may be proposed that the combination therapy of NG2 suppression
and cilengitide treatment showed no considerable effect on glioblastoma compared
to cilengitide therapy alone. Response to therapy may be further improved by
targeting other factors act in concert in this signaling pathway. |
What is BBCAnalyzer? | BBCAnalyzer (Bases By CIGAR Analyzer) provides a novel visual approach to facilitate this step of time-consuming, manual inspection of common mutation sites. BBCAnalyzer is able to visualize base counts at predefined positions or regions in any sequence alignment data that are available as BAM files. Thereby, the tool provides a straightforward solution for evaluating any list of expected mutations like hotspot mutations, or even whole regions of interest. In addition to an ordinary textual report, BBCAnalyzer reports highly customizable plots. Information on the counted number of bases, the reference bases, known mutations or polymorphisms, called mutations and base qualities is summarized in a single plot. By uniting this information in a graphical way, the user may easily decide on a variant being present or not - completely independent of any internal filters or frequency thresholds. | BACKGROUND: Deriving valid variant calling results from raw next-generation
sequencing data is a particularly challenging task, especially with respect to
clinical diagnostics and personalized medicine. However, when using classic
variant calling software, the user usually obtains nothing more than a list of
variants that pass the corresponding caller's internal filters. Any expected
mutations (e.g. hotspot mutations), that have not been called by the software,
need to be investigated manually.
RESULTS: BBCAnalyzer (Bases By CIGAR Analyzer) provides a novel visual approach
to facilitate this step of time-consuming, manual inspection of common mutation
sites. BBCAnalyzer is able to visualize base counts at predefined positions or
regions in any sequence alignment data that are available as BAM files. Thereby,
the tool provides a straightforward solution for evaluating any list of expected
mutations like hotspot mutations, or even whole regions of interest. In addition
to an ordinary textual report, BBCAnalyzer reports highly customizable plots.
Information on the counted number of bases, the reference bases, known mutations
or polymorphisms, called mutations and base qualities is summarized in a single
plot. By uniting this information in a graphical way, the user may easily decide
on a variant being present or not - completely independent of any internal
filters or frequency thresholds.
CONCLUSIONS: BBCAnalyzer provides a unique, novel approach to facilitate variant
calling where classical tools frequently fail to call. The R package is freely
available at http://bioconductor.org . The local web application is available at
Additional file 2. A documentation of the R package (Additional file 1) as well
as the web application (Additional file 2) with detailed descriptions, examples
of all input- and output elements, exemplary code as well as exemplary data are
included. A video demonstrates the exemplary usage of the local web application
(Additional file 3). Additional file 3: Supplement_3. Video demonstrating the
exemplary usage of the web application "BBCAnalyzer". (MP4 11571 kb). |
Can multiple myeloma patients develop hyperviscosity syndrome? | Yes, multiple myeloma patients can develop hyperviscosity syndrome. Multiple myeloma is a neoplastic plasma-cell disorder resulting from malignant plasma cells in the bone marrow. It can cause a hyperviscosity syndrome secondary to the paraproteinaemia associated with the disease. The increased hyperviscosity can lead to retinal vein occlusions and other ocular problems. | A case of IgA (kappa type) myeloma complicated by fractures of the bones and
hyperviscosity syndrome is presented. A 56-year-old woman who had been followed
as an outpatient with diabetes mellitus for about 16 years, developed multiple
myeloma. She also showed symptoms and signs of hyperviscosity syndrome;
hemorrhagic diathesis, blurred vision and episodes of transient ischemic attacks
of the brain, and fractures of the bones by small powers of trauma. At autopsy,
almost all bones showed infiltration of multiple myeloma of IgA-kappa type and
severe osteoporosis accompanied with proliferation of osteoclasts. The
association of IgA myeloma with hyperviscosity syndrome and/or bone destruction
was discussed. The "serum hyperviscosity syndrome" has been described clinically
as the triad of bleeding, visual signs and symptoms, and neurologic
manifestations. And this syndrome has been associated frequently with
macroglobulinemia of Waldenström, occasionally with immunoglobulin (Ig) G
myeloma, rarely with IgA myeloma, and with other dysproteinemia. Myeloma is also
characterized by extensive bone destruction and is accompanied by susceptibility
to fracture, although Waldenström's macroglobulinemia, acute leukemia or chronic
leukemia are rarely associated with bone resorption. The present report
describes a patient with IgA myeloma complicated by hyperviscosity syndrome and
multiple bone fractures. A prospective study of 9 patients with plasma cell dyscrasia was performed to
evaluate the need of plasma exchange (PE) and its possible effect in the acute
and chronic management of hyperviscosity syndrome. The underlying dyscrasia was
an IgG myeloma in 5 cases, IgA myeloma in 2 cases, one patient had IgD myeloma
and in one patient Waldemström's macroglobulinemia was diagnosed. The main
sequelae of circulatory disturbances, caused by increased blood resistance to
flow, were fundus alterations (55.6%), neurologic manifestations (88.9%), a
tendency to bleeding (44.4%) and renal failure (55.6%). In total, 49 PE
procedures were performed. Following PE, hyperviscosity symptoms improved in
88.9% of the treated patients. The improvement in neurologic manifestations and
hematologic complications was very fast, within the first PE session. The effect
was less evident in ocular fundus alterations. Only one myeloma patient
developed chronic renal failure. PE is the most effective method in the
treatment of hyperviscosity syndrome often seen with multiple myeloma and
Waldenström's macroglobulinemia, and it is therapy of choice for this
complication. PURPOSE: To report a case of bilateral central retinal vein occlusion as the
presenting feature of new onset multiple myeloma in an otherwise healthy man.
METHODS: A 44-year-old man presented with painless visual changes in his left
eye. Ophthalmic examination revealed what appeared to be bilateral central
retinal vein occlusion and hematologic assessment resulted in the diagnosis of
immunoglobulin G multiple myeloma.
RESULTS: Initial management was plasma exchange followed by a chemotherapy
regimen of cyclophosphamide, bortezomib, and dexamethasone, and subsequent plans
for bone marrow transplant.
CONCLUSION: Hyperviscosity syndrome seems similar to central retinal vein
occlusion and may be associated with systemic conditions such as diabetes and
atherosclerosis; however, alternative etiologies should be considered in young
otherwise healthy individuals. This case underscores the need for diligent and
thorough investigations for less common systemic conditions associated with
retinal vein occlusions by primary care ophthalmologists. Author information:
(1)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address:
[email protected].
(2)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address: [email protected].
(3)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address:
[email protected].
(4)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address:
[email protected].
(5)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address:
[email protected].
(6)Service de réanimation médicale, CHU d'Angers, 4, rue Larrey, 49100 Angers,
France. Electronic address: [email protected].
(7)Service de réanimation médicale, hôpital Saint-Louis, AP-HP, 1, avenue
Claude-Vellefaux, 75010 Paris, France. Electronic address:
[email protected]. A 12 year old, 38 kg, mix-breed, intact male dog presented with a 20 day history
of clinical signs consistent with hyperviscosity syndrome secondary to multiple
myeloma. The dog received three double filtration plasmapheresis treatments on
day 0, 7 and 22 after presentation. A significant (p<0.05) reduction in serum
total protein, alpha-2 and gamma globulins was found following each treatment.
These reductions were accompanied by a complete resolution, although temporary,
of the clinical signs of hyperviscosity syndrome. The present study reported for
the first time the use of double filtration plasmapheresis to reduce clinical
signs of hyperviscosity syndrome in a dog with multiple myeloma. Multiple myeloma is a neoplastic plasma-cell disorder resulting from maligt
plasma cells in the bone marrow. It can cause a hyperviscosity syndrome
secondary to the paraproteinaemia associated with the disease. The increased
hyperviscosity can lead to retinal vein occlusions and other ocular problems
that may challenge clinicians. In patients with multiple myeloma and
hypertension and/or diabetes mellitus, retinal changes appear similar and
changes due to one disease or the other may be difficult to determine. A
48-year-old white female presented to the clinic with a complaint of blurry
vision in her left eye. A full comprehensive ocular examination revealed a
central retinal vein occlusion presumably from the patient's history of
hypertension, diabetes mellitus and hypercholesterolaemia. Further bloodwork
revealed monoclonal protein in the patient's serum and an increased percentage
of plasma cells in the bone marrow. She was diagnosed with monoclonal gammopathy
of undetermined significance, part of the multiple myeloma disease spectrum. She
was referred to a retinal specialist for initiation of intravitreal injections
of anti-vascular endothelial growth factor. Multiple myeloma has been implicated
in younger patients as an underlying cause of retinal vein occlusions. Multiple
myeloma should be considered as a differential diagnosis in young patients with
retinal vein occlusions, even if other risk factors for venous occlusion like
hypertension, diabetes mellitus and hypercholesterolaemia are present. Timely
referral to the patient's primary care physician and haematologist is important
for appropriate treatment and control of underlying systemic conditions. Multiple myeloma (MM) is an immedicable maligcy of the human plasma cells
producing abnormal antibodies (also referred to as paraproteins) leading to
kidney problems and hyperviscosity syndrome. In this paper, we report on the
N-glycosylation analysis of paraproteins from total human serum as well as the
fragment crystallizable region (Fc ) and fragment antigen binding (Fab ) κ/λ
light chain fractions of papain digested immunoglobulins from multiple myeloma
patients. CE-LIF detection was used for the analysis of the N-glycans after
endoglycosidase (PNGase F) mediated sugar release and fluorophore labeling
(APTS). While characteristic N-glycosylation pattern differences were found
between normal control and untreated, treated and remission stage multiple
myeloma patient samples at the global serum level, less distinctive changes were
observed at the immunoglobulin level. Principal component analysis adequately
differentiated the four groups (control and three patient groups) on the basis
of total serum N-glycosylation analysis. 12 N-glycan features showed
statistically significant differences (p <0.05) among various stages of the
disease in comparison to the control at the serum level, while only six features
were identified with similar significance at the immunoglobulin level, including
the analysis of the partitioned Fc fragment as well as the Fab κ and Fab λ
chains. Multiple myeloma (MM) rarely presents with a primary neurological dysfunction,
and if it does it is usually due to a plasmacytoma. This is the first case to
discuss hypoglossal nerve dysfunction as the first sign of MM progression
secondary to severe pathophysiologic bone lysis. A PubMed-based literature
search was completed on April 17, 2016 for the terms "multiple myeloma" and
"hypoglossal nerve neuropathy". A 73-year-old woman with known MM who received
little treatment for several years, presented secondary to dysarthria and at
first was thought to have hyperviscosity syndrome. On further examination, it
was found she had light chain disease and her symptoms were secondary to severe
disease progression. Imaging revealed multiple lytic lesions in the skull on
skeletal survey and brain MRI revealed boney lysis near the occipital condyle
and clivus likely interfering with the coursing of the hypoglossal nerve.
Advanced progressing MM can cause severe boney destruction which can interfere
with cranial nerve canals and cause neuropathy as a presenting symptom. Renal impairment (RI) is a common complication of multiple myeloma (MM), which
is presented as chronic kidney disease (CKD) or acute kidney injury (AKI). The
typical pathological feature is cast nephropathy. Presently international system
staging (ISS) is used in evaluating MM. Although the classic Durie-Salmon
staging system could be still used in clinical practice, it may miss out some
patients with renal impairment. For evaluations of RI in MM patients with CKD,
it's recommended to assess the estimated glomerular filtration rate (eGFR) by
creatinine based formula CKD-epidemiology collaboration (EPI) or modification of
diet in renal disease(MDRD) and to stage the renal injuries according to 2013
Kidney Disease Improving Global Outcomes (KDIGO) CKD guidelines. For MM patients
with AKI, KDIGO AKI guidelines is recommended for evaluation. Renal biopsy is
not a routine procedure in all MM patients. It's necessary for patients
presenting with glomerular injuries such as albuminuria > 1 g/24 h to eliminate
immunoglobulin associated amyloidosis (AL) and monoclonal immunoglobulin
deposition disease (MIDD). The effective treatment of MM can reduce serum light
chain concentration and improve renal function. The basis of the RI treatment in
MM is bortizomib-based regimen, which does not require dosage adjustment in
patients with dialysis or renal insufficiency. Thalidomide and lenalidomide are
two major immunomodulators in MM treatment. Thalidomide can be used effectively
in RI patients without dosage adjustment while lenalidomide should be used
cautiously in patients with mild or moderate RI with dosage adjustment and serum
toxicity surveillance. High-dose therapy (HDT) and autologous peripheral blood
stem cell transplantation (APBSCT) can be therapeutical options for RI patients
younger than 65 y, and they should be considered more prudently in patients with
severe renal insufficiency (GFR<30 ml/min). For patients who are not suitable
for the treatment mentioned above, they can be treated with conventional
chemotherapy, including VAD (vincristine, adriamycin and dexamethasone), MP
(mephalan and prednisolone) and high-dose dexamethasone regimen. Adequate
hydration (at least 3 litres of fluid intake a day or 2 L·m(-2)·d(-1)) and
correcting reversible causes of RI are key points for the supportive care. Renal
replacement therapy (more often hemodialysis) should be started in patients with
severe AKI and end stage renal disease (ESRD). High flux or high cut-off
membrane are recommended because routine hemodialysis could not remove the serum
free light chain (sFLC) effectively. Plasmapheresis (PE) is recommended for
patients with hyperviscosity syndrome or cast nephropathy presented with AKI,
which may help to increase the dialysis-independency. This case report describes a 54-year-old, asymptomatic man who presented with
hyperkalemia on routine lab testing who was later found to have acute renal
failure, unresponsive to fluid resuscitation, with minimal improvement after
hemodialysis. After a comprehensive evaluation ruled out common causes of acute
renal failure, the patient underwent testing with a bone survey, urine protein
electrophoresis (UPEP), serum protein electrophoresis (SPEP), and
immunoelectrophoresis for suspected plasma cell dyscrasia and received
plasmapheresis for hyperviscosity syndrome and nephrotoxicity, which resulted in
improved renal function. Lab results showed monoclonal gammopathy, elevated
serum free light chains, and Bence Jones protein in the urine with a follow-up
bone marrow biopsy indicating plasma cell dyscrasia. The patient received a
diagnosis of multiple myeloma (MM) and was started on chemotherapy and
immunosuppression. In patients presenting with acute renal failure with an
evaluation ruling out prerenal and postrenal causes, multiple myeloma should be
considered. |
What is the purpose of the FaceBase consortium? | The FaceBase Consortium, funded by the National Institute of Dental and Craniofacial Research, National Institutes of Health, is designed to accelerate understanding of craniofacial developmental biology by generating comprehensive data resources to empower the research community, exploring high-throughput technology, fostering new scientific collaborations among researchers and human/computer interactions, facilitating hypothesis-driven research and translating science into improved health care to benefit patients. | We introduce the Ontology of Craniofacial Development and Malformation (OCDM) as
a mechanism for representing knowledge about craniofacial development and
malformation, and for using that knowledge to facilitate integrating
craniofacial data obtained via multiple techniques from multiple labs and at
multiple levels of granularity. The OCDM is a project of the NIDCR-sponsored
FaceBase Consortium, whose goal is to promote and enable research into the
genetic and epigenetic causes of specific craniofacial abnormalities through the
provision of publicly accessible, integrated craniofacial data. However, the
OCDM should be usable for integrating any web-accessible craniofacial data, not
just those data available through FaceBase. The OCDM is based on the
Foundational Model of Anatomy (FMA), our comprehensive ontology of canonical
human adult anatomy, and includes modules to represent adult and developmental
craniofacial anatomy in both human and mouse, mappings between homologous
structures in human and mouse, and associated malformations. We describe these
modules, as well as prototype uses of the OCDM for integrating craniofacial
data. By using the terms from the OCDM to annotate data, and by combining
queries over the ontology with those over annotated data, it becomes possible to
create "intelligent" queries that can, for example, find gene expression data
obtained from mouse structures that are precursors to homologous human
structures involved in malformations such as cleft lip. We suggest that the OCDM
can be useful not only for integrating craniofacial data, but also for
expressing new knowledge gained from analyzing the integrated data. We introduce the Ontology of Craniofacial Development and Malformation (OCDM), a
project of the NIH-funded FaceBase consortium, whose goal is to gather data from
multiple species, at levels ranging from genes to gross anatomy, in order to
understand the causes of craniofacial abnormalities. The OCDM is being developed
in order to facilitate integration of these diverse forms of data in a central
Hub. It currently consists of several components, including human adult and
developmental anatomy, corresponding mouse structures, and malformations.
Example queries show the potential of the OCDM for intelligent data annotation
and querying. The NIH FACEBASE consortium was established in part to create a central resource
for craniofacial researchers. One purpose is to provide a molecular anatomy of
craniofacial development. To this end we have used a combination of laser
capture microdissection and RNA-Seq to define the gene expression programs
driving development of the murine palate. We focused on the E14.5 palate, soon
after medial fusion of the two palatal shelves. The palate was divided into
multiple compartments, including both medial and lateral, as well as oral and
nasal, for both the anterior and posterior domains. A total of 25 RNA-Seq
datasets were generated. The results provide a comprehensive view of the region
specific expression of all transcription factors, growth factors and receptors.
Paracrine interactions can be inferred from flanking compartment growth
factor/receptor expression patterns. The results are validated primarily through
very high concordance with extensive previously published gene expression data
for the developing palate. In addition selected immunostain validations were
carried out. In conclusion, this report provides an RNA-Seq based atlas of gene
expression patterns driving palate development at microanatomic resolution. This
FACEBASE resource is designed to promote discovery by the craniofacial research
community. Author information:
(1)Structural Informatics Group, Department of Biological Structure, University
of Washington, Seattle, WA 98195, USA.
(2)Department of Pharmacology and Experimental Therapeutics, Boston University
School of Medicine, Boston, MA 02118, USA.
(3)Department of Orthopedic Research, Boston Children's Hospital and Department
of Genetics, Harvard Medical School, Boston, MA 02115, USA.
(4)Department of Genetics and Genomic Sciences, Icahn School of Medicine at
Mount Sinai, New York, NY 10029, USA.
(5)Cell and Developmental Biology, School of Medicine, University of Colorado,
Aurora, CO 80045, USA.
(6)Department of Biochemistry and Molecular Genetics, School of Medicine,
University of Colorado, Aurora, CO 80045, USA.
(7)Information Sciences Institute, Viterbi School of Engineering, University of
Southern California, Marina del Rey, CA 90292, USA.
(8)Program in Craniofacial Biology, Departments of Orofacial Sciences and
Pediatrics, Institute for Human Genetics, University of California San
Francisco, San Francisco, CA 94143, USA.
(9)Division of Genetics, Brigham and Women's Hospital, Harvard Medical School,
Boston, MA 02115, USA.
(10)Center for Craniofacial and Dental Genetics, Department of Oral Biology,
School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
Department of Human Genetics, Graduate School of Public Health, University of
Pittsburgh, Pittsburgh, PA 15213, USA.
(11)Human Medical Genetics and Genomics Program, School of Medicine, University
of Colorado, Aurora, CO 80045, USA.
(12)Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA U.S.
Department of Energy Joint Genome Institute, Walnut Creek, CA 94598, USA School
of Natural Sciences, University of California Merced, Merced, CA 95343, USA.
(13)Department of Craniofacial Biology, School of Dental Medicine, University of
Colorado, Aurora, CO 80045, USA.
(14)Department of Chemical and Systems Biology and of Developmental Biology,
School of Medicine, Stanford University, Stanford, CA 94305, USA.
(15)Center for Craniofacial Molecular Biology, Herman Ostrow School of
Dentistry, University of Southern California, Los Angeles, CA 90033, USA
[email protected]. In this paper we describe an ontological scheme for representing anatomical
entities undergoing morphological transformation and changes in phenotype during
prenatal development. This is a proposed component of the Anatomical
Transformation Abstraction (ATA) of the Foundational Model of Anatomy (FMA)
Ontology that was created to provide an ontological framework for capturing
knowledge about human development from the zygote to postnatal life. It is
designed to initially describe the structural properties of the anatomical
entities that participate in human development and then enhance their
description with developmental properties, such as temporal attributes and
developmental processes. This approach facilitates the correlation and
integration of the classical but static representation of embryology with the
evolving novel concepts of developmental biology, which primarily deals with the
experimental data on the mechanisms of embryogenesis and organogenesis. This is
important for describing and understanding the underlying processes involved in
structural malformations. In this study we focused on the development of the
lips and the palate in conjunction with our work on the pathogenesis and
classification of cleft lip and palate (CL/P) in the FaceBase program. Our aim
here is to create the Craniofacial Human Development Ontology (CHDO) to support
the Ontology of Craniofacial Development and Malformation (OCDM), which provides
the infrastructure for integrating multiple and disparate craniofacial data
generated by FaceBase researchers. |
What is TCGA2BED? | Data extraction and integration methods are becoming essential to effectively access and take advantage of the huge amounts of heterogeneous genomics and clinical data increasingly available. TCGA2BED is a software tool to search and retrieve TCGA (The Cancer Genome Atlas) data, and convert them in the structured BED format for their seamless use and integration. Additionally, it supports the conversion in CSV, GTF, JSON, and XML standard formats. Furthermore, TCGA2BED extends TCGA data with information extracted from other genomic databases (i.e., NCBI Entrez Gene, HGNC, UCSC, and miRBase). | BACKGROUND: Data extraction and integration methods are becoming essential to
effectively access and take advantage of the huge amounts of heterogeneous
genomics and clinical data increasingly available. In this work, we focus on The
Cancer Genome Atlas, a comprehensive archive of tumoral data containing the
results of high-throughout experiments, mainly Next Generation Sequencing, for
more than 30 cancer types.
RESULTS: We propose TCGA2BED a software tool to search and retrieve TCGA data,
and convert them in the structured BED format for their seamless use and
integration. Additionally, it supports the conversion in CSV, GTF, JSON, and XML
standard formats. Furthermore, TCGA2BED extends TCGA data with information
extracted from other genomic databases (i.e., NCBI Entrez Gene, HGNC, UCSC, and
miRBase). We also provide and maintain an automatically updated data repository
with publicly available Copy Number Variation, DNA-methylation, DNA-seq,
miRNA-seq, and RNA-seq (V1,V2) experimental data of TCGA converted into the BED
format, and their associated clinical and biospecimen meta data in
attribute-value text format.
CONCLUSIONS: The availability of the valuable TCGA data in BED format reduces
the time spent in taking advantage of them: it is possible to efficiently and
effectively deal with huge amounts of cancer genomic data integratively, and to
search, retrieve and extend them with additional information. The BED format
facilitates the investigators allowing several knowledge discovery analyses on
all tumor types in TCGA with the final aim of understanding pathological
mechanisms and aiding cancer treatments. |
Does the human lncRNA LINC-PINT promote tumorigenesis? | No. LINC-PINT is downregulated in multiple types of cancer and acts as a tumor suppressor lncRNA by reducing the invasive phenotype of cancer cells. | Long intergenic non-protein coding RNA, p53 induced transcript (Linc-pint) is a
long noncoding RNA (lncRNA) that regulates tumor cell viability and
proliferation. We used qRT-PCR and RNA FISH analysis to evaluate Linc-pint
levels in the plasma and tumor tissues of pancreatic cancer (PCa) patients. Our
data demonstrate that Linc-pint expression is lower in plasma samples from PCa
patients than from healthy individuals, and indicate that plasma Linc-pint
levels are more sensitive than CA19-9 for detecting PCa. Our data also show that
Linc-pint levels are lower in PCa tumors than in adjacent tissues, carcinoma of
the ampulla of Vater (CAV) and cholangiocarcinoma (CCA), and suggest that
Linc-pint could be used for distinguishing the cause of maligt obstructive
jaundice. Low plasma Linc-pint levels correlate with tumor recurrence, while low
tumor Linc-pint levels correlate with poor prognosis for PCa patients after
pancreatectomy. These results thus indicate that low plasma Linc-pint expression
could serve as a minimally invasive biomarker for early PCa detection, and that
low Linc-pint levels in PCa tumors could be used for predicting patient
prognosis. |
Is LDB1-mediated enhancer looping dependent on cohesin? | No. LDB1-mediated enhancer looping can be established independent of mediator and cohesin. | Mechanistic studies in erythroid cells indicate that LDB1, as part of a
GATA1/TAL1/LMO2 complex, brings erythroid-expressed genes into proximity with
enhancers for transcription activation. The role of co-activators in
establishing this long-range interaction is poorly understood. Here we tested
the contributions of the RNA Pol II pre-initiation complex (PIC), mediator and
cohesin to establishment of locus control region (LCR)/β-globin proximity.
CRISPR/Cas9 editing of the β-globin promoter to eliminate the RNA Pol II PIC by
deleting the TATA-box resulted in loss of transcription, but enhancer-promoter
interaction was unaffected. Additional deletion of the promoter GATA1 site
eliminated LDB1 complex and mediator occupancy and resulted in loss of
LCR/β-globin proximity. To separate the roles of LDB1 and mediator in LCR
looping, we expressed a looping-competent but transcription-activation deficient
form of LDB1 in LDB1 knock down cells: LCR/β-globin proximity was restored
without mediator core occupancy. Further, Cas9-directed tethering of mutant LDB1
to the β-globin promoter forced LCR loop formation in the absence of mediator or
cohesin occupancy. Moreover, ENCODE data and our chromatin immunoprecipitation
results indicate that cohesin is almost completely absent from validated and
predicted LDB1-regulated erythroid enhancer-gene pairs. Thus, lineage specific
factors largely mediate enhancer-promoter looping in erythroid cells independent
of mediator and cohesin. |
Describe nursemaid's elbow injury. | Nursemaid's elbow is a radial head subluxation caused by axial traction on the extended arm while the forearm is pronated, allowing for slippage of the radial head. Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. | Six instances of subluxation of the radial head ("nursemaid's elbow, pulled
elbow") in babies in the first 6 months of life are presented. In four cases,
the pulled elbow was produced in a previously unreported fashion. Acute annular ligament interposition into the radiocapitellar joint
("nursemaid's elbow") is a common injury in children younger than 5 years. The
injury occurs when axial traction is applied to an extended, pronated arm. There
are no abnormal radiographic findings associated with this condition. We
recommend that children with a classic history and clinical presentation of an
acute annular ligament interposition into the radiocapitellar joint be treated
without obtaining radiographs. Subluxation of the radial head, or "nursemaid's elbow," is a common injury among
children aged 1 to 4 years. The authors present a technique for flexed-elbow
stabilization designed especially for very young children, which provides
adequate immobilization without the use of a sling. Imagine a parent innocently swinging around a toddler ... a yank on an
outstretched arm to keep a preschooler from falling ... a caregiver attempting
to move a reluctant child by dragging the child by the hand ... a helping hand
to lift a young child up over the curb or a high step. None of these activities
is ever intended to hurt a child, yet the result of these specific activities
send many children with anxious parents and caregivers to emergency departments
and unscheduled pediatrician appointments each year. Nursemaid's elbow, also
known as a pulled elbow or a subluxated radial head, may result from the
specific activities described above and is the most common dislocation injury
handled by pediatricians. Most commonly occurring in the 1-year to 4-year old
age group, nursemaid's elbow is easily treated and generally has no long-term
sequelae. Annular ligament displacement (ALD)--also termed radial head subluxation,
nursemaid's elbow, or pulled elbow--can be successfully diagnosed and treated
over the telephone by properly trained medical professionals instructing
nonmedical caretakers. Two case reports of successful ALD reduction via
telephone are described. The pathology of ALD and techniques for its treatment
are reviewed, and guidelines are given. The rationale for the introduction of
the new term annular ligament displacement as well as areas for additional
investigation are discussed. To our knowledge, this is the first published
account of ALD reduction via telephone. The purpose of imaging of the elbow region in children after acute trauma is the
diagnosis of injuries that require further treatment. Basic diagnostic consists
of standard X-rays of the elbow in two planes. Exceptions can be made in the
case of nursemaid's elbow lesion (subluxation of the radial head; pronation
douloureuse; Chassaignac lesion) with unambiguous mechanism of the trauma where
no X-ray imaging is needed and in heavily dislocated fractures for which one
plane can be sufficient. X-ray imaging of the uninjured side is obsolete.
Follow-up X-ray imaging is only allowed if consequences for the further
treatment are expected. Ultrasound may partially replace X-rays in the future if
further standardization of this technique can be achieved. MRI provides
additional information in acute trauma which, however, remains currently without
consequences for the further treatment strategy. Nursemaid's elbow (subluxation of the radial head) is a common pediatric upper
extremity injury encountered in the emergency and urgent care settings.
Subluxation of the radial head accounts for more than 20% of upper extremity
injuries in the pediatric population. A clinical case of a three-year old girl
who presented to the emergency department with a nursemaids elbow requiring
reduction is presented in this article. The purpose of this article is to
discuss the identification and treatment of this injury and delineate the two
methods of supination and pronation for reduction of the annular ligament. BACKGROUND: A nursemaid's elbow most frequently occurs with transient
longitudinal traction of the pronated forearm and extended elbow, which can be
reduced by manipulation without sedation. There are circumstances in which the
history is atypical and reduction of the elbow is unsuccessful. Imaging may be
helpful in these cases.
METHODS: A 33-month-old child was injured in a fall from a tire swing and
sustained what was thought to be a nursemaid's elbow. Typical reduction
maneuvers were unsuccessful. The patient underwent magnetic resoce imaging
(MRI) with conscious sedation, which demonstrated the entrapment of the annular
ligament in the radicapitellar joint. A presumed successful reduction was
performed with confirmed reduction of the annular ligament by immediate MRI.
CONCLUSIONS: To our knowledge, this is the first case report on MRI being used
to diagnose and confirm treatment of an atypical nursemaid's elbow.
LEVEL OF EVIDENCE: IV. BACKGROUND: Disagreement exists between physicians on the usefulness of a
prereduction radiograph for diagnosis and treatment of nursemaid's elbows in
children. Some evidence suggests that nursemaid's elbows have identifying
features on radiographs. This study compares the radiographs of nursemaid's
elbows to normal, control elbows in children and hypothesizes that
differentiating features do not exist on radiograph.
METHODS: For this retrospective case-control study, hospital billing records
were searched to identify all patients under age 6 treated with closed reduction
for a nursemaid's elbow between November 2005 and October 2009. Twenty-seven
nursemaid's elbows were age-matched and sex-matched to 27 normal "comparison
view," control elbows. Radiocapitellar line offset, proximal radial length,
anterior fat pad angle, and visibility of the posterior fat pad were measured on
the radiographs by 2 raters. Their interrater reliability was assessed with
intraclass correlations, and the nursemaid's and control elbow measures were
compared using Wilcoxon tests.
RESULTS: Nursemaid's elbows and healthy control elbows did not differ
significantly in offset of the radiocapitellar line from the capitellum center
on anteroposterior (P=0.49) or lateral views (P=0.67), in proximal radial length
(P=0.95), anterior fat pad angle (P=0.49), or posterior fat pad visibility
(P=1.00) on lateral views.
CONCLUSIONS: Nursemaid's elbows are indistinguishable from healthy elbows on
radiograph. Thus, the term "radial head subluxation" appears to be a misnomer,
and prereduction radiographs should only be used to eliminate the possibility of
fracture. From a radiologic perspective, nursemaid's elbows remain a diagnosis
of exclusion.
LEVEL OF EVIDENCE: Therapeutic Level III-retrospective comparative study. CONTEXT: Radial head subluxation, also known as 'pulled elbow', 'dislocated
elbow' or 'nursemaid's elbow', is one of the most common upper extremity
injuries in young children and a common reason to visit Emergency Department
(ED).
AIM: To compare supination of the wrist followed by flexion of the elbow (the
traditional reduction technique) to hyperpronation of the wrist in the reduction
of radial head subluxations (nursemaid's elbow) maneuvers in children presented
to ED with painful pronation and to determine which method is less painful by
children.
SETTINGS AND DESIGN: This prospective randomize study involved a consecutive
sampling of children between 1-5 year old who were presented to the ED with
painful pronation.
MATERIALS AND METHODS: The initial procedure was repeated if baseline
functioning did not return 20 minutes after the initial reduction attempt.
Failure of that technique 30 minutes after the initial reduction attempt
resulted in a cross-over to the alternate method of reduction.
STATISTICAL ANALYSIS USED: Datas were analyzed using SPSS for Windows 16.0.
Mean, standard deviation, independent samples t test, Chi-square test, and
paired t test were used in the assessment of pain scores before and after
reduction.
RESULTS: When pain scores before and after reduction were compared between
groups to determine which technique is less painful by children, no significant
difference was found between groups.
CONCLUSIONS: It was found that in the reduction of radial head subluxations, the
hyperpronation technique is more effective in children who were presented to ED
with painful pronation compared with supination-flexion. However, there was no
significant difference between these techniques in terms of pain. INTRODUCTION: To provide an epidemiological description of radial head
subluxation, also known as nursemaid's elbow, from a database of emergency
department visits.
METHODS: We conducted a retrospective medical record review of patients 6 years
of age and younger, who presented to the ED between January 1, 2005, and
December 31, 2012, and were diagnosed with nursemaid's elbow. Inclusion criteria
consisted of chart information, including date, unique account number, medical
record number, weight, age, sex, and arm affected. Exclusion criteria included
any charts with missing or incomplete data.
RESULTS: There were 1,228 charts that met inclusion criteria. The majority of
patients were female (60%). The mean age was 28.6 months (±12.6). The left arm
was affected 60% of the time. Most of the included patients were over the 75(th)
percentile for weight and more than one quarter were over the 95(th) percentile
in each gender.
CONCLUSION: The average age of children presenting with nursemaid's elbow was
28.6 months. Females were affected more than males, and the left arm was
predominately affected. Most patients were above the 75(th) percentile for
weight and more than one quarter were over the 95(th) percentile for weight. Point-of-care ultrasound has become a useful clinical adjunct, especially in
emergency medicine, because it is noninvasive, repeatable, and nonradiating. In
cases of pulled elbow also known as nursemaid's elbow or radial head
subluxation, diagnosis is usually performed clinically. However, there is the
potential for a failed reduction or misdiagnosis. We introduce a potentially
useful diagnostic finding for pulled elbow ("Hook sign") using point-of-care
ultrasound in the emergency department. BACKGROUND/AIM: Nursemaid's elbow usually occurs in young children when
longitudinal traction is placed on the arm. Several manipulative maneuvers have
been described, although, the most effective treatment technique is yet unclear.
The aim of this systematic review and meta-analysis was to compare the two most
commonly performed maneuvers (supination-flexion and hyperpronation) in the
treatment of nursemaid's elbow.
METHODS: A literature search was performed in PubMed, Embase, and Cochrane
databases to identify randomized controlled trials comparing supination-flexion
and hyperpronation. Data were extracted and pooled independently by two authors.
Methodological quality assessment of included studies was performed.
Meta-analysis was performed using a fixed-effect model in case of homogeneity
across studies, and using a random-effect model in case of heterogeneity.
Heterogeneity was calculated with the χ2 test and inconsistency in study effects
across trials was quantified by I2 values.
RESULTS: Seven randomized trials, including 701 patients (62% female), were
included. A total of 350 patients were treated with the hyperpronation maneuver
versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis
showed that hyperpronation was more effective than supination-flexion (risk
ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk
difference between maneuvers was 26% in favor of hyperpronation, resulting in a
number needed to treat of 4 patients. Trials lacked blinding of assessors and
universal pain measures.
CONCLUSIONS: Hyperpronation was more effective in terms of success rate and
seems to be less painful compared to the supination-flexion maneuver in children
with nursemaid's elbow. Nursemaid's elbow is a radial head subluxation caused by axial traction on the
extended arm while the forearm is pronated, allowing for slippage of the radial
head. A 2-year-old boy presented with pain, swelling and reduced range of
movement of the right elbow for 4 days. The mother noted that the child was
moving the right upper limb less often and there was tenderness over the right
elbow. X-ray of the right elbow showed subluxation of the elbow joint with no
obvious fracture. A trial of conservative management was decided upon and the
patient was placed on a right elbow backslab with the right forearm in a supine
position. On follow-up, there was no swelling, tenderness or neurological
deficit noted. A repeate x-ray revealed normal findings. BACKGROUND: Pulled elbow (nursemaid's elbow) is a common injury in young
children. It often results from a sudden pull on the arm, usually by an adult or
taller person, which pulls the radius through the annular ligament, resulting in
subluxation (partial dislocation) of the radial head. It can also be caused by a
fall or twist. The child experiences sudden acute pain and loss of function in
the affected arm. Pulled elbow is usually treated by manual reduction of the
subluxed radial head. Various manoeuvres can be applied; most commonly,
supination of the forearm, often combined with flexion, and (hyper-)pronation.
It is unclear which is most successful. This is an update of a Cochrane review
first published in 2009 and last updated in 2011.
OBJECTIVES: To compare the effects (benefits and harms) of the different methods
used to manipulate pulled elbow in young children.
SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group
Specialised Register, the Cochrane Central Register of Controlled Trials,
MEDLINE, Embase, CINAHL, LILACS, PEDro, clinical trial registers and reference
lists of articles. Date of last search: September 2016.
SELECTION CRITERIA: Randomised or quasi-randomised controlled clinical trials
evaluating manipulative interventions for pulled elbow were included. Our
primary outcome was failure at the first attempt, necessitating further
treatment.
DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials
for inclusion, assessed risk of bias, and extracted data. We pooled data using a
fixed-effect model.
MAIN RESULTS: Overall, nine trials with 906 children (all younger than seven
years old and 58% of whom were female) were included, of which five trials were
newly identified in this update. Eight trials were performed in emergency
departments or ambulatory care centres, and one was performed in a tertiary
paediatric orthopaedic unit. Four trials were conducted in the USA, three in
Turkey, one in Iran, and one in Spain. Five trials were at high risk of
selection bias because allocation was not concealed and all trials were at high
risk of detection bias due to the lack of assessor blinding. Eight trials
compared hyperpronation with supination-flexion. We found low-quality evidence
that hyperpronation resulted in less failure at first attempt than
supination-flexion (9.2% versus 26.4%, risk ratio (RR) 0.35; 95% confidence
interval (CI) 0.25 to 0.50; 811 participants, 8 studies). Based on an
illustrative risk of 268 failures at first attempt per 1000 children treated
using supination-flexion, this amounted to 174 fewer failures per 1000 children
treated using hyperpronation (95% CI 134 to 201 fewer). Based on risk
differences data, we also estimated a number needed to treat of 6 (95% CI 5 to
8); this means that six children would need to be treated with the
hyperpronation method rather than the supination-flexion method to avoid one
additional failure at the first attempt.The very low-quality evidence (from four
studies) for pain during or after manipulation means that it is uncertain
whether there is or is not a difference between pronation and
supination-flexion. There was very low-quality evidence from six studies that
repeat pronation may be more effective than repeat supination-flexion for the
second attempt after initial failure. The remaining outcomes were either not
reported (adverse effects, recurrence) or unsuitable for pooling (ultimate
failure). Ultimate failure, reported for the overall population only because of
the differences in the study protocols with respect to what to do after the
first attempt failed, ranged from no ultimate failures in two studies to six
failures (4.1% of 148 episodes) in one study.One trial compared
supination-extension versus supination-flexion. It provided very low-quality
evidence (downgraded three levels for very serious risk of bias and serious
imprecision) of no clear difference in failure at first attempt between the two
methods.
AUTHORS' CONCLUSIONS: There was low-quality evidence from eight small trials
that the pronation method may be more effective at first attempt than the
supination method for manipulating pulled elbow in young children. For other
outcomes, no conclusions could be drawn either because of very low-quality
evidence or the outcomes not being reported. We suggest that a high-quality
randomised clinical trial comparing hyperpronation and supination-flexion is
required to provide definitive evidence. We recommend that this is preceded by a
survey among clinicians to establish the extent of clinical equipoise and to
optimise the study design and recruitment. |
What is trismus? | Trimus is defined as restricted mouth opening due to disorder of the temporomandibular joint. | Trismus is a restriction in the ability to open the mouth. Trismus can occur
following trauma, surgery, radiation therapy, infection, inflammatory diseases,
temporomandibular disorders (TMD) or less commonly as a result of maligcy.
Following two cases of delayed diagnosis of carcinoma presenting with features
of TMD to a specialist clinic, a checklist was developed for completion in cases
of trismus, to alert the clinician to suspicious features suggesting a possible
non-TMD cause. The use of this checklist, together with an increased awareness,
has improved early recognition of atypical features in patients presenting with
trismus and has contributed to the early diagnosis of a further case of
maligcy presenting to this clinic. This article discusses the presentation of
maligcy with trismus, the relevance of imaging in these cases, and the
implementation of a checklist to reduce the risk of future misdiagnosis. BACKGROUND: Trismus indicates severely restricted mouth opening of any
aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim
of this study was to review the etiopathogenesis, incidence, treatment and
prevention of trismus in patients with head and neck cancer.
OBJECTIVE OF REVIEW: Trismus is frequently seen in patients suffering from
maligt tumours of the head and neck. The reported prevalence of trismus in
those patients varies considerably in the literature and ranges from 0 to 100%
depending on the tumour site and extension. Trismus may worsen or remain the
same over time, or the symptoms may reduce, even in the absence of treatment.
When a patient presents with trismus after tumour treatment, it is important to
determine whether the trismus is the result of the treatment, or is the first
sign of a recurrence. Restricted mouth opening may impede inspection of the oral
cavity as needed for dental care, and particularly for oncologic follow-up.
CONCLUSIONS: Mouth opening after radiotherapy (RT) decreases on average by
approximately 20% compared to mouth opening prior to RT. The prevalence of
trismus increases with increasing doses of RT to mastication structures. The use
of intensity-modulated RT seems to lower the percentage and severity of
RT-induced trismus. Treatment of trismus can be conservative (with either
medical or physical therapy) or surgical. Exercise therapy is the mainstay of
treatment and exercise should start as soon as possible after treatment. The
prevention of trismus, rather than its treatment, is the most important
objective. PURPOSE: In patients with oral cancer, trismus (maximum interincisal opening
[MIO] <35 mm) can develop as a result of surgery and radiotherapy. The aim of
this study was to provide an alternative operation to both eradicate oral cancer
and prevent postsurgical trismus.
MATERIALS AND METHODS: In our retrospective cohort study of oral cancer patients
who underwent operations during 2010 to 2014, the predictor variable was the
type of operation (alternative operation or traditional operation) and the
outcome variable was MIO. All of the cases were allocated by 2 periods: the
traditional operations were performed from 2010 to 2011, and the alternative
operations were performed from 2011 to 2014. All patients received marginal
mandibulectomy, anterolateral thigh free flap, and adjuvant radiotherapy or
concurrent chemoradiotherapy. In addition to traditional marginal
mandibulectomy, the alternative operation included ipsilateral coronoidectomy
and myotomy of the temporalis muscle insertion, masseter muscle, and medial
pterygoid muscle. MIO was measured at 10 time points. The adjusted variables
included demographic data, diagnostic parameters, treatment, and response.
RESULTS: Of the 36 male patients with oral cancer, 16 were placed in the
alternative operation group (AOG; mean age, 53.5 ± 11.9 years) and 20 were
placed in the traditional operation group (TOG; mean age, 50.7 ± 7.1 years).
Regarding the outcome indicator of patient MIO, the preoperative MIO in the AOG
was on average 7.5 mm shorter than that in the TOG (P < .01), but it was
consistently superior to the MIO in the TOG after the operation. Multivariate
analysis of variance showed that patients in the AOG were more likely to have
postoperative non-trismus.
CONCLUSIONS: The alternative operation exhibited superior postoperative MIO
values and similar postoperative complication rates. For the prevention of
trismus, it is practical to perform the combined operation simultaneously,
cutting all ipsilateral jaw closing muscles and the coronoid process and
eradicating the tumor. Nasopharyngeal carcinoma (NPC) is endemic in southern China, and its incidence
in Hong Kong is relatively high. Radiotherapy is the mainstay treatment for NPC
due to its relatively high radiosensitivity and deep-seated anatomical position,
which is not readily accessible by surgery. Although the technique of
radiotherapy in NPC has been advancing and offers promising treatment outcome,
complications around the irradiation areas are inevitable and the quality of
life of the post-radiotherapy patients is often compromised. Trismus, which is
defined as the restricted mouth opening or jaw movement due to the disorder of
temporo-mandibular joint (TMJ), is one of the possible late complications for
radiotherapy of NPC and is found in 5-17% of the post-radiotherapy (post-RT)
patients. Trismus at early stage may only affect the speech, but in severe cases
nutritional intake and oral hygiene condition may deteriorate seriously. This
article reviewed the possible causes of radiation-induced TMJ damage, the
various assessments including imaging modalities and possible treatments. The
conclusion is that the availability of simple, yet effective examinations for
trismus is essential for delaying the progression and restoring TMJ functions.
Although there is no absolutely effective treatment for trismus, many
supportive, restorative and palliative management are possible under different
clinical situations. |
What is mechanism of action of Benralizumab? | Benralizumab is a humanised, anti-interleukin 5 receptor α monoclonal antibody that directly and rapidly depletes eosinophils, reduces asthma exacerbations, and improves lung function for patients with severe eosinophilic asthma. | BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with
eosinophilic airway inflammation in 10-20% of patients. Benralizumab, an
anti-interleukin-5 receptor α monoclonal antibody, depletes blood and sputum
eosinophils. We aimed to establish whether benralizumab reduces acute
exacerbations of COPD in patients with eosinophilia and COPD.
METHODS: We did this randomised, double-blind, placebo-controlled, phase 2a
study between Nov 18, 2010, and July 13, 2013, at 26 sites in the UK, Poland,
Germany, Canada, the USA, Denmark, and Spain. Adults aged 40-85 years, with
moderate-to-severe COPD, at least one acute exacerbation of COPD, and a sputum
eosinophil count of 3·0% or more within the previous year, were randomly
assigned (1:1) via computer-generated permuted block randomisation (block size
of four), with an interactive voice or web-response system, to receive placebo
or 100 mg benralizumab subcutaneously, every 4 weeks (three doses), then every 8
weeks (five doses) over 48 weeks. Study site personnel included in study
assessments, participants, and data analysts, were masked to treatment
allocation. The primary endpoint was the annualised rate of acute exacerbations
of COPD at week 56, defined as the number of acute exacerbations divided by
total duration of person-year follow-up. Secondary and exploratory endpoints
included COPD-specific Saint George's Respiratory Questionnaire (SGRQ-C),
Chronic Respiratory Questionnaire self-administered standardised format
(CRQ-SAS), pre-bronchodilator forced expiratory volume in 1 second (FEV1), and
safety. We did a prespecified subgroup analysis by baseline blood eosinophil
count. Analyses were by intention to treat and per-protocol. This trial is
registered with ClinicalTrials.gov, number NCT01227278.
FINDINGS: We randomly assigned 101 patients to receive placebo (n=50) or
benralizumab (n=51), of whom 88 (87%) patients completed the study. Six patients
who completed the study were excluded from the per-protocol population because
of major protocol violations; the per-protocol population thus included 82
patients. Benralizumab did not reduce the annualised rate of acute exacerbations
of COPD compared with placebo in the per-protocol population, with rates of 0·95
(0·68-1·29; n=40) versus 0·92 (0·67-1·25; n=42). Mean pre-bronchodilator FEV1
change from baseline to week 56 was -0·06 L (SD 0·24) with placebo, and 0·13 L
(0·41) with benralizumab (p=0·014). Numerical, albeit non-significant,
improvement in acute exacerbations of COPD, SGRQ-C, CRQ-SAS, and FEV1 were
greater in benralizumab-treated patients with baseline blood eosinophil
concentrations of 200 cells per μL or more or 300 cells per μL or more.
Incidence of treatment-emergent adverse events was similar between the two
groups, with the most common events being respiratory disorders (31 [62%] of 50
patients given placebo vs 32 [63%] of 51 given benralizumab) and infections (28
[56%] vs 27 [53%]). A higher incidence of serious treatment-emergent adverse
events were recorded in patients in the benralizumab group than in those in the
placebo group (14 vs nine patients), although none of these events were
considered by the investigator to be benralizumab related.
INTERPRETATION: Compared with placebo, benralizumab did not reduce the rate of
acute exacerbations of COPD. However, the results of prespecified subgroup
analysis support further investigation of benralizumab in patients with COPD and
eosinophilia.
FUNDING: MedImmune. BACKGROUND: Persistent eosinophilic airway inflammation in asthma increases the
risk of exacerbations. In a phase 2b dose-ranging study, we aimed to assess the
efficacy and safety of benralizumab, an anti-interleukin 5 receptor α monoclonal
antibody that depletes blood and airway eosinophils, in adults with uncontrolled
eosinophilic asthma.
METHODS: We did a randomised, controlled, double-blind, dose-ranging phase 2b
study. Eligible participants were adults aged 18-75 years with uncontrolled
asthma using medium-dose or high-dose inhaled corticosteroids and longacting β
agonists, with two to six exacerbations in the past year. Current or former
smokers were excluded. We used the ELEN index (an algorithm to predict elevated
sputum eosinophils) or baseline fraction of exhaled nitric oxide to stratify
patients by eosinophilic status, and with an interactive web-voice response
system randomly assigned eosinophilic individuals in a 1:1:1:1 ratio to receive
placebo, 2 mg benralizumab, 20 mg benralizumab, or 100 mg benralizumab, and
non-eosinophilic individuals in a 1:1 ratio to receive placebo or 100 mg
benralizumab. Study drugs were given as two subcutaneous injections every 4
weeks for the first three doses, then every 8 weeks, for 1 year. Patients,
treating physicians, and study investigators were masked to treatment
allocation. The primary endpoint was annual exacerbation rate in eosinophilic
individuals after 1 year of follow-up. Analysis was by modified intention to
treat. This study was designed with a two-sided α of 0·2 and powered at 78% for
the primary outcome in the eosinophilic population. This study is registered
with ClinicalTrials.gov, number NCT01238861.
FINDINGS: Between Jan 3, 2011, and March 6, 2012, we randomly assigned 324
eosinophilic individuals to placebo (n=80) or benralizumab 2 mg dose (n=81), 20
mg dose, (n=81), or 100 mg dose (n=82), and 285 non-eosinophilic individuals to
100 mg benralizumab (n=142, 140 included in analysis) or placebo (n=143, 142
included in analysis). In eosinophilic individuals, benralizumab reduced
exacerbation rates compared with placebo in the 100 mg group (0·34 vs 0·57,
reduction 41%, 80% CI 11 to 60, p=0·096) but not in the 2 mg group (0·65 vs
0·57, difference -9%, 80% CI -59 to 26, p=0·781) or the 20 mg group (0·37 vs
0·57, reduction 36%, 80% CI 3 to 58, p=0·173). In patients with a baseline blood
eosinophil cutoff of at least 300 cells per μL, exacerbation rates in the
benralizumab 20 mg group (n=70) and 100 mg group (n=97) were lower than in the
placebo group (n=83; 0·30 vs 0·68, reduction 57%, 80% CI 33 to 72, p=0·015 for
20 mg dose; 0·38 vs 0·68, difference 43%, 80% CI 18 to 60, p=0·049 for 100 mg
dose). Our findings suggested that benralizumab 20 mg and 100 mg resided at the
dose-response plateau. Treatment-emergent adverse events occurred in 277 (72%)
of 385 participants receiving any benralizumab dose compared with 143 (65%) of
221 receiving placebo. Nasopharyngitis (44 [11%] patients receiving benralizumab
vs 13 [6%] patients receiving placebo) and injection site reactions (60 [16%] vs
eight [4%]) occurred more frequently with benralizumab than with placebo.
INTERPRETATION: Benralizumab at 20 mg and 100 mg doses seemed to reduce asthma
exacerbations in adults with uncontrolled eosinophilic asthma and baseline blood
eosinophils of at least 300 cells per μL, possibly due to targeting of the
interleukin 5 receptor rather than interleukin 5 ligand. Further investigation
of benralizumab treatment in phase 3 studies is warranted.
FUNDING: MedImmune. BACKGROUND: Benralizumab is a humanised, afucosylated, anti-interleukin-5
receptor α monoclonal antibody that induces direct, rapid, and nearly complete
depletion of eosinophils. We aimed to assess the efficacy and safety of
benralizumab as add-on therapy for patients with severe, uncontrolled asthma and
elevated blood eosinophil counts.
METHODS: In this randomised, double-blind, parallel-group, placebo-controlled,
phase 3 study (CALIMA) undertaken at 303 sites in 11 countries, we enrolled
patients aged 12-75 years with severe asthma uncontrolled by medium-dosage to
high-dosage inhaled corticosteroids plus long-acting β₂-agonists (ICS plus LABA)
and a history of two or more exacerbations in the previous year. Patients were
randomly assigned (1:1:1) to receive 56 weeks of benralizumab 30 mg every 4
weeks (Q4W), benralizumab 30 mg every 8 weeks (Q8W; first three doses 4 weeks
apart), or placebo (all subcutaneous injection). Patients were stratified (2:1)
by baseline blood eosinophil counts 300 cells per μL or greater and less than
300 cells per μL, respectively. Patients and study centre staff were masked to
treatment allocation. The primary endpoint was annual exacerbation rate ratio
versus placebo for patients receiving high-dosage ICS plus LABA with baseline
blood eosinophils 300 cells per μL or greater (intention-to-treat analysis). Key
secondary endpoints were pre-bronchodilator forced expiratory volume in 1 s
(FEV1) and total asthma symptom score. This study is registered with
ClinicalTrials.gov, number NCT01914757.
FINDINGS: Between Aug 21, 2013, and March 16, 2015, 2505 patients were enrolled,
of whom 1306 patients were randomised; 425 patients were randomly assigned to
and received benralizumab 30 mg Q4W, 441 to benralizumab 30 mg Q8W, and 440 to
placebo. 728 patients were included in the primary analysis population.
Benralizumab resulted in significantly lower annual exacerbation rates with the
Q4W regimen (rate 0·60 [95% CI 0·48-0·74], rate ratio 0·64 [95% CI 0·49-0·85],
p=0·0018, n=241) and Q8W regimen (rate 0·66 [95% CI 0·54-0·82], rate ratio 0·72
[95% CI 0·54-0·95], p=0·0188, n=239) compared with placebo (rate 0·93 [95% CI
0·77-1·12], n=248). Benralizumab also significantly improved pre-bronchodilator
FEV1 (Q4W and Q8W) and total asthma symptom score (Q8W only) in these patients.
The most common adverse events were nasopharyngitis (90 [21%] in the Q4W group,
79 [18%] in the Q8W group, and 92 [21%] in the placebo group) and worsening
asthma (61 [14%] in the Q4W group, 47 [11%] in the Q8W group, and 68 [15%] in
the group).
INTERPRETATION: Benralizumab significantly reduced annual exacerbation rates and
was generally well tolerated for patients with severe, uncontrolled asthma with
blood eosinophils 300 cells per μL or greater. Our data further refine the
patient population likely to receive the greatest benefit from benralizumab
treatment.
FUNDING: AstraZeneca and Kyowa Hakko Kirin. BACKGROUND: Eosinophilia is associated with worsening asthma severity and
decreased lung function, with increased exacerbation frequency. We assessed the
safety and efficacy of benralizumab, a monoclonal antibody against interleukin-5
receptor α that depletes eosinophils by antibody-dependent cell-mediated
cytotoxicity, for patients with severe, uncontrolled asthma with eosinophilia.
METHODS: We did a randomised, double-blind, parallel-group, placebo-controlled
phase 3 study at 374 sites in 17 countries. We recruited patients (aged 12-75
years) with a physician-based diagnosis of asthma for at least 1 year and at
least two exacerbations while on high-dosage inhaled corticosteroids and
long-acting β2-agonists (ICS plus LABA) in the previous year. Patients were
randomly assigned (1:1:1) by an interactive web-based voice response system to
benralizumab 30 mg either every 4 weeks (Q4W) or every 8 weeks (Q8W; first three
doses every 4 weeks) or placebo Q4W for 48 weeks as add on to their standard
treatment. Patients were stratified 2:1 according to blood eosinophil counts of
at least 300 cells per μL and less than 300 cells per μL. All patients and
investigators involved in patient treatment or clinical assessment were masked
to treatment allocation. The primary endpoint was annual exacerbation rate ratio
versus placebo, and key secondary endpoints were prebronchodilator forced
expiratory volume in 1 s (FEV1) and total asthma symptom score at week 48, for
patients with blood eosinophil counts of at least 300 cells per μL. Efficacy
analyses were by intention to treat (based on the full analysis set); safety
analyses included patients according to study drug received. This study is
registered with ClinicalTrials.gov, number NCT01928771.
FINDINGS: Between Sept 19, 2013, and March 16, 2015, 2681 patients were
enrolled, 1205 of whom met the study criteria and were randomly assigned: 407 to
placebo, 400 to benralizumab 30 mg Q4W, and 398 to benralizumab 30 mg Q8W. 267
patients in the placebo group, 275 in the benralizumab 30 mg Q4W group, and 267
in the benralizumab 30 mg Q8W group had blood eosinophil counts at least 300
cells per μL and were included in the primary analysis population. Compared with
placebo, benralizumab reduced the annual asthma exacerbation rate over 48 weeks
when given Q4W (rate ratio 0·55, 95% CI 0·42-0·71; p<0·0001) or Q8W (0·49,
0·37-0·64; p<0·0001). Both benralizumab dosing regimens significantly improved
prebronchodilator FEV1 in patients at week 48 compared with placebo
(least-squares mean change from baseline: Q4W group 0·106 L, 95% CI 0·016-0·196;
Q8W group 0·159 L, 0·068-0·249). Compared with placebo, asthma symptoms were
improved by the Q8W regimen (least-squares mean difference -0·25, 95% CI -0·45
to -0·06), but not the Q4W regimen (-0·08, -0·27 to 0·12). The most common
adverse events were worsening asthma (105 [13%] of 797 benralizumab-treated
patients vs 78 [19%] of 407 placebo-treated patients) and nasopharyngitis (93
[12%] vs 47 [12%]).
INTERPRETATION: These results confirm the efficacy and safety of benralizumab
for patients with severe asthma and elevated eosinophils, which are uncontrolled
by high-dosage ICS plus LABA, and provide support for benralizumab to be an
additional option to treat this disease in this patient population.
FUNDING: AstraZeneca and Kyowa Hakko Kirin. Inconsistent results have been reported regarding IL-5 blockade treatment in
asthma. There were no direct between-treatment comparisons. Only differences
between each drug and placebo were studied. We identified all RCTs with anti-IL5
treatments for patients with asthma over the 1990-September 2015 period. RCTs
were searched on Medline, Cochrane and Embase. At least 50 patients were
enrolled in each study. Outcomes considered were exacerbation rate reduction,
FEV1 changes, ACQ-5 improvement, adverse events and serious adverse events. A
global meta-analysis was first conducted followed by an indirect comparison of
each IL-5-targeting drug: benralizumab, reslizumab and mepolizumab. Further
eosinophilic subgroup analysis and sensitivity analysis were also conducted in
case of heterogeneity. Ten trials involving 3421 patients were eligible for
meta-analysis. IL-5 blockade significantly reduced annual exacerbation rates vs.
placebo by 40% [29-50] (P < 0.01, I2 = 0.61). ACQ-5 was significantly improved
vs. placebo but below the recognized MCID level (-0.31 [-0.41, -0.21], P < 0.01,
I2 = 0.11). FEV1 changes from baseline were improved vs. placebo by 0.09 L
[0.05-0.12] (P < 0.01, I2 = 0.28). The subgroup analysis identified a slight
additional improvement in mean treatment effects in eosinophilic (> 300 mm3 /L)
patients with severe asthma. Similar patterns and rates of adverse events and
severe adverse events were reported with the three drugs. The data
interpretations were not affected by the sensitivity analysis. IL-5 blockade
appears to be a relevant treatment strategy to improve severe asthma management,
particularly for eosinophilic patients. No clear superiority appeared between
the drugs when appropriate doses were compared. Benralizumab is a humanized, afucosylated, anti-interleukin-5 receptor α,
immunoglobulin G (IgG) 1 κ monoclonal antibody. We developed a population
pharmacokinetic (PK)/pharmacodynamic (PD) model for benralizumab by analyzing PK
and blood eosinophil count data from two healthy volunteer studies (N = 48) and
four studies in patients with asthma (N = 152). Benralizumab PK was
dose-proportional and adequately described by a two-compartment model with
first-order elimination from the central compartment and first-order absorption
from the subcutaneous dosing site. The estimated systemic clearance and volume
of distribution were typical for human IgG. Body weight and high-titer antidrug
antibodies were identified as relevant covariates influencing the PK of
benralizumab. Depletion of blood eosinophil counts was depicted by a modified
transit model in which benralizumab induced depletion of eosinophils in each age
compartment. Stochastic simulations supported an every-8-week dosing schedule of
benralizumab for a phase IIb study in patients with uncontrolled asthma. BACKGROUND: Many patients with severe asthma rely on oral glucocorticoids to
manage their disease. We investigated whether benralizumab, a monoclonal
antibody directed against the alpha subunit of the interleukin-5 receptor that
significantly reduces the incidence of asthma exacerbations, was also effective
as an oral glucocorticoid-sparing therapy in patients relying on oral
glucocorticoids to manage severe asthma associated with eosinophilia.
METHODS: In a 28-week randomized, controlled trial, we assessed the effects of
benralizumab (at a dose of 30 mg administered subcutaneously either every 4
weeks or every 8 weeks [with the first three doses administered every 4 weeks])
versus placebo on the reduction in the oral glucocorticoid dose while asthma
control was maintained in adult patients with severe asthma. The primary end
point was the percentage change in the oral glucocorticoid dose from baseline to
week 28. Annual asthma exacerbation rates, lung function, symptoms, and safety
were assessed.
RESULTS: Of 369 patients enrolled, 220 underwent randomization and started
receiving benralizumab or placebo. The two benralizumab dosing regimens
significantly reduced the median final oral glucocorticoid doses from baseline
by 75%, as compared with a reduction of 25% in the oral glucocorticoid doses in
the placebo group (P<0.001 for both comparisons). The odds of a reduction in the
oral glucocorticoid dose were more than 4 times as high with benralizumab as
with placebo. Among the secondary outcomes, benralizumab administered every 4
weeks resulted in an annual exacerbation rate that was 55% lower than the rate
with placebo (marginal rate, 0.83 vs. 1.83, P=0.003), and benralizumab
administered every 8 weeks resulted in an annual exacerbation rate that was 70%
lower than the rate with placebo (marginal rate, 0.54 vs. 1.83, P<0.001). At 28
weeks, there was no significant effect of either benralizumab regimen on the
forced expiratory volume in 1 second (FEV1), as compared with placebo. The
effects on various measures of asthma symptoms were mixed, with some showing
significant changes in favor of benralizumab and others not showing significant
changes. Frequencies of adverse events were similar between each benralizumab
group and the placebo group.
CONCLUSIONS: Benralizumab showed significant, clinically relevant benefits, as
compared with placebo, on oral glucocorticoid use and exacerbation rates. These
effects occurred without a sustained effect on the FEV1. (Funded by AstraZeneca;
ZONDA ClinicalTrials.gov number, NCT02075255 .). Asthma and COPD are prevalent chronic inflammatory airway diseases that are
responsible for a large global disease burden. Both diseases are complex and
heterogeneous, and they are increasingly recognized as overlapping syndromes
that may share similar pathophysiologic mechanisms and treatable traits.
Eosinophilic airway inflammation is considered the most influential treatable
trait of chronic airway disease, and over the last decade, several monoclonal
antibodies and small molecule therapies have been developed to target this
trait. These include monoclonal antibodies against IL-5 or IL-5 receptor alpha
(mepolizumab, reslizumab, and benralizumab), IL-13 (lebrikizumab and
tralokinumab), IL-4 receptor alpha (dupilumab), IgE (omalizumab), and
anti-thymic stromal lymphopoietin (tezepelumab) and small molecule therapies
such as prostaglandin D2 blockers (fevipiprant and timapiprant). Although these
novel biologic agents have shown promising results in many patients with asthma
and COPD who have eosinophilic airway inflammation, it is evident that not all
patients respond equally well, despite similar clinical, functional, and
inflammatory characteristics. This heterogeneity in treatment response is
probably related to different molecular pathways or endotypes leading to
eosinophilic airway inflammation, including adaptive immune pathways mediated by
T helper 2 cells and innate immune pathways mediated by innate lymphoid cells.
The relative contribution of these pathways in asthma and COPD is not yet
clarified, and there are currently no reliable biomarkers that represent the
various pathways. Therefore, there is an urgent need for easily measurable and
reproducible biomarkers that are linked to underlying pathophysiologic disease
mechanisms and can predict and monitor responses to novel biologic agents. In many severe asthmatics, eosinophils cause inflammation and airways
hyperresponsiveness, resulting in frequent exacerbations, impaired lung
function, and reduced quality of life. Interleukin-5 (IL-5) is a key cytokine
for eosinophil growth, differentiation, recruitment, activation, and survival.
Anti-IL-5-based therapies (mepolizumab and reslizumab are humanized monoclonal
antibodies (hmAbs) that recognize free IL-5, benralizumab is a hmAb directed at
the α subunit of the IL-5R) target the IL-5-signaling in eosinophilic asthma.
Areas covered: The pharmacodynamic/pharmacokinetic profile of benralizumab and
how it provided indications that permitted optimization of the design and
timelines of the pivotal trials are described. Expert opinion: Benralizumab has
the advantage over other anti-IL-5 therapies to target the IL-5Rα itself.
Afucosylation enhances its interaction with its binding site and facilitates its
pharmacological activity. Other benefits of benralizumab are fast (within 24 h)
depletion of peripheral blood eosinophils, potent suppressive activity of bone
marrow eosinophils and eosinophil precursors, tissue eosinophil apoptosis
regardless of the presence of eosinophil survival factors and even at low IL-5R
densities. The fact that benralizumab is dosed subcutaneously and is equally
effective when given every eight weeks instead than every four weeks provides
patients with convenience of self-administration and make it appealing for
patients who dislike injections. BACKGROUND: Benralizumab is an anti-eosinophilic, anti-interleukin-5 receptor α
monoclonal antibody that has been shown to significantly reduce asthma
exacerbations and improve lung function for patients with severe, uncontrolled
asthma. We further explored the efficacy of benralizumab for patients with
different baseline blood eosinophil thresholds and exacerbation histories.
METHODS: This study is a pooled analysis of the results from the randomised,
double-blind, placebo-controlled SIROCCO (NCT01928771) and CALIMA (NCT01914757)
phase 3 studies. In these studies, patients with severe, uncontrolled asthma
were randomly assigned (1:1:1) to receive subcutaneous benralizumab 30 mg,
either every 4 weeks or every 8 weeks (with first three doses given every 4
weeks), or placebo every 4 weeks. The primary endpoint was annual exacerbation
rate (AER) ratio versus placebo, analysed by baseline eosinophil counts (≥0,
≥150, ≥300, or ≥450 cells per μL) and by number of exacerbations (two vs three
or more) during the year before enrolment. The analyses were done in accordance
with the intention-to-treat principle.
FINDINGS: Of 2295 patients, 756 received benralizumab every 4 weeks, 762
received benralizumab every 8 weeks, and 777 patients received placebo. AER
among patients with baseline blood eosinophil counts of at least 0 cells per μL
was 1·16 (95% CI 1·05-1·28) in patients who received placebo versus 0·75
(0·66-0·84) in patients who received benralizumab every 8 weeks (rate ratio
0·64, 0·55-0·75; p<0·0001). In patients who received benralizumab every 4 weeks
who had eosinophil counts of 0 or more cells per μL, AER was 0·73 (0·65-0·82);
rate ratio versus placebo was 0·63 (0·54-0·74; p<0·0001). The extent to which
exacerbation rates were reduced increased with increasing blood eosinophil
thresholds and with greater exacerbation history in patients in the 4-weekly and
8-weekly benralizumab groups. Greater improvements in AER were seen with
benralizumab compared with placebo for patients with a combination of high blood
eosinophil thresholds and a history of more frequent exacerbations.
INTERPRETATION: These results will help to guide clinicians when they are
deciding whether to use benralizumab to treat patients with severe,
uncontrolled, eosinophilic asthma.
FUNDING: AstraZeneca. Asthma is an inflammatory disease which affects millions of people worldwide.
Therefore, it is necessary to search for new sources of therapies for the
treatment of these patients in order to improve their quality of life. From
content analysis of literature of new therapeutic targets, there are various
targets and drugs reported to be promising for the treatment of asthma.
Interleukins involved in inflammatory processes are often presented as candidate
targets for new drugs. The action of such therapeutics would not only affect
interleukins, but also their receptors. Small molecules (e.g. ligustrazine and
SP600125) and large molecule antibodies (e.g. lebrikizumab, benralizumab,
dupilumab) are being considered as novel agents for the pharmacotherapy of
asthma. Therefore, through this research, we can see advances in the search for
new targets and promising drugs to treat asthma. It is expected that these new
drug candidates will eventually be approved and marketed so that asthma patients
can use them to enhance their quality of life. |
Is there any link between ERCC1-XPF and cohesin? | Yes. ERCC1-XPF cooperates with CTCF and cohesin to facilitate the developmental silencing of imprinted genes. | Inborn defects in DNA repair are associated with complex developmental disorders
whose causal mechanisms are poorly understood. Using an in vivo biotinylation
tagging approach in mice, we show that the nucleotide excision repair (NER)
structure-specific endonuclease ERCC1-XPF complex interacts with the insulator
binding protein CTCF, the cohesin subunits SMC1A and SMC3 and with MBD2; the
factors co-localize with ATRX at the promoters and control regions (ICRs) of
imprinted genes during postnatal hepatic development. Loss of Ercc1 or exposure
to MMC triggers the localization of CTCF to heterochromatin, the dissociation of
the CTCF-cohesin complex and ATRX from promoters and ICRs, altered histone marks
and the aberrant developmental expression of imprinted genes without altering
DNA methylation. We propose that ERCC1-XPF cooperates with CTCF and cohesin to
facilitate the developmental silencing of imprinted genes and that persistent
DNA damage triggers chromatin changes that affect gene expression programs
associated with NER disorders. |
Describe the Match BAM to VCF (MBV) method. | MBV (Match BAM to VCF) is a method to quickly solve sample mislabeling and detect cross-sample contamination and PCR amplification bias. | MOTIVATION: Large genomic datasets combining genotype and sequence data, such as
for expression quantitative trait loci (eQTL) detection, require perfect
matching between both data types.
RESULTS: We described here MBV (Match BAM to VCF); a method to quickly solve
sample mislabeling and detect cross-sample contamination and PCR amplification
bias.
AVAILABILITY AND IMPLEMENTATION: MBV is implemented in C ++ as an independent
component of the QTLtools software package, the binary and source codes are
freely available at https://qtltools.github.io/qtltools/ .
CONTACT: [email protected] or [email protected].
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. |
Does Evolocumab improve cognitive function? | No, Evolocumab does not improve cognitive functioning. | Some observational studies raised concern that statins may cause memory
impairment, leading to a US Food and Drug Administration warning. Similar
questions were raised regarding proprotein convertase subtilisin/kexin-type 9
inhibitors (PCSK9i) and neurocognitive function. No prospectively designed study
has evaluated the relationship between long-term PCSK9i use and cognition
changes. Patients with prior cardiovascular disease treated with maximally
tolerated statin enrolled in FOURIER (the randomized, double-blind,
placebo-controlled cardiovascular outcome study of the PCSK9i evolocumab) could
participate in this prospective assessment of cognitive function (EBBINGHAUS).
Key additional exclusion criteria for EBBINGHAUS were dementia, cognitive
impairment, or other significant mental or neurological disorder. Cognitive
testing was performed using the Cambridge Neuropsychological Test Automated
Battery, a tablet-based tool assessing executive function, working memory,
memory function, and psychomotor speed at baseline, weeks 24 and 48, every 48
weeks thereafter, and study end. The primary endpoint was spatial working memory
strategy index of executive function (SWMSI). The primary hypothesis was that
evolocumab would be noninferior to placebo in the mean change from baseline over
time in SWMSI. Fifteen hundred cognitively normal patients completing the
assessments provided approximately 97% power to demonstrate that the upper 95%
confidence interval for the treatment difference in mean change from baseline in
SWMSI over time is <20% of the SD of the mean change in the placebo group. An
exploratory analysis will compare neurocognitive function in patients with
post-baseline low-density lipoprotein cholesterol <25 mg/dL. EBBINGHAUS will
evaluate whether the addition of evolocumab to statin therapy affects cognitive
function over time in patients with stable cardiovascular disease. BACKGROUND: Despite the availability of effective drug therapies that reduce
low-density lipoprotein (LDL)-cholesterol (LDL-C), cardiovascular disease (CVD)
remains an important cause of mortality and morbidity. Therefore, additional
LDL-C reduction may be warranted, especially for patients who are unresponsive
to, or unable to take, existing LDL-C-reducing therapies. By inhibiting the
proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme, monoclonal
antibodies (PCSK9 inhibitors) may further reduce LDL-C, potentially reducing CVD
risk as well.
OBJECTIVES: Primary To quantify short-term (24 weeks), medium-term (one year),
and long-term (five years) effects of PCSK9 inhibitors on lipid parameters and
on the incidence of CVD. Secondary To quantify the safety of PCSK9 inhibitors,
with specific focus on the incidence of type 2 diabetes, cognitive function, and
cancer. Additionally, to determine if specific patient subgroups were more or
less likely to benefit from the use of PCSK9 inhibitors.
SEARCH METHODS: We identified studies by systematically searching the Cochrane
Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of
Science. We also searched Clinicaltrials.gov and the International Clinical
Trials Registry Platform and screened the reference lists of included studies.
We identified the studies included in this review through electronic literature
searches conducted up to May 2016, and added three large trials published in
March 2017.
SELECTION CRITERIA: All parallel-group and factorial randomised controlled
trials (RCTs) with a follow-up time of at least 24 weeks were eligible.
DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed and
extracted data. When data were available, we calculated pooled effect estimates.
MAIN RESULTS: We included 20 studies with data on 67,237 participants (median
age 61 years; range 52 to 64 years). Twelve trials randomised participants to
alirocumab, three trials to bococizumab, one to RG7652, and four to evolocumab.
Owing to the small number of trials using agents other than alirocumab, we did
not differentiate between types of PCSK9 inhibitors used. We compared PCSK9
inhibitors with placebo (thirteen RCTs), ezetimibe (two RCTs) or ezetimibe and
statins (five RCTs).Compared with placebo, PCSK9 inhibitors decreased LDL-C by
53.86% (95% confidence interval (CI) 58.64 to 49.08; eight studies; 4782
participants; GRADE: moderate) at 24 weeks; compared with ezetimibe, PCSK9
inhibitors decreased LDL-C by 30.20% (95% CI 34.18 to 26.23; two studies; 823
participants; GRADE: moderate), and compared with ezetimibe and statins, PCSK9
inhibitors decreased LDL-C by 39.20% (95% CI 56.15 to 22.26; five studies; 5376
participants; GRADE: moderate).Compared with placebo, PCSK9 inhibitors decreased
the risk of CVD events, with a risk difference (RD) of 0.91% (odds ratio (OR) of
0.86, 95% CI 0.80 to 0.92; eight studies; 59,294 participants; GRADE: moderate).
Compared with ezetimibe and statins, PCSK9 inhibitors appeared to have a
stronger protective effect on CVD risk, although with considerable uncertainty
(RD 1.06%, OR 0.45, 95% CI 0.27 to 0.75; three studies; 4770 participants;
GRADE: very low). No data were available for the ezetimibe only comparison.
Compared with placebo, PCSK9 probably had little or no effect on mortality (RD
0.03%, OR 1.02, 95% CI 0.91 to 1.14; 12 studies; 60,684 participants; GRADE:
moderate). Compared with placebo, PCSK9 inhibitors increased the risk of any
adverse events (RD 1.54%, OR 1.08, 95% CI 1.04 to 1.12; 13 studies; 54,204
participants; GRADE: low). Similar effects were observed for the comparison of
ezetimibe and statins: RD 3.70%, OR 1.18, 95% CI 1.05 to 1.34; four studies;
5376 participants; GRADE: low. Clinical event data were unavailable for the
ezetimibe only comparison.
AUTHORS' CONCLUSIONS: Over short-term to medium-term follow-up, PCSK9 inhibitors
reduced LDL-C. Studies with medium-term follow-up time (longest median follow-up
recorded was 26 months) reported that PCSK9 inhibitors (compared with placebo)
decreased CVD risk but may have increased the risk of any adverse events (driven
by SPIRE-1 and -2 trials). Available evidence suggests that PCSK9 inhibitor use
probably leads to little or no difference in mortality. Evidence on relative
efficacy and safety when PCSK9 inhibitors were compared with active treatments
was of low to very low quality (GRADE); follow-up times were short and events
were few. Large trials with longer follow-up are needed to evaluate PCSK9
inhibitors versus active treatments as well as placebo. Owing to the predomit
inclusion of high-risk patients in these studies, applicability of results to
primary prevention is limited. Finally, estimated risk differences indicate that
PCSK9 inhibitors only modestly change absolute risks (often to less than 1%). |
Can radius fracture cause carpal tunnel syndrome? | Yes, carpal tunnel syndrome is a common complication associated with distal radius fractures. | We report the incidence of late onset post-operative carpal tunnel syndrome
(late carpal tunnel syndrome) and late median nerve neuropathy after volar
plating of distal radius fracture by conducting a retrospective study on volar
plating for distal radius fracture performed during 2002 to 2006. Two hundred
eighty-two volar plating were performed for acute distal radius fracture after
exclusion. Post-operative hand numbness occurred in 24 patients of which nine
had carpal tunnel syndrome. Thus, the incidence of late carpal tunnel syndrome
was 3.2% (9/282). Of the eight (8/24, 33%) patients with post-operative hand
numbness that failed to respond to conservative treatment, five had carpal
tunnel release and three had neurolysis of median nerve at distal forearm. All
had clinical improvement except in one patient. The incidence of late carpal
tunnel syndrome after volar plating of distal radius in the present series is
similar to the prevalence of carpal tunnel syndrome in general population. The
incidence is low compared with other series, regardless of treatment method
(conservative treatment, volar or dorsal plating). The outcome of post-operative
hand numbness is generally favourable. OBJECTIVE: To investigate the effects of open reduction by palm side for the
distal radius fracture and T shape plate internal fixation with simultaneous
anterior transverse carpal ligament resection for the prevention of delayed
carpal tunnel syndrome after operation.
METHODS: From March 2000 to March 2007, 32 patients (8 males and 24 females,
ranging in age from 46 to 66 years) with distal radius fracture were treated
with open reduction by palm side and T shape plate internal fixation with
simultaneous anterior transverse carpal ligament resection; while 30 patients (7
males and 23 females,ranging in age from 45 to 65 years) only with open
reduction by palm side and T shape plate internal fixation. The incidences of
delayed carpal tunnel syndrome between the two groups were compared.
RESULTS: Among 32 patients treated with open reduction by palm side and T shape
plate internal fixation with anterior transverse carpal ligament resection, 3
patients had delayed carpal tunnel syndrome; while in 30 patients treated with
open reduction by palm side and T shape plate internal fixation, 10 patients had
delayed carpal tunnel syndrome. There was significant statistically difference
(P < 0.05%).
CONCLUSION: Simultaneous anterior transverse carpal ligament resection can
effectively prevent the delayed carpal tunnel syndrome occurrence for the distal
radius fracture with open reduction by palm side. Carpal tunnel syndrome is a common condition and is a well-recognized phenomenon
following a distal radius fracture. The treating surgeon should be vigilant in
noticing the signs and symptoms. If acute carpal tunnel syndrome is noted, then
surgical release of the carpal tunnel and fracture fixation should be performed
urgently. If early carpal tunnel syndrome findings are noted during distal
radius fracture management, all potential causes should be evaluated. Delayed
carpal tunnel syndrome presenting after a distal radius fracture has healed is
best managed in standard fashion. There is no role for prophylactic carpal
tunnel release at the time of distal radius fixation in a patient who is
asymptomatic. Although the rupture of extensor tendons after distal radius fractures is well
described, acute flexor tendon ruptures are much less common. We report a case
of acute rupture of the flexor pollicis longus and flexor carpi radialis tendons
with acute carpal tunnel syndrome after a Gustilo-Anderson type II open distal
radius fracture. We reviewed the literature to identify risk factors for tendon
rupture and the development of carpal tunnel syndrome. Carpal tunnel syndrome is a common complication associated with distal radius
fractures. Open carpal tunnel release in the same setting as open reduction and
internal fixation of distal radius fractures is widely accepted. In this paper,
we describe the technical details of a minimally invasive carpal tunnel release
in the same setting as the fixation of a distal radius fracture via the same
incision. Two options of minimally invasive techniques are described: The
Knifelight® (Stryker, Kalamazoo, Michigan, USA) instrument and the single portal
carpal tunnel release system (Agee, 3M Healthcare, St Paul, Minnesota, USA).
Being well known and accepted techniques of carpal tunnel release, we believe
that the techniques described in this paper provide a viable alternative for
carpal tunnel release in the setting of distal radius fracture fixation; with
the added advantages of the original minimally invasive techniques. BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become
the favoured treatment. The complication rates vary from 3 to 36%. The purpose
of the study was to estimate the complication rate of volar plating of DRF and
its association with AO/OTA fracture type, surgeon experience and type of volar
plate.
METHODS: Retrospectively, all patients treated with volar plating of a DRF
between February 2009 and June 2013 at Aarhus University Hospital, Denmark were
included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year
resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications
were extracted from the electronic medical records. Complications were
categorized as carpal tunnel syndrome, other sensibility issues, tendon
complications including irritation and rupture, deep infections, complex
regional pain syndrome and unidentified DRUJ or scapholunar problems.
Reoperations including hardware removal were also charted.
RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were
included. 78% were female and the mean observation time was 3.2 years (min: 2.0;
max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125)
with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7)
including carpal tunnel syndrome or change in sensibility in 5.2% and tendon
complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon
ruptures were observed. The reoperation rate was 10.4% including 41 cases of
hardware removal. A statistically significant association between AO/OTA
fracture type C and complications was found. No statistically significant
association between complication rate and surgeon experience and type of plate
was observed.
CONCLUSION: The majority of DRF patients treated with a volar plate suffer no
complications. However, the overall complication rate of 14.6% is substantial.
Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher
complication rates. Neither surgeon experience, nor type of volar plate was able
to predict complications. BACKGROUND: Although median nerve neuropathy and carpal tunnel syndrome (CTS)
are known complications of both untreated and acutely treated distal radius
fracture, median neuropathy after correction of distal radius malunion is not
commonly reported in hand surgery literature. We describe a patient with severe
CTS after corrective osteotomy, open reduction internal fixation (ORIF) with a
volar locking plate (VLP), and bone grafting for distal radius malunion.
METHODS: We report a case of severe acute CTS as a complication of corrective
osteotomy with bone grafting for distal radius malunion.
RESULTS: The patient was treated with surgical exploration of the median nerve
and carpal tunnel release.
CONCLUSION: The authors report a case of acute CTS after ORIF with VLP for a
distal radius malunion warranting surgical exploration and carpal tunnel
release. Treatment teams must be aware of this potential complication so that
the threshold for reoperation is low and irreversible damage to the median nerve
is prevented. PURPOSE: The aim of this study in adult patients with a distal radial fracture
was to determine whether socioeconomic status influenced the epidemiology,
mechanism of injury, fracture severity, or the outcome according to function,
radiographic assessment, and rate of associated complications.
METHODS: We identified 3983 distal radial fractures over a 7-year period.
Socioeconomic status was assigned using the Carstairs score, and the population
was divided into quintiles depending on deprivation. Patient demographics,
mechanism of injury, fracture severity, and radiographic assessment at time of
injury were assessed for epidemiological differences according to social
quintile. Functional outcome was assessed using grip strength, Moberg pickup
test, return to normal use of the hand, and range of movement. Radiographs were
assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion,
carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain,
and subjective cosmetic deformity of the wrist.
RESULTS: Socioeconomically deprived patients were significantly younger
(p < 0.001) and more likely to be male (p = 0.017); after adjusting for
confounding factors, deprived patients were 3.1 (95% CI 1.4-4.7) years younger
than the most affluent patients (p < 0.001). Deprived patients were more likely
to sustain their fracture by a high-energy mechanism (p = 0.004). There were no
significant differences between quintiles in outcome. There was a significantly
greater prevalence of CRPS in more affluent patients (p = 0.004).
CONCLUSIONS: Socioeconomically deprived patients sustaining a distal radial
fracture are more likely to be younger and male. Outcome is not influenced by
socioeconomic status, but the prevalence of CRPS is greater in more affluent
patients. Carpal tunnel syndrome (CTS) after distal radius fractures can present in 3
forms: acute, transient, and delayed. Acute CTS requires an emergent carpal
tunnel release. Many patients with transient CTS after distal radius fracture do
not require surgical release of the carpal tunnel once the fracture is repaired.
Prophylactic carpal tunnel release in the absence of signs and symptoms of CTS
after a distal radius fracture is not indicated. For patients with delayed CTS
after a distal radius fracture, all possible causes of nerve compression should
be considered and addressed in standard fashion. |
Can Logic Alignment Free (LAF) be used for bacterial genomes classification? | Yes. Logic Alignment Free (LAF), a method that combines alignment-free techniques and rule-based classification algorithms can be used in order to assign biological samples to their taxa. | Alignment-free algorithms can be used to estimate the similarity of biological
sequences and hence are often applied to the phylogenetic reconstruction of
genomes. Most of these algorithms rely on comparing the frequency of all the
distinct substrings of fixed length (k-mers) that occur in the analyzed
sequences. In this paper, we present Logic Alignment Free (LAF), a method that
combines alignment-free techniques and rule-based classification algorithms in
order to assign biological samples to their taxa. This method searches for a
minimal subset of k-mers whose relative frequencies are used to build
classification models as disjunctive-normal-form logic formulas (if-then rules).
We apply LAF successfully to the classification of bacterial genomes to their
corresponding taxonomy. In particular, we succeed in obtaining reliable
classification at different taxonomic levels by extracting a handful of rules,
each one based on the frequency of just few k-mers. State of the art methods to
adjust the frequency of k-mers to the character distribution of the underlying
genomes have negligible impact on classification performance, suggesting that
the signal of each class is strong and that LAF is effective in identifying it. |
Is Marfan syndrome associated with chordal rupture? | Yes, chordal rupture was described in patients with Marfan syndrome. | Mitral Valve Prolapse (MVP) is usually a variant of normal occurring in about 4%
of the population. Complications are relatively uncommon, but false associations
due to ascertainment bias have had a potential for iatrogenic harm. Adverse
outcomes which do occur in a subset of MVP subjects are considered here in
relation to the contributions of genes, gender and geometry. There are definite
associations between MVP and several domitly inherited connective tissue
abnormalities; it occurs in 85% of adults with Marfan syndrome. All these
contribute to a very small proportion of the MVP population. A larger less
easily characterised group with domit inheritance and some features of a
connective tissue disorder awaits DNA studies for identification. For most MVP
subjects our data define significant family aggregation consistent with
polygenic inheritance; the likelihood of a first degree relative having MVP is
about two and a half times the population average. There is a higher prevalence
in young women than in men-5% versus 3%; this has also been demonstrated for
floppy mitral valve (MV) at autopsy. MVP complications of chordal rupture,
severe mitral regurgitation and infective endocarditis are, however, two to
three times more common in men, are age related and evident after the age of 50
years. Higher blood pressure in men may contribute to this in accordance with a
response-to-injury hypothesis to explain progressive valve changes. Leaflet,
annulus and left ventricular size differences and septal changes are geometric
variants with a potential for increasing tension-related valve injury.(ABSTRACT
TRUNCATED AT 250 WORDS) The cardiac valves develop from the endocardial cushions of the fetus. Some
congenital anomalies such as the 21-trisomy syndrome (Down syndrome) show poorly
differentiated immature valves similar to those under development. The normally
mature valves have four layers of the connective tissue, i.e., proximalis,
spongiosa, fibrosa and distalis. Gargoylism promotes abnormal thickening of
collagen fibers in the fibrosa via acid-mucopolysaccharide (aMPS)
overproduction, but Marfan syndrome weakens the valves in spite of increased
aMPS. The reversed conditions could be caused by the difference of increased
aMPS; i.e., dermatan sulfate B or heparitin sulfate in gargoylism, on the
contrary, dermatan sulfate A and C or hyaluronic acid in Marfan syndrome.
Hemodynamic changes in the valves consist of diffuse hypertrophy of the
proximalis and fibrosa in high flow cases and focal thickening of the proximalis
at the line of closure and of the spongiosa at the anatomical edge in high
pressure cases. Aging of the valves simulates partly the hemodynamic changes but
degeneration of collagen fibers in the fibrosa after consumption of the
spongiosa is more prominent than the latter. So-called myxomatous degeneration
in the mitral valve prolapse cases seems reactive hypertrophy of the spongiosa
replacing the interrupted fibrosa. Spontaneous chordal rupture is partly related
to myxomatous change, but that in the elderly cases shows only simple disruption
of collagen fibers with loss of the spongiosa tissue. Calcification of the
valvular rings and bodies often observed in the elderly cases with parallelism
to degeneration of the connective tissue produces mitral regurgitation, aortic
stenosis or both, showing a preponderance of females.(ABSTRACT TRUNCATED AT 250
WORDS) We experienced a rare case of Marfan's syndrome with annulo-aortic ectasia,
aortic regurgitation and Prinzmetal's variant angina. In a modified Bentall's
operation (button technique), perioperative severe coronary artery spasm
occurred in spite of the preventive use of nitroglycerin infusion, which
resulted in profound ventricular fibrillation and subsequent chordal rupture of
the mitral valve with Sellers IV regurgitation. Use of nicardipine contained in
cardioplegia, continuous infusion of nicardipine and nitroglycerin after aortic
declamping completely prevented coronary spasm throughout the course of a second
surgery for mitral valve replacement. It is worthy to report this case because
of rarities such as Marfan's syndrome accompanied by Prinzmetal's variant
angina, perioperative coronary artery spasm in modified Bentall's operation, and
perioperative chordal rupture of the mitral valve and progression of mitral
valve regurgitation. We also stress the efficacy of a new calcium antagonist,
nicardipine, to prevent coronary artery spasm during open heart surgery. The neonatal Marfan syndrome is an autosomal domitly inherited disease with
an extremely poor prognosis. This report gives a clinical and echocardiographic
description of an infant with a mutation in exon 29 of the fibrillin-1 gene
(FBN1), a region in which this severe form of Marfan syndrome seems to cluster.
The infant died at the age of 3 months due to severe acute mitral regurgitation
leading to intractable heart failure. INTRODUCTION: There are multiple causes of mitral regurgitation. Its etiology
includes floppy valve, postinflammatory disease, infective endocarditis, and
other disorders. Recently, there has been an increased tendency to remove only
portions of the mitral valve, causing difficulty in the determination of
etiology. Our objective was to study the pathology and etiology of mitral
regurgitation from surgically removed specimens.
METHODS: Native mitral valve specimens surgically excised due to mitral
insufficiency were examined. Etiology was determined according to macroscopic,
microscopic, clinical, and operative findings.
RESULTS: Among 278 mitral valve specimens, 43% were classified as floppy valve,
31% as postinflammatory disease (presumably associated with rheumatic fever),
12% as infective endocarditis, and 14% as miscellaneous group. In floppy valves,
diffuse myxoid change and chordal rupture were the main findings. In
postinflammatory disease, moderate neovascularization and chronic inflammatory
cell infiltration were most commonly found. Aschoff bodies were found in two
cases. In infective endocarditis, gram-positive cocci were found in 70% of
cases. In the miscellaneous group, three cases were related to Marfan syndrome
and one case was related to papillary muscle necrosis. In comparison with
postinflammatory disease, the posterior leaflet in the floppy valve had a
significantly longer basal free-edge length, a more frequent chordal rupture,
and an higher mean age of patients. Among completely and partially excised
specimens with postinflammatory disease, there were no significant differences
in microscopic findings.
CONCLUSION: The three most common etiologies in mitral regurgitation were floppy
valve, postinflammatory disease, and infective endocarditis. Macroscopic,
microscopic, clinical, and operative findings are important in the evaluation of
etiology, especially in partially excised specimens. Mitral valve repair has become an established treatment in adults, but there is
limited experience with the procedure in children, in whom the avoidance of a
valve prosthesis is particularly advantageous. Repair of the mitral valve in
children who have Marfan syndrome is especially difficult due to the presence of
generalized connective tissue disorder, which may lead to future elongation and
rupture of chordae tendineae that were unaffected at the time of mitral valve
repair. We performed a total augmentation of all segments of the mitral valve,
using artificial chordae tendineae. Herein, we describe the procedure and the
positive outcome in a 10-year-old girl. |
What is the mechanism of action of Fremanezumab? | Fremanezumab is a monoclonal antibody directed against calcitonin-gene-related peptide (CGRP). It was shown to be effective for migraine preventive therapy. Other three monoclonal antibodies targeting the CGRP pathway are eptinezumab, erenumab and galcanezumab. | PURPOSE OF REVIEW: The results of phase 2 randomized controlled trials for the
prevention of episodic and chronic migraine demonstrating the efficacy and
safety of four mAbs targeting the calcitonin gene-related peptide (CGRP) pathway
[ALD403 (eptinezumab), AMG334 (erenumab), LY2951742 (galcanezumab) and TEV48125
(fremanezumab)] have been published recently, and phase 3 trials are in process.
This development will change headache management fundamentally. We aim to
summarize and compare the phase 2 data.
RECENT FINDINGS: The change from baseline in the number of migraine days at the
end of treatment in high-frequency episodic migraine was -1 (at weeks 5-8), -1.1
(at weeks 9-12), -1.2 (at weeks 9-12) and -2.6 (at weeks 9-12) days for ALD403,
AMG344, LY2951742 and TEV48125 (225 mg), respectively. Number needed to treats
for responders and odds ratio for any adverse event were 4.7, 6.2, 4.0 and 4.0
and 1.09, 0.96, 1.07 and 1.05, respectively.
SUMMARY: All four CGRP antibodies display comparable efficacy that does not
differ significantly from that of the currently available oral antimigraine
drugs. However, their safety and tolerability profiles as well as low frequency
of administration looks promising but remains to be verified in long-term and
large-scale trials. Considerations related to pregcy, risk for cardiovascular
effects and cost are subject for further evaluation. A large body of evidence supports an important role for calcitonin gene-related
peptide (CGRP) in migraine pathophysiology. This evidence gave rise to a global
effort to develop a new generation of therapeutics that inhibit the interaction
of CGRP with its receptor in migraineurs. Recently, a new class of such drugs,
humanized anti-CGRP monoclonal antibodies (CGRP-mAbs), were found to be
effective in reducing the frequency of migraine. The purpose of this study was
to better understand how the CGRP-mAb fremanezumab (TEV-48125) modulates
meningeal sensory pathways. To answer this question, we used single-unit
recording to determine the effects of fremanezumab (30 mg/kg, IV) and its
isotype control Ab on spontaneous and evoked activity in naive and cortical
spreading depression (CSD)-sensitized trigeminovascular neurons in the spinal
trigeminal nucleus of anesthetized male and female rats. The study demonstrates
that, in both sexes, fremanezumab inhibited naive high-threshold (HT) neurons,
but not wide-dynamic range trigeminovascular neurons, and that the inhibitory
effects on the neurons were limited to their activation from the intracranial
dura but not facial skin or cornea. In addition, when given sufficient time,
fremanezumab prevents the activation and sensitization of HT neurons by CSD.
Mechanistically, these findings suggest that HT neurons play a critical role in
the initiation of the perception of headache and the development of cutaneous
allodynia and central sensitization. Clinically, the findings may help to
explain the therapeutic benefit of CGRP-mAb in reducing headaches of
intracranial origin such as migraine with aura and why this therapeutic approach
may not be effective for every migraine patient.SIGNIFICANCE STATEMENT
Calcitonin gene-related peptide (CGRP) monoclonal antibodies (CGRP-mAbs) are
capable of preventing migraine. However, their mechanism of action is unknown.
In the current study, we show that, if given enough time, a CGRP-mAb can prevent
the activation and sensitization of high-threshold (central) trigeminovascular
neurons by cortical spreading depression, but not their activation from the skin
or cornea, suggesting a potential explanation for selectivity to migraine
headache, but not other pains, and a predomitly peripheral site of action. BACKGROUND: Fremanezumab (formerly TEV-48125) is a monoclonal antibody directed
against calcitonin-gene-related peptide (CGRP), a validated target for migraine
preventive therapy. In two previous phase 2 studies, fremanezumab administered
once every 28 days for 12 weeks was found to be effective and safe as a
preventive treatment for patients suffering from episodic migraine (EM) and
chronic migraine (CM).
OBJECTIVE: To evaluate the efficacy and safety of fremanezumab as an add-on
preventive therapy in individuals with EM and CM who are on stable doses of
preventive migraine medications.
METHODS: Two randomized placebo-controlled studies tested once-monthly
subcutaneous injections of various dosing regimens of fremanezumab versus
placebo in EM and CM. Headache information was captured daily using an
electronic headache diary. For these post hoc analyses, data were pooled from
patients who were on stable preventive medications and taking fremanezumab doses
of 225 mg or 675/225 mg, or placebo.
RESULTS: The sample consisted of 133 patients, (67 fremanezumab and 66 placebo).
Total reduction in migraine days for the duration of the study was 12.4 for
fremanezumab and 7.4 for placebo (P = .0321). There were also decreases in
moderate/severe headache days (12.5 vs 7.1, P = .0058), and days using acute
medication for headaches relative to placebo (11.6 vs 7.5, P = .0414). Treatment
emergent adverse events were generally mild and transient, and no serious
adverse events were considered to be treatment-related by the site
investigators.
CONCLUSIONS: The findings from these post hoc analyses suggest that fremanezumab
is a safe and effective add-on treatment for migraine patients being
concomitantly treated with other migraine preventive medications. Trials are
registered at Clinicaltrials.gov NCT02025556 and NCT02021773. Calcitonin gene-related peptide (CGRP), the most abundant neuropeptide in
primary afferent sensory neurons, is strongly implicated in the pathophysiology
of migraine headache, but its role in migraine is still equivocal. As a new
approach to migraine treatment, humanized anti-CGRP monoclonal antibodies
(CGRP-mAbs) were developed to reduce the availability of CGRP, and were found
effective in reducing the frequency of chronic and episodic migraine. We
recently tested the effect of fremanezumab (TEV-48125), a CGRP-mAb, on the
activity of second-order trigeminovascular dorsal horn neurons that receive
peripheral input from the cranial dura, and found a selective inhibition of
high-threshold but not wide-dynamic range class of neurons. To investigate the
basis for this selective inhibitory effect, and further explore the mechanism of
action of CGRP-mAbs, we tested the effect of fremanezumab on the cortical
spreading depression-evoked activation of mechanosensitive primary afferent
meningeal nociceptors that innervate the cranial dura, using single-unit
recording in the trigeminal ganglion of anesthetized male rats. Fremanezumab
pretreatment selectively inhibited the responsiveness of Aδ neurons, but not
C-fiber neurons, as reflected in a decrease in the percentage of neurons that
showed activation by cortical spreading depression. These findings identify Aδ
meningeal nociceptors as a likely site of action of fremanezumab in the
prevention of headache. The selectivity in its peripheral inhibitory action may
partly account for fremanezumab's selective inhibition of high-threshold, as a
result of a predomit A-δ input to high-threshold neurons, but not wide
dynamic-range dorsal horn neurons, and why it may not be effective in all
migraine patients.SIGNIFICANCE STATEMENT Recently, we reported that humanized
CGRP monoclonal antibodies (CGRP-mAbs) prevent activation and sensitization of
high-threshold (HT) but not wide-dynamic range trigeminovascular neurons by
cortical spreading depression (CSD). In the current paper, we report that
CGRP-mAbs prevent the activation of Aδ but not C-type meningeal nociceptors by
CSD. This is the first identification of an anti-migraine drug that appears to
be selective for Aδ-fibers (peripherally) and HT neurons (centrally). As the
main CGRP-mAb site of action appears to be situated outside the brain, we
conclude that the initiation of the headache phase of migraine depends on
activation of meningeal nociceptors, and that for selected patients, activation
of the Aδ-HT pain pathway may be sufficient for the generation of headache
perception. INTRODUCTION: Migraine and cluster headache are challenging to manage, with no
tailored preventive medications available. Targeting the calcitonin gene-related
peptide (CGRP) pathway to treat these headaches may be the first focused
therapeutic option to date, with the potential for promising efficacy.
METHODS: We systematically searched PubMed and clinicaltrials.gov for randomized
controlled trials investigating the preventive potential of monoclonal
antibodies against the CGRP pathway in the treatment of migraine and cluster
headache.
RESULTS: The literature search returned a total of 136 records, of which 32 were
eligible for review.
DISCUSSION: Clinical data from phase II and III trials of the four monoclonal
antibodies targeting the CGRP pathway: Eptinezumab, erenumab, fremanezumab, and
galcanezumab, collectively show a positive effect in the preventive treatment of
episodic and chronic migraine. Multiple phase II and III trials are under way to
further determine the efficacy and safety of this new drug class. It may be
particularly important to assess the cardiovascular effects of long-term CGRP
blockade. Phase III trials are also currently in progress for the preventive
treatment of cluster headache.
CONCLUSION: Efficacy of anti-CGRP monoclonal antibodies spells a promising
future for the many patients suffering from migraine, and possibly also for the
smaller but severely-affected population with cluster headache. BACKGROUND: Fremanezumab, a humanized monoclonal antibody targeting calcitonin
gene-related peptide (CGRP), is being investigated as a preventive treatment for
migraine. We compared two fremanezumab dose regimens with placebo for the
prevention of chronic migraine.
METHODS: In this phase 3 trial, we randomly assigned patients with chronic
migraine (defined as headache of any duration or severity on ≥15 days per month
and migraine on ≥8 days per month) in a 1:1:1 ratio to receive fremanezumab
quarterly (a single dose of 675 mg at baseline and placebo at weeks 4 and 8),
fremanezumab monthly (675 mg at baseline and 225 mg at weeks 4 and 8), or
matching placebo. Both fremanezumab and placebo were administered by means of
subcutaneous injection. The primary end point was the mean change from baseline
in the average number of headache days (defined as days in which headache pain
lasted ≥4 consecutive hours and had a peak severity of at least a moderate level
or days in which acute migraine-specific medication [triptans or ergots] was
used to treat a headache of any severity or duration) per month during the 12
weeks after the first dose.
RESULTS: Of 1130 patients enrolled, 376 were randomly assigned to fremanezumab
quarterly, 379 to fremanezumab monthly, and 375 to placebo. The mean number of
baseline headache days (as defined above) per month was 13.2, 12.8, and 13.3,
respectively. The least-squares mean (±SE) reduction in the average number of
headache days per month was 4.3±0.3 with fremanezumab quarterly, 4.6±0.3 with
fremanezumab monthly, and 2.5±0.3 with placebo (P<0.001 for both comparisons
with placebo). The percentage of patients with a reduction of at least 50% in
the average number of headache days per month was 38% in the
fremanezumab-quarterly group, 41% in the fremanezumab-monthly group, and 18% in
the placebo group (P<0.001 for both comparisons with placebo). Abnormalities of
hepatic function occurred in 5 patients in each fremanezumab group (1%) and 3
patients in the placebo group (<1%).
CONCLUSIONS: Fremanezumab as a preventive treatment for chronic migraine
resulted in a lower frequency of headache than placebo in this 12-week trial.
Injection-site reactions to the drug were common. The long-term durability and
safety of fremanezumab require further study. (Funded by Teva Pharmaceuticals;
ClinicalTrials.gov number, NCT02621931 .). |
Is trastuzumab associated cardiotoxicity reversible? | Cardiotoxicity is a potential adverse effect of trastuzumab, manifesting as either an asymptomatic decline in left-ventricular ejection fraction or infrequently as largely reversible symptomatic heart failure (HF). Reduction of cardiac function by trastuzumab is mostly reversible, however, some patients, especially those with cardiac risk factors, may rarely experience chronic heart failure or prolonged left ventricular ejection fraction reduction. | PURPOSE: Trastuzumab is an important biologic agent with significant activity in
breast cancers that overexpress the HER2/neu marker. However, trastuzumab is
associated with cardiotoxicity that has not yet been fully explored. We present
our experience with patients who developed trastuzumab-related cardiotoxicity.
PATIENTS AND METHODS: Over a 4-year period, 38 patients with HER2/neu-positive
breast cancer were referred for suspected trastuzumab-related cardiotoxicity.
All patients had previously received anthracycline-based chemotherapy. Results
After doxorubicin but before trastuzumab, the mean (+/- standard deviation) left
ventricular ejection fraction (LVEF) was 0.61 +/- 0.13, and the LVEF decreased
to 0.43 +/- 0.16 after trastuzumab (P < .0001). After withdrawal of trastuzumab,
the LVEF increased to 0.56 +/- 0.11. Mean time to recovery of LVEF was 1.5
months and was temporally associated with medical treatment in 32 (84%) of the
38 patients but occurred without treatment in six patients (16%). Increases in
LVEF were noted in 37 of the 38 patients. Twenty-five of these patients were
re-treated with trastuzumab; three patients had recurrent left ventricular
dysfunction, but 22 patients (88%) did not. All re-treatment patients continued
on their therapeutic regimen for heart failure when rechallenged with
trastuzumab. Nine patients underwent endomyocardial biopsy. Ultrastructural
changes were not seen.
CONCLUSION: Patients who develop cardiotoxicity while receiving trastuzumab
therapy generally improve on removal of the agent. The mechanism of
trastuzumab-related cardiac dysfunction is different from that of anthracycline
cardiotoxicity, in part, demonstrated by the absence of anthracycline-like
ultrastructural changes. Reintroducing trastuzumab may be appropriate for some
individuals who previously have experienced trastuzumab-related cardiac
dysfunction. Trastuzumab is a monoclonal antibody that targets the human epidermal growth
factor receptor tyrosine kinase HER2/ErbB2. This agent has shown a highly
significant antitumour effect for patients with HER2-positive breast cancer, and
is now considered part of the standard regimens for the treatment of this
disease in both the metastatic and adjuvant setting. Cardiotoxicity has been
associated with trastuzumab, and this issue has now been studied and documented
in a number of adjuvant trials for which data have now been released.
Cardiotoxicity has been shown to be potentiated when the agent is used
concurrently or sequentially with an anthracycline, and this has limited the use
of trastuzumab in some patients. Determining the overall impact of trastuzumab
is further complicated by the administration of other cardiotoxic agents such as
the taxanes and cyclophosphamide as well as by pre-existing cardiac disease. The
incidence of severe congestive heart failure (New York Heart Association class
III or IV) was 0-3.9% in the trastuzumab arms versus 0-1.3% in the control arms
in the five major randomized adjuvant trials. Only one cardiac death was related
to trastuzumab whereas two cardiac deaths occurred in the control arms. Ejection
fraction decline of >or=10% or 15% was reported in 3-34% of trastuzumab
recipients in these trials. Patients affected by trastuzumab-related
cardiotoxicity do not exhibit the cellular death and distinctive ultrastructural
myocardial changes seen on electron microscopy with anthracycline-induced
cardiotoxicity. The cardiotoxicity of trastuzumab also differs from traditional
chemotherapy-induced cardiotoxicity in that it appears to be at least partially
reversible, not related to the cumulative dose, and re-challenge is generally
tolerated. There remain a number of uncertainties regarding the diagnosis and
management of trastuzumab-related cardiotoxicity. While no formal guidelines or
consensus statements exist at present regarding cardiac monitoring during use of
trastuzumab, proposed recommendations include a careful assessment of ejection
fraction prior to initiating trastuzumab, avoidance of concurrent administration
of trastuzumab with anthracyclines, and regular monitoring of symptoms and
cardiac function during and for several years after therapy. Increased vigilance
is appropriate for higher risk patients. Trastuzumab is a recombit humanized monoclonal antibody used for the
treatment of advanced breast cancer. It improves survival and increases response
to chemotherapy. The major side effect of trastuzumab is cardiotoxicity
manifesting as a reduction in left ventricular systolic function, either
asymptomatic or with signs and symptoms of heart failure. Although reversible in
most cases, cardiotoxicity frequently results in the discontinuation of
trastuzumab. The objective of this review is to summarize facts about
trastuzumab-induced cardiotoxicity and to highlight the areas of future
investigations. We searched PubMed for trials involving trastuzumab used as an
adjuvant therapy for breast cancer, including the metastatic breast cancer
setting, and focused on cardiotoxicity. Numerous clinical studies have demonstrated the therapeutic benefit of
trastuzumab in women with breast cancer. However, a small but not insignificant
proportion of patients have experienced trastuzumab-associated cardiotoxicity
during these trials. This phenomenon is generally characterized by an
asymptomatic reduction in left ventricular ejection fraction (LVEF) or, less
often, congestive heart failure (CHF). Concomitant anthracycline therapy
significantly increases the risk for cardiotoxicity during trastuzumab
treatment, and such regimens are therefore not recommended. The cardiac
dysfunction associated with trastuzumab is most often reversible upon
discontinuation of treatment and initiation of standard medical therapy for CHF.
Prior to treatment initiation, a risk-benefit analysis should be performed for
each individual patient, including a thorough assessment of potential risk
factors and cardiac function. Cardiac monitoring should be continued throughout
trastuzumab therapy and the follow-up period, because early recognition of
trastuzumab-associated cardiac dysfunction can allow effective medical
intervention. Following the occurrence of asymptomatic LVEF reduction or CHF and
appropriate medical intervention, reintroduction of trastuzumab may be
considered in patients following resolution of normal cardiac function, or in
those for whom the benefit of antitumor therapy outweighs the risk for CHF. INTRODUCTION: Although having high clinical efficacy in the treatment of human
epidermal growth factor receptor-2 (HER2+) metastatic breast cancer, trastuzumab
has been associated with cardiotoxicity, and the etiology and pathogenesis of
this condition is currently under investigation.
METHODS: This paper reviews the cardiotoxicity, associated with trastuzumab use
and discusses the risk assessment and management of cardiac dysfunction.
RESULTS: The increased risk of cardiotoxicity is lower when trastuzumab is given
as monotherapy (3%-7%) compared with anthracyclines + trastuzumab therapy (27%).
Type II cardiac changes occur in trastuzumab-treated patients, which do not
appear to be dose-related, are not associated with histological changes, and are
generally reversible. Several risk factors for cardiac events have been
identified and assessing levels of troponin I and N-terminal pro-brain B-type
natriuretic peptide before and after treatment with trastuzumab may allow early
detection of cardiotoxicity. A symptomatic and functional evaluation scheme for
patients indicated for treatment with trastuzumab has also been proposed to work
alongside therapeutic options for the treatment of heart failure.
CONCLUSION: The risk of cardiac dysfunction associated with trastuzumab can be
justified given the increase in overall survival. This risk is lower when
trastuzumab is given as monotherapy. The paradigm for cardiologists remains the
same: treat the cancer effectively whilst preventing cardiotoxicity. The use of trastuzumab in the adjuvant and metastatic treatment of breast cancer
is associated with both symptomatic and asymptomatic cardiotoxicity. The
long-term significance of these events, isolating known cardiotoxic effects of
anthracyclines from those of trastuzumab, and the appropriateness of referring
to trastuzumab-related cardiotoxicity as reversible rather than responsive to
trastuzumab withdrawal and heart failure medical therapy, are issues that
continue to be debated. This article provides an overview of the available
cardiac safety data from the major trastuzumab clinical trials in breast cancer,
highlighting areas of ongoing controversy. Important recent data documenting the
occurrence and prognostic use of cardiac troponin I elevations among patients
treated with trastuzumab are placed into context with the mechanistic insight
these data provide and the implications for clinical practice today. We report a 54-year-old woman with an stage IIA (T2N0M0) RE and RP negative and
HER2-positive ductal invasive breast cancer who developed a reversible
cardiotoxicity associated with chemotherapy. After surgery, she received four
cycles of doxorubicin and cyclophosfamide. Later, she used paclitaxel and
trastuzumab. At the 7th cycle of trastuzumab, she had symptoms of heart failure
with left ventricle ejection fraction = 59%. Trastuzumab dosage was reduced in
25%, and heart function progressively improved. Two years after her discharge,
the patient remains asymptomatic. Systolic function of the left ventricle was
normal before the initial dosis of trastuzumab, but significantly worsened
following the beginning of drug administration. Moreover, a clear improvement of
heart function was observed soon after the daily dose of trastuzumab was
reduced. Better knowledge of risk factors for cardiotoxicity related to
chemotherapy, and longstanding surveillance with serial echocardiograms can
avoid more severe cardiotoxicity by chemotherapy. Trastuzumab-induced cardiotoxicity may induce reversible damage that is usually
transitory and improves with trastuzumab withdrawal. In clinical trials with
trastuzumab in the adjuvant setting patients with cardiac risks were not
included. Subgroup analysis identified subpopulations that were most likely to
experience cardiac damage upon trastuzumab exposure. Although there is a risk of
cardiac toxicity with adjuvant trastuzumab, the improvement of outcome in
patients treated with this drug outweighs this. It is essential, therefore, to
properly assess cardiac function prior to, during and after trastuzumab therapy
in all patients. The incidence of congestive heart failure in older patients
treated with trastuzumab is expected to be higher than in the overall population
evaluated in large clinical trials. Therefore, cardiac risk assessment, breast
cancer recurrence risk, and discussion between cardiologists and oncologists
should take place prior to deciding which adjuvant treatment is appropriate for
a woman with early breast cancer. A longer follow-up period is recommended in
order to verify whether cardiac reversibility remains and, accordingly, whether
the short-term risk is exaggerated or understated. With the NSABP-B31 trial
regimen, the benefit of trastuzumab definitely outweighs the risk; indeed, the
occurrence of late congestive heart failure after adding trastuzumab to
chemotherapy is fairly unusual. In the era of personalized medicine, efforts are
needed to promote strategies for risk detection and management to avoid
dangerous toxicities that may impede the development of and patient access to
new agents. Several breast cancer therapies can lead to cardiovascular toxicity: drugs such
anthracyclines can cause permanent damage, anti-HER2 agents may cause transitory
and reversible cardiac dysfunction and others, such as those used in endocrine
therapy, primarily disturb lipid metabolism. Considering the seriousness of
these complications, trials are now being conducted to address cardiotoxicity
associated with new drugs; however, to fully understand their toxicity profiles,
longer follow-up is needed. In this review, we compile the information available
about cardiac toxicity related to well-established systemic breast cancer
treatments, as well as newer drugs, including antiangiogenics, mTOR inhibitors
and novel anti-HER2 agents. We also describe current and next generation cardiac
biomarkers and functional tests that can optimize treatment and reduce and
prevent the incidence of treatment-related cardiotoxicity. BACKGROUND: Although it is known that trastuzumab causes cardiotoxicity, its
extent and reversibility are still in question. Earlier studies have not
evaluated consecutive patients with reproducible nuclear ventriculography.
OBJECTIVE: We sought to evaluate the baseline characteristics which predispose
patients to increased risk of trastuzumab cardiotoxicity and to determine the
natural history of the cardiotoxicity.
METHODS AND RESULTS: Left ventricular ejection fraction (LVEF) was measured in
76 women aged 36-73 years who had been treated with trastuzumab at the
University of Maryland Greenebaum Cancer Center. LVEF was determined at baseline
and then 3, 6, 9, and 12 months after treatment initiation. Cardiotoxicity was
defined as ≥ 16% decrease in LVEF or ≥ 10% decrease in LVEF to <50%. There were
no differences in comorbidities, earlier treatment, or demographics between
patients with and without trastuzumab-induced cardiomyopathy except that African
Americans were more likely to develop decreased LVEF (P < .05). Twenty-one
patients (28%) met criteria for cardiotoxicity. Four of those patients were
continued on trastuzumab and 17 patients had therapy withheld at some point.
Only 1 patient developed symptomatic heart failure requiring inpatient
hospitalization. LVEF improved in most patients regardless of whether or not
trastuzumab was continued.
CONCLUSIONS: Decreased LVEF while undergoing trastuzumab therapy occurs
frequently and is usually reversible. African Americans had a higher risk of
developing decreased LVEF. These findings raise clinically important questions
as to whether it is necessary to discontinue trastuzumab for asymptomatic
decrease in LVEF and whether African Americans are more predisposed to a
decrease in LVEF while receiving trastuzumab. Further studies carefully
assessing LVEF should address these hypotheses. BACKGROUND: Trastuzumab, a HER2 monoclonal antibody, has transformed the
prognosis of patients with the aggressive HER2-positive breast cancer type.
Trastuzumab augments the cardiotoxic effects of anthracyclines, but its effect
is thought to be at least partially reversible. The objective of this study was
to examine the time trends of left ventricular (LV) size and function in a
cohort of women treated with anthracyclines and trastuzumab.
METHODS: Twenty-nine patients >18 years of age with first-time breast cancer
treated with anthracyclines and trastuzumab were monitored using
echocardiography before, at the completion of, and at a median follow-up of 24.7
months (interquartile range, 15.9-34 months) after the end of their cancer
treatment. LV volume, LV ejection fraction, and global peak systolic
longitudinal strain and strain rate were measured in the apical four- and
two-chamber views. Left ventricular ejection fraction was measured using a
modified Simpson's biplane method.
RESULTS: LV end-diastolic and end-systolic volumes increased at the end of
treatment compared with baseline and did not recover during follow-up. Left
ventricular ejection fraction, strain, and strain rate decreased at the end of
treatment compared with baseline (from 64 ± 6% to 59 ± 8%, from -20.0 ± 2.5% to
-17.6 ± 2.6%, and from -1.26 ± 0.23 to -1.13 ± 0.16 sec(-1), respectively;
P < .05 for all parameters) and remained decreased at follow-up.
CONCLUSIONS: LV dilation and subclinical impairment in cardiac function persists
>2 years after the end of anthracycline and trastuzumab treatment, without
significant recovery after trastuzumab cessation, suggestive of long-term
underlying cardiac damage and remodeling. PURPOSE: Patients treated with adjuvant trastuzumab require adequate cardiac
monitoring. We describe the patterns of cardiac monitoring and evaluate factors
associated with adequate monitoring in a large population-based study of older
patients with breast cancer.
PATIENTS AND METHODS: Patients age 66 years or older with full Medicare
coverage, diagnosed with stage I to III breast cancer between 2005 and 2009, and
treated with adjuvant trastuzumab-based chemotherapy were identified in the
SEER-Medicare and the Texas Cancer Registry-Medicare databases. The adequacy of
cardiac monitoring was determined. Chemotherapy, trastuzumab use, cardiac
monitoring, and comorbidities were identified by using International
Classification of Diseases, 9th revision and Healthcare Common Procedure Coding
System codes. Prescribing physician characteristics were also evaluated.
Analyses included descriptive statistics and multilevel logistic regression
models.
RESULTS: In all, 2,203 patients were identified; median age was 72 years.
Adequate monitoring was identified in only 36.0% of the patients (n = 793). In
the multivariable model, factors associated with optimal cardiac monitoring
included a more recent year of diagnosis (hazard ratio [HR], 1.83; 95% CI, 1.32
to 2.54), anthracycline use (HR, 1.39; 95% CI, 1.14 to 1.71), female prescribing
physician (HR, 1.37; 95% CI, 1.10 to 1.70), and physician graduating after 1990
(HR, 1.66; 95% CI, 1.29 to 2.12). The presence of cardiac comorbidities was not
a determit for cardiac monitoring. Of the variance in the adequacy of cardiac
monitoring, 15.3% was attributable to physician factors and 5.2% to measured
patient factors.
CONCLUSION: A large proportion of patients had suboptimal cardiac monitoring.
Physician characteristics had more influence than measured patient-level factors
in the adequacy of cardiac monitoring. Because trastuzumab-related
cardiotoxicity is reversible, efforts to improve the adequacy of cardiac
monitoring are needed, particularly in vulnerable populations. BACKGROUND: This article reports, the cardiac toxicity according to 6- versus
12-month durations of adjuvant trastuzumab in PHARE randomised trial
(NCT00381901).
PATIENTS AND METHODS: Cardiac follow-up and Left Ventricular Ejection Fraction
(LVEF) assessment by echocardiography or multigated acquisition scan were
performed every 3 months while patients received trastuzumab and after
completion of treatment over the first 2 years and every 6 months afterwards.
The primary cardiac end-point was Cardiac Heart Failure (CHF) defined as New
York Heart Association (NYHA) class III or IV. The secondary cardiac end-points
were: cardiac events, cardiac dysfunctions defined by NYHA class I and II; LVEF
decreases, cardiac recoveries. The cardiac subcommittee reviewed cardiac events
and assessed if patients had favourable outcomes or not on the basis of trends
from LVEF measurements.
RESULTS: Among 3380 patients the cardiac dysfunction assessment included 14,055
and 13,218 LVEF measurements in the 12- and 6-month arms. The overall incidences
of CHF were 0.65% (11/1690) and 0.53% (9/1690) in the 12 and 6 month arms,
respectively (p>0.05). Cardiac dysfunction occurred in 5.9% (100/1690) and 3.4%
(58/1690) of patients in the 12 and 6 month arms, respectively (p=0.001).
Recoveries were observed for the majority patients and 0.79% (27/3380) of
patients experienced an unfavourable cardiac outcome.
CONCLUSION: PHARE confirm that the incidence of cardiac end-points remains low
and mostly reversible after trastuzumab. Identification at baseline of cardiac
risk categories of patients should be of interest to provide an optimal
adaptation of adjuvant modalities and a shorter duration might be an option. BACKGROUND: Trastuzumab targets the human epidermal growth factor receptor-2
(HER2). Cardiotoxicity is a potential adverse effect, manifesting as either an
asymptomatic decline in left-ventricular ejection fraction or infrequently as
largely reversible symptomatic heart failure (HF). Monitoring recommendations
differ between product labeling and 2012 guidelines, and the clinical utility of
serial cardiac monitoring in patients with metastatic breast cancer remains
controversial.
OBJECTIVE: The objectives of this study were to describe the frequency of
monitoring, incidence of symptomatic or asymptomatic HF, overall effect on
treatment, and cost of monitoring for cardiotoxicity.
METHODS: We preformed an institutional review board-approved retrospective chart
review of breast cancer patients receiving trastuzumab from January 1, 2009,
through January 1, 2014, at an academic medical center.
RESULTS: Out of 154 treatments, 72% were adjuvant, and 28% were metastatic. In
the adjuvant setting, a mean of 4.5 (interquartile range [IQR] = 4-5)
echocardiograms (echos) over a mean of 11.5 (IQR = 11-12) months were performed.
In the metastatic setting, a mean of 3.1 (IQR = 1-5) echos over a mean of 20.2
(IQR = 9-31) months were performed. Symptomatic HF events occurred in 4 adjuvant
(3.6%) and 2 metastatic patients (6.5%); 10 patients (6.5%) had a treatment
interruption, with 9 (90%) tolerating restart of trastuzumab. Two patients
(1.3%) changed treatment as a result of cardiotoxicity. Using population
incidence of HER2-positive breast cancer, $13 million could be saved if
monitoring were reduced by 1 echo per patient.
CONCLUSIONS: Given the low incidence of clinically significant HF and cost of
monitoring, less frequent monitoring may be justified. Trastuzumab-induced cardiotoxicity (TIC) is the primary adverse event that
limits the use of trastuzumab in HER2-positive breast cancer patients. However,
the incidence and risk factors of TIC in HER2-positive gastric cancer are not
known. Therefore, we evaluated the incidence and predictive factors of TIC in
gastric cancer patients treated with trastuzumab in clinical practice. We
reviewed cardiac dysfunction in HER2-positive gastric cancer patients between
December 2005 and April 2015 in a prospectively-collected database that included
prospective clinical trials at Yonsei Cancer Center, Republic of Korea. TIC was
defined as an absolute decline in left ventricular ejection fraction (LVEF) of
at least 10 percentage points from the baseline to a value less than 55%, as
identified by a multiple-gated acquisition scan or an echocardiogram. Among the
115 patients, 70 patients (60.9%) received trastuzumab combined with
chemotherapy, and 45 patients (39.1%) received chemotherapy alone as a
first-line therapy. Symptomatic heart failure was not observed in either group,
but a significant asymptomatic drop in LVEF was noted in five (7.1%) of the
trastuzumab combined-group patients and in one (2.2%) chemotherapy-only group
patient [hazard ratio (HR), 3.47; 95% confidence interval (CI), 0.40-29.8;
P=0.257]. TIC was observed more frequently in elderly patients than in younger
patients (HR, per age in year, 1.16; 95% CI, 1.02-1.31; P=0.019). Similar to
prior observations in breast cancer, TIC in gastric cancer patients is not
frequent or reversible. However, the asymptomatic drop in LVEF should be
monitored continually in HER2-positive gastric cancer patients treated with
trastuzumab, especially in elderly patients. |
What is the role of nimotuzumab in treatment of pontine glioma? | Nimotuzumab (an anti-EGFR monoclonal antibody) is being used for treatment of pontine gliomas. Nimotuzumab is a very well-tolerated drug with acceptable toxicity, and it may have promising value in the combination treatment. Clinical trials evaluating efficacy of nimotuzumab are ongoing. | Pediatric high-grade gliomas (HGGs)--including glioblastoma multiforme,
anaplastic astrocytoma, and diffuse intrinsic pontine glioma--are difficult to
treat and are associated with an extremely poor prognosis. There are no
effective chemotherapeutic regimens for the treatment of pediatric HGG, but many
new treatment options are in active investigation. There are crucial molecular
differences between adult and pediatric HGG such that results from adult
clinical trials cannot simply be extrapolated to children. Molecular markers
overexpressed in pediatric HGG include PDGFRα and P53. Amplification of EGFR is
observed, but to a lesser degree than in adult HGG. Potential molecular targets
and new therapies in development for pediatric HGG are described in this review.
Research into bevacizumab in pediatric HGG indicates that its activity is less
than that observed in adult HGG. Similarly, tipifarnib was found to have minimal
activity in pediatric HGG, whereas gefitinib has shown greater effects. After
promising phase I findings in children with primary CNS tumors, the integrin
inhibitor cilengitide is being investigated in a phase II trial in pediatric
HGG. Studies are also ongoing in pediatric HGG with 2 EGFR inhibitors: cetuximab
and nimotuzumab. Other novel treatment modalities under investigation include
dendritic cell-based vaccinations, boron neutron capture therapy, and telomerase
inhibition. While the results of these trials are keenly awaited, the current
belief is that multimodal therapy holds the greatest promise. Research efforts
should be directed toward building multitherapeutic regimens that are well
tolerated and that offer the greatest antitumor activity in the setting of
pediatric HGG. Primary metastatic diffuse intrinsic pontine glioma (DIPG) is relatively rare
and associated with a dismal prognosis. Combining craniospinal irradiation (CSI)
with concurrent temozolomide and nimotuzumab therapy may slightly improve tumor
control and overall survival. However, little is known about the feasibility and
toxicity of this treatment approach. Here, we describe the case of an 8-year-old
girl with primary metastatic DIPG who received craniospinal radiotherapy, a
local boost, and concurrent temozolomide and nimotuzumab treatment based on an
individual therapy recommendation. Radiotherapy could be completed without any
interruption. However, concurrent temozolomide had to be disrupted several times
due to considerable acute myelotoxicity (grade III-IV).Maintece
immunochemotherapy could be started with a delay of 5 days and was performed
according to treatment schedule. The disease could be stabilized for a few
months. A routine MRI scan finally depicted disease progression 5.7 months after
the start of irradiation. The patient died 1.9 months later. Author information:
(1)Pediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Via
Venezian 1, 20133, Milano, Italy. [email protected].
(2)Pediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Via
Venezian 1, 20133, Milano, Italy.
(3)Medical Statistics, Biometry and Bioinformatics Unit, Fondazione IRCCS
Istituto Nazionale dei Tumori (INT), Via Venezian 1, 20133, Milano, Italy.
(4)Department of Neuroradiology, University of Würzburg, Josef-Schneider-Str.11,
97080, Wurzburg, Germany.
(5)Genetics Unit, Pathology Department, Ospedale S. Anna, San Fermo della
Battaglia, 22100, Como, Italy.
(6)Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Via
Venezian 1, 20133, Milano, Italy.
(7)Radiological and Oncological Sciences Department, Universita` Sapienza, Viale
del Policlinico, 00151, Roma, Italy.
(8)Pathology Department, Universita` Sapienza, Viale del Policlinico, 00151,
Roma, Italy.
(9)Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Via
Venezian 1, 20133, Milano, Italy.
(10)Neuropathology Unit, IRCCS Istituto Neurologico Carlo Besta, Via Celoria,
20133, Milano, Italy.
(11)Human Tumor Immunobiology Unit, Fondazione IRCCS Istituto Nazionale dei
Tumori (INT), Via Venezian 1, 20133, Milano, Italy.
(12)Physiopathology Department, State Medical School, Via Festa del Perdono,
20100, Milano, Italy.
(13)Neuro-Oncology Unit, Ospedale Meyer, Viale Pieraccini 24, 50139, Firenze,
Italy.
(14)Molecular Therapies Unit, Fondazione IRCCS Istituto Nazionale dei Tumori
(INT), Via Venezian 1, 20133, Milano, Italy.
(15)Department of Pediatric Hematology/Oncology, University of Bonn Medical
School, Bonn, Germany.
(16)Oncoscience AG, Hafenstraße 32, 22880, Wedel, Germany. BACKGROUND: The prognosis of diffuse intrinsic pontine glioma (DIPG) remains
poor, with no drug proven to be effective.
METHODS: Patients with clinically and radiologically confirmed, centrally
reviewed DIPG, who had failed standard first-line therapy were eligible for this
multicenter phase II trial. The anti-epidermal growth factor receptor (EGFR)
antibody, nimotuzumab (150 mg/m(2)), was administered intravenously once weekly
from weeks 1 to 7 and once every 2 weeks from weeks 8 to 18. Response evaluation
was based on clinical and MRI assessments. Patients with partial response (PR)
or stable disease (SD) were allowed to continue nimotuzumab.
RESULTS: Forty-four patients received at least one dose of nimotuzumab
(male/female, 20/24; median age, 6.0 years; range, 3.0-17.0 years). All had
received prior radiotherapy. Treatment was well tolerated. Eighteen children
experienced serious adverse events (SAEs). The majority of SAEs were associated
with disease progression. Nineteen patients completed 8 weeks (W8) of treatment:
There were 2 PRs, 6 SDs, and 11 progressions. Five patients completed 18 weeks
(W18) of treatment: 1 of 2 patients with PR at W8 remained in PR at W18, and 3
of 6 children with SD at W8 maintained SD at W18. Time to progression following
initiation of nimotuzumab for the 4 patients with SD or better at W18 was 119,
157, 182 and 335 days, respectively. Median survival time was 3.2 months. Two
patients lived 663 and 481 days from the start of nimotuzumab.
CONCLUSIONS: Modest activity of nimotuzumab in DIPG, which has been shown
previously, was confirmed: A small subset of DIPG patients appeared to benefit
from anti-EGFR antibody treatment. |
Describe annotatr | Analysis of next-generation sequencing data often results in a list of genomic regions. These may include differentially methylated CpGs/regions, transcription factor binding sites, interacting chromatin regions, or GWAS-associated SNPs, among others. A common analysis step is to annotate such genomic regions to genomic annotations (promoters, exons, enhancers, etc.). The annotatr Bioconductor package flexibly and quickly summarizes and plots annotations of genomic regions. The annotatr package reports all intersections of regions and annotations, giving a better understanding of the genomic context of the regions. | MOTIVATION: Analysis of next-generation sequencing data often results in a list
of genomic regions. These may include differentially methylated CpGs/regions,
transcription factor binding sites, interacting chromatin regions, or
GWAS-associated SNPs, among others. A common analysis step is to annotate such
genomic regions to genomic annotations (promoters, exons, enhancers, etc.).
Existing tools are limited by a lack of annotation sources and flexible options,
the time it takes to annotate regions, an artificial one-to-one
region-to-annotation mapping, a lack of visualization options to easily
summarize data, or some combination thereof.
RESULTS: We developed the annotatr Bioconductor package to flexibly and quickly
summarize and plot annotations of genomic regions. The annotatr package reports
all intersections of regions and annotations, giving a better understanding of
the genomic context of the regions. A variety of graphics functions are
implemented to easily plot numerical or categorical data associated with the
regions across the annotations, and across annotation intersections, providing
insight into how characteristics of the regions differ across the annotations.
We demonstrate that annotatr is up to 27× faster than comparable R packages.
Overall, annotatr enables a richer biological interpretation of experiments.
AVAILABILITY AND IMPLEMENTATION: http://bioconductor.org/packages/annotatr/ and
https://github.com/rcavalcante/annotatr.
CONTACT: [email protected].
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. |
What is Blount's disease? | Blount's disease (tibia vara) is a progressive form of genu varum due to asymmetrical inhibition of the postero medial portion of the proximal tibial epiphysis. It causes causes genu varum and internal tibial torsion. It is the most common cause of pathologic genu varum in children and adolescents | A review of the English literature on Blount disease (osteochondrosis deformans
tibiae; tibia vara) revealed that two forms of the disease, infantile and
adolescent, are recognized. The cause of Blount disease is probably
multifactorial. Most recent evidence on the pathogenesis implicates mechanical
factors. The diagnosis can be difficult in very young children and must be based
on history, physical examination, and radiographic findings. A proximal tibial
metaphyseal-diaphyseal angle of greater than 11 degrees should be observed
carefully for the development of Blount disease. Both nonoperative and operative
treatment has been used successfully. The differentiation between physiological bowlegs and infantile Blount's disease
in patients aged 11-30 months is very difficult. Nevertheless, diagnosis is
deemed important because treatment of infantile Blount's disease is recommended.
Fourteen patients with severe bowing of the legs seen in our outpatient clinic
were investigated retrospectively. We examined them and measured the
tibiofemoral and metaphyseal/diaphyseal angles in radiographs taken at their
first presentation. The finding that the tibiofemoral angle is not helpful in
differential diagnosis could be confirmed but, contrary to reports by other
authors, neither was the metaphyseal/diaphyseal angle. In view of the
spontaneous recovery of all investigated patients, it must be doubted whether a
diagnosis of infantile tibia vara can be made in early infancy, and whether
infantile Blount's disease is a diagnosis in its own right. Blount's disease or congenital tibia vara is a clinical entity characterized by
tibia bowing, tibia torsion, and beaking of the medial tibia metaphysis on plain
radiograph. In our environment, burnt-out rickets patients with biochemical and
radiological diagnosis of rickets who after treatment still have residual bone
changes despite normal bone biochemistry) can also present with similar clinical
and radiological features as Blount's disease. However, certain biochemical
variations, including antioxidants, may serve as a basis for differentiation
between these two disorders. The serum levels of calcium, inorganic phosphate,
zinc, copper, and alkaline phosphatase in 15 patients (10 females and five
males) aged between two- and five years (mean 3.8 +/- 1.1 (SD)) with clinical
and radiological features of Blount's disease were determined. The mean weight
of the patients with Blount's disease was 14.0 +/- 2.4 kg (range: 11.5-16.3 kg).
Fifteen subjects (nine females and six males) matched for age and sex without
clinical features of any metabolic bone and/or nutritional diseases who were
attending the surgical outpatient clinic served as control subjects. The serum
concentrations of inorganic phosphate and calcium, though lower in patients with
Blount's disease compared with controls, did not reach statistical significance.
Alkaline phosphatase activity was increased in the serum of all patients with
Blount's disease. In addition, there was an observed significant reduction in
serum concentration of zinc (P < 0.03) compared to the control subjects. As for
calcium level, the concentration of serum copper in Blount's patients was
reduced, but this was not statistically significant. These biochemical
observations, especially those of the antioxidant micronuent zinc, may serve as
a basis for the differentiaion of the sometimes clinically inseparable disorders
of Blount's and rckets and may aid in early differential diagnosis, appropriate
treatment as well as prevention of complications. Adolescents bariatric surgery (ABS) in morbid obesity (MO), with or without
comorbid conditions, is and will be more and more indicated. Restrictive
operations have the advantage of no influence on absorption. Laparoscopic sleeve
gastrectomy (LSG) can be an excellent alternative. A LSG was done in a
10-year-old boy, body mass index (BMI) 42, who has Blount's disease (tibia vara)
with severe pain at the knee joints that made him a wheelchair-bound person. He
had a LSG and gallbladder removal without incidents. Eight months later, he has
a BMI 28 and almost all his knees pain is gone. No side effects have been
detected. A LSG may be the ideal bariatric operation for ABS with MO. In 1937 Blount described a series of 28 patients with 'Tibia vara'. Since then,
a number of deformities in the tibia and the femur have been described in
association with this condition. We analysed 14 children with Blount's disease
who were entered into a cross-sectional study. Their mean age was 10 (2 to 18).
They underwent a clinical assessment of the rotational profile of their legs and
a CT assessment of the angle of anteversion of their hips (femoral version). We
compared our results to previously published controls. A statistically
significant increase in femoral anteversion was noted in the affected legs, with
on average the femurs in patients with Blount's disease being 26 degrees more
anteverted than those in previously published controls. We believe this to be a
previously unrecognised component of Blount's disease, and that the marked
intoeing seen in the disease may be partly caused by internal femoral version,
in addition to the well-recognised internal tibial version. PURPOSE: Oblique proximal tibial osteotomy is a useful option for correcting
deformity associated with Blount's disease (tibia vara). Safe, adequate
correction depends on technical issues that have evolved since the original
description of the procedure.
METHODS: Retrospective review of surgical experience.
RESULTS: The refinement of osteotomy plane orientation, based on the distal
rather than the proximal tibia, reduces the likelihood of procurvatum after
surgery. The stability of the osteotomy is enhanced by an improved screw
fixation technique. The risk of compartment syndrome is low if prophylactic
partial fasciotomy is performed concurrently. Avoidance of spinal or regional
block anesthesia minimizes the possibility of failure to detect post-operative
compartment syndrome.
CONCLUSIONS: Improvements in the technical execution of oblique proximal tibial
osteotomy enhances the correction and predictability of the procedure. INTRODUCTION: In stage 1 of all currently accepted classifications for infantile
tibia vara, the diagnosis is difficult between physiological bowing and true
Blount's disease. There is no evidence of prognosis criteria for surgical
treatment at this stage.
PATIENT AND METHODS: We retrospectively studied a series of 26 patients born in
the Indian Ocean area, presenting at stage 1 of the disease, in order to
determine whether any of them were likely to heal without treatment.
RESULTS: It was found that children seen at stage 1 of infantile tibia vara have
a one-in-three chance of healing spontaneously.
DISCUSSION: An alternative classification in three stages could then provide
more suitable therapeutic indications: stage 0: possible Blount's disease
(patient older than 2.5 years); stage 1: certain Blount's disease, active physis
(+) (progressive varus, age >3 years, typical image with no epiphysiodesis
bridging); stage 2: certain Blount's disease, inactive physis (-) (superomedial
tibial bony bridge).
LEVEL OF EVIDENCE: Level IV. Retrospective study. Infantile Blount's disease is a condition that causes genu varum and internal
tibial torsion. Treatment options include observation, orthotics, corrective
osteotomy, elevation of the medial tibial plateau, resection of a physeal bar,
lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis.
Each of these treatment options has its disadvantages. Treating the coronal
deformity alone (genu varum) will result in persistence of the internal tibial
torsion (the axial deformity). In this report, we describe the combination of
lateral growth modulation and distal tibial external rotation osteotomy to
correct all the elements of the disease. This has not been described before for
treatment of Blount's disease. Both coronal and axial deformities were corrected
in this patient. We propose this combination (rather than the lateral growth
modulation alone) as the method of treatment for early stages of Blount's
disease as it corrects both elements of the disease and in the same time avoids
the complications of proximal tibial osteotomy. INTRODUCTION: Blount disease can be defined as idiopathic proximal tibial vara.
Several etiologies including the mechanical theory have been described. Obesity
is the only causative factor proven to be associated with Blount disease. The
aim of this study is to assess if there is an association of vitamin D
deficiency and Blount disease.
METHODS: This a retrospective study of preoperative and postoperative patients
with Blount disease who were screened for vitamin D deficiency. Patients with
genu varum due to confirmed vitamin D deficiency and rickets were excluded. The
study patients had the following blood tests done: calcium, phosphate, alkaline
phosphatase, parathyroid, and 25-hydroxyvitamin D (25(OH)D) hormones.
RESULTS: We recruited 50 patients. The mean age of these patients was 10.4 years
(SD±3.88) with average body mass index of 28.7 kg/m (±10.2). Thirty (60%)
patients were diagnosed with infantile, 4 (8%) juvenile, and 16 (32%) adolescent
Blount disease. Eight (16%) patients were found to be vitamin D deplete (25(OH)D
levels <50 nmol/L). Of these, 8 patients, 6 were insufficient (25(OH)D levels
between 30 and 50 nmol/L) and the other 2 were deficient (25(OH)D levels <30
nmol/L).
CONCLUSIONS: This study showed that the prevalence of vitamin D deficiency in
children with Blount disease was similar to that of healthy children living in
Johannesburg. There is no evidence that vitamin D deficiency is a factor in
causing Blount disease.
LEVEL OF EVIDENCE: Level III-retrospective study. Blount's disease is a progressive form of genu varum due to asymmetrical
inhibition of the postero medial portion of the proximal tibial epiphysis. The
surgical treatments involved in correction of Blount's disease are often
technically demanding, complicated procedures. These procedures can lead to
prolonged recovery times and poor patient compliance. In such a context we are
suggesting "fibulectomy with Z osteotomy" of the proximal tibia, a relatively
simple and highly effective technique. This technique is based on correcting the
mechanical axis of the lower limb thereby restoring growth from the medial
physis of proximal tibia. We have used a new surgical technique, which includes
fibulectomy followed by a Z-shaped osteotomy. We have used this simple technique
in a 5 year-old boy with unilateral Blount's disease. The femoro-tibial angle
was corrected from 18.2° of varus to 4.2° of valgus. The angular correction
obtained after operation was 22°. There were no postoperative complications.
This technique has the advantages of correcting both angular and rotational
deformities simultaneously. The purpose of this case study is to introduce a
new surgical technique in the treatment of Blount's disease. Blount's disease is commonly attributed to an intrinsic, idiopathic defect in
the posteromedial proximal tibial physis resulting in progressive bowing of the
leg, intoeing, and lateral knee thrust. Treatment has historically included
bracing, physeal stapling, or corrective osteotomy, and was determined primarily
by age at presentation. As we feel the pathology is not necessarily age
dependent, we have elected to use the technique of guided growth using a lateral
tension band plate to correct limb alignment as a first-line treatment in all
patients presenting to our clinic as long as they had growth remaining and no
evidence of a physeal bar.We identified 17 patients with tibia vara (27 limbs)
who were managed by means of guided growth of the proximal tibia, from age 1.8
years to 15.1 years. Clinical and radiographic parameters were followed pre- and
postoperatively. The response to guided growth was documented as were any
related complications.Twenty-one (78%) limbs had complete normalization of their
mechanical axis (middle 50% of knee). Time to correction averaged 13.5 months
(8-19 months). There were no peri-operative complications. We observed hardware
failure in 3 patients; 2 with screw breakage and 1 patient with hardware
migration, none requiring subsequent osteotomy or further treatment. Two
patients had rebound varus: one is being observed and another has undergone a
repeat procedure.Patients with pathologic tibia vara present at various ages and
have historically undergone various treatments ranging from bracing to tibial
osteotomy based on age at presentation. We have found that guided growth
utilizing tethering plates can be used effectively as first-line treatment in
all patients with growth remaining. This minimally invasive method is
predictable and well tolerated. Recurrent deformity, though unlikely, is easily
remedied by repeating the process and does not preclude osteotomy if eventually
needed. Concomitant resolution of ligamentous laxity and inward torsion can be
anticipated as the mechanical axis is restored to neutral. The only
contraindications for guided growth include an unresectable physeal bar or
skeletal maturity. |
Describe mechanism of action of Nusinersen. | Nusinersen is a modified antisense oligonucleotide that binds to a specific sequence in the intron, downstream of exon 7 on the pre-messenger ribonucleic acid (pre-mRNA) of the SMN2 gene. This modulates the splicing of the SMN2 mRNA transcript to include exon 7, thereby increasing the production of full-length SMN protein. It is approved for treatment of spinal muscular atrophy. | BACKGROUND: Nusinersen is a 2'-O-methoxyethyl phosphorothioate-modified
antisense drug being developed to treat spinal muscular atrophy. Nusinersen is
specifically designed to alter splicing of SMN2 pre-mRNA and thus increase the
amount of functional survival motor neuron (SMN) protein that is deficient in
patients with spinal muscular atrophy.
METHODS: This open-label, phase 2, escalating dose clinical study assessed the
safety and tolerability, pharmacokinetics, and clinical efficacy of multiple
intrathecal doses of nusinersen (6 mg and 12 mg dose equivalents) in patients
with infantile-onset spinal muscular atrophy. Eligible participants were of
either gender aged between 3 weeks and 7 months old with onset of spinal
muscular atrophy symptoms between 3 weeks and 6 months, who had SMN1 homozygous
gene deletion or mutation. Safety assessments included adverse events, physical
and neurological examinations, vital signs, clinical laboratory tests,
cerebrospinal fluid laboratory tests, and electrocardiographs. Clinical efficacy
assessments included event free survival, and change from baseline of two
assessments of motor function: the motor milestones portion of the Hammersmith
Infant Neurological Exam-Part 2 (HINE-2) and the Children's Hospital of
Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) motor function
test, and compound motor action potentials. Autopsy tissue was analysed for
target engagement, drug concentrations, and pharmacological activity. HINE-2,
CHOP-INTEND, and compound motor action potential were compared between baseline
and last visit using the Wilcoxon signed-rank test. Age at death or permanent
ventilation was compared with natural history using the log-rank test. The study
is registered at ClinicalTrials.gov, number NCT01839656.
FINDINGS: 20 participants were enrolled between May 3, 2013, and July 9, 2014,
and assessed through to an interim analysis done on Jan 26, 2016. All
participants experienced adverse events, with 77 serious adverse events reported
in 16 participants, all considered by study investigators not related or
unlikely related to the study drug. In the 12 mg dose group, incremental
achievements of motor milestones (p<0·0001), improvements in CHOP-INTEND motor
function scores (p=0·0013), and increased compound muscle action potential
amplitude of the ulnar nerve (p=0·0103) and peroneal nerve (p<0·0001), compared
with baseline, were observed. Median age at death or permanent ventilation was
not reached and the Kaplan-Meier survival curve diverged from a published
natural history case series (p=0·0014). Analysis of autopsy tissue from patients
exposed to nusinersen showed drug uptake into motor neurons throughout the
spinal cord and neurons and other cell types in the brainstem and other brain
regions, exposure at therapeutic concentrations, and increased SMN2 mRNA exon 7
inclusion and SMN protein concentrations in the spinal cord.
INTERPRETATION: Administration of multiple intrathecal doses of nusinersen
showed acceptable safety and tolerability, pharmacology consistent with its
intended mechanism of action, and encouraging clinical efficacy. Results
informed the design of an ongoing, sham-controlled, phase 3 clinical study of
nusinersen in infantile-onset spinal muscular atrophy.
FUNDING: Ionis Pharmaceuticals, Inc and Biogen. Spinal muscular atrophy (SMA) is a rare autosomal recessive disorder
characterized by muscle atrophy and weakness resulting from motor neuron
degeneration in the spinal cord and brainstem. It is most commonly caused by
insufficient levels of survival motor neuron (SMN) protein (which is critical
for motor neuron maintece) secondary to deletions or mutations in the SMN1
gene. Nusinersen (SPINRAZA™) is a modified antisense oligonucleotide that binds
to a specific sequence in the intron, downstream of exon 7 on the pre-messenger
ribonucleic acid (pre-mRNA) of the SMN2 gene. This modulates the splicing of the
SMN2 mRNA transcript to include exon 7, thereby increasing the production of
full-length SMN protein. Nusinersen is approved in the USA for intrathecal use
in paediatric and adult patients with SMA. Regulatory assessments for nusinersen
as a treatment for SMA are underway in the EU and several other countries. This
article summarizes the milestones in the development of nusinersen leading to
this first approval for SMA in paediatric and adult patients. Oligonucleotide therapies are currently experiencing a resurgence driven by
advances in backbone chemistry and discoveries of novel therapeutic pathways
that can be uniquely and efficiently modulated by the oligonucleotide drugs. A
quarter of a century has passed since oligonucleotides were first applied in
living mammalian brain to modulate gene expression. Despite challenges in
delivery to the brain, multiple oligonucleotide-based compounds are now being
developed for treatment of human brain disorders by direct delivery inside the
blood brain barrier (BBB). Notably, the first new central nervous system
(CNS)-targeted oligonucleotide-based drug (nusinersen/Spinraza) was approved by
US Food and Drug Administration (FDA) in late 2016 and several other compounds
are in advanced clinical trials. Human testing of brain-targeted
oligonucleotides has highlighted unusual pharmacokinetic and pharmacodynamic
properties of these compounds, including complex active uptake mechanisms, low
systemic exposure, extremely long half-lives, accumulation and gradual release
from subcellular depots. Further work on oligonucleotide uptake, development of
formulations for delivery across the BBB and relevant disease biology studies
are required for further optimization of the oligonucleotide drug development
process for brain applications. Spinal muscular atrophy (SMA) is one of the leading genetic diseases of children
and infants. SMA is caused by deletions or mutations of Survival Motor Neuron 1
(SMN1) gene. SMN2, a nearly identical copy of SMN1, cannot compensate for the
loss of SMN1 due to predomit skipping of exon 7. While various regulatory
elements that modulate SMN2 exon 7 splicing have been proposed, intronic
splicing silencer N1 (ISS-N1) has emerged as the most promising target thus far
for antisense oligonucleotide-mediated splicing correction in SMA. Upon
procuring exclusive license from the University of Massachussets Medical School
in 2010, Ionis Pharmaceuticals (formerly ISIS Pharamaceuticals) began clinical
development of Spinraza™ (synonyms: Nusinersen, IONIS-SMNRX, ISIS-SMNRX), an
antisense drug based on ISS-N1 target. Spinraza™ showed very promising results
at all steps of the clinical development and was approved by US Food and Drug
Administration (FDA) on December 23, 2016. Spinraza™ is the first FDA-approved
treatment for SMA and the first antisense drug to restore expression of a fully
functional protein via splicing correction. The success of Spinraza™ underscores
the potential of intronic sequences as promising therapeutic targets and sets
the stage for further improvement of antisense drugs based on advanced
oligonucleotide chemistries and delivery protocols. Spinal muscular atrophy (SMA), a prominent genetic disease of infant mortality,
is caused by low levels of survival motor neuron (SMN) protein owing to
deletions or mutations of the SMN1 gene. SMN2, a nearly identical copy of SMN1
present in humans, cannot compensate for the loss of SMN1 because of predomit
skipping of exon 7 during pre-mRNA splicing. With the recent US Food and Drug
Administration approval of nusinersen (Spinraza), the potential for correction
of SMN2 exon 7 splicing as an SMA therapy has been affirmed. Nusinersen is an
antisense oligonucleotide that targets intronic splicing silencer N1 (ISS-N1)
discovered in 2004 at the University of Massachusetts Medical School. ISS-N1 has
emerged as the model target for testing the therapeutic efficacy of antisense
oligonucleotides using different chemistries as well as different mouse models
of SMA. Here, we provide a historical account of events that led to the
discovery of ISS-N1 and describe the impact of independent validations that
raised the profile of ISS-N1 as one of the most potent antisense targets for the
treatment of a genetic disease. Recent approval of nusinersen provides a
much-needed boost for antisense technology that is just beginning to realize its
potential. Beyond treating SMA, the ISS-N1 target offers myriad potentials for
perfecting various aspects of the nucleic-acid-based technology for the
amelioration of the countless number of pathological conditions. |
Describe King–Kopetzky syndrome. | The principal symptom of subjects suffering from King-Kopetzky syndrome (Obscure Auditory Dysfunction) is perceived difficulty in recognizing and understanding speech in noisy backgrounds. For some patients, minor disturbances in auditory function, e.g. a deteriorated signal-to-noise ratio for speech, can be demonstrated; for others, all measurements of hearing are normal. | King-Kopetzky syndrome is characterized by auditory disability with a clinically
normal hearing threshold. The main reported disability is hearing speech in the
presence of background noise. The degrees of speech-hearing disability in
patients with King-Kopetzky syndrome have been investigated with the use of the
Social Hearing Handicap Index (SHHI), and the relationships between the SHHI
scores and a number of physiological, psychoacoustical and psychological factors
determined in 109 patients. The significantly higher (worse) SHHI scores in
patients with King-Kopetzky syndrome indicate that this group suffer a
considerable degree of speech-hearing disability. In our study, the main
findings are that some psychological factors, performance of the sentence in
noise test and auditory thresholds are significantly correlated with the SHHI
scores. We were unable to find any relationships between the SHHI and frequency
resolution or EOAEs. In a multiple stepwise regression, somatic anxiety and the
performance of the sentence in noise test are the significant predictors of SHHI
scores. These two variables appear to be the main determits of speech-hearing
disability in King-Kopetzky syndrome. The hearing complaints in patients with King-Kopetzky syndrome were studied by
use of the open-ended hearing problem questionnaire. The main findings are that
complaints were commonly focused on the categories of 'live speech' and
'electronic speech' difficulties in patients with King-Kopetzky syndrome,
particularly the auditory difficulties of speech in noise and group
conversation. However, they reported problems with warning signals significantly
less frequently than a control 'audiological rehabilitation' group and the
patients studied by Barcham and Stephens (1980). In addition, main psychological
problems were related to anxiety (e.g. irritability, nervousness and moodiness)
in patients with King-Kopetzky syndrome. The open-ended hearing problem
questionnaire appears to be a useful tool that can be used to high-light the
speech hearing disability encountered by patients with King-Kopetzky syndrome. In this study, the Audioscan test has been used to detect early signs of hearing
abnormalities in 80 patients with King-Kopetzky syndrome. A significantly higher
prevalence of Audioscan notches between 500 and 3,000 Hz was found for each age
band and gender in patients with King-Kopetzky syndrome than in control
subjects. This indicates that Audioscan notches between 500 and 3,000 Hz may
represent a fine hearing deficit as an indicator of mild auditory dysfunction in
patients with King-Kopetzky syndrome. However, there was no significant
difference in the percentage of notches in the 3,001-8,000 Hz frequency band
between the King-Kopetzky syndrome and control groups. King Kopetzky Syndrome (KKS) is a common condition in which individuals with
normal audiograms complain of hearing difficulties, particularly in noisy
places. Several studies have shown many patients with KKS to have a family
history of hearing problems. In 82 consecutive patients with KKS and normal
middle ear function, we compared the performance of those with and without a
family history of hearing impairment on a number of sensitized tests. Those with
a family history were more likely to have notches on Audioscan testing (p <
0.005) and these notches were broader than those found in patients with no
family history (p < 0.05). There was also a tendency for those with a family
history to be more likely to have notches on DPOAEs (p < 0.07), and the
reproducibility of the TOAEs was poorer in those with a family history.
Psychological testing showed males with a family history to have higher scores
on free-floating anxiety (p < 0.01) and obsessionality (p < 0.05). The condition in which individuals with normal pure tone audiograms complain of
hearing difficulties, especially in the presence of background noise, (normal
pure tone audiograms), has had a number of different names. The present term
King-Kopetzky Syndrome was coined by Hinchcliffe in 1992. This is a common
condition reported in 5 - 10% of those attending clinics complaining of hearing
problems. A domit genetic aetiology has been found in a proportion of cases.
It may be associated with minor peripheral or central auditory dysfunction, and
frequently the individuals exhibit anxious or depressive personalities. We found
no relationship with noise exposure in a series of patients compared with
matched controls. Here we review the evidence for and against such an influence
and present fresh data in an attempt to define the role of noise, if any, in the
causation of this condition. Our final conclusion is that there is no clear
association between KKS and noise exposure The principal symptom of subjects suffering from King-Kopetzky syndrome is a
perceived difficulty in recognizing and understanding speech in noisy
backgrounds. For some patients, minor disturbances in auditory function, e.g. a
deteriorated signal-to-noise ratio for speech, can be demonstrated; for others,
all measurements of hearing are normal. A conceptual framework developed for the
analysis of communication disorders is applied to King-Kopetzky syndrome in the
present article. The usefulness of the framework is evaluated, and an extended
system for the analysis of King-Kopetzky syndrome patients is suggested. It is
emphasized that changes in demands resulting from external conditions and
altered perception and evaluation of the conditions may generate the symptoms. A
change in the subjects' desired self-image (preferendum) and a change in social
role, new, unfamiliar vocabulary, as well as minor dysfunctions in peripheral
and central auditory processing, might generate the characteristic features of
the syndrome. The framework is related to the current literature, and arguments
for the usefulness of the framework in the planning of support and
rehabilitation are presented. Several new questions are generated for further
analysis of King-Kopetzky syndrome. In the present study, mild impairment of cochlear function in patients with
King-Kopetzky syndrome was investigated using DPOAEs. A significant decrease in
DPOAE levels in both ears was found in patients with King-Kopetzky syndrome
compared with the controls after considering the thresholds as a co-variable. It
is noteworthy that the global mean levels of DPOAEs were still significantly
greater in controls than in patients with matched thresholds. Further frequency
analyses showed a significant decrease in DPOAE levels over the mid- and
high-frequency range in patients with better hearing thresholds when compared
with those in the control group. Moreover, significantly smaller DPOAEs were
found in the ears of patients with King-Kopetzky syndrome and without SOAEs,
than in such ears of control subjects after considering the thresholds as a
co-variable. However, when SOAEs were present there was no difference. Decreases
in DPOAE level appear to represent evidence of minor cochlear pathology, and
provide a pathological basis for the difficulty of hearing speech in the
presence of background noise, which characterizes King-Kopetzky syndrome. At least 10% of people who present for help with hearing difficulties will be
found to have normal hearing thresholds. These cases are clinically categorized
as King-Kopetzky syndrome (KKS), obscure auditory dysfunction (OAD), or auditory
processing disorder (APD). While recent research has focussed on the possible
mechanistic basis for these difficulties, the perceptions of the hearing
difficulties that lead people to seek help have not hitherto been identified.
This study presents findings from an observational survey of causal attributions
of hearing difficulties from 100 people with KKS. The findings suggest that
participants regard immunity and risk related causes of hearing difficulties as
pre-domit. Psychological factors were not considered to be causal for hearing
difficulties. These factors were not affected by diagnostic classification.
These findings inform audiologists about their patient beliefs for the first
time. The authors suggest that clinicians take care to ensure that their
counselling is responsive to these beliefs. The present study explored illness perceptions of hearing difficulties amongst
one hundred participants who reported experiencing hearing difficulties despite
normal audiometric thresholds. This experience is referred to as King-Kopetzky
syndrome (KKS), obscure auditory dysfunction (OAD), or auditory processing
disorder (APD). Logistic regression was used to consider the associations
between help-seeking and a range of audiological and illness perception
measures. Results indicate that help-seekers present with poorer speech in noise
thresholds than non help-seekers, and that coherent illness perceptions and a
negative belief in the consequences of hearing difficulties are associated with
help-seeking status, regardless of hearing sensitivity. |
What is the 959 Nematode Genomes initiative? | The phylum Nematoda is rich and diverse and of interest to a wide range of research fields from basic biology through ecology and parasitic disease. For all these communities, it is now clear that access to genome scale data will be key to advancing understanding, and in the case of parasites, developing new ways to control or cure diseases. The advent of second-generation sequencing technologies, improvements in computing algorithms and infrastructure and growth in bioinformatics and genomics literacy is making the addition of genome sequencing to the research goals of any nematode research program a less daunting prospect. To inspire, promote and coordinate genomic sequencing across the diversity of the phylum, a community wiki and the 959 Nematode Genomes initiative (www.nematodegenomes.org/) has been launched. Just as the deciphering of the developmental lineage of the 959 cells of the adult hermaphrodite C. elegans was the gateway to broad advances in biomedical science, it is anticipated that a nematode phylogeny with (at least) 959 sequenced species will underpin further advances in understanding the origins of parasitism, the dynamics of genomic change and the adaptations that have made Nematoda one of the most successful animal phyla. | Genome sequencing has been democratized by second-generation technologies, and
even small labs can sequence metazoan genomes now. In this article, we describe
'959 Nematode Genomes'--a community-curated semantic wiki to coordinate the
sequencing efforts of individual labs to collectively sequence 959 genomes
spanning the phylum Nematoda. The main goal of the wiki is to track sequencing
projects that have been proposed, are in progress, or have been completed. Wiki
pages for species and strains are linked to pages for people and organizations,
using machine- and human-readable metadata that users can query to see the
status of their favourite worm. The site is based on the same platform that runs
Wikipedia, with semantic extensions that allow the underlying taxonomy and data
storage models to be maintained and updated with ease compared with a
conventional database-driven web site. The wiki also provides a way to track and
share preliminary data if those data are not polished enough to be submitted to
the official sequence repositories. In just over a year, this wiki has already
fostered new international collaborations and attracted newcomers to the
enthusiastic community of nematode genomicists. www.nematodegenomes.org. The sequencing of the complete genome of the nematode Caenorhabditis elegans was
a landmark achievement and ushered in a new era of whole-organism, systems
analyses of the biology of this powerful model organism. The success of the C.
elegans genome sequencing project also inspired communities working on other
organisms to approach genome sequencing of their species. The phylum Nematoda is
rich and diverse and of interest to a wide range of research fields from basic
biology through ecology and parasitic disease. For all these communities, it is
now clear that access to genome scale data will be key to advancing
understanding, and in the case of parasites, developing new ways to control or
cure diseases. The advent of second-generation sequencing technologies,
improvements in computing algorithms and infrastructure and growth in
bioinformatics and genomics literacy is making the addition of genome sequencing
to the research goals of any nematode research program a less daunting prospect.
To inspire, promote and coordinate genomic sequencing across the diversity of
the phylum, we have launched a community wiki and the 959 Nematode Genomes
initiative (www.nematodegenomes.org/). Just as the deciphering of the
developmental lineage of the 959 cells of the adult hermaphrodite C. elegans was
the gateway to broad advances in biomedical science, we hope that a nematode
phylogeny with (at least) 959 sequenced species will underpin further advances
in understanding the origins of parasitism, the dynamics of genomic change and
the adaptations that have made Nematoda one of the most successful animal phyla. |
Which are the constitutive parts of a Genomic Regulatory Block (GRB)? | GRBs are spanned by highly conserved noncoding elements (HCNEs), their developmental regulatory target genes, and phylogenetically and functionally unrelated "bystander" genes. | We report evidence for a mechanism for the maintece of long-range conserved
synteny across vertebrate genomes. We found the largest mammal-teleost conserved
chromosomal segments to be spanned by highly conserved noncoding elements
(HCNEs), their developmental regulatory target genes, and phylogenetically and
functionally unrelated "bystander" genes. Bystander genes are not specifically
under the control of the regulatory elements that drive the target genes and are
expressed in patterns that are different from those of the target genes.
Reporter insertions distal to zebrafish developmental regulatory genes pax6.1/2,
rx3, id1, and fgf8 and miRNA genes mirn9-1 and mirn9-5 recapitulate the
expression patterns of these genes even if located inside or beyond bystander
genes, suggesting that the regulatory domain of a developmental regulatory gene
can extend into and beyond adjacent transcriptional units. We termed these
chromosomal segments genomic regulatory blocks (GRBs). After whole genome
duplication in teleosts, GRBs, including HCNEs and target genes, were often
maintained in both copies, while bystander genes were typically lost from one
GRB, strongly suggesting that evolutionary pressure acts to keep the single-copy
GRBs of higher vertebrates intact. We show that loss of bystander genes and
other mutational events suffered by duplicated GRBs in teleost genomes permits
target gene identification and HCNE/target gene assignment. These findings
explain the absence of evolutionary breakpoints from large vertebrate
chromosomal segments and will aid in the recognition of position effect
mutations within human GRBs. |
Glecaprevir and Pibrentasvir are used for tratment of which disease? | The combination of direct-acting antivirals glecaprevir and pibrentasvir is effective for treatment of Hepatitis C virus infection. | Although direct-acting antiviral (DAA) therapies for chronic hepatitis C virus
(HCV) infection have demonstrated high rates of sustained virologic response,
virologic failure may still occur, potentially leading to the emergence of viral
resistance, which can decrease the effectiveness of subsequent treatment.
Treatment options for patients who failed previous DAA-containing regimens,
particularly those with nonstructural protein 5A inhibitors, are limited and
remain an area of unmet medical need. This phase 2, open-label study
(MAGELLAN-1) evaluated the efficacy and safety of glecaprevir (GLE) +
pibrentasvir (PIB) ± ribavirin (RBV) in HCV genotype 1-infected patients with
prior virologic failure to HCV DAA-containing therapy. A total of 50 patients
without cirrhosis were randomized to three arms: 200 mg GLE + 80 mg PIB (arm A),
300 mg GLE + 120 mg PIB with 800 mg once-daily RBV (arm B), or 300 mg GLE + 120
mg PIB without RBV (arm C). By intent-to-treat analysis, sustained virologic
response at posttreatment week 12 was achieved in 100% (6/6, 95% confidence
interval 61-100), 95% (21/22, 95% confidence interval 78-99), and 86% (19/22,
95% confidence interval 67-95) of patients in arms A, B, and C, respectively.
Virologic failure occurred in no patients in arm A and in 1 patient each in arms
B and C (two patients were lost to follow-up in arm C). The majority of adverse
events were mild in severity; no serious adverse events related to study drug
and no relevant laboratory abnormalities in alanine aminotransferase, total
bilirubin, or hemoglobin were observed.
CONCLUSION: The combination of GLE and PIB was highly efficacious and well
tolerated in patients with HCV genotype 1 infection and prior failure of
DAA-containing therapy; RBV coadministration did not improve efficacy.
(Hepatology 2017;66:389-397). OBJECTIVE: To review the role and utility of baseline resistance testing with
currently available and pipeline genotype 1 hepatitis C virus (HCV) treatment.
DATA SOURCES: Authors reviewed liver meeting abstracts for data on
currently-available and pipeline genotype 1 retreatment regimens from January 1,
2015, to March 23, 2017. Additional trials were identified from a review of
clinicaltrials.gov using the pipeline medication names.
STUDY SELECTION AND DATA EXTRACTION: Authors identified reports of current and
pipeline genotype 1 retreatment regimens. Seven references were clinical study
results presented at the meetings of the American Association for the Study of
Liver Diseases and the European Association for the Study of the Liver, and 2
studies were from clinicaltrials.gov .
DATA SYNTHESIS: Retreatment trial data of currently available salvage regimens
indicate that baseline NS5A resistance-associated substitutions (RASs) may
decrease sustained virological response (SVR) rates when retreating with
ledipasvir/sofosbuvir but are not affected when using elbasvir/grazoprevir +
sofosbuvir + ribavirin, paritaprevir/ritonavir/ombitasvir + dasabuvir +
sofosbuvir, or sofosbuvir/velpatasvir + ribavirin. Pipeline data indicate that
baseline NS5A RASs do not affect SVR rates when retreating with
sofosbuvir/velpatasvir/voxilaprevir or glecaprevir/pibrentasvir.
CONCLUSIONS: Baseline resistance testing was used for decisional support for 3
clinical scenarios in patients with HCV genotype 1 infection at the time of
manuscript submission. Pending the approval of 2 new direct-acting antiviral
regimens in the third quarter of 2017, the rapidly evolving HCV treatment
guidelines will likely reflect a decreased clinical utility for resistance
testing. BACKGROUND: Chronic hepatitis C virus (HCV) infection is more prevalent among
patients who have chronic kidney disease than among those who do not have the
disease. Patients with chronic kidney disease who also have HCV infection are at
higher risk for progression to end-stage renal disease than those who have
chronic kidney disease without HCV infection. Patients with both HCV infection
and advanced chronic kidney disease have limited treatment options.
METHODS: We conducted a multicenter, open-label, phase 3 trial to evaluate the
efficacy and safety of treatment with the combination of the NS3/4A protease
inhibitor glecaprevir and the NS5A inhibitor pibrentasvir for 12 weeks in adults
who had HCV genotype 1, 2, 3, 4, 5, or 6 infection and also had compensated
liver disease (with or without cirrhosis) with severe renal impairment,
dependence on dialysis, or both. Patients had stage 4 or 5 chronic kidney
disease and either had received no previous treatment for HCV infection or had
received previous treatment with interferon or pegylated interferon, ribavirin,
sofosbuvir, or a combination of these medications. The primary end point was a
sustained virologic response 12 weeks after the end of treatment.
RESULTS: Among the 104 patients enrolled in the trial, 52% had genotype 1
infection, 16% had genotype 2 infection, 11% had genotype 3 infection, 19% had
genotype 4 infection, and 2% had genotype 5 or 6 infection. The sustained
virologic response rate was 98% (102 of 104 patients; 95% confidence interval,
95 to 100). No patients had virologic failure during treatment, and no patients
had a virologic relapse after the end of treatment. Adverse events that were
reported in at least 10% of the patients were pruritus, fatigue, and nausea.
Serious adverse events were reported in 24% of the patients. Four patients
discontinued the trial treatment prematurely because of adverse events; three of
these patients had a sustained virologic response.
CONCLUSIONS: Treatment with glecaprevir and pibrentasvir for 12 weeks resulted
in a high rate of sustained virologic response in patients with stage 4 or 5
chronic kidney disease and HCV infection. (Funded by AbbVie; ClinicalTrials.gov
number, NCT02651194 .). |
What is the drug target(s) for Belsomra? | Belsomra is a dual orexin receptor antagonist for both the Ox1 and Ox2 receptors | Suvorexant (Belsomra(®)), a first-in-class, orally active dual orexin-1 receptor
and orexin-2 receptor antagonist, has been developed by Merck for the treatment
of insomnia. Variations in the levels of the neuropeptides orexin A and orexin B
have been linked to circadian rhythms and wakefulness. Orexin-producing neurons
in the lateral hypothalamus regulate wakefulness by signalling through orexin
receptors. Blockade of orexin receptors is known to promote sleep. Suvorexant
was approved in the US in August 2014 for the treatment of adults with sleep
onset and/or sleep maintece insomnia. The drug is also preregistration in
Japan, with approval submissions planned for other countries worldwide for this
indication. This article summarizes the milestones in the development of
suvorexant leading to this first approval for insomnia. Idelalisib (Zydelig) for certain types of leukemia and lymphoma, peginterferon
beta-1a (Plegridy) for relapsing forms of multiple sclerosis, and suvorexant
(Belsomra) for insomnia. The orexin receptors OX1 and OX2 play important roles in the regulation of
sleep-wake cycles, feeding, reward and energy homeostasis. Since these G
protein-coupled receptors were deorphanised in 1998, more than 200 patents
containing orexin receptor antagonists have been filed and, in 2014, suvorexant
(Belsomra®) became the first of these compounds to receive approval from the
FDA. Suvorexant is a dual orexin receptor antagonist (DORA) which is available
for the treatment of insomnia. This review provides a historical perspective on
the discovery and development of DORAs as well as selective OX1 receptor
antagonists (1-SORAs) and selective OX2 receptor antagonists (2-SORAs). 2-SORAs
are under clinical evaluation for their ability to modulate sleep, and 1-SORAs
have shown promise for the treatment of addiction in pre-clinical animal models.
Detailed medicinal chemistry case studies are presented and future opportunities
for orexin receptor antagonists are considered. Insomnia, a highly prevalent disorder, can be detrimental to patients' overall
health and worsen existing comorbidities. Patients may have acute episodes of
insomnia related to a traumatic event, but more commonly insomnia occurs
chronically. While proper sleep hygiene and behavioral therapy play important
roles in the nonpharmacologic management of short-term and chronic insomnia,
medications may also be required. Historically, insomnia has been treated with
agents such as benzodiazepines, nonbenzodiazepine receptor agonists, and
melatonin agonists. Dual orexin receptor antagonists represent a new class of
medications for the treatment of insomnia, which block the binding of
wakefulness-promoting neuropeptides orexin A and orexin B to their respective
receptor sites. Suvorexant (Belsomra) is the first dual orexin receptor
antagonist to be approved in the US and Japan and has demonstrated efficacy in
decreasing time to sleep onset and increasing total sleep time. Its unique
mechanism of action, data to support efficacy and safety over 12 months of use,
and relative lack of withdrawal effects when discontinued may represent an
alternative for patients with chronic insomnia who cannot tolerate or do not
receive benefit from more traditional sleep agents. Suvorexant is effective and
well tolerated, but precautions exist for certain patient populations, including
females, obese patients, and those with respiratory disease. Suvorexant has only
been studied vs placebo, and hence it is unknown how it directly compares with
other medications approved by the US Food and Drug Administration for insomnia.
Suvorexant is not likely to replace benzodiazepines or nonbenzodiazepine
receptor antagonists as a first-line sleep agent but does represent a novel
option for the treatment of patients with chronic insomnia. Suvorexant (Belsomra®) is a novel sedative hypnotic drug that is prescribed to
promote sleep in patients with insomnia. It is the first of a new class of drugs
classified as dual orexin receptor antagonists (DORAs). Sedative hypnotics with
central nervous system depressant effects feature prominently in forensic
toxicology investigations. For this reason, a new analytical method was
developed to identify suvorexant in urine using liquid-liquid extraction (LLE)
and gas chromatography/mass spectrometry (GC/MS). Due to the absence of a
commercially available isotopically labeled internal standard, estazolam-D5 was
used due to its azepine, triazole and chlorinated functionality. The limit of
detection and limit of quantitation was 10ng/mL and the linear range of the
assay was 10-1000ng/mL. Accuracy and precision (%CV) were 98-101% and <11% at
30, 250 and 800ng/mL. Interferences from matrix and fifty common drugs were not
present and processed samples were stable for 24h at room temperature.
Suvorexant is a new drug of significant forensic interest due to its hypnotic
and central nervous system depressant effects. The absence of commercially
available metabolites and its chromatographic properties present some challenges
in terms of identification. Nevertheless, a robust, reliable and sensitive assay
was developed to identify suvorexant using GC/MS analysis. Suvorexant is a dual orexin receptor agonist and is currently approved for the
treatment of insomnia in the United States and Japan. We conducted a systematic
review and meta-analysis to assess the efficacy and safety of suvorexant for the
treatment of primary insomnia. We searched PubMed, EMBASE, and the Cochrane
central register of controlled trials, contacted a relevant pharmaceutical
company, and accessed websites of the U.S. Food and Drug Administration (FDA)
and Pharmaceuticals and Medical Devices Agency (PMDA) for published and
unpublished data. A total of four randomized trials involving 3076 patients with
primary insomnia were included in our analysis. Our analysis suggested that
suvorexant was associated with significant improvements in subjective time to
sleep onset, subjective total sleep time, and subjective quality of sleep at
1 mo and 3 mo. Somnolence, fatigue, and abnormal dreams were the most common
adverse effects. We concluded that suvorexant was associated with improvement in
some sleep parameters and some adverse effects. To determine the place of
suvorexant in the treatment of insomnia, comparative effectiveness trials are
needed. |
Can canagliflozin cause euglycemic diabetic ketoacidosis? | Yes, canagliflozin use can cause euglycemic diabetic ketoacidosis. In May 2015, the FDA issued a warning of ketoacidosis with use of sodium-glucose cotransporter-2 (SGLT-2) drug class. | The purpose of this feature is to heighten awareness of specific adverse drug
reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs
to the US Food and Drug Administration's (FDA's) MedWatch program
(800-FDA-1088). If you have reported an interesting, preventable ADR to
MedWatch, please consider sharing the account with our readers. Write to Dr.
Mancano at ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044 (phone:
215-707-4936; e-mail: [email protected]). Your report will be published
anonymously unless otherwise requested. This feature is provided by the
Institute for Safe Medication Practices (ISMP) in cooperation with the FDA's
MedWatch program and Temple University School of Pharmacy. ISMP is an FDA
MedWatch partner. Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2)
inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes
mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been
justified by the fact that its mechanism of action is independent of insulin
secretion or action. However, some serious side effects, including severe anion
gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been
reported. Prompt identification of the causal association and initiation of
appropriate therapy should be instituted for this life threatening condition. Sodium glucose co-transporter (SGLT-2) inhibitor is a relatively new medication
used to treat diabetes. At present, the Food and Drug Administration (FDA) has
only approved three medications (canagliflozin, dapagliflozin and empagliflozin)
in this drug class for the management of Type 2 diabetes. In May 2015, the FDA
issued a warning of ketoacidosis with use of this drug class. Risk factors for
the development of ketoacidosis among patients who take SGLT-2 inhibitors
include decrease carbohydrate intake/starvation, acute illness and decrease in
insulin dose. When identified, immediate cessation of the medication and
administration of glucose must be done, and in some instances, starting an
insulin drip might be necessary. We present a case of a patient with diabetes
mellitus being on empagliflozin (SGLT-2 antagonist) who was admitted for acute
cholecystitis. The hospital course was complicated by euglycemic diabetic
ketoacidosis after being kept nothing per orem before a contemplated
cholecystectomy. BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitor medications are a
class of antihyperglycemic agents that increase urinary glucose excretion by
interfering with the reabsorption of glucose in the proximal renal tubules. In
May of 2015, the U.S. Food and Drug Administration released a warning concerning
a potential increased risk of ketoacidosis and ketosis in patients taking these
medications.
CASE REPORT: We present a case of a 57-year-old woman with type 2 diabetes
mellitus taking a combination of canagliflozin and metformin who presented with
progressive altered mental status over the previous 2 days. Her work-up
demonstrated a metabolic acidosis with an anion gap of 38 and a venous serum pH
of 7.08. The serum glucose was 168 mg/dL. The urinalysis showed glucose >
500 mg/dL and ketones of 80 mg/dL. Further evaluation demonstrated an elevated
serum osmolality of 319 mOsm/kg and an acetone concentration of 93 mg/dL. She
was treated with intravenous insulin and fluids, and the metabolic abnormalities
and her altered mental status resolved within 36 h. This was the first episode
of diabetic ketoacidosis (DKA) for this patient. WHY SHOULD AN EMERGENCY
PHYSICIAN BE AWARE OF THIS?: Diabetic patients on SGLT2 inhibitor medications
are at risk for ketoacidosis. Due to the renal glucose-wasting properties of
these drugs, they may present with ketoacidosis with only mild elevations in
serum glucose, potentially complicating the diagnosis. Acetone is one of the
three main ketone bodies formed during DKA and it may be present at considerable
concentrations, contributing to the serum osmolality. Ketoacidosis is a significant and often a life-threatening complication of
diabetes mellitus seen mostly in type 1 diabetes mellitus as well as
occasionally in type 2 diabetes mellitus. Diabetic ketoacidosis usually
manifests with high blood glucose more than 250 mg/dL, but euglycemic diabetic
ketoacidosis is defined as ketoacidosis associated with blood glucose level less
than 250 mg/dL. Normal blood glucose in such patients results in significant
delay in diagnosis and management of diabetic ketoacidosis, thus increasing
mortality and morbidity. We present a case of euglycemic diabetic ketoacidosis
secondary to canagliflozin in a type 2 diabetic patient. Diabetic ketoacidosis is characterized by hyperglycemia, anion-gap acidosis, and
increased plasma ketones. After the resolution of hyperglycemia, persistent
diuresis is rare. We herein report the case of a 27-year-old Asian woman with
type 2 diabetes who was treated with a sodium-glucose cotransporter 2 (SGLT2)
inhibitor (canagliflozin) who developed euglycemic diabetic ketoacidosis and
persistent diuresis in the absence of hyperglycemia. Physicians should consider
euglycemic diabetic ketoacidosis in the differential diagnosis of patients
treated with SGLT2 inhibitors. Sodium-glucose cotransporter-2 (SGLT2) inhibitors improve glycemic control by a
reversible inhibition of the sodium-glucose cotransporters in the renal proximal
tubules resulting in increased urinary glucose. This unique mechanism,
independent of insulin secretion and beta cell function, has made this class of
medication desirable in patients with type 2 diabetes. However in May 2015, the
US Food and Drug Administration issued a safety warning pertaining to the
development of diabetic ketoacidosis (DKA) with the use of SGLT2 inhibitors. DKA
associated with SGLT2 inhibitors frequently develops in the absence of
hyperglycemia, which makes the diagnosis more challenging. Due to the reversible
inhibition of SGLT2 by this class of medication, a quick recovery of glucosuria
after cessation of medication is expected. In this article, we present a case of
a 50-year-old woman with type 2 diabetes who developed euglycemic DKA after
initiating therapy with canagliflozin. This case of DKA associated with SGLT2
inhibitor use was unique due to her hypoglycemic presentation and persistent
glucosuria. SGLT2 inhibitors such as canagliflozin may predispose patients not
only to diabetic ketoacidosis but also to prolonged glucosuria. Sodium-glucose linked transporter type 2 (SGLT2) inhibitors are a relatively new
class of antidiabetic drugs with positive cardiovascular and kidney effects. The
aim of this review is to present the safety issues associated with SGLT2
inhibitors. Urogenital infections are the most frequently encountered adverse
events, although tend to be mild to moderate and are easily manageable with
standard treatment. Although no increased acute kidney injury risk was evident
in the major trials, the mechanism of action of these drugs requires caution
when they are administered in patients with extracellular volume depletion or
with drugs affecting renal hemodynamics. Canagliflozin raised the risk of
amputations and the rate of fractures in the CANVAS trial, although more data
are necessary before drawing definite conclusions. The risk of euglycemic
diabetic ketoacidosis seems to be minimal when the drugs are prescribed
properly. Regarding other adverse events, SGLT2 inhibitors do not increase the
risk of hypoglycemia even when co-administered with insulin, but a decrease in
the dose of sulphonylureas may be needed. The available data do not point to a
causative role of SGLT2 inhibitors on maligcy risk, however, these drugs
should be used with caution in patients with known hematuria or history of
bladder cancer. SGLT2 inhibitors seem to be safe and effective in the treatment
of diabetes but more studies are required to assess their long-term safety. OBJECTIVE: Canagliflozin is a sodium-glucose co-transporter 2 (SGLT-2)
inhibitor, one of a class of novel antiglycemic agents that are gaining in
popularity in the treatment of diabetes.
METHODS: We describe a case in which a patient experienced difficult-to-treat
metabolic ketoacidosis in the setting of canagliflozin use.
RESULTS: A 52-year-old man with type 2 diabetes mellitus developed profound
ketoacidosis without overt hyperglycemia while taking canagliflozin. Despite
initiation of an insulin infusion, the metabolic acidosis persisted for 3 days.
CONCLUSION: Treatment with canagliflozin was associated with development of
euglycemic ketoacidosis. |
What is CellMaps? | CellMaps is an HTML5 open-source web tool that allows displaying, editing, exploring and analyzing biological networks as well as integrating metadata into them. | Author information:
(1)Computational Genomics Department, Centro de Investigación Príncipe Felipe
(CIPF), Valencia 46012, Spain Bioinformatics of Rare Diseases (BIER), CIBER de
Enfermedades Raras (CIBERER), Valencia, Spain.
(2)Computational Genomics Department, Centro de Investigación Príncipe Felipe
(CIPF), Valencia 46012, Spain.
(3)Computational Genomics Department, Centro de Investigación Príncipe Felipe
(CIPF), Valencia 46012, Spain Bull-CIPF, Computational Genomics Chair, Valencia
46012, Spain.
(4)Department of Medicine, University of Cambridge, School of Clinical Medicine,
Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
(5)HPC Service, UIS, University of Cambridge, Cambridge, UK.
(6)Computational Genomics Department, Centro de Investigación Príncipe Felipe
(CIPF), Valencia 46012, Spain Bioinformatics of Rare Diseases (BIER), CIBER de
Enfermedades Raras (CIBERER), Valencia, Spain Functional Genomics Node, (INB,
PRB2, ISCIII) at CIPF, Valencia 46012, Spain. |
Is there an association between Klinefelter syndrome and breast cancer? | Yes, Klinefelter syndrome is associated with increased risk of male breast cancer. Other risk factors of male breast cancer are positive family history, and mutations in BRCA1 and specially BRCA2. | Breast cancer in a patient with Klinefelter's syndrome is reported. Possible
correlation between testosterone and estradiol serum levels after
testosterone-ethate substitution, estrogen receptors in tumor tissue and
clinical symptomatology are discussed. The various theories of etiology
concerning breast cancer in this syndrome are reviewed. The increased conversion
of testosterone to estradiol at the therapy with androgens might be responsible
for the development of breast cancer in Klinefelter's syndrome. The current way
of treatment is described. Klinefelter's syndrome is one of the most common forms of primary hypogonadism
and infertility in males. It is characterized by small and firm testes,
gynecomastia, azoospermia, and an elevated gonadotropin level. The frequencies
of diabetes mellitus, breast cancer, and germ cell neoplasia increases in
Klinefelter's syndrome. We report upon a 35 year-old male patient with Graves'
disease in association with Klinefelter's syndrome; as confirmed by chromosome
analysis. The patient is being treated with antithyroid medication for Graves'
disease and by testosterone replacement for Klinefelter's syndrome. Breast cancer in men is a rare disease, accounting for approximately 1% of all
breast cancer cases. Although the epidemiologic literature regarding female
breast cancer is extensive, relatively little is known about the etiology of
male breast cancer (MBC). This review is intended to summarize the existing body
of evidence on genetic and epidemiologic risk factors for breast cancer in men.
Overall, the epidemiology of MBC presents similarities with the epidemiology of
female breast cancer. Major genetic factors associated with an increased risk of
breast cancer for men include BRCA2 mutations, which are believed to account for
the majority of inherited breast cancer in men, Klinefelter syndrome, and a
positive family history. Suspected genetic factors include AR gene mutations,
CYP17 polymorphism, Cowden syndrome, and CHEK2. Epidemiologic risk factors for
MBC include disorders relating to hormonal imbalances, such as obesity,
testicular disorders (e.g., cryptorchidism, mumps orchitis, and orchiectomy),
and radiation exposure. Suspected epidemiologic risk factors include prostate
cancer,prostate cancer treatment, gynecomastia, occupational exposures (e.g.,
electromagnetic fields, polycyclic aromatic hydrocarbons, and high
temperatures), dietary factors (e.g., meat intake and fruit and vegetable
consumption), and alcohol intake. AIM: To evaluate male breast cancer (MBC) risk among patients with Klinefelter
syndrome (KS) and relate this to possible biological explanations.
METHODS: A literature review was conducted to identify case series and
epidemiologic studies that have evaluated MBC risk among patients with KS.
RESULTS: Case reports without expected values have often led to false
impressions of risk. Problems include that a diagnosis of cancer can prompt a
karyotypic evaluation and that many cases of KS are unrecognized, resulting in
incomplete denominators. Few carefully conducted epidemiologic studies have been
undertaken given that both KS and MBC are rare events. The largest study found
19.2- and 57.8-fold increases in incidence and mortality, respectively, with
particularly high risks among 47,XXY mosaics. These risks were still
approximately 70% lower than among females, contradicting case reports that
patients with KS have breast cancer rates similar to females. Altered hormone
levels (especially the ratio of oestrogens to androgens), administration of
exogenous androgens, gynaecomastia and genetic factors have been offered as
possible explanations for the high risks.
CONCLUSIONS: Additional well-designed epidemiologic studies are needed to
clarify which patients with KS are at a high risk of developing MBC and to
distinguish between possible predisposing factors, including altered endogenous
hormones. PURPOSE: Men with Klinefelter syndrome have one or more extra X chromosomes and
have endocrine abnormalities. Klinefelter syndrome has been consistently
associated with breast cancer in men (MBC).
CASE REPORT: We report a 54-year old man was diagnosed as synchronous bilateral
breast cancer with Klinefelter syndrome. On clinical examination there was mass
in the lateral upper quadrant right breast. The overlying skin was slightly
retracted. In the left breast, there was also a subareolar mass. Mammography,
ultrasonography imaging showed bilateral suspicious breast masses with
microcalcifications. There were no radiological findings of muscle invasion or
axillary lymphadenopathy. We performed bilateral fine-needle aspiration biopsy
(FNAB), and the aspiration smears were positive for carcinoma. The pathologic
diagnosis of infiltrating ductal carcinoma in the biopsy specimen on the
bilateral breast. The patient was successfully treated by bilateral radical
modified mastectomy according to Madden's technique followed by external
irradiation and adjuvant endocrine therapy.
CONCLUSION: Breast cancer commonly occurs in women, but now the incidence is
also seen in men. Risk factors include age, family history, genes, liver
diseases (cirrhosis), alcohol, diet, and obesity. Klinefelter syndrome, in which
patients carry XXY chromosome, may be present in men with breast cancer for this
reason they often develop gynecomastia. Surgical therapy for occult breast cancer has traditionally centered on
mastectomy; however, breast conservation with whole breast radiotherapy followed
by axillary lymph node dissection has shown equivalent results. Patients with
breast cancer in pregcy can be safely and effectively treated; given a
patient's pregcy trimester and stage of breast cancer, a clinician must be
able to guide therapy accordingly. Male breast cancer risk factors show strong
association with BRCA2 mutations, as well as Klinefelter syndrome. Several
retrospective trials of surgical therapy in stage IV breast cancer have
associated a survival advantage with primary site tumor extirpation. Breast cancer in men is 100 times less common than in women. The main risk
factors include: the mutation of genes BRCA 1 and 2, Klinefelter's syndrome,
alcohol, liver disease, obesity. Clinical examinations, mammography and
ultrasound are informative and highly sensitive for early detection of these
tumors, but are rarely implemented due to lack of awareness of general
practitioners. Local treatment includes the Patey-Dyson mastectomy and radiation
therapy. Adjuvant systemic therapy is determined by pTNM and typically involves
tamoxifen. BACKGROUND: The etiology of male breast cancer is poorly understood, partly
because of its relative rarity. Although genetic factors are involved, less is
known regarding the role of anthropometric and hormonally related risk factors.
METHODS: In the Male Breast Cancer Pooling Project, a consortium of 11
case-control and 10 cohort investigations involving 2405 case patients (n = 1190
from case-control and n = 1215 from cohort studies) and 52013 control subjects,
individual participant data were harmonized and pooled. Unconditional logistic
regression generated study design-specific (case-control/cohort) odds ratios
(ORs) and 95% confidence intervals (CIs), with exposure estimates combined using
fixed effects meta-analysis. All statistical tests were two-sided.
RESULTS: Risk was statistically significantly associated with weight
(highest/lowest tertile: OR = 1.36; 95% CI = 1.18 to 1.57), height (OR = 1.18;
95% CI = 1.01 to 1.38), and body mass index (BMI; OR = 1.30; 95% CI = 1.12 to
1.51), with evidence that recent rather than distant BMI was the strongest
predictor. Klinefelter syndrome (OR = 24.7; 95% CI = 8.94 to 68.4) and
gynecomastia (OR = 9.78; 95% CI = 7.52 to 12.7) were also statistically
significantly associated with risk, relations that were independent of BMI.
Diabetes also emerged as an independent risk factor (OR = 1.19; 95% CI = 1.04 to
1.37). There were also suggestive relations with cryptorchidism (OR = 2.18; 95%
CI = 0.96 to 4.94) and orchitis (OR = 1.43; 95% CI = 1.02 to 1.99). Although age
at onset of puberty and histories of infertility were unrelated to risk, never
having had children was statistically significantly related (OR = 1.29; 95% CI =
1.01 to 1.66). Among individuals diagnosed at older ages, a history of fractures
was statistically significantly related (OR = 1.41; 95% CI = 1.07 to 1.86).
CONCLUSIONS: Consistent findings across case-control and cohort investigations,
complemented by pooled analyses, indicated important roles for anthropometric
and hormonal risk factors in the etiology of male breast cancer. Further
investigation should focus on potential roles of endogenous hormones. |
Which R packages have been developed for the discovery of mutational signatures in cancer? | signeR: an empirical Bayesian approach to mutational signature discovery. Mutational signatures can be used to understand cancer origins and provide a unique opportunity to group tumor types that share the same origins and result from similar processes. These signatures have been identified from high throughput sequencing data generated from cancer genomes by using non-negative matrix factorisation (NMF) techniques. The extraction of mutational signatures from high-throughput data still remains a daunting task.RESULTS: Here we present a new method for the statistical estimation of mutational signatures based on an empirical Bayesian treatment of the NMF model. | Mutational signatures are patterns in the occurrence of somatic
single-nucleotide variants that can reflect underlying mutational processes. The
SomaticSignatures package provides flexible, interoperable and easy-to-use tools
that identify such signatures in cancer sequencing data. It facilitates
large-scale, cross-dataset estimation of mutational signatures, implements
existing methods for pattern decomposition, supports extension through
user-defined approaches and integrates with existing Bioconductor workflows.
AVAILABILITY AND IMPLEMENTATION: The R package SomaticSignatures is available as
part of the Bioconductor project. Its documentation provides additional details
on the methods and demonstrates applications to biological datasets.
CONTACT: [email protected], [email protected]
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. Recent advances in sequencing technologies have enabled the production of
massive amounts of data on somatic mutations from cancer genomes. These data
have led to the detection of characteristic patterns of somatic mutations or
"mutation signatures" at an unprecedented resolution, with the potential for new
insights into the causes and mechanisms of tumorigenesis. Here we present new
methods for modelling, identifying and visualizing such mutation signatures. Our
methods greatly simplify mutation signature models compared with existing
approaches, reducing the number of parameters by orders of magnitude even while
increasing the contextual factors (e.g. the number of flanking bases) that are
accounted for. This improves both sensitivity and robustness of inferred
signatures. We also provide a new intuitive way to visualize the signatures,
analogous to the use of sequence logos to visualize transcription factor binding
sites. We illustrate our new method on somatic mutation data from urothelial
carcinoma of the upper urinary tract, and a larger dataset from 30 diverse
cancer types. The results illustrate several important features of our methods,
including the ability of our new visualization tool to clearly highlight the key
features of each signature, the improved robustness of signature inferences from
small sample sizes, and more detailed inference of signature characteristics
such as strand biases and sequence context effects at the base two positions 5'
to the mutated site. The overall framework of our work is based on probabilistic
models that are closely connected with "mixed-membership models" which are
widely used in population genetic admixture analysis, and in machine learning
for document clustering. We argue that recognizing these relationships should
help improve understanding of mutation signature extraction problems, and
suggests ways to further improve the statistical methods. Our methods are
implemented in an R package pmsignature
(https://github.com/friend1ws/pmsignature) and a web application available at
https://friend1ws.shinyapps.io/pmsignature_shiny/. MOTIVATION: Mutational signatures can be used to understand cancer origins and
provide a unique opportunity to group tumor types that share the same origins
and result from similar processes. These signatures have been identified from
high throughput sequencing data generated from cancer genomes by using
non-negative matrix factorisation (NMF) techniques. Current methods based on
optimization techniques are strongly sensitive to initial conditions due to high
dimensionality and nonconvexity of the NMF paradigm. In this context, an
important question consists in the determination of the actual number of
signatures that best represent the data. The extraction of mutational signatures
from high-throughput data still remains a daunting task.
RESULTS: Here we present a new method for the statistical estimation of
mutational signatures based on an empirical Bayesian treatment of the NMF model.
While requiring minimal intervention from the user, our method addresses the
determination of the number of signatures directly as a model selection problem.
In addition, we introduce two new concepts of significant clinical relevance for
evaluating the mutational profile. The advantages brought by our approach are
shown by the analysis of real and synthetic data. The later is used to compare
our approach against two alternative methods mostly used in the literature and
with the same NMF parametrization as the one considered here. Our approach is
robust to initial conditions and more accurate than competing alternatives. It
also estimates the correct number of signatures even when other methods fail.
Results on real data agree well with current knowledge.
AVAILABILITY AND IMPLEMENTATION: signeR is implemented in R and C ++, and is
available as a R package at http://bioconductor.org/packages/signeR CONTACT:
[email protected] information: Supplementary data are
available at Bioinformatics online. MOTIVATION: Cancers arise as the result of somatically acquired changes in the
DNA of cancer cells. However, in addition to the mutations that confer a growth
advantage, cancer genomes accumulate a large number of somatic mutations
resulting from normal DNA damage and repair processes as well as carcinogenic
exposures or cancer related aberrations of DNA maintece machinery. These
mutagenic processes often produce characteristic mutational patterns called
mutational signatures. The decomposition of a cancer genome's mutation catalog
into mutations consistent with such signatures can provide valuable information
about cancer etiology. However, the results from different decomposition methods
are not always consistent. Hence, one needs to be able to not only decompose a
patient's mutational profile into signatures but also establish the accuracy of
such decomposition.
RESULTS: We proposed two complementary ways of measuring confidence and
stability of decomposition results and applied them to analyze mutational
signatures in breast cancer genomes. We identified both very stable and highly
unstable signatures, as well as signatures that previously have not been
associated with breast cancer. We also provided additional support for the novel
signatures. Our results emphasize the importance of assessing the confidence and
stability of inferred signature contributions.
AVAILABILITY AND IMPLEMENTATION: All tools developed in this paper have been
implemented in an R package, called SignatureEstimation, which is available from
https://www.ncbi.nlm.nih.gov/CBBresearch/Przytycka/index.cgi\#signatureestimation.
SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics
online. |
According to guidelines, insulin resistance is one risk factor in the diagnosis of metabolic syndrome, name 3 more risk factors. | Metabolic syndrome (MetS) is generally defined as a cluster of metabolically related cardiovascular risk factors which are often associated with the condition of insulin resistance, elevated blood pressure, and abdominal obesity. | Insulin resistance syndrome (IRS), also termed syndrome X, is a distinctive
constellation of risk factors for the development of type 2 diabetes mellitus
and cardiovascular disease. The syndrome's hallmarks are glucose intolerance,
hyperinsulinemia, a characteristic dyslipidemia (high triglycerides; low
high-density lipoprotein cholesterol, and small, dense low-density lipoprotein
cholesterol), obesity, upper-body fat distribution, hypertension, and increased
prothrombotic and antifibrinolytic factors. Insulin resistance, caused by a
complex of genetic and environmental influences, is now recognized not just as a
mechanism contributing to hyperglycemia in type 2 diabetes, but also as an early
metabolic abnormality that precedes the development of overt diabetes. The
clinical definition of insulin resistance is the impaired ability of insulin
(either endogenous or exogenous) to lower blood glucose. In some
insulin-resistant individuals, insulin secretion will begin to deteriorate under
chronic stress (glucose toxicity) and overt diabetes will result. If not,
individuals will remain hyperinsulinemic, with perhaps some degree of glucose
intolerance, together with other hallmarks of the IRS. The statistical
correlation between hypertension and impaired glucose tolerance is clear,
although the mechanism is not yet fully understood. Epidemiologic evidence of
insulin resistance as an independent risk factor for atherosclerosis and
coronary heart disease (CHD) completed the evolving concept of IRS as the common
soil for the development of both diabetes and CHD. No single laboratory test
exists for diagnosis of IRS. Rather, IRS remains a clinically evident syndrome
that can be suspected on the basis of physical and laboratory findings. This
identifies individual patients whom the clinician should screen for associated
comorbid conditions, aggressively control cardiovascular risk factors, and
tailor drug therapy for optimal benefit. This article provides practical
guidelines to achieve these goals and specific strategies to ameliorate
cardiovascular and metabolic risk in the IRS. The metabolic syndrome is a complex association of several risk factors
including insulin resistance, dyslipidemia, and essential hypertension. Insulin
resistance has been associated with sympathetic activation and endothelial
dysfunction, which are the main mechanisms involved in the pathophysiology of
hypertension and its related cardiovascular risk. According to the Sixth Report
of the Joint National Committee, and guidelines of the World Health
Organization/International Society of Hypertension, the presence of multiple
risk markers suggests that both hypertension and risk factors should be
aggressively managed in order to obtain a better outcome. Primary prevention of
obesity at different levels--individual, familial, and social-- starting early
in childhood has proven to be cost effective, and will be mandatory to reduce
the world epidemic of obesity and its severe consequences. Metabolic Syndrome X is a clinical entity which comprises the following factors:
diabetes mellitus, arterial hypertension, high levels of triglyceride and/or low
levels of HDL cholesterol, central obesity and microalbuminuria (by WHO
criteria). The first goal of this study was to determine the frequency of the
Metabolic Syndrome X (MSX) in patients with acute myocardial infarction compared
with the general population. The second goal of the study was to examine the
frequency of heart failure and reinfarction rate in the patients with myocardial
infarction, with and without MSX. Furthermore, the relationship between gender
and MSX was analyzed. A total of 101 patients with acute myocardial infarction
took part in randomized trial (32 women and 69 men). MSX and all of its
components were diagnosed according to WHO criteria. To determine statistical
significance of our results, we used chi2 test and t-test for independent
samples. From 101 patient 48 had MSX (47.52%), while in the general population
incidence of MSX is 3-4%. The reinfarction and the heart failure rate were
significantly higher in the group of patients with MSX (p = 0.0067 and p =
0.0217, respectively). To conclude, the results of the present study confirm
that MSX is a high risk factor for myocardial infarction and its complications. Insulin resistance represents a common metabolic abnormality leading to
cardiovascular disease, the major cause of morbidity and mortality in most parts
of the world. Insulin resistance is also associated with an increased risk of
type 2 diabetes which is strongly associated with obesity. The insulin
resistance of obese people and subjects with type 2 diabetes is characterised by
defects at many levels, affecting insulin receptor concentration, glucose
transport mechanisms and the activities of intracellular enzymes. Around 25% of
western populations show some features of the insulin resistance syndrome (often
referred to as syndrome X or the metabolic syndrome) ie, a clustering of
metabolic, atheromatous risk factors, including hypertriglyceridaemia,
hyperinsulinaemia, hyper-tension, hypercholesterinaemia and obesity. However,
the known metabolic cardiovascular risk factors associated with the insulin
resistance syndrome do not sufficiently explain the excess vascular risk
attributed to this syndrome. The observation, that increased plasma plasminogen
activator inhibitor 1 (PAI-1) levels were associated with insulin resistance and
atherothrombosis added for the first time a pathological basis for an
association of the insulin resistance syndrome not only with metabolic,
atheromatous (atherosclerotic) risk but also with atherothrombotic risk. It is
very likely that not only PAI-1, but also other abnormalities in haemostatic
variables contribute to this excess vascular risk. Knowledge of how haemostatic
variables cluster with classical metabolic risk factors associated with the
insulin resistance syndrome could help to better understand the pathogenesis of
cardiovascular diseases. Indeed, many coagulation and fibrinolytic proteins have
been shown to be associated with features of the insulin resistance syndrome and
these associations suggest that some coagulation and fibrinolytic proteins have
a role in atherothrombotic disorders, principally through an association with
other established metabolic (atheromatous) risk factors in the presence of
underlying insulin resistance. Interestingly, new therapeutic approaches in the
prevention and treatment of insulin resistance do show some influence on
coagulation and fibrinolysis. The newest drugs are the thiazolidinediones, a
totally novel class of insulin sensitisers. They have the potential to offer
improvements both in glycaemic control and in cardiovascular events. Metabolic syndrome is widely spread in population especially among subjects with
risk factors of atherosclerosis related diseases. Since 1988 criteria of
metabolic syndrome have undergone substantial transformation. Technical
difficulties related to detection of insulin resistance created obstacles to
application of the term "metabolic syndrome" in clinical practice. In 2001
experts of National Cholesterol Education Program in USA suggested new set of
criteria. The presence of 3 or more of the following 5 components (abdominal
obesity, hypertriglyceridemia, low level of high density lipoprotein
cholesterol, hypertension and high fasting blood glucose) allows to diagnose
metabolic syndrome. These worldwide used criteria do not imply detection of
insulin resistance. Feasibility of this approach has been confirmed by analysis
of correlation between presence of markers of insulin resistance and that of
metabolic syndrome according to novel criteria. This analysis has shown that
combination of 3 or more components is significantly associated with insulin
resistance. Approximately 2500 Americans die from cardiovascular disease (CVD) each day.
Each year, CVD claims more lives than the next four leading causes of death
combined. Direct and indirect costs of CVD are estimated to be Dollars 403.1
billion in 2006. Despite advancements in conventional therapy, the residual risk
of CVD continues to rise. One component of the cardiometabolic risk is metabolic
syndrome. Metabolic syndrome is a constellation of interrelated risk factors of
metabolic origin including abdominal obesity, atherogenic dyslipidemia, elevated
blood pressure, elevated plasma glucose level, and prothrombotic and
proinflammatory states that promote atherosclerotic CVD and increase the risk of
type 2 diabetes mellitus. Approximately 47 million residents of the United
States have metabolic syndrome. Abdominal obesity and insulin resistance appear
to be its predomit underlying risk factors. Abdominal adiposity is considered
high-risk fat, and it is associated with insulin resistance, hyperglycemia,
dyslipidemia, hypertension, and prothrombotic and/or proinflammatory states.
Despite notable advances in cardiovascular risk management, the prevalence of
cardiovascular events and type 2 diabetes remains high. First-line therapy for
individuals with metabolic syndrome should be directed to the major CVD risk
factors, namely, elevated low-density lipoprotein cholesterol levels,
hypertension, and diabetes, and it should emphasize lifestyle modification.
Until additional research better defines the most appropriate therapies,
conventional cardiovascular risk factors, such as lipid levels, blood pressure,
and diabetes, should be managed in individuals with metabolic syndrome according
to nationally accepted clinical guidelines. The metabolic syndrome is a clustering of risk factors which predispose an
individual to cardiovascular morbidity and mortality. There is general consensus
regarding the main components of the syndrome (glucose intolerance, obesity,
raised blood pressure and dyslipidaemia [elevated triglycerides, low levels of
high-density lipoprotein cholesterol]) but different definitions require
different cut points and have different mandatory inclusion criteria. Although
insulin resistance is considered a major pathological influence, only the World
Health Organization (WHO) and European Group for the study of Insulin Resistance
(EGIR) definitions include it amongst the diagnostic criteria and only the
International Diabetes Federation (IDF) definition has waist circumference as a
mandatory component. The prevalence of metabolic syndrome within individual
cohorts varies with the definition used. Within each definition, the prevalence
of metabolic syndrome increases with age and varies with gender and ethnicity.
There is a lack of diagnostic concordance between different definitions. Only
about 30% of people could be given the diagnosis of metabolic syndrome using
most definitions, and about 3540% of people diagnosed with metabolic syndrome
are only classified as such using one definition. There is currently debate
regarding the validity of the term metabolic syndrome, but the presence of one
cardiovascular risk factor should raise suspicion that additional risk factors
may also be present and encourage investigation. Individual risk factors should
be treated. The metabolic syndrome is a constellation of risk factors including glucose
dysregulation, central obesity, dyslipidemia, and hypertension. There are
multiple definitions that have been described by various health organizations.
However, we do know that insulin resistance plays a major role as the underlying
cause for the development and potentiation of the metabolic syndrome. At
present, it is unclear if the diagnosis of metabolic syndrome is greater than
the sum of its parts. However, the presence of more than one of the associated
risk factors should indicate that a patient is at increased risk for developing
diabetes, cardiovascular disease and death. Thus, the primary care physician
should aggressively treat the metabolic risk factors in their patients to
prevent the onset and progression to more severe disease. The waist circumference cut point for diagnosing the metabolic syndrome in
sub-Saharan African subjects is based on that obtained from studies in European
populations. The aim of this study was to measure the prevalence of obesity and
related metabolic disorders in an urban population of African females, a group
at high risk for such diseases, and to determine the appropriate waist cut point
for diagnosing the metabolic syndrome. Anthropometry and fasting lipid, glucose
and insulin levels were measured in a cohort of 1251 African females
participating in the Birth to Twenty cohort study in Soweto, Johannesburg. The
waist circumference cut points for diagnosing metabolic syndrome (as defined
using the new harmonised guidelines), insulin resistance, dysglycaemia,
hypertension and dyslipidaemia were obtained using receiver operator
characteristic curve analysis. The prevalence of obesity, type 2 diabetes and
metabolic syndrome were 50.1%, 14.3% and 42.1%, respectively. The appropriate
waist cut point for diagnosing metabolic syndrome was found to be 91.5 cm and
was similar to the cuts points obtained for detecting increased risk of insulin
resistance (89.0 cm), dysglycaemia (88.4 cm), hypertension (90.1 cm), hypo-high
density lipoproteinaemia (87.6 cm) and hyper-low density lipoproteinaemia (90.5
cm). The present data demonstrates that urban, African females have a high
prevalence of obesity and related disorders and the waist cut point currently
recommended for the diagnosis of the metabolic syndrome (80.0 cm) in this
population should be increased to 91.5 cm. This latter finding demonstrates a
clear ethnic difference in the relationship between abdominal adiposity and
metabolic disease risk. The similar waist cut points identified for the
detection of the individual components of the metabolic syndrome and related
cardiovascular risk factors demonstrates that the risk for different metabolic
diseases increases at the same level of abdominal adiposity suggesting a common
aetiological pathway. Obesity and overweight are nowadays very prevalent worldwide. They are known to
be linked with an increased risk of developing cardiovascular comorbidities and
mortality. Abdominal obesity is frequently associated with a collection of
metabolic disorders that include elevated blood pressure, characteristic lipid
abnormalities (low high-density lipoprotein cholesterol and high triglycerides)
and increased fasting glucose, with an underlying situation of insulin
resistance, which has been defined as metabolic syndrome, conferring a high
cardiovascular risk profile to these subjects. A multidisciplinary approach is
required, including lifestyle changes and pharmacological and surgical
approaches. Intensive management of all the risk factors of the metabolic
syndrome is also needed to reduce body weight and waist circumference, lessen
insulin resistance and avoid the development of new-onset diabetes and
cardiovascular disease associated with this entity. This article will review the
recently published literature and guideline updates on this topic, although it
is not yet included in the highlights. Metabolic syndrome is a cluster of conditions that synergistically increase the
risk of cardiovascular disease, type 2 diabetes, and premature mortality. The
components are abdominal obesity, impaired glucose metabolism, dyslipidemia, and
hypertension. Prediabetes, which is a combination of excess body fat and insulin
resistance, is considered an underlying etiology of metabolic syndrome.
Prediabetes manifests as impaired fasting glucose and/or impaired glucose
tolerance. Impaired fasting glucose is defined as a fasting blood glucose level
of 100 to 125 mg/dL; impaired glucose tolerance requires a blood glucose level
of 140 to 199 mg/dL 2 hours after a 75-g oral intake of glucose. In patients
with prediabetes, the rate of progression to diabetes within 3 years can be
decreased by approximately 58% with lifestyle modifications. These include
weight loss through exercise (30 minutes or more of moderate physical activity
on most, preferably all, days of the week) and dietary modifications.
Recommended diets are high in fruits, vegetables, whole grains, and fish.
Consumption of sweetened beverages, including diet soda, should be avoided. For
patients who do not achieve goals with lifestyle modifications, metformin can be
considered. Weight loss drugs and bariatric surgery are appropriate for select
patients. Hypertension and dyslipidemia should be managed according to current
guidelines. This article reviews the relationship between metabolic syndrome (MetS) and
nephrolithiasis, as well as the clinical implications for patients with this
dual diagnosis. MetS, estimated to affect 25% of adults in the United States, is
associated with a fivefold increase in the risk of developing diabetes, a
doubling of the risk of acquiring cardiovascular disease, and an increase in
overall mortality. Defined as a syndrome, MetS is recognized clinically by
numerous constitutive traits, including abdominal obesity, hypertension,
dyslipidemia (elevated triglycerides, low high-density lipoprotein cholesterol),
and hyperglycemia. Urologic complications of MetS include a 30% higher risk of
nephrolithiasis, with an increased percentage of uric acid nephrolithiasis in
the setting of hyperuricemia, hyperuricosuria, low urine pH, and low urinary
volume. Current American Urological Association and European Association of
Urology guidelines suggest investigating the etiology of nephrolithiasis in
affected individuals; however, there is no specific goal of treating MetS as
part of the medical management. Weight loss and exercise, the main lifestyle
treatments of MetS, counter abdominal obesity and insulin resistance and reduce
the incidence of cardiovascular events and the development of diabetes. These
recommendations may offer a beneficial adjunctive treatment option for
nephrolithiasis complicated by MetS. Although definitive therapeutic
recommendations must await further studies, it seems both reasonable and
justifiable for the urologist, as part of a multidisciplinary team, to recommend
these important lifestyle changes to patients with both conditions. These
recommendations should accompany the currently accepted management of
nephrolithiasis. BACKGROUND: Metabolic syndrome (MetS) is a collection of clinical conditions,
including central obesity, hypertension, glucose intolerance and dyslipidemia.
The long-term inflammatory and metabolic dysfunction associated with MetS may
contribute to osteoarthritic processes leading up to total joint arthroplasty
(TJA). The purpose of this study was to investigate levels of metabolic
biomarkers and the prevalence of MetS in patients undergoing TJA.
METHODS: Under IRB approval, citrated plasma samples were collected from 41
patients undergoing total hip and knee arthroplasty (THA/TKA) preoperatively and
day 1 postoperatively. Control group consisted of 25 healthy human plasma
samples (female and male, 18-35 years old) purchased from George King Biomedical
Inc. (Overland Park, KS, USA). Samples were profiled for c-peptide, ferritin,
IL-6, insulin, resistin, TNF-α, IL-1a, leptin, and PAI-1 using metabolic
biochips purchased from RANDOX Co. (Antrim, Northern Ireland). NCEP/ATP III
guidelines were used to evaluate which patients met MetS criteria.
RESULTS: Levels of IL-6, resistin, TNF-a, IL-1a, leptin, and PAI-1 were
significantly elevated in patients undergoing TJA compared to normal. C-peptide
and insulin were both decreased in TJA compared to normal. No significance was
found when comparing TJA to normal for ferritin. TNFα was significantly lower in
TJA+MetS compared to TJA-MetS, while other biomarkers showed no difference in
TJA±MetS populations. Insulin & c-peptide both showed a significant decrease in
TJA-MetS compared to normal, but levels in TJA+MetS patients were not
significantly different from controls. Resistin showed significant increases in
TJA+MetS vs. normal, but not in TJA-MetS vs. normal.
CONCLUSIONS: Overall, the differing metabolic profile seen in patients
undergoing TJA suggest ongoing metabolic dysfunction. Insulin and c-peptide
patterns among the different test groups hint toward a complex and dysfunctional
metabolic process involved, with leptin and underlying insulin resistance
playing a role. Increased resistin in TJA+MetS, but not in TJA-MetS, compared to
normal, suggests that while elevated resistin levels may be associated with the
osteoarthritic process, levels are further attenuated by MetS, which is highly
prevalent in this population. Increased TNFα in TJA-MetS compared to TJA+MetS
may be an artifact of differing sample populations or a true complication of the
complex pathophysiology and medical regimen seen in patients with both OA and
MetS. The lack of difference seen in the remaining biomarkers suggest that
having MetS as a comorbidity does not contribute to the elevated levels seen in
patients undergoing TJA. Metabolic syndrome (MetS) is generally defined as a cluster of metabolically
related cardiovascular risk factors which are often associated with the
condition of insulin resistance, elevated blood pressure, and abdominal obesity.
During the past decades, MetS has become a major public health issue worldwide
in both adults and children. In this study, data from the China Health and
Nutrition Surveys (CHNS) was used to assess the prevalence of MetS based on both
the National Cholesterol Education Program Adult Treatment Panel III
(NCEP-ATPIII) guidelines and the International Diabetes Federation (IDF)
criteria, and to evaluate its possible correlates. A total of 831 children aged
7-18 years were included in this study, and 28 children were classified as
having MetS as defined by the modified NCEP-ATPIII definition, which yielded an
overall prevalence of 3.37%. Elevated blood pressure was the most frequent MetS
component. The results of logistic regression models revealed that increased
body mass index (BMI), hyperuricemia, and insulin resistance (IR) were all
associated with the presence of MetS. To conclude, our study revealed the
prevalence of MetS in Chinese children at the national level. Further
large-scale studies are still needed to identify better MetS criteria in the
general paediatric population in China. |
Silent Allosteric Modulation of mGluR5 is a form of treatment for what disease? | silent allosteric modulation of mGluR5 has promise as a disease-modifying AD intervention with a broad therapeutic window. | |
What are check point inhibitors? | Immune checkpoint blocking monoclonal antibodies are heralded as a promising therapeutic approach in clinical oncology. These mAbs do not directly attack the malignant cells as most anticancer mAbs; rather, they enhance the anti-tumor response of the immune system by targeting immune regulatory pathways. | The immune system plays an active role in the pathogenesis of ovarian cancer
(OC), as well as in the mechanisms of disease progression and overall survival
(OS). Immunotherapy in gynecological cancers could help to revert
immunosuppression and lymphocyte depletion due to prior treatments. Current
immunotherapies for ovarian cancer, like all cancer immunotherapy, are based on
either stimulating the immune system or reverting immune suppression. Several
approaches have been used, including therapeutic vaccines, monoclonal
antibodies; checkpoint inhibitors and adoptive T cell transfer. Most of these
therapies are still in early-phase testing (phase I and II) for ovarian cancer,
but the initial data in ovarian cancer and successful use in other types of
cancers suggests some of these approaches may ultimately prove useful for
ovarian cancer as well. Ovarian cancer vaccines have shown only a modest benefit
in ovarian cancer when used as monotherapy, but these agents may be able to
enhance antitumor activity when combined with chemotherapy, checkpoint
inhibitors, or other immunotherapies. Monoclonal antibodies have been explored
in ovarian cancer but despite encouraging phase II data, randomized studies
failed to demonstrate significant clinical benefit. Check point inhibitors have
promising activity in several solid tumors and have demonstrated a favorable
toxicity profile. Data from early clinical trials utilizing PD1 and PD-L1
inhibitors showed encouraging results. Ongoing clinical trials are evaluating
the role of check point inhibitors in combination with chemotherapy. Adoptive T
cell transfer involves the infusion of ex vivo activated and expanded tumor
specific T cells, using various sources and types of T cells. While this
approach has been explored in several hematologic maligcies, it constitutes
early research in ovarian cancer. Immunotherapy remains investigational in
ovarian cancer and the benefit of this approach in improving progression-free
survival (PFS) or OS is unknown. Previous clinical trials have not selected
patients based on biomarkers and this may explain the negative results. We
expect to discover that tumor response will relate to the patient's immune
features and specific tumor characteristics. We are only beginning to realize
the potential of immunotherapy for ovarian cancer patients, and one goal of
future clinical trials will be to identify subsets of patient based on
histologic, molecular, and immune characteristics. INTRODUCTION: The treatment of melanoma is evolving rapidly over the past few
years. Patients with BRAFv600 mutations can be treated with a combination of a
BRAF-inhibitor and an MEK-inhibitor. Patients with BRAF wild-type tumors and
BRAFv600 mutated tumors can be treated with immunotherapy i.e. check point
inhibitors.
AREAS COVERED: We conducted a comprehensive review of the literature on the
efficacy and predictive markers, safety, and pharmacoeconomics of ipilimumab in
melanoma Expert commentary: Ipilimumab was the first check point inhibitor
reaching the clinic, gaining FDA and EMA approval for metastatic melanoma in
2011. Ipilimumab was also approved by FDA in the adjuvant setting for patients
with high risk, stage III melanoma. The anti-PD1 directed antibodies
pembrolizumab and nivolumab are superior to single agent ipilimumab, which is no
longer considered the standard first line treatment in metastatic melanoma. The
addition ipilimumab to nivolumab is associated with a higher response rate and a
better PFS, particularly in patients with PD-L1 negative tumors, albeit at the
cost of a steep increase in grade 3-4 adverse event rate. Definitive survival
data on this combination are pending and the selection of patients potentially
requiring the combination and its pharmacoeconomic implications are to be
elucidated. BACKGROUND: Glioblastoma multiforme (GBM) is the most frequent brain tumor.
Despite recent advances in treatment approaches the prognosis remains poor, with
a median overall survival of 14.6 months. Immunotherapy is the subject of
ongoing research and its benefit is becoming evident in other maligcies.
Immune check-points such as cytotoxic T lymphocyte associated antigen 4
(CTLA-4), programmed cell death receptor (PD-1) and indoleamine 2,3-dioxygenase
(IDO) reduce immune response.
OBJECTIVE: To clarify the role of immune check point inhibitors in GBM
management.
METHODS: Preclinical and clinical trials of immune check-point inhibitors in GBM
were obtained by searching for English peer-reviewed articles on PubMed
databases, trials registered on clincaltrials. gov and abstracts recently
presented at international congresses.
RESULTS: Immune check point inhibitors may be of critical importance for the
design of future immunotherapy approaches in GBM management.
CONCLUSION: Immune check-point inhibitors should be considered a promising
treatment option in GBM. Immune check-point inhibitors are now employed as single-agents in current
practice for the treatment of advanced non-small cell lung cancer (NSCLC), while
combinations of different inhibitors are being evaluated in clinical trials.
Although the safety profile of these compounds, with particular reference to
drugs targeting programmed death protein 1 (PD-1) and its ligand (PD-L1), is
generally considered manageable, peculiar, immune-related toxicities may onset.
Areas covered: This review focuses on the immune-related adverse events (irAEs)
observed during immune check-point blockade in NSCLC and their management. The
authors report the incidence of irAEs based on the currently available data
involving NSCLC and provide recommendations on the general approach to irAEs, as
well as indications for the most relevant site-specific events. Expert opinion:
Since irAEs may involve a wide range of organs and systems and are potentially
reversible if promptly treated, early diagnosis should always be achieved; this
might be particularly challenging when other potential causes of toxicity are
suspected, such as infections or concurrent treatments. Finally, drugs active on
the PD-1/PD-L1 axis appear to be generally manageable even when they are
administered to patients with relevant comorbidities, provided that adequate
clinical monitoring is performed. Drug resistance of tumor cells to chemotherapy is limiting the therapeutic
efficacy of most anticancer drugs and represents a major obstacle in medical
oncology. However, treatment of various human maligcies with biologics,
mostly monoclonal antibodies (mAbs), is not limited by such chemoresistance
mechanisms. However, other resistance or evasion mechanisms limit the efficacy
to anticancer therapeutic mAbs that engage tumor-associated antigens on the
surface of the maligt cells. Immune checkpoint blocking monoclonal antibodies
are heralded as a promising therapeutic approach in clinical oncology. These
mAbs do not directly attack the maligt cells as most anticancer mAbs; rather,
they enhance the anti-tumor response of the immune system by targeting immune
regulatory pathways. Three mAbs targeting immune checkpoint molecules are
currently used in the clinic and new mAbs that target other potential inhibitory
targets are being actively investigated. This therapeutic approach, while
proving as highly beneficial for many patients, is prone to toxicities and side
effects of an autoimmune nature. Defining suitable management algorithms and
biomarkers that predict therapeutic effects and adverse toxicity are required to
provide survival benefit for larger numbers of cancer patients. Overcoming these
challenges, along with opportunities for new agents and combinatorial strategies
are the main focus of immune checkpoint blockade research today. The recent successes of immune check point targeting therapies in treating
cancer patients has driven a resurgence of interest in targeting these pathways
in chronically infected patients. While still in early stages, basic and
clinical data suggest that blockade of CTLA-4 and PD-1 can be beneficial in the
treatment of chronic HIV, HBV, and HCV infection, as well as other chronic
maladies. Furthermore, novel inhibitory receptors such as Tim-3, LAG-3, and
TIGIT are the potential next wave of check points that can be manipulated for
the treatment of chronic infection. Blockade of these pathways influences more
than simply T cell responses, and may provide new therapeutic options for
chronically infected patients. Several cancers are highly refractory to conventional chemotherapy. The survival
of tumors in several cases is assisted by checkpoint immunomodulation to
maintain the imbalance between immune surveillance and cancer cell
proliferation. Check point antibody inhibitors, such as anti-PD-1/PD-L1, are a
novel class of inhibitors that function as a tumor suppressing factor via
modulation of immune cell-tumor cell interaction. These checkpoint blockers are
rapidly becoming a highly promising cancer therapeutic approach that yields
remarkable antitumor responses with limited side effects. In recent times, more
than four check point antibody inhibitors have been commercialized for targeting
PD-1, PDL-1, and CTLA-4. Despite the huge success and efficacy of the anti-PD
therapy response, it is limited to specific types of cancers, which attributes
to the insufficient and heterogeneous expression of PD-1 in the tumor
microenvironment. Herein, we review the current landscape of the PD-1/PD-L1
mechanistic role in tumor immune evasion and therapeutic outcome for cancer
treatment. We also review the current progress in clinical trials, combination
of drug therapy with immunotherapy, safety, and future of check point inhibitors
for multiple types of cancer. |
Are the human bombesin receptors, GRPR and NMBR, frequently overexpressed G-protein-coupled-receptors by lung-cancers? | The human bombesin receptors, GRPR and NMBR, are two of the most frequently overexpressed G-protein-coupled-receptors by lung-cancers | Gastrin-releasing peptide (GRP), a member of the bombesin family of peptides,
has been shown to have mitogenic activity in small cell lung carcinoma (SCLC),
and to be produced by SCLC in an autocrine fashion. In this report, we
demonstrate that both GRP and another member of the bombesin family of peptides,
neuromedin B (NMB), are also autocrine growth factors for non-small cell lung
carcinoma (NSCLC). Using the reverse transcription-polymerase chain reaction
(RT-PCR), we have detected mRNA for the neuromedin B receptor (NMBR) in all 14
of the NSCLC cell lines examined. GRP receptor (GRPR) mRNA was also expressed in
the majority of NSCLC cell lines (nine of 14). By immunoblotting using SDS-PAGE
gradient gels fixed in trichloroacetic acid, GRP and NMB were found in fractions
of culture medium that had been purified by high pressure liquid chromatography
(HPLC) from NSCLC cell lines. NMB was detected in the conditioned medium of
seven of nine cell lines and GRP in seven of nine cell lines; both peptides were
produced in six cell lines. In four of the cell lines where both peptides were
produced, the relative amount of NMB secreted into the medium was 7-15 times
that of GRP; in the other two cases, the relative amounts of GRP and NMB were
equivalent. Cultured human bronchial epithelial (HBE) cells expressed the GRPR
and NMBR but did not produce either peptide. A subline of A549 cells that was
adapted to grow in serum-free and growth factor-free conditions, termed
A549-R(0), secreted both bombesin-like peptides (BLPs) into the culture medium.
Using either a colony-forming assay or a BrDU incorporation assay, both NMB and
GRP were found to be mitogens for three NSCLC cell lines that express mRNA for
BLP receptors and secrete BLPs, regardless of which peptide and/or receptor
subtype was detected. The monoclonal antibody 2A11, which preferentially
recognizes GRP, was able to block the in vitro proliferative response to GRP in
the BrDU incorporation assay, and partially blocked the response to NMB. The
2A11 antibody could only partially block the in vivo growth of cell lines that
showed proliferative responses to BLPs. 2A11 antibody was more effective against
the 239T cell line, which secreted a low amount of GRP into the medium (0.6 nM),
compared to the 201T cell line, which secreted a higher amount of both GRP and
NMB (4.2 nM and 36.6 nM, respectively). These results suggest that both NMB and
GRP are autocrine growth factors for NSCLC, but that the production of NMB and
expression of the NMBR may be more prominent than the production of GRP and
expression of the GRP receptor. If BLP ligand-receptor systems are to be
targeted therapeutically in NSCLC, it will be necessary to inhibit both NMB and
GRP. INTRODUCTION: Carcinoids are mainly found in the gastrointestinal (65%) and
bronchopulmonary tract (25%). These neuroendocrine tumors secrete a wide range
of bioactive peptides, including gastrin releasing peptide and neuromedin B, the
mammalian analogs of bombesin. The purpose of this study was to investigate the
quantity and localization of bombesin receptors in gastrointestinal and
pulmonary carcinoids, and to reveal whether bombesin-like peptides (BLP) and
their receptors are of any value in distinguishing pulmonary carcinoids from
carcinoids of intestinal origin.
METHODS: Carcinoid tumors with pulmonary (no.=9) or intestinal (no.=15)
localizations were analyzed by immunohistochemistry, autoradiography, and
radioimmunoassay, to examine the presence of bombesin receptor subtypes and
determine BLP levels in these tumors.
RESULTS: All 3 bombesin receptor subtypes (GRPR, NMBR, and BRS-3) were present
on pulmonary and intestinal carcinoids by immunohistochemistry. In pulmonary
carcinoids, low receptor ligand binding densities together with high and low BLP
levels were found. Intestinal carcinoids showed predomitly high receptor
ligand binding densities in combination with low BLP levels.
CONCLUSIONS: The expression of bombesin receptor subtypes is independent from
the carcinoid tumor origin, and is therefore not recommended as a distinction
marker, although carcinoids of pulmonary and intestinal origin possess different
receptor binding affinities for bombesin and dissimilar BLP levels. The combined
presence of bombesin and its receptors might suggest the presence of a paracrine
or autocrine growth loop in carcinoids. There is increased interest in the Bn-receptor family because they are
frequently over/ectopically expressed by tumors and thus useful as targets for
imaging or receptor-targeted-cytotoxicity. The synthetic Bn-analog, [D-Tyr(6),
β-Ala(11), Phe(13), Nle(14)]Bn(6-14) [Univ.Lig] has the unique property of
having high affinity for all three human BNRs (GRPR, NMBR, BRS-3), and thus
could be especially useful for this approach. However, the molecular basis of
this property is unclear and is the subject of this study. To accomplish this,
site-directed mutagenesis was used after identifying potentially important amino
acids using sequence homology analysis of all BnRs with high affinity for
Univ.Lig compared to the Cholecystokinin-receptor (CCK(A)R), which has low
affinity. Using various criteria 74 amino acids were identified and 101
mutations made in GRPR by changing each to those of CCK(A)R or to alanine. 22
GRPR mutations showed a significant decrease in affinity for Univ.Lig (>2-fold)
with 2 in EC2[D97N, G112V], 1 in UTM6[Y284A], 2 in EC4[R287N, H300S] showing
>10-fold decrease in Univ.Lig affinity. Additional mutations were made to
explore the molecular basis for these changes. Our results show that high
affinity for Univ.Lig by human Bn-receptors requires positively charged amino
acids in extracellular (EC)-domain 4 and to a lesser extent EC2 and EC3
suggesting charge-charge interactions may be particularly important for
determining the general high affinity of this ligand. Furthermore, transmembrane
amino acids particularly in UTM6 are important contributing both charge-charge
interactions as well as interaction with a tyrosine residue in close proximity
suggesting possible receptor-peptide cation-π or H-bonding interactions are also
important for determining its high affinity. |
Which data simulator is available for CLIP-SEQ experiments? | CLIP-Seq protocols such as PAR-CLIP, HITS-CLIP or iCLIP allow a genome-wide analysis of protein-RNA interactions. For the processing of the resulting short read data, various tools are utilized. Some of these tools were specifically developed for CLIP-Seq data, whereas others were designed for the analysis of RNA-Seq data. To this date, however, it has not been assessed which of the available tools are most appropriate for the analysis of CLIP-Seq data. This is because an experimental gold standard dataset on which methods can be accessed and compared, is still not available. To address this lack of a gold-standard dataset, Cseq-Simulator was developed as a simulator for PAR-CLIP, HITS-CLIP and iCLIP-data. This simulator can be applied to generate realistic datasets that can serve as surrogates for experimental gold standard dataset. | CLIP-Seq protocols such as PAR-CLIP, HITS-CLIP or iCLIP allow a genome-wide
analysis of protein-RNA interactions. For the processing of the resulting short
read data, various tools are utilized. Some of these tools were specifically
developed for CLIP-Seq data, whereas others were designed for the analysis of
RNA-Seq data. To this date, however, it has not been assessed which of the
available tools are most appropriate for the analysis of CLIP-Seq data. This is
because an experimental gold standard dataset on which methods can be accessed
and compared, is still not available. To address this lack of a gold-standard
dataset, we here present Cseq-Simulator, a simulator for PAR-CLIP, HITS-CLIP and
iCLIP-data. This simulator can be applied to generate realistic datasets that
can serve as surrogates for experimental gold standard dataset. In this work, we
also show how Cseq-Simulator can be used to perform a comparison of steps of
typical CLIP-Seq analysis pipelines, such as the read alignment or the peak
calling. These comparisons show which tools are useful in different settings and
also allow identifying pitfalls in the data analysis. |
Falciform ligament sign is characteristic to which disease? | The falciform ligament sign (gas outlining the falciform ligament) is characteristic to pneumoperitoneum due to intestinal perforation. | A blinded, retrospective study was performed to determine the value of supine
abdominal radiographs in diagnosing pneumoperitoneum. Supine films from 44 cases
of pneumoperitoneum were randomly interspersed among supine films from 87
control subjects without free air, and the films were reviewed for the presence
or absence of various signs of pneumoperitoneum, including Rigler's sign (gas on
both sides of the bowel wall), the falciform ligament sign (gas outlining the
falciform ligament), the football sign (gas outlining the peritoneal cavity),
the inverted-V sign (gas outlining the medial umbilical folds), and the
right-upper-quadrant gas sign (localized gas in the right upper quadrant). One
or more of these signs were present in 26 cases (59%) of pneumoperitoneum,
including the right-upper-quadrant gas sign in 18 cases (41%), Rigler's sign in
14 cases (32%), and the falciform ligament and football signs in one case each
(2%). Unfortunately, there were frequent errors in the interpretation of the
right-upper-quadrant gas sign and Rigler's sign, with a total of 11
false-positive cases (13%). Further analysis of the true-positive
right-upper-quadrant gas signs showed that these gas collections were always
triangular or linear with an inferolateral to superomedial orientation and, if
triangular, a concave superolateral border. In the true-positive Rigler's signs,
the bowel wall thickness ranged from 1 to 8 mm, whereas the false positives all
had a bowel wall thickness of 1 mm or less. Proper interpretation of the various
signs of pneumoperitoneum on supine films should lead to more accurate diagnosis
of this condition. The purpose of this study is to review the computed tomography (CT) appearance
of gastrointestinal tract (GI) perforation. Forty-two patients with 10 cases of
proximal GI perforation and 32 cases of distal GI perforation were evaluated
based on the CT findings of extraluminal air (which was subdivided into the
CT-falciform ligament sign crossing the midline and scattered pockets of air),
bowel wall thickening (>8 mm in gastroduodenal wall, >3 mm in the small bowel
wall, >6 mm in the caliber of the appendix and >5 mm in the colonic wall),
associated abscess formation, ascites and adjacent fat stranding. The results
were compared using Fisher's Exact Test. Detection of extraluminal air in the
upright plain films and CT was analyzed by Z test. Our results showed that
CT-falciform ligament sign was more frequent in the proximal GI perforation,
while pockets of extraluminal air (excluding the cases accompanying CT-falciform
ligament sign), bowel wall thickening and fat stranding were found in higher
incidence in distal GI perforation (P<.05). CT detected extraluminal air in more
cases than the upright plain films did (69% vs. 19%; Z=4.62>Z(0.01)=2.326). We
concluded that CT is a good imaging tool to differentiate the various GI
perforations. PURPOSE: To evaluate the usefulness of the periportal free air (PPFA) sign on
computed tomography (CT) to distinguish upper from lower gastrointestinal (GI)
tract perforation.
MATERIALS AND METHODS: During a 30-month period, we retrospectively analyzed
abdominal CT images of 53 consecutive patients with surgically proven GI tract
perforation. We divided the patients into two groups, i.e. upper and lower GI
tract perforation groups. According to the distribution of free air, we divided
the peritoneal cavity into supramesocolic compartment and inframesocolic
compartment. We observed the presence or absence of free air in each compartment
in each group. When there was free air in the periportal area, it was defined as
periportal free air (PPFA) and the sign was positive. To evaluate the usefulness
of the PPFA sign, we compared the PPFA sign with the falciform ligament sign and
the ligamentum teres sign, both of which are well-known CT signs of
pneumoperitoneum. Statistical analyses were performed with univariate and
multivariate analyses using SPSS version 11.5 for significant findings among the
CT signs.
RESULTS: Free air was seen in supramesocolic compartment in 29 of 30 (97%)
patients in the upper GI perforation group and in 17 of 23 (74%) in the lower GI
perforation group. Free air in inframesocolic compartment did not show
significant difference in either group (p=.16). The PPFA sign was seen in 28 of
30 (93%) patients with upper GI tract perforation, but in only 8 of 23 (35%)
patients with lower GI tract perforation (p<.0001). The falciform ligament sign
was seen in 24 of 30 (80%) patients with upper GI tract perforation and in 10 of
23 (43%) patients with lower GI tract perforation (p=.020). The ligamentum teres
sign was seen in 16 of 30 (53%) patients with upper GI tract perforation and in
2 of 23 (8%) patients with lower GI tract perforation (p=.008). Multivariate
logistic regression analysis showed that the PPFA sign was the only variable,
which adjusted odds ratio of 15.5 (p=.002).
CONCLUSION: The PPFA sign is a useful finding which can help to distinguish
upper from lower GI tract perforation. When this sign is present, upper GI tract
perforation is strongly suggested. PURPOSE: The purpose of this retrospective study was to determine what gives
rise to the periportal free air, and ligamentum teres and falciform ligament
signs on CT in patients with gastrointestinal (GI) tract perforation, and
whether these specific air distributions can play a clinically meaningful role
in the diagnosis of gastroduodenal perforation.
MATERIAL AND METHODS: Ninety-three patients who underwent a diagnostic CT scan
before laparotomy for a GI tract perforation were included. The readers assessed
the presence of specific air distributions on CT (periportal free air, and
ligamentum teres and falciform ligament signs). The readers also assessed the
presence of strong predictors of gastroduodenal perforation (focal defects in
the stomach and duodenal bulb wall, concentrated extraluminal air bubbles in
close proximity to the stomach and duodenal bulb, and wall thickening at the
stomach and duodenal bulb). The specific air distributions were assessed
according to perforation sites, and the elapsed time and amount of free air, and
then compared with the strong predictors of gastroduodenal perforation by using
statistical analysis.
RESULTS: All specific air distributions were more frequently present in patients
with gastroduodenal perforation than lower GI tract perforation, but only the
falciform ligament sign was statistically significant (p<0.05). The presence of
all three specific air distributions was demonstrated in only 13 (20.6%) of 63
patients with gastroduodenal perforation. Regardless of the perforation sites,
the falciform ligament sign was present significantly more frequently with an
increase in the amount of free air on multiple logistic regression analysis
(adjusted odds ratio, 1.29; p<0.001). The sensitivity, specificity, accuracy,
and positive predictive and negative predictive values of each strong predictor
for the diagnosis of gastroduodenal perforation were higher than those of
specific air distributions. The focal wall thickening (accuracy, 95.7%) was the
most useful parameter for the diagnosis of gastroduodenal perforation.
CONCLUSION: The prediction of the perforation site of the GI tract on CT should
be based on the presence of strong predictors of the site of bowel perforation,
and the specific free air distribution should be regarded as complementary
predictors. |
Is vorinostat effective for glioblastoma? | No. Although vorinostat is well tolerated it does not improve survival of glioblastoma patients. | A phase I study was conducted to determine the dose-limiting toxicities (DLT)
and maximum tolerated dose (MTD) for the combination of vorinostat with
bevacizumab and CPT-11 in recurrent glioblastoma. Vorinostat was combined with
bevacizumab and CPT-11 and was escalated using a standard 3 + 3 design.
Vorinostat was escalated up to 2 actively investigated doses of this compound or
until the MTD was identified on the basis of DLTs. Correlative science involving
proteomic profiling of serial patient plasma samples was performed. Nineteen
patients were treated. The MTD of vorinostat was established at 400 mg on days
1-7 and 15-21 every 28 days when combined with bevacizumab and CPT-11. Common
toxicities were fatigue and diarrhea. DLTs included fatigue,
hypertension/hypotension, and central nervous system ischemia. Although the MTD
was established, CPT-11 dose reductions were common early in therapy. High-dose
vorinostat had an improved progression-free survival and overall survival when
compared with low-dose vorinostat. Serum proteomic profiling identified IGFBP-5
and PDGF-AA as markers for improved PFS and recurrence, respectively. A MTD for
the combination of vorinostat with bevacizumab and CPT-11 has been established,
although it has poor long-term tolerability. With the increased toxicities
associated with CPT-11 coupled with its unclear clinical significance,
investigating the efficacy of vorinostat combined with bevacizumab alone may
represent a more promising strategy to evaluate in the context of a phase II
clinical trial. Vorinostat, a histone deacetylase (HDAC) inhibitor, has shown evidence of
single-agent activity in glioblastoma (GBM), and in preclinical studies, we have
demonstrated significant synergistic cytotoxicity between HDAC inhibitors and
proteasome inhibitors in GBM cell lines. We therefore conducted a phase II trial
to evaluate the efficacy of vorinostat in combination with the proteasome
inhibitor bortezomib in patients with recurrent GBM. Vorinostat was administered
at a dose of 400 mg daily for 14 days of a 21-day cycle, and bortezomib was
administered at a dose of 1.3 mg/m(2) intravenously on days 1, 4, 8, and 11 of
the cycle. A total of 37 patients were treated, and treatment was well
tolerated: grade 3, 4 nonhematologic toxicity occurred in 30% of patients and
consisted mainly of fatigue (14%) and neuropathy (5%); grade 3, 4 hematologic
toxicity occurred in 37% of patients and consisted of thrombocytopenia (30%),
lymphopenia (4%), and neutropenia (4%). The trial was closed at the
predetermined interim analysis, with 0 of 34 patients being progression-free at
6 months. One patient achieved a partial response according to the Macdonald
criteria. The median time to progression for all patients was 1.5 months (range,
0.5-5.6 months), and median overall survival (OS) was 3.2 months. Patients who
had received prior bevacizumab therapy had a shorter time to progression and OS,
compared with those who had not. On the basis of the results of this phase II
study, further evaluation of the vorinostat-bortezomib combination in GBM
patients in this dose and schedule is not recommended. Patients undergoing treatment for glioblastoma multiforme are routinely placed
on prophylactic treatment for Pneumocystis jirovecii pneumonia because of
significant therapy-induced lymphopenia. In patients with sulfa allergies,
dapsone prophylaxis is often used due to its efficacy, long half-life, cost
effectiveness, and general safety at low doses. However, dapsone may uncommonly
induce a hemolytic anemia, particularly in patients deficient of
glucose-6-phosphate dehydrogenase. This hemolysis is thought to be a result of
oxidative stress on red blood cells induced by dapsone metabolites which produce
reactive oxygen species that disrupt the red blood cell membrane and promote
splenic sequestration. A single case report of dapsone-induced hemolytic anemia
in a patient with glioblastoma multiforme has been reported. We present two
patients with glioblastoma multiforme who developed severe hemolytic anemia
shortly after initiating therapy with vorinostat, a pan-active histone
deacetylase inhibitor, while on prophylactic dapsone. There are several
potential mechanisms by which histone deacetylase inhibition may alter dapsone
metabolism including changes in hepatic acetylation or N-glucuronidation leading
to an increase in the bioavailability of dapsone's hematotoxic metabolites. In
addition, vorinostat may lead to increased hemolysis through inhibition of heat
shock protein-90, a chaperone protein that maintains the integrity of the red
blood cell membrane cytoskeleton. The potential interaction between dapsone and
vorinostat may have important clinical implications as more than 10 clinical
trials evaluating drug combinations with vorinostat in patients with maligt
glioma are either ongoing or planned in North America. Epigenetic mechanisms are increasingly recognized as a major factor contributing
to pathogenesis of cancer including glioblastoma, the most common and most
maligt primary brain tumour in adults. Enzymatic modifications of histone
proteins regulating gene expression are being exploited for therapeutic drug
targeting. Over the last decade, numerous studies have shown promising results
with histone deacetylase (HDAC) inhibitors in various maligcies. This article
provides a brief overview of mechanism of anti-cancer effect and pharmacology of
HDAC inhibitors and summarizes results from pre-clinical and clinical studies in
glioblastoma. It analyses experience with HDAC inhibitors as single agents as
well as in combination with targeted agents, cytotoxic chemotherapy and
radiotherapy. Hallmark features of glioblastoma, such as uncontrolled cellular
proliferation, invasion, angiogenesis and resistance to apoptosis, have been
shown to be targeted by HDAC inhibitors in experiments with glioblastoma cell
lines. Vorinostat is the most advanced HDAC inhibitor that entered clinical
trials in glioblastoma, showing activity in recurrent disease. Multiple phase II
trials with vorinostat in combination with targeted agents, temozolomide and
radiotherapy are currently recruiting. While the results from pre-clinical
studies are encouraging, early clinical trials showed only modest benefit and
the value of HDAC inhibitors for clinical practice will need to be confirmed in
larger prospective trials. Further research in epigenetic mechanisms driving
glioblastoma pathogenesis and identification of molecular subtypes of
glioblastoma is needed. This will hopefully lead to better selection of patients
who will benefit from treatment with HDAC inhibitors. BACKGROUND: Vorinostat, a histone deacetylase (HDAC) inhibitor, has shown
radiosensitizing properties in preclinical studies. This open-label, single-arm
trial evaluated the maximum tolerated dose (MTD; phase I) and efficacy (phase
II) of vorinostat combined with standard chemoradiation in newly diagnosed
glioblastoma.
METHODS: Patients received oral vorinostat (300 or 400 mg/day) on days 1-5
weekly during temozolomide chemoradiation. Following a 4- to 6-week rest,
patients received up to 12 cycles of standard adjuvant temozolomide and
vorinostat (400 mg/day) on days 1-7 and 15-21 of each 28-day cycle. Association
between vorinostat response signatures and progression-free survival (PFS) and
overall survival (OS) was assessed based on RNA sequencing of baseline tumor
tissue.
RESULTS: Phase I and phase II enrolled 15 and 107 patients, respectively. The
combination therapy MTD was vorinostat 300 mg/day and temozolomide 75 mg/m2/day.
Dose-limiting toxicities were grade 4 neutropenia and thrombocytopenia and grade
3 aspartate aminotransferase elevation, hyperglycemia, fatigue, and wound
dehiscence. The primary efficacy endpoint in the phase II cohort, OS rate at 15
months, was 55.1% (median OS 16.1 mo), and consequently, the study did not meet
its efficacy objective. Most common treatment-related grade 3/4 toxicities in
the phase II component were lymphopenia (32.7%), thrombocytopenia (28.0%), and
neutropenia (21.5%). RNA expression profiling of baseline tumors (N = 76)
demonstrated that vorinostat resistance (sig-79) and sensitivity (sig-139)
signatures had a reverse and positive association with OS/PFS, respectively.
CONCLUSIONS: Vorinostat combined with standard chemoradiation had acceptable
tolerability in newly diagnosed glioblastoma. Although the primary efficacy
endpoint was not met, vorinostat sensitivity and resistance signatures could
facilitate patient selection in future trials. LESSONS LEARNED: Combination regimen with bevacizumab (BEV) and vorinostat is
well tolerated in patients with recurrent glioblastoma.Treatment of recurrent
glioblastoma remains challenging as this study and others attempt to improve
progression-free survival and overall survival with BEV-containing regimens.
BACKGROUND: Recurrent glioblastoma (GBM; World Health Organization grade 4)
continues to have a very poor prognosis. Bevacizumab (BEV) has been shown to
improve progression-free survival (PFS) in recurrent GBM and is approved by the
U.S. Food and Drug Administration for the treatment of recurrent GBM.
Combination regimens have been explored, and in this phase II nonrandomized
trial, we evaluated the efficacy of BEV combined with histone deacetylase
inhibitor vorinostat (VOR) in recurrent GBM.
MATERIALS AND METHODS: In this phase II, single-center, nonrandomized study,
subjects with recurrent GBM received BEV 10 mg/kg intravenously (IV) every 2
weeks combined with VOR 400 mg p.o. daily for 7 days on, 7 days off, in a 28-day
cycle. The primary endpoint was 6-month PFS (PFS6).
RESULTS: Forty patients with recurrent GBM were enrolled and evaluated. PFS6 was
30.0% (95% confidence interval [CI] 16.8%-44.4%). Median overall survival (OS)
was 10.4 months (95% CI 7.6-12.8 months). Overall radiographic response rate was
22.5% based on 9 partial responses. The most common grade 2 and above
treatment-related adverse events were lymphopenia (55%), leukopenia (45%),
neutropenia (35%), and hypertension (33%). Grade 4 adverse events were
leukopenia (3%), neutropenia (3%), sinus bradycardia (3%), and venous
thromboembolism (3%). Two deaths occurred in this study, with one due to tumor
progression and another possibly related as death not otherwise specified.
CONCLUSION: Combination treatment of BEV and VOR was well tolerated. This
combination therapy for this study population did not improve PFS6 or median OS
when compared with BEV monotherapy. |
Is there any role of Dlx1 and Dlx2 transcription factors in cortical interneurons? | Yes. DLX2 directly drives Gad1, Gad2, and Vgat expression, and mutants have reduced mIPSC amplitude. In addition, the mutants formed fewer GABAergic synapses on excitatory neurons and have reduced mIPSC frequency. Furthermore, Dlx1/2 CKO have hypoplastic dendrites, fewer excitatory synapses, and reduced excitatory input. | Author information:
(1)Department of Psychiatry, Neuroscience Program and the Nina Ireland
Laboratory of Developmental Neurobiology, University of California San
Francisco, San Francisco, CA, USA.
(2)Department of Neurological Surgery, University of California San Francisco,
San Francisco, CA, USA.
(3)Departments of Neurobiology, Physiology, and Behavior and Psychiatry and
Behavioral Sciences, University of California, Davis, Davis, CA, USA.
(4)Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
(5)U.S. Department of Energy Joint Genome Institute, Walnut Creek, CA, USA.
(6)School of Natural Sciences, University of California, Merced, CA, USA.
(7)Department of Otolaryngology and Center for Integrative Neuroscience,
University of California San Francisco, San Francisco, CA, USA.
(8)Departments of Pediatrics and Neurological Surgery, Eli and Edyth Broad
Institute for Stem Cell Research and Regenerative Medicine, University of
California San Francisco, San Francisco, CA, USA. |
Describe SNP2TFBS | SNP2TFBS is a computational resource intended to support researchers investigating the molecular mechanisms underlying regulatory variation in the human genome. The database essentially consists of a collection of text files providing specific annotations for human single nucleotide polymorphisms (SNPs), namely whether they are predicted to abolish, create or change the affinity of one or several transcription factor (TF) binding sites. A SNP's effect on TF binding is estimated based on a position weight matrix (PWM) model for the binding specificity of the corresponding factor. These data files are regenerated at regular intervals by an automatic procedure that takes as input a reference genome, a comprehensive SNP catalogue and a collection of PWMs. SNP2TFBS is also accessible over a web interface, enabling users to view the information provided for an individual SNP, to extract SNPs based on various search criteria, to annotate uploaded sets of SNPs or to display statistics about the frequencies of binding sites affected by selected SNPs. Homepage: http://ccg.vital-it.ch/snp2tfbs/. | |
What is SMiLE-seq? | Selective microfluidics-based ligand enrichment followed by sequencing (SMiLE-seq) is a semiautomated protein-DNA interaction characterization technology. SMiLE-seq is neither limited by DNA bait length nor biased toward strong affinity binders; it probes the DNA-binding properties of TFs over a wide affinity range in a fast and cost-effective fashion. | Resolving the DNA-binding specificities of transcription factors (TFs) is of
critical value for understanding gene regulation. Here, we present a novel,
semiautomated protein-DNA interaction characterization technology, selective
microfluidics-based ligand enrichment followed by sequencing (SMiLE-seq).
SMiLE-seq is neither limited by DNA bait length nor biased toward strong
affinity binders; it probes the DNA-binding properties of TFs over a wide
affinity range in a fast and cost-effective fashion. We validated SMiLE-seq by
analyzing 58 full-length human, mouse, and Drosophila TFs from distinct
structural classes. All tested TFs yielded DNA-binding models with predictive
power comparable to or greater than that of other in vitro assays. De novo motif
discovery on all JUN-FOS heterodimers and several nuclear receptor-TF complexes
provided novel insights into partner-specific heterodimer DNA-binding
preferences. We also successfully analyzed the DNA-binding properties of
uncharacterized human C2H2 zinc-finger proteins and validated several using
ChIP-exo. |
What is libgapmis? | libgapmis is a library for extending pairwise short-read alignments. Apart from the standard CPU version, it includes ultrafast SSE- and GPU-based implementations. libgapmis is based on an algorithm computing a modified version of the traditional dynamic-programming matrix for sequence alignment. The open-source code of libgapmis is available at http://www.exelixis-lab.org/gapmis. | BACKGROUND: A wide variety of short-read alignment programmes have been
published recently to tackle the problem of mapping millions of short reads to a
reference genome, focusing on different aspects of the procedure such as time
and memory efficiency, sensitivity, and accuracy. These tools allow for a small
number of mismatches in the alignment; however, their ability to allow for gaps
varies greatly, with many performing poorly or not allowing them at all. The
seed-and-extend strategy is applied in most short-read alignment programmes.
After aligning a substring of the reference sequence against the high-quality
prefix of a short read--the seed--an important problem is to find the best
possible alignment between a substring of the reference sequence succeeding and
the remaining suffix of low quality of the read--extend. The fact that the reads
are rather short and that the gap occurrence frequency observed in various
studies is rather low suggest that aligning (parts of) those reads with a single
gap is in fact desirable.
RESULTS: In this article, we present libgapmis, a library for extending pairwise
short-read alignments. Apart from the standard CPU version, it includes
ultrafast SSE- and GPU-based implementations. libgapmis is based on an algorithm
computing a modified version of the traditional dynamic-programming matrix for
sequence alignment. Extensive experimental results demonstrate that the
functions of the CPU version provided in this library accelerate the
computations by a factor of 20 compared to other programmes. The analogous SSE-
and GPU-based implementations accelerate the computations by a factor of 6 and
11, respectively, compared to the CPU version. The library also provides the
user the flexibility to split the read into fragments, based on the observed gap
occurrence frequency and the length of the read, thereby allowing for a
variable, but bounded, number of gaps in the alignment.
CONCLUSIONS: We present libgapmis, a library for extending pairwise short-read
alignments. We show that libgapmis is better-suited and more efficient than
existing algorithms for this task. The importance of our contribution is
underlined by the fact that the provided functions may be seamlessly integrated
into any short-read alignment pipeline. The open-source code of libgapmis is
available at http://www.exelixis-lab.org/gapmis. |
Has ATF4 transcription factor been linked to cancer and neoplastic transformation? | Yes, ATF4 transcription factor has been linked to cancer and neoplastic transformation. | Activating transcription factor 4 (ATF4) belongs to the ATF/CREB (activating
transcription factor/cyclic AMP response element binding protein) family of
basic region-leucine zipper (bZip) transcription factors, which have the
consensus binding site cAMP responsive element (CRE). ATF4 has numerous
dimerization partners. ATF4 is induced by stress signals including
anoxia/hypoxia, endoplasmic reticulum stress, amino acid deprivation, and
oxidative stress. ATF4 expression is regulated transcriptionally,
translationally via the PERK pathway of eIF2alpha phosphorylation, and
posttranslationally by phosphorylation, which targets ATF4 to proteasomal
degradation. ATF4 regulates the expression of genes involved in oxidative
stress, amino acid synthesis, differentiation, metastasis and angiogenesis.
Transgenic studies have demonstrated ATF4 to be involved in hematopoiesis, lens
and skeletal development, fertility, proliferation, differentiation, and
long-term memory. ATF4 expression is upregulated in cancer. Since ATF4 is
induced by tumour microenvironmental factors, and regulates processes relevant
to cancer progression, it might serve as a potential therapeutic target in
cancer. Many cancers overexpress ATF4, a stress-induced transcription factor that
promotes cell survival under hypoxic conditions and other stresses of the tumor
microenvironment, but the potential contributions of ATF4 to oncogenesis itself
have been little explored. Here, we report that ATF4 promotes oncogene-induced
neoplastic transformation by suppressing the expression of cellular
senescence-associated genes. Strikingly, primary embryo fibroblasts from
ATF4-deficient mice were resistant to transformation by coexpression of
H-ras(V12) and SV40 large T antigen. In wild-type cells these oncogenes induced
expression of the murine Atf4 gene along with the cyclin-dependent kinase
inhibitor Cdkn2a, which encodes the cell senescence-associated proteins p16INK4
and p19ARF. Elevated levels of ATF4 were sufficient to suppress expression of
these proteins and drive oncogenic transformation. Conversely, genetic ablation
of ATF4 led to constitutive expression of p16INK4a and p19ARF, triggering
cellular senescence. Our findings define a central function for ATF4 in
promoting oncogenic transformation by suppressing a central pathway of cellular
senescence. B-cell lymphoma/leukemia 10 (BCL10) is an apoptotic regulatory protein related
to advanced TNM stage and disease recurrence in oral squamous cell carcinoma
(OSCC). However, the regulatory mechanism of BCL10 in OSCC progression is still
unknown. Here, we showed that knockdown of endogenous BCL10 could significantly
reduce cell migration and invasion abilities, retard cell proliferation by G0/G1
phase accumulation and inhibit tumorigenicity in vivo. In molecular level, we
identified S100P as a crucial downstream effector of BCL10-inhibited OSCC
progression by high-throughput microarray analysis. S100P messenger RNA and
protein expression levels were significantly diminished in silenced-BCL10
clones, and transfected S100P expression plasmids restored migration, invasion,
proliferation abilities and tumorigenicity in shBCL10 transfectants.
Furthermore, we provided evidence that BCL10 regulated S100P expression through
signal transducers and activators of transcription 1 (STAT1) and activating
transcription factor 4 (ATF4). Knockdown of BCL10 decreased S100P promoter
activity, but showed no effect in truncated STAT1/ATF4 S100P promoter. In
addition, we also found that the P50/P65 signaling pathway was involved in
BCL10-enhanced OSCC progression. Restored S100P in silenced-BCL10 clones could
markedly reverse P65 activation via outside-in signaling. Taken together, we
discovered a novel axis of BCL10-regulated OSCC progression via
STAT1/ATF4/S100P/P65 signaling, which could predict the prognosis of OSCC and
will be beneficial for developing therapeutic strategy against advanced OSCC. Angiogenesis plays an important role in the progression of tumor. Besides being
regulated by tumor cells per se, tumor angiogenesis is also influenced by
stromal cells in tumor microenvironment (TME), for example, tumor associated
macrophages (TAMs). Activating transcription factor 4 (ATF4), a member of the
ATF/CREB family, has been reported to be related to tumor angiogenesis. In this
study, we found that exogenous overexpression of ATF4 in mouse breast cancer
cells promotes tumor growth via increasing tumor microvascular density. However,
ATF4 overexpression failed to increase the expression level of a series of
proangiogenic factors including vascular endothelial growth factor A (VEGFA) in
tumor cells in this model. Thus, we further investigated the infiltration of
proangiogenic macrophages in tumor tissues and found that ATF4-overexpressing
tumors could recruit more macrophages via secretion of macrophage colony
stimulating factor (M-CSF). Overall, we concluded that exogenous overexpression
of ATF4 in breast cancer cells may facilitate the recruitment of macrophages
into tumor tissues and promote tumor angiogenesis and tumor growth indirectly. Hypoxia is a major hallmark of the tumor microenvironment that is strictly
associated with rapid cancer progression and induction of metastasis. Hypoxia
inhibits disulfide bond formation and impairs protein folding in the Endoplasmic
Reticulum (ER). The stress in the ER induces the activation of Unfolded Protein
Response (UPR) pathways via the induction of protein kinase RNA-like endoplasmic
reticulum kinase (PERK). As a result, the level of phosphorylated Eukaryotic
Initiation Factor 2 alpha (eIF2α) is markedly elevated, resulting in the
promotion of a pro-adaptive signaling pathway by the inhibition of global
protein synthesis and selective translation of Activating Transcription Factor 4
(ATF4). On the contrary, during conditions of prolonged ER stress, pro-adaptive
responses fail and apoptotic cell death ensues. Interestingly, similar to the
activity of the mitochondria, the ER may also directly activate the apoptotic
pathway through ER stress-mediated leakage of calcium into the cytoplasm that
leads to the activation of death effectors. Apoptotic cell death also ensues by
ATF4-CHOP- mediated induction of several pro-apoptotic genes and suppression of
the synthesis of anti-apoptotic Bcl-2 proteins. Advancing molecular insight into
the transition of tumor cells from adaptation to apoptosis under hypoxia-induced
ER stress may provide answers on how to overcome the limitations of current
anti-tumor therapies. Targeting components of the UPR pathways may provide more
effective elimination of tumor cells and as a result, contribute to the
development of more promising anti-tumor therapeutic agents. Activating transcription factor 4 (ATF4), an endoplasmic reticulum
stress-inducible transcription factor, plays important roles in cancer
progression and resistance to therapy. However, no report is available about its
roles in endometrial cancer (EC). In this study, we found that ATF4 is commonly
expressed in EC cell lines. Loss-of-function studies in two EC cell lines showed
that ATF4 knockdown suppresses tumor growth of EC in vivo without influencing
cell proliferation in vitro. And xenograft tumors derived from ATF4-knockdown
cells had reduced M2 macrophage infiltration. In clinical specimens, ATF4-high
expressing tumors indeed contained more macrophage infiltration compared to
those with lower ATF4 expression. Moreover, we identified that ATF4-mediated
chemokine CCL2 expression ultimately results in macrophage infiltration and
tumor growth of EC. Taken together, our findings suggest that ATF4 contributes
to tumor growth of EC by promoting CCL2 and subsequent recruitment of
macrophage, and that ATF4/CCL2 axis might be a potential therapeutic target for
EC. |
Are patients with Sjogren syndrome at increased risk for lymphoma? | Yes, the heightened risk of non-Hodgkin lymphoma (NHL) development in primary Sjogren syndrome is well established. Five per cent of patients with primary Sjogren's syndrome develop malignant non-Hodgkin's lymphoma, usually of the mucosa-associated lymphoid tissue (MALT) and most frequently located in the major salivary glands. The incidence of lymphoma is higher in patients with Sjögren's syndrome than in the general population. | A case of pulmonary pseudolymphoma and Sjogren syndrome is presented. Unusually,
the lung involvement preceded the salivary disease by more than two years. The
initial gammopathy and abnormal serologies are more consistent with
uncomplicated Sjogren syndrome, but were present when the pseudolymphoma was
solely apparent. Sjogren's syndrome is an autoimmune disease with a known predisposition for
lymphoma development. Eight of 120 patients with primary Sjogren's syndrome
followed at the University of Ioannina over the past 7 years developed
non-Hodgkin's lymphoma diagnosed according to the Kiel classification. The
lymphomas differed by location and grading. Six were called low grade
(immunocytoma) and two intermediate grade non-Hodgkin's lymphomas. Five of the
immunocytomas involved the minor salivary or lacrimal glands. Immunoperoxidase
staining for light chains revealed monoclonal populations. Two patients showed
spontaneous regression not previously reported in Sjogren's syndrome. Thus, in
Sjogren's syndrome, low grade non-Hodgkin's lymphomas and especially
immunocytomas are the most common lymphomas. These lymphomas tend to evolve very
slowly and may regress spontaneously. Given these facts, a conservative approach
to treatment is indicated in those patients with only localized disease. LYMPHOMA RISK: Lymphoma is a very severe complication of primary Sjögren's
syndrome: 5 to 10% of patients followed for more than 10 years will develop a
lymphoma. Predictive factors include serum monoclonal immunoglobulins or
cryoglobulins and a B clone population in accessory salivary glands. TYPICAL
CLINICAL AND HISTOLOGICAL PRESENTATION: Mucosal involvement (parotid as well as
gastric or pulmonary localizations) is frequent. According to the recent
classification of lymphomas, most lymphomas developing in patients with
Sjögren's syndrome are B lymphomas of the marginal zone: MALT lymphomas or
low-grade nodal monocytoid lymphomas which are sometimes not identified until
transformation to the giant cell stage. SIMILARITIES WITH HEPATITIS C LYMPHOMAS:
The pathophysiology of lymphoma in Sjögrën's syndrome remains unknown. To date,
there is no argument favoring a viral infection or a deregulation of a unique
oncogene or anti-oncogene. Certain similarities between lymphomas in Sjögren's
syndrome and lymphomas associated with hepatitic C virus would suggest a common
pathogenisis: possibly a permanent stimulation of auto-reactive B cells carrying
a surface immunoglobulin with rheumatoid factor activity in the target organs of
the autoimmune disease. These B lymphocytes would then proliferate secondarily. We describe a patient with primary biliary cirrhosis (PBC) and secondary
Sjogren's syndrome (SS) with pulmonary involvement who developed a cutaneous T
cell lymphoma. The clinical course of secondary SS in PBC is thought to be less
complicated than in progressive systemic scleroderma and SS. In contrast to
secondary SS, the risk for developing non-Hodgkin's lymphoma is highly increased
in patients with primary SS. Moreover, these lymphomas are usually of B cell
origin. There are few reports of T cell lymphoma in primary SS. The occurrence
of a T cell lymphoma in a patient with PBC and secondary SS indicates the
necessity to investigate lymphoma in patients with secondary SS. OBJECTIVE: To describe and correlate the clinical and imaging findings of
lymphomas in patients with Sjögren syndrome.
METHODS: The authors reviewed the medical and imaging records of 27 cases of
lymphoma from among a total of 463 patients with Sjögren syndrome. The estimated
prevalence of lymphoma in patients with Sjögren syndrome was 5.8%. There were 22
women and 5 men. Histopathologically, 26 of the 27 neoplasms were non-Hodgkin
lymphoma, including 6 mucosa-associated lymphoid tissue lymphomas, and the other
neoplasm was Hodgkin lymphoma. The clinical and imaging findings of lymphomas
were analyzed.
RESULTS: No obvious correlations were present between the duration or severity
of Sjögren syndrome and the lymphoma development. At the initial diagnosis,
extranodal involvement was observed in 14 (52%) of the 27 patients, including
the salivary gland (n = 9), lacrimal gland (n = 2), lung (n = 2), and thyroid
gland (n = 1), mostly in the neck organs. On the other hand, nodal involvement
was observed in 21 (78%) of the 27 patients. Of these 21 patients, 19 had at
least cervical lymph node involvement.
CONCLUSION: Patients with Sjögren syndrome are at increased risk of lymphoma
development. Because most lymphomas initially involve the neck organs, including
the lymph nodes, meticulous imaging studies mainly focused on the cervical
regions are recommended in the follow-up of patients with Sjögren syndrome. Certain autoimmune and chronic inflammatory conditions, such as Sjögren's
syndrome and rheumatoid arthritis (RA), have consistently been associated with
an increased risk of maligt lymphomas, but it is unclear whether elevated
lymphoma risk is a phenomenon that accompanies inflammatory conditions in
general. Likewise, it is debated whether the increased risk identified in
association with some disorders pertains equally to all individuals or whether
it varies among groups of patients with different phenotypic or
treatment-related characteristics. It is similarly unclear to what extent the
increased lymphoma occurrence is mediated through specific lymphoma subtypes.
This update reviews the many findings on risks, risk levels, and lymphoma
characteristics that have been presented recently in relation to a broad range
of chronic inflammatory, including autoimmune, conditions. Recent results
clearly indicate an association between severity of chronic inflammation and
lymphoma risk in RA and Sjögren's syndrome. Thus, the average risk of lymphoma
in RA may be composed of a markedly increased risk in those with most severe
disease and little or no increase in those with mild or moderate disease. The
roles of immunosuppressive therapy and EBV infection seem to be limited.
Furthermore, RA, Sjögren's syndrome, systemic lupus erythematosus, and possibly
celiac disease may share an association with risk of diffuse large B-cell
lymphoma, in addition to well-established links of Sjögren's syndrome with risk
of mucosa-associated lymphoid tissue lymphoma and of celiac disease with risk of
small intestinal lymphoma. However, there is also obvious heterogeneity in risk
and risk mediators among different inflammatory diseases. Among autoimmune diseases, Sjogren's syndrome (SS) displays the highest
incidence of non-Hodgkin lymphoma (NHL) development with the salivary extranodal
marginal zone B cell lymphomas being the most common type. The majority of
SS-associated NHLs are characterized by localized stage, indolent clinical
course, and recurrence in other extranodal sites. Although the transition from a
chronic inflammatory condition to maligt lymphoma is a multistep process yet
poorly understood, there is increasing evidence that chronic antigenic
stimulation by an exoantigen or autoantigens plays an essential role in the
development of SS associated lymphoproliferation. Additional molecular oncogenic
events such as microsatellite instability, loss of the B cell cycle control, and
the forced overproduction of specific B cell biologic stimulators seem to
contribute to the emergence and progression of the maligt overgrowth. Among
the clinical and serological parameters that have been associated with lymphoma
development in SS patients, the presence of palpable purpura, low C4, and mixed
monoclonal cryoglobulinemia constitute the main predictive markers, and patients
displaying these risk factors should be monitored closely. The diverse hematologic manifestations of primary Sjögren syndrome (pSS) have
not been systematically investigated, and their prognostic relevance remains
unclear. We conducted a retrospective study of 536 consecutive patients followed
in our institution to assess the prevalence of hematologic abnormalities and
their associations with various disease manifestations in pSS. We also aimed to
identify risk factors for the development of non-Hodgkin lymphoma (NHL) overall
and by subtype. Anemia of chronic disease and hypergammaglobulinemia were the
most prevalent hematologic manifestations encountered at diagnosis and during
the course of pSS. Univariate analysis between cytopenias and glandular
manifestations revealed a statistically significant correlation between
lymphocytopenia and parotid gland enlargement (p = 0.002), as well as between
neutropenia and xerostomia (p = 0.019). Anemia, lymphocytopenia,
thrombocytopenia, hypergammaglobulinemia, the presence of monoclonal serum
proteins, and cryoglobulinemia correlated significantly with the presence of
extraglandular symptoms such as palpable purpura, lymphadenopathy, and
splenomegaly. Lymphoma was diagnosed in 7.5% (95% confidence interval [CI],
5.4%-10%) of patients. Marginal zone B-cell lymphomas (MZBCLs) were the
predomit histologic type (65%; 95% CI, 48.3%-79.4%), while diffuse large
B-cell lymphomas (DLBCLs) accounted for 17.5% (95% CI, 7.3%-32.8%) of all cases.
The development of NHL in patients with pSS could be predicted by the presence
of simple clinical and laboratory factors at diagnosis: neutropenia (p = 0.041),
cryoglobulinemia (p = 0.008), splenomegaly (p = 0.006), lymphadenopathy (p =
0.021), and low C4 levels (p = 0.009). Patients carrying any of these factors
had a more than 5-fold increased risk of NHL compared to patients with no risk
factors at all. The above set of disease characteristics could predict
subsequent development of MZBCL; the presence of lymphocytopenia (p = 0.044) at
diagnosis served as a risk factor for the development of a non-MZBCL, most
commonly DLBCL. Anemia of chronic disease and hypergammaglobulinemia are common
hematologic manifestations at diagnosis and during the course of pSS.
Neutropenia and cryoglobulinemia at diagnosis are significantly associated with
an increased risk of lymphoma development. BACKGROUND: The prevalence of peripheral neuropathy in patients with Sjögren
syndrome remains unclear owing to conflicting results in the published series,
with numbers ranging from 2% to over 60% of Sjögren syndrome patients. Whether
peripheral neuropathy is a feature of the systemic or glandular disease or
whether it is related to a circulating antineuronal antibody remains also
uncertain.
METHODS: The authors reviewed the records of patients with primary Sjögren
syndrome (pSS), fulfilling the Revised European-American Classification
Criteria, seen in their department from 1992 to 2009. The patients with
previously recorded neuropathic features were re-examined clinically and
electrophysiologically. Other causes of polyneuropathy were excluded. The
authors also searched for circulating antineural antibodies using
immunofluorescence and western blot and for antibodies against muscarinic and
nicotinic acetylcholine receptors as potential biomarkers.
RESULTS: 509 cases met the diagnostic criteria for pSS. Among these, 44 patients
were recorded as having neuropathic symptoms. After completing the evaluation,
however, only nine (1.8%) had polyneuropathy with objective clinical signs and
abnormal electrophysiological findings. The neuropathy was axonal in all, in
five pure sensory and in four sensorimotor. The patients with peripheral
neuropathy had extraglandular manifestations such as palpable purpura and
vasculitis. No evidence of antineural autoimmunity was found, and no candidate
biomarkers were identified.
CONCLUSION: Polyneuropathy is a rare manifestation of pSS occurring in 1.8% of
patients. In the majority of patients, it is a late event and frequently
associated with systemic disease or risk factors for lymphoma development. Five per cent of patients with primary Sjogren's syndrome (pSS) develop
maligt non-Hodgkin's lymphoma (NHL), usually of the mucosa-associated
lymphoid tissue (MALT) and most frequently located in the major salivary glands.
Rituximab (RTX), a chimeric monoclonal antibody against the CD20 molecule
expressed on the surface of mature B cells that has been approved for the
treatment of NHL, has been used to treat pSS-associated lymphoma. We have
described two cases: one with MALT lymphoma in the parotid glands and the other
with a rare thymus lymphoma accompanied by the rare complication of a bullous
pneumopathy. Both were treated with RTX at haematological doses, which was
unsuccessful in the patient with a salivary lymphoma; in the case of the patient
with a thymus lymphoma, the mediastinum mass disappeared and did not relapse.
Both patients experienced an improvement in the subjective symptoms of dryness,
and their Schirmer's test and scialoscintigraphy results stabilised. The
pulmonary bullae remained unchanged. A 62-year-old woman with Sjogren syndrome was admitted for computed tomographic
(CT) evaluation of a thickened trachea and parotid tumor. She had been given a
diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma 6 years
previously, and had undergone surgical resection of the parotid tumor.
Endoscopic examination revealed an annular tumor that had formed a stricture in
the mid-trachea. Pathologic specimens were obtained by surgical resection of the
parotid tumor and bronchoscopic biopsy of the tracheal tumor. Both histological
examinations revealed MALT-type marginal zone B-cell lymphoma. Because CD20
immunostaining was positive, the patient received 6 cycles of rituximab plus
cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) without any
signs of major toxicity. All lesions disappeared after treatment, and this
patient remained disease-free for 40 months. It has long been demonstrated that a subset of patients with Sjogren's syndrome
(SS) develop ectopic lymphoid structures (ELS) in the salivary glands (SG).
These structures are characterised by periductal clusters of T and B
lymphocytes, development of high endothelial venules and differentiation of
follicular dendritic cells (FDC) networks. Evidence in patients with and animal
models of SS demonstrated that the formation and maintece of ELS in the SG is
critically dependent on the ectopic expression of lymphotoxins (LT) and lymphoid
chemokines CXCL13, CCL19, CCL21 and CXCL12. Several cell types, including
resident epithelial, stromal and endothelial cells as well as different subsets
of infiltrating immune cells, have been shown to be capable of producing some of
these factors during chronic inflammation in SS. In this review we focus on the
cellular and molecular mechanisms regulating the formation of ELS in SS SG, with
particular emphasis on the role of lymphoid chemokines. In addition, we
summarise accumulating data in support of the notion that ELS in SS represent
functional niches whereby autoreactive B cells undergo affinity maturation,
clonal selection and differentiation into autoantibody producing cells, thus
contributing to autoimmunity over and above secondary lymphoid organs.
Furthermore, we review the emerging role of ELS and lymphoid chemokines in
driving extranodal B cell lymphomagenesis in SS and we focus on recent evidence
suggesting that ELS identify subsets of SS patients at increased risk of
developing systemic manifestations and lymphoma. Oral Diseases (2012) doi:10.1111/j.1601-0825.2012.01932.x Biologic therapy has a
potential to benefit patients with orofacial manifestations of Sjogren syndrome
(SS). The most appropriate use of biologics would appear to be in patients with
severe or multisystem features of SS, but their use early in the pathogenesis
has the potential to prevent disease progression. Tumour necrosis factor-alpha
blockade has not proven effective in SS. B-cell depletion using rituximab has
been of benefit, mainly in relation to extraglandular features, and to some
extent in relation to hyposalivation where there is still residual salivary
function. Rituximab is also effective in the treatment of SS-associated
(extrasalivary) lymphomas, although the therapeutic response in salivary
lymphoma is poorer. Rituximab is given as a single or periodic intravenous
infusion. Potential adverse effects exist, notably infusion reactions and
infection, and so a full risk/benefit analysis is indicated for prospective
patients. This and clinical use is best performed and monitored in conjunction
with rheumatologists with appropriate training and experience in biologic
therapies. Further studies of rituximab in SS are ongoing, and newer agents
under trial include belimumab. Sjogren's syndrome (SS) is a chronic autoimmune disorder with the highest risk
for lymphoma development among all autoimmune diseases. In order to evaluate
whether the presence of the recently described MYD88 L265P mutation in patients
with Waldenström's macroglobulinemia (WM) is contributory to SS-associated
lymphomagenesis, a quantitative allele-specific PCR method was performed in
peripheral blood derived from 90 SS patients as well as in minor salivary gland
tissues derived from 12 primary SS patients with or without lymphoma. MYD88
L265P was not detected in either of the samples tested. Although the absence of
the MyD88 L265P somatic mutation in our SS cohort does not exclude a common
germline susceptibility gene in SS, it might suggest a distinct operating
pathogenetic mechanism in SS-related lymphoma compared with WM and other
hematological maligcies. Several autoimmune diseases, including primary Sjögren's syndrome (pSS), are
associated with an increased risk for lymphoma. Polymorphisms of TNFAIP3, which
encodes the A20 protein that plays a key role in controlling nuclear factor κB
activation, have been associated with several autoimmune diseases. Somatic
mutations of TNFAIP3 have been observed in the mucosa-associated lymphoid tissue
lymphoma subtype frequently associated with pSS. We studied germline and somatic
abnormalities of TNFAIP3 in 574 patients with pSS, including 25 with lymphoma.
Nineteen additional patients with pSS and lymphoma were available for exome
sequence analysis. Functional abnormalities of A20 were assessed by gene
reporter assays. The rs2230926 exonic variant was associated with an increased
risk for pSS complicated by lymphoma (odds ratio, 3.36 [95% confidence interval,
1.34-8.42], and odds ratio, 3.26 [95% confidence interval, 1.31-8.12], vs
controls and pSS patients without lymphoma, respectively; P = .011). Twelve
(60%) of the 20 patients with paired germline and lymphoma TNFAIP3 sequence data
had functional abnormalities of A20: 6 in germline DNA, 5 in lymphoma DNA, and 1
in both. The frequency was even higher (77%) among pSS patients with
mucosa-associated lymphoid tissue lymphoma. Some of these variants showed
impaired control of nuclear factor κB activation. These results support a key
role for germline and somatic variations of A20 in the transformation between
autoimmunity and lymphoma. The heightened risk of non-Hodgkin lymphoma (NHL) development in primary Sjogren
syndrome (SS) is well established. Several adverse clinical and laboratory
predictors have been described. In the current work, we aimed to formulate a
predictive score for NHL development, based on clinical, serological, and
histopathological findings at the time of SS diagnosis. In the present
case-control study of 381 primary SS patients and 92 primary SS patients with
concomitant NHL, clinical, serological, and histopathological variables at the
time of SS diagnosis were retrospectively recorded. For the identification of
predictors for NHL development univariate and multivariate models were
constructed. Salivary gland enlargement (SGE), lymphadenopathy, Raynaud
phenomenon, anti-Ro/SSA or/and anti-La/SSB autoantibodies, rheumatoid factor
(RF) positivity, monoclonal gammopathy, and C4 hypocomplementemia were shown to
be independent predictors for NHL development. On the basis of the number of
independent risk factors identified, a predictive risk score for NHL development
was formulated. Thus, patients presenting with ≤2 risk factors had a 3.8%
probability of NHL development, those with 3 to 6 risk factors 39.9% (OR
(95%CI): 16.6 [6.5-42.5], P < 0.05), while in the presence of all 7 risk factors
the corresponding probability reached 100% (OR [95%CI]: 210.0 [10.0-4412.9],
P < 0.0001). In conclusion, an easy to use diagnostic scoring tool for NHL
development in the context of SS is presented. This model is highly significant
for the design of early therapeutic interventions in high risk SS patients for
NHL development. Author information:
(1)Department of Physiology, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece.
(2)Institute of Biology, Medicinal Chemistry and Biotechnology, National
Hellenic Research Foundation, Athens, Greece.
(3)Department of Pathology, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece.
(4)Research Group of Clinical Pharmacology and Pharmacogenomics, Faculty of
Pharmacy, School of Health Sciences, National and Kapodistrian University of
Athens, Athens, Greece.
(5)Department of Pathophysiology, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece.
(6)Joint Academic Rheumatology Program, National and Kapodistrian University of
Athens, School of Medicine, Athens, Greece.
(7)First Department of Propaedeutic Internal Medicine, National and Kapodistrian
University of Athens School of Medicine, Athens, Greece.
(8)Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, Weill
Medical College of Cornell University, New York, NY, USA.
(9)Department of Physiology, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece. [email protected].
(10)Department of Pathophysiology, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece. [email protected].
(11)Joint Academic Rheumatology Program, National and Kapodistrian University of
Athens, School of Medicine, Athens, Greece. [email protected]. |
Describe JACUSA | JACUSA detects single nucleotide variants by comparing data from next-generation sequencing experiments (RNA-DNA or RNA-RNA). In practice, JACUSA shows higher recall and comparable precision in detecting A→I sites from RNA-DNA comparisons, while showing higher precision and recall in RNA-RNA comparisons. | BACKGROUND: RNA editing is a co-transcriptional modification that increases the
molecular diversity, alters secondary structure and protein coding sequences by
changing the sequence of transcripts. The most common RNA editing modification
is the single base substitution (A→I) that is catalyzed by the members of the
Adenosine deaminases that act on RNA (ADAR) family. Typically, editing sites are
identified as RNA-DNA-differences (RDDs) in a comparison of genome and
transcriptome data from next-generation sequencing experiments. However, a
method for robust detection of site-specific editing events from replicate
RNA-seq data has not been published so far. Even more surprising,
condition-specific editing events, which would show up as differences in RNA-RNA
comparisons (RRDs) and depend on particular cellular states, are rarely
discussed in the literature.
RESULTS: We present JACUSA, a versatile one-stop solution to detect single
nucleotide variant positions from comparing RNA-DNA and/or RNA-RNA sequencing
samples. The performance of JACUSA has been carefully evaluated and compared to
other variant callers in an in silico benchmark. JACUSA outperforms other
algorithms in terms of the F measure, which combines precision and recall, in
all benchmark scenarios. This performance margin is highest for the RNA-RNA
comparison scenario. We further validated JACUSA's performance by testing its
ability to detect A→I events using sequencing data from a human cell culture
experiment and publicly available RNA-seq data from Drosophila melanogaster
heads. To this end, we performed whole genome and RNA sequencing of HEK-293
cells on samples with lowered activity of candidate RNA editing enzymes. JACUSA
has a higher recall and comparable precision for detecting true editing sites in
RDD comparisons of HEK-293 data. Intriguingly, JACUSA captures most A→I events
from RRD comparisons of RNA sequencing data derived from Drosophila and HEK-293
data sets.
CONCLUSION: Our software JACUSA detects single nucleotide variants by comparing
data from next-generation sequencing experiments (RNA-DNA or RNA-RNA). In
practice, JACUSA shows higher recall and comparable precision in detecting A→I
sites from RNA-DNA comparisons, while showing higher precision and recall in
RNA-RNA comparisons. |
What is the mechanism of action of Tezepelumab? | Tezepelumab is human monoclonal antibody specific for the epithelial-cell-derived cytokine thymic stromal lymphopoietin (TSLP). | The pro-inflammatory cytokine thymic stromal lymphopoietin (TSLP) is pivotal to
the pathophysiology of widespread allergic diseases mediated by type 2 helper T
cell (Th2) responses, including asthma and atopic dermatitis. The emergence of
human TSLP as a clinical target against asthma calls for maximally harnessing
its therapeutic potential via structural and mechanistic considerations. Here we
employ an integrative experimental approach focusing on productive and
antagonized TSLP complexes and free cytokine. We reveal how cognate receptor
TSLPR allosterically activates TSLP to potentiate the recruitment of the shared
interleukin 7 receptor α-chain (IL-7Rα) by leveraging the flexibility,
conformational heterogeneity and electrostatics of the cytokine. We further show
that the monoclonal antibody Tezepelumab partly exploits these principles to
neutralize TSLP activity. Finally, we introduce a fusion protein comprising a
tandem of the TSLPR and IL-7Rα extracellular domains, which harnesses the
mechanistic intricacies of the TSLP-driven receptor complex to manifest high
antagonistic potency. Asthma and COPD are prevalent chronic inflammatory airway diseases that are
responsible for a large global disease burden. Both diseases are complex and
heterogeneous, and they are increasingly recognized as overlapping syndromes
that may share similar pathophysiologic mechanisms and treatable traits.
Eosinophilic airway inflammation is considered the most influential treatable
trait of chronic airway disease, and over the last decade, several monoclonal
antibodies and small molecule therapies have been developed to target this
trait. These include monoclonal antibodies against IL-5 or IL-5 receptor alpha
(mepolizumab, reslizumab, and benralizumab), IL-13 (lebrikizumab and
tralokinumab), IL-4 receptor alpha (dupilumab), IgE (omalizumab), and
anti-thymic stromal lymphopoietin (tezepelumab) and small molecule therapies
such as prostaglandin D2 blockers (fevipiprant and timapiprant). Although these
novel biologic agents have shown promising results in many patients with asthma
and COPD who have eosinophilic airway inflammation, it is evident that not all
patients respond equally well, despite similar clinical, functional, and
inflammatory characteristics. This heterogeneity in treatment response is
probably related to different molecular pathways or endotypes leading to
eosinophilic airway inflammation, including adaptive immune pathways mediated by
T helper 2 cells and innate immune pathways mediated by innate lymphoid cells.
The relative contribution of these pathways in asthma and COPD is not yet
clarified, and there are currently no reliable biomarkers that represent the
various pathways. Therefore, there is an urgent need for easily measurable and
reproducible biomarkers that are linked to underlying pathophysiologic disease
mechanisms and can predict and monitor responses to novel biologic agents. BACKGROUND: In some patients with moderate-to-severe asthma, particularly those
with noneosinophilic inflammation, the disease remains uncontrolled. This trial
evaluated the efficacy and safety of tezepelumab (AMG 157/MEDI9929), a human
monoclonal antibody specific for the epithelial-cell-derived cytokine thymic
stromal lymphopoietin (TSLP), in patients whose asthma remained uncontrolled
despite treatment with long-acting beta-agonists and medium-to-high doses of
inhaled glucocorticoids.
METHODS: In this phase 2, randomized, double-blind, placebo-controlled trial, we
compared subcutaneous tezepelumab at three dose levels with placebo over a
52-week treatment period. The primary end point was the annualized rate of
asthma exacerbations (events per patient-year) at week 52.
RESULTS: The use of tezepelumab at a dose of 70 mg every 4 weeks (low dose; 145
patients), 210 mg every 4 weeks (medium dose; 145 patients), or 280 mg every 2
weeks (high dose; 146 patients) resulted in annualized asthma exacerbation rates
at week 52 of 0.26, 0.19, and 0.22, respectively, as compared with 0.67 in the
placebo group (148 patients). Thus, exacerbation rates in the respective
tezepelumab groups were lower by 61%, 71%, and 66% than the rate in the placebo
group (P<0.001 for all comparisons). Similar results were observed in patients
regardless of blood eosinophil counts at enrollment. The prebronchodilator
forced expiratory volume in 1 second at week 52 was higher in all tezepelumab
groups than in the placebo group (difference, 0.12 liters with the low dose
[P=0.01], 0.11 liters with the medium dose [P=0.02], and 0.15 liters with the
high dose [P=0.002]). A total of 2 patients in the medium-dose group, 3 in the
high-dose group, and 1 in the placebo group discontinued the trial regimen
because of adverse events.
CONCLUSIONS: Among patients treated with long-acting beta-agonists and
medium-to-high doses of inhaled glucocorticoids, those who received tezepelumab
had lower rates of clinically significant asthma exacerbations than those who
received placebo, independent of baseline blood eosinophil counts. (Funded by
MedImmune [a member of the AstraZeneca Group] and Amgen; PATHWAY
ClinicalTrials.gov number, NCT02054130 .). |
What is the association between kidney donation risk of gestational complications? | Kidney donation seems to elevate the risks of gestational complications. Postdonation pregnancies were associated with a higher risk of gestational diabetes, gestational hypertension, proteinuria and preeclampsia. However, others reported that donor nephrectomy is not detrimental to the prenatal course or outcome of future pregnancies. | Potential female donors frequently ask whether unilateral nephrectomy will
impair future childbearing capabilities. To address this question, we surveyed
220 women who underwent donor nephrectomy between 1985 and 1992. Of the 144
women who responded, 33 became pregt after donation for a total of 45
pregcies. Seventy-five percent of the pregcies were carried to term
without difficulty. Complications incurred during gestation included miscarriage
(13.3%), preeclampsia (4.4%), gestational hypertension (4.4%), proteinuria
(4.4%), and tubal pregcy (2.2%). Four of the 45 pregcies (excluding
miscarriages) required preterm hospitalization, resulting in an overall
morbidity of 8.8%. There were no pregcy-related deaths, and no fetal
abnormalities were reported. Problems with persistent hypertension, proteinuria,
or changes in renal function were not noted. None of the above complications
exceeded what has been noted for the general population. Infertility was a
problem in 8.3% (3/36) of our respondents, compared with a worldwide incidence
of 16.7%. Based on these results, we conclude that donor nephrectomy is not
detrimental to the prenatal course or outcome of future pregcies. The outcome of pregcy in kidney donors has generally been viewed to be
favorable. We determined fetal and maternal outcomes in a large cohort of kidney
donors. A total of 2102 women have donated a kidney at our institution; 1589
donors responded to our pregcy surveys; 1085 reported 3213 pregcies and
504 reported none. Fetal and maternal outcomes in postdonation pregcies were
comparable to published rates in the general population. Postdonation (vs.
predonation) pregcies were associated with a lower likelihood of full-term
deliveries (73.7% vs. 84.6%, p = 0.0004) and a higher likelihood of fetal loss
(19.2% vs. 11.3%, p < 0.0001). Postdonation pregcies were also associated
with a higher risk of gestational diabetes (2.7% vs. 0.7%, p = 0.0001),
gestational hypertension (5.7% vs. 0.6%, p < 0.0001), proteinuria (4.3% vs.
1.1%, p < 0.0001) and preeclampsia (5.5% vs. 0.8%, p < 0.0001). Women who had
both pre- and post-donation pregcies were also more likely to have these
adverse maternal outcomes in their postdonation pregcies. In this large
survey of previous living donors in a single center, fetal and maternal outcomes
and pregcy outcomes after kidney donation were similar to those reported in
the general population, but inferior to predonation pregcy outcomes. Since the first living-donor kidney transplantation in 1954, more than half a
million living kidney donations have occurred and research has advanced
knowledge about long-term donor outcomes. Donors in developed countries have a
similar life expectancy and quality of life as healthy non-donors. Living kidney
donation is associated with an increased risk of end-stage renal disease,
although this outcome is uncommon (<0·5% increase in incidence at 15 years).
Kidney donation seems to elevate the risks of gestational hypertension and
pre-eclampsia. Many donors incur ficial expenses due to factors such as lost
wages, need for sick days, and travel expenses. Yet, most donors have no regrets
about donation. Living kidney donation is practised ethically when informed
consent incorporates information about risks, uncertainty about outcomes is
acknowledged when it exists, and a donor's risks are proportional to benefits
for the donor and recipient. Future research should determine whether outcomes
are similar for donors from developing countries and donors with pre-existing
conditions such as obesity. Communicating the current knowledge of medical outcomes after live kidney
donation necessary to support donor candidates in well informed decision-making
requires grounding in perspectives of comparison. Baseline risk (without
donating), risk attributable to donation, and absolute risk (after donating)
need to be considered. Severe perioperative complications and death are rare,
but vary by demographic, clinical, and procedure factors. Innovative capture of
"healthy" controls designed to simulate donor selection processes has identified
higher risk of ESRD attributable to donation in two studies; importantly,
however, the absolute 15-year ESRD incidence in donors remains very low (0.3%).
In the first decade after donation, the risk of all-cause mortality and
cardiovascular events is no higher than in healthy nondonors. Pregcies in
donors may incur attributable risk of gestational hypertension or preeclampsia
(11% versus 5% incidence in one study). A modest rise in uric acid levels
beginning early after donation, and a small (1.4%) increase in the 8-year
incidence of gout, have also been reported in comparisons to healthy nondonors.
As in the general population, postdonation outcomes vary by race, sex, and age.
Efforts to improve the counseling and selection of living donors should focus on
developing tools for tailored risk prediction according to donor
characteristics, and ideally, compared with similar healthy nondonors. |
Does prolactinoma increase osteoporosis risk? | Yes, prolactinomas increase risk of osteoporosis. Prolactinomas also cause hypogonadism, infertility, and tumor mass effects. | The aim of the study was to evaluate the osteoporotic fracture risk in
premenopausal women with hyperprolactinemia due to prolactinoma. Bone mineral
density (BMD) was measured in 20 white, premenopausal women with prolactinoma
and in 60 healthy control white women, using quantitative ultrasound (QUS) at
the os calcis, with an Achilles Lunar Plus device. We measured all three
parameters of QUS: broadband ultrasound attenuation (BUA), speed of sound (SOS)
and stiffness. BMD results were expressed also as T- and Z-scores. Age and body
mass index (BMI) were not statistically significantly different between the two
groups. Comparative analysis showed reduced values of QUS parameters in women
with prolactinoma versus controls. Only the difference in SOS parameter was
statistically significant between the two studied groups (p = 0.0001). The
Z-score was significant lower in women with prolactinoma than in healthy women.
These data reveal a significant bone loss in women with prolactinoma compared to
controls. The SOS parameter showed a good negative correlation with age, and all
the QUS parameters were positively correlated with BMI. The relative risk for
developing osteoporosis in women with prolactinoma was found to be 4.5,
indicating that hyperprolactinemia in women is a major risk factor for
osteoporosis. The aim of this cross-sectional study was to analyze bone mineral density (BMD)
and prevalence of osteopenia and osteoporosis in 30 men with prolactinoma, and
compare them to 22 control subjects. BMD of lumbar spine and femur was evaluated
by dual-energy X-ray absorptiometry. PRL, testosterone, estradiol, sexual
hormone-binding globulin and free androgen and estrogen indexes (FAI and FEI,
respectively) were measured in all the subjects. In patients with prolactinoma,
mean values of PRL and testosterone were calculated for the 12-month period that
preceded the study. The mean T-score of the four sites analyzed by bone
densitometry was lower in men with prolactinoma than in controls (p-values:
lumbar spine=0.015, femoral neck <0.0001, trochanter=0.037, total femur=0.036),
and 55.6% of the former presented osteopenia or osteoporosis at one or more
sites (p =0.035). The lumbar spine was the most seriously affected site, where
29.6% had osteopenia and 14.8% had osteoporosis. By the time of BMD
determination, significant associations were found between BMD and PRL,
testosterone, FAI, estradiol, FEI, and duration of hypogonadism. Considering the
period of 12 months that preceded BMD evaluation, trochanter BMD was associated
with mean PRL levels, while there was an association between lumbar spine BMD
and mean testosterone levels. However, the multiple regression analysis showed
that estradiol was the main determit of BMD. In conclusion, men with
prolactinoma have high prevalence of osteopenia and osteoporosis. Bone loss in
such patients is associated with hyperprolactinemia and hypogonadism, and mainly
influenced by estrogen. INTRODUCTION: Osteopenia and osteoporosis because of hyperprolactinaemia caused
by prolactinoma may be followed by an increased risk of fracture. There are no
data on the bone effects of functional hyperprolactinaemia. The aim was to
assess the influence of hyperprolactinaemia of various origins on bone turnover
and density in different skeletal sites.
MATERIAL AND METHODS: The study was carried out in 75 women (aged 30.53 +/-
7.8): Group I--32 women with prolactinoma and Group II--43 women with functional
hyperprolactinaemia. Both groups of patients were subdivided into those with
hypogonadism and those with normal gonadal function. The control group consisted
of 29 healthy women aged (33.59 +/- 4.7). In all subjects PRL and bone turnover
markers (BAP, OC, ICTP) were studied. BMD measurements (lumbar spine, forearm,
proximal femur and total body) were carried out using DXA.
RESULTS: Higher PRL concentrations were observed in patients than in controls.
The values of bone turnover markers (BAP, ICTP) were shown to be higher in
patient groups and subgroups than in controls. In patients with prolactinoma
lumbar spine BMD was lower than in patients with functional hyperprolactinaemia
and controls. Total body BMD was also lower, albeit to a lesser extent.
CONCLUSIONS: Hyperprolactinaemia caused by prolactinoma in women influences bone
metabolism unfavourably, more by the impact on the activity of bone turnover
markers than on BMD. This provides an opportunity for earlier assessment of bone
metabolism disturbances before the BMD changes can be observed. Functional
hyperprolactinaemia does not determine such a harmful effect on bone metabolism
as hyperprolactinemia due to prolactinoma. INTRODUCTION: Unexplained anaemia is a rare mode of presentation for
prolactinoma. We describe a case of a man, with chronic anaemia ascribed to old
age. Six years later, he was evaluated and diagnosed with a prolactinoma and
resultant osteoporosis. Prolactinoma in old people may present insidiously with
chronic anaemia and osteoporosis with or without sexual dysfunction.
CASE PRESENTATION: We describe the case of a 70-year-old Caucasian man who
presented with mild anaemia and tiredness. His anaemia was investigated and
ascribed to senescence. Endocrine causes were not considered or tested for. Six
years later, he was again referred. Reassessment and direct questioning revealed
long-standing sexual dysfunction. It was also discovered that our patient had
fractured his radius twice, with minor trauma, during the preceding year. His
serum prolactin was massively increased and a magnetic resoce imaging (MRI)
scan of the head demonstrated a pituitary mass consistent with a prolactinoma.
Dual X-ray absorptiometry revealed osteoporosis. Treatment of the prolactinoma
led to a reduction in his serum prolactin with a rise in his haemoglobin to
normal levels. This suggested that the prolactinoma was present during the
initial presentation and was the cause of his anaemia.
CONCLUSION: This case highlights the importance of fully evaluating and
investigating unexplained anaemia in older people and that endocrine causes
should be considered. Osteoporosis also requires evaluation with secondary
causes considered. OBJECTIVE: Patients with prolactinoma seem to be at high risk for osteopenia.
However, whether patients with various pathological sellar tumors have risk for
osteopenia remains unclear. The aim of the present study is to assess the bone
mass alteration in patients with various sellar tumors and further to
investigate the risk factors of bone mass alteration.
MATERIALS AND METHODS: 65 premenopausal female patients with diverse sellar
tumors and 325 normal controls were enrolled in this study. Bone mineral density
(BMD) of lumbar spine and comprehensive endocrinological evaluations were
undergone.
RESULTS: Compared to the matched controls, BMD of patients with prolactinoma or
craniopharyngioma significantly decreased. Patients with sellar meningioma and
nonfunctioning adenoma are with a decreasing tendency and patients with growth
hormone-secreting adenoma are with an increasing tendency compared to controls.
Univariate and multivariate regression analysis indicated that the bone loss in
prolactinomas was significantly correlated to disease duration and hypogonadism.
CONCLUSION: In the premenopausal women, patients with prolactinoma or
craniopharyngioma are often accompanied with osteopenia or osteoporosis, and
disease duration and hypogonadism are the risk factors of bone loss in
prolactinoma. Continuous surveillance of BMD is recommended in patients with
meningioma or nonfunctioning adenoma. Dysregulation of the signaling pathways that govern lactotrope biology
contributes to tumorigenesis of prolactin (PRL)-secreting adenomas, or
prolactinomas, leading to a state of pathological hyperprolactinemia.
Prolactinomas cause hypogonadism, infertility, osteoporosis, and tumor mass
effects, and are the most common type of neuroendocrine tumor. In this review,
we highlight signaling pathways involved in lactotrope development, homeostasis,
and physiology of pregcy, as well as implications for signaling pathways in
pathophysiology of prolactinoma. We also review mutations found in human
prolactinoma and briefly discuss animal models that are useful in studying
pituitary adenoma, many of which emphasize the fact that alterations in
signaling pathways are common in prolactinomas. Although individual mutations
have been proposed as possible driving forces for prolactinoma tumorigenesis in
humans, no single mutation has been clinically identified as a causative factor
for the majority of prolactinomas. A better understanding of lactotrope-specific
responses to intracellular signaling pathways is needed to explain the mechanism
of tumorigenesis in prolactinoma. The authors present an update on the various treatment modalities and discuss
management strategies for prolactinomas. Prolactinomas are the most common type
of functional pituitary tumor. Effective hyperprolactinemia treatment is of
great importance, due to its potential deleterious effects including
infertility, gonadal dysfunction and osteoporosis. Dopamine agonist therapy is
the first line of treatment for prolactinomas because of its effectiveness in
normalizing serum prolactin levels and shrinking tumor size. Though withdrawal
of dopamine agonist treatment is safe and may be implemented following certain
recommendations, recurrence of disease after cessation of the drug occurs in a
substantial proportion of patients. Concerns regarding the safety of dopamine
agonists have been raised, but its safety profile remains high, allowing its use
during pregcy. Surgery is typically indicated for patients who are resistant
to medical therapy or intolerant of its adverse side effects, or are
experiencing progressive tumor growth. Surgical resection can also be considered
as a primary treatment for those with smaller focal tumors where a biochemical
cure can be expected as an alternative to lifelong dopamine agonist treatment.
Stereotactic radiosurgery also serves as an option for those refractory to
medical and surgical therapy. This case highlights a prolactinoma in a young male, and its impact on bone
health. Osteoporosis has been noted to be an issue in postmenopausal women with
prolactinomas. This case shows a similar impact on bone health in a young male
resulting in low bone mineral density for age based on Z-score. This case report
highlights the possible mechanisms for the bone loss in the setting of
prolactinoma and the need for assessing bone health in such patients.
Furthermore it highlights the need for a thorough evaluation in such patients. |
In November 2017, in what phase was the clinical trial for the drug SYL040012? | SYL040012 is in phase 2 clinical trials | Ten years after Fire and Melo's Nobel Prize for discovery of gene silencing by
double-stranded RNA, a remarkable progress was achieved in RNA interference
(RNAi). Changes in the chemical structure of synthetic oligonucleotides make
them more stable and specific, and new delivery strategies became progressively
available. The attention of pharmaceutical industry rapidly turned to RNAi, as
an opportunity to explore new drug targets. This review addresses nine
small-interfering RNAs (siRNAs) and one unique microRNA (miRNA) inhibitor, which
entered the phase 2-3 clinical trials. The siRNAs in focus are PF-04523655,
TKM-080301, Atu027, SYL040012, SYL1001, siG12D-LODER (phase 2), QPI-1002,
QPI-1007, and patisiran (phase 3). Regarding miRNAs, their content can be down-
or up-regulated, by using miRNA inhibitors (AntimiRs) or miRNA mimics.
Miravirsen is an AntimiR-122 for hepatitis C virus infection. The flexibility of
RNAi technology is easily understood taking into account: (i) the different drug
targets (i.e. p53, caspase 2, PKN3, β2-adrenergic receptor, mutated KRAS,
microRNAs); (ii) therapeutic conditions, including ophthalmic diseases, kidney
injury, amyloidosis, pancreatic cancer, viral hepatitis; and (iii) routes of
administration (ocular, intravenous, subcutaneous, intratumoral). Although some
issues are still matters of concern (delivery, toxicity, cost, and biological
barriers), RNAi definitively opens a wide avenue for drug development. |
Describe the RNA Centric Annotation System (RCAS) | The RNA Centric Annotation System (RCAS) is an R package which is designed to ease the process of creating gene-centric annotations and analysis for the genomic regions of interest obtained from various RNA-based omics technologies. The design of RCAS is modular, which enables flexible usage and convenient integration with other bioinformatics workflows. RCAS is an R/Bioconductor package but there are also graphical user interfaces including a Galaxy wrapper and a stand-alone web service. The application of RCAS on published datasets shows that RCAS is not only able to reproduce published findings but also helps generate novel knowledge and hypotheses. The meta-gene profiles, gene-centric annotation, motif analysis and gene-set analysis provided by RCAS provide contextual knowledge which is necessary for understanding the functional aspects of different biological events that involve RNAs. In addition, the array of different interfaces and deployment options adds the convenience of use for different levels of users. RCAS is available at http://bioconductor.org/packages/release/bioc/html/RCAS.html and http://rcas.mdc-berlin.de. | In the field of RNA, the technologies for studying the transcriptome have
created a tremendous potential for deciphering the puzzles of the RNA biology.
Along with the excitement, the unprecedented volume of RNA related omics data is
creating great challenges in bioinformatics analyses. Here, we present the RNA
Centric Annotation System (RCAS), an R package, which is designed to ease the
process of creating gene-centric annotations and analysis for the genomic
regions of interest obtained from various RNA-based omics technologies. The
design of RCAS is modular, which enables flexible usage and convenient
integration with other bioinformatics workflows. RCAS is an R/Bioconductor
package but we also created graphical user interfaces including a Galaxy wrapper
and a stand-alone web service. The application of RCAS on published datasets
shows that RCAS is not only able to reproduce published findings but also helps
generate novel knowledge and hypotheses. The meta-gene profiles, gene-centric
annotation, motif analysis and gene-set analysis provided by RCAS provide
contextual knowledge which is necessary for understanding the functional aspects
of different biological events that involve RNAs. In addition, the array of
different interfaces and deployment options adds the convenience of use for
different levels of users. RCAS is available at
http://bioconductor.org/packages/release/bioc/html/RCAS.html and
http://rcas.mdc-berlin.de. |
What is Chronic Wasting Disease (CWD) in deer? | Chronic wasting disease (CWD) is a transmissible spongiform encephalopathy (TSE) affecting members of the cervid species, and is one of the few TSEs with an expanding geographic range. | Chronic wasting disease (CWD) has emerged as an important disease of wildlife in
North America. The disease is a unique member of the transmissible spongiform
encephalopathies (TSEs) or prion diseases, which naturally affect only a few
species. Of the TSEs, CWD is the only one found in free-ranging species.
However, interest in CWD has recently grown, by association with the
better-known TSEs such as variant Creutzfeldt-Jakob disease of humans and bovine
spongiform encephalopathy. Knowledge of the geographic distribution of CWD,
though still limited, has greatly improved since the mid-1990s as a result of
surveillance in free-ranging deer and elk and in commercially owned Rocky
Mountain elk (Cervus elaphus nelsoni), and the disease has now been found in
multiple areas of the plains and Rocky Mountain foothills of western North
America. Studies of the biology and natural history of CWD over recent years
have resulted in a better understanding of the pathogenesis and epidemiology of
the disease. Early involvement of the lymphoid tissues of the alimentary tract
during the incubation period of CWD suggests plausible routes for agent exit
from an infected individual, such as in faeces or saliva. Chronic wasting
disease is laterally transmitted and environmental contamination may play an
important role in local maintece of the disease. Studies on the epidemiology
of CWD have led to the development of models to help explain the history of CWD
and to simulate future impacts on deer and elk populations. Diagnostic tests
have been improved, allowing diagnosis early in the incubation period, long
before the appearance of clinical disease. Surveillance techniques and
programmes have been developed and instituted by wildlife management agencies
for free-ranging deer and elk and by state and federal agricultural agencies for
privately-owned elk. During the 1990s, perceptions of TSEs have altered
dramatically; perhaps most remarkably, the goal of global eradication of all
prion diseases is now being discussed. Chronic wasting disease (CWD) has recently emerged in North America as an
important prion disease of captive and free-ranging cervids (species in the deer
family). CWD is the only recognized transmissible spongiform encephalopathy
(TSE) affecting free-ranging species. Three cervid species, mule deer
(Odocoileus hemionus), white-tailed deer (O. virginianus), and Rocky Mountain
elk (Cervus elaphus nelsoni), are the only known natural hosts of CWD. Endemic
CWD is well established in southern Wyoming and northern Colorado, and has been
present in this 'core area' for two decades or more. Apparently CWD has also
infected farmed cervids in numerous jurisdictions, and has probably been endemic
in North America's farmed deer and elk for well over a decade. Several
free-ranging foci distant to the Colorado-Wyoming core area have been discovered
since 2000, and new or intensified surveillance may well identify even more foci
of infection. Whether all of the identified captive and free-ranging foci are
connected via a common original exposure source remains undetermined. Some of
this recently observed 'spread' may be attributable to improved detection or
natural movements of infected deer and elk, but more distant range extensions
are more likely caused by movements of infected captive deer and elk in
commerce, or by some yet unidentified exposure risk factor. Research on CWD over
the last 5 years has resulted in a more complete understanding of its
pathogenesis and epidemiology. CWD is infectious, transmitting horizontally from
infected to susceptible cervids. Early accumulation of PrP(CWD) in alimentary
tract-associated lymphoid tissues during incubation suggests agent shedding in
feces or saliva as plausible transmission routes. Residual infectivity in
contaminated environments also appears to be important in sustaining epidemics.
Improved tests allow CWD to be reliably diagnosed long before clinical signs
appear. Implications of CWD are not entirely clear at this time. Natural
transmission to humans or traditional domestic livestock seems relatively
unlikely, but the possibility still evokes public concerns; impacts on wildlife
resources have not been determined. Consequently, where CWD is not known to
occur surveillance programs and regulations that prevent or reduce the
likelihood that CWD will be introduced into these jurisdictions should be
encouraged. Where CWD is known to occur, affected jurisdictions are conducting
surveillance to estimate and monitor trends in geographic distribution and
prevalence, managing deer and elk populations in attempts to limit spread, and
developing and evaluating techniques for further controlling and perhaps
eradicating CWD. Programs for addressing the challenges of CWD management will
require interagency cooperation, commitment of funds and personnel, and applied
research. Chronic wasting disease (CWD) is perhaps the most enigmatic of the
naturally occurring prion diseases. Although recognized as a transmissible
spongiform encephalopathy (TSE) since the late 1970s (Williams and Young 1980,
1982), interest in and concern about CWD has only recently emerged. CWD most
closely resembles scrapie in sheep in most respects, but recent media and public
reaction to CWD has been more reminiscent of that afforded to bovine spongiform
encephalopathy (BSE) less than a decade ago. Yet, with the exception of
transmissible mink encephalopathy (TME), CWD is the rarest of the known animal
TSEs: fewer than 1,000 cases have been diagnosed worldwide, and all but two of
these occurred in North America. CWD is unique among the TSEs in that it affects
free-living species (Spraker et al. 1997; Miller et al. 2000). The three natural
host species for CWD, mule deer (Odocoileus hemionus), white-tailed deer (O.
virginianus), and Rocky Mountain elk (Cervus elaphus nelsoni), are all in the
family Cervidae and native to North America. Like scrapie, CWD is contagious:
epidemics are self-sustaining in both captive and free-ranging cervid
populations (Miller et al. 1998, 2000). The geographic extent of endemic CWD in
free-ranging wildlife was initially thought to be quite limited and its natural
rate of expansion slow; however, recent investigations have revealed that CWD
has been inadvertently spread much more widely via market-driven movements of
infected, farmed elk and deer. Both the ecological and economic consequences of
CWD and its spread remain to be determined; moreover, public health implications
remain a question of intense interest. Here, we review current understanding of
CWD, its implications, and its management. Chronic wasting disease (CWD) is a unique transmissible spongiform
encephalopathy (TSE) of mule deer (Odocoileus hemionus), white-tailed deer (O.
virginianus), and Rocky Mountain elk (Cervus elaphus nelsoni). The natural
history of CWD is incompletely understood, but it differs from scrapie and
bovine spongiform encephalopathy (BSE) by virtue of its occurrence in
nondomestic and free-ranging species. CWD has many features in common with
scrapie, including early widespread distribution of disease-associated prion
protein (PrP(d)) in lymphoid tissues, with later involvement of central nervous
system (CNS) and peripheral tissues. This distribution likely contributes to
apparent efficiency of horizontal transmission and, in this, is similar to
scrapie and differs from BSE. Clinical features and lesions of CWD are
qualitatively similar to the other animal TSEs. Microscopically, marked
spongiform lesions occur in the central nervous system (CNS) after a prolonged
incubation period and variable course of clinical disease. During incubation,
PrP(d) can be identified in tissues by antibody-based detection systems.
Although CWD can be transmitted by intracerebral inoculation to cattle, sheep,
and goats, ongoing studies have not demonstrated that domestic livestock are
susceptible via oral exposure, the presumed natural route of exposure to TSEs.
Surveillance efforts for CWD in captive and free-ranging cervids will continue
in concert with similar activities for scrapie and BSE. Eradication of CWD in
farmed cervids is the goal of state, federal, and industry programs, but
eradication of CWD from free-ranging populations of cervids is unlikely with
currently available management techniques. Chronic wasting disease (CWD) is a fatal, emerging disease of cervids associated
with transmissible protease-resistant prion proteins. The potential for CWD to
cause dramatic declines in deer and elk populations and perceived human health
risks associated with consuming CWD-contaminated venison have led wildlife
agencies to embark on extensive CWD control programs, typically involving
culling to reduce deer populations. We characterized the spatial distribution of
CWD in white-tailed deer (Odocoileus virginianus) in Wisconsin to facilitate CWD
management. We found that CWD prevalence declined with distance from a central
location, was locally correlated at a scale of 3.6 km, and was correlated with
deer habitat abundance. The latter result is consistent with patterns expected
for a positive relationship between density and prevalence of CWD. We recommend
management activities focused on culling in geographic areas with high
prevalence to have the greatest probability of removing infected individuals.
Further research is needed to elucidate the factors involved in CWD spread and
infection rates, especially the role of density-dependent transmission. Chronic wasting disease (CWD), a contagious prion disease of the deer family,
has the potential to severely harm deer populations and disrupt ecosystems where
deer occur in abundance. Consequently, understanding the dynamics of this
emerging infectious disease, and particularly the dynamics of its transmission,
has emerged as an important challenge for contemporary ecologists and wildlife
managers. Although CWD is contagious among deer, the relative importance of
pathways for its transmission remains unclear. We developed seven competing
models, and then used data from two CWD outbreaks in captive mule deer and model
selection to compare them. We found that models portraying indirect transmission
through the environment had 3.8 times more support in the data than models
representing transmission by direct contact between infected and susceptible
deer. Model-averaged estimates of the basic reproductive number (R0) were 1.3 or
greater, indicating likely local persistence of CWD in natural populations under
conditions resembling those we studied. Our findings demonstrate the apparent
importance of indirect, environmental transmission in CWD and the challenges
this presents for controlling the disease. Chronic wasting disease (CWD), a prion disease of North American deer, elk and
moose, affects both free-ranging and captive cervids. The potential host range
for CWD remains uncertain. The susceptibility of the ferret to CWD was examined
experimentally by administering infectious brain material by the intracerebral
(IC) or oral (PO) route. Between 15 and 20 months after IC inoculation, ferrets
developed neurological signs consistent with prion disease, including
polyphagia, somnolence, piloerection, lordosis and ataxia. Upon first
sub-passage of ferret-adapted CWD, the incubation period decreased to 5 months.
Spongiform change in the neuropil was most marked in the basal ganglia,
thalamus, midbrain and pons. The deposition of PrP(CWD) was granular and was
occasionally closely associated with, or localized within, neurons. There were
no plaque-like or perivascular PrP aggregates as seen in CWD-infected cervids.
In western blots, the PrP(CWD) glycoform profile resembled that of CWD in deer,
typified by a domit diglycosylated glycoform. CWD disease in ferrets followed
IC but not PO inoculation, even after 31 months of observation. These findings
indicate that CWD-infected ferrets share microscopical and biochemical features
of CWD in cervids, but appear to be relatively resistant to oral infection by
primary CWD inoculum of deer origin. Chronic wasting disease (CWD) is a prion disease of cervids that causes
neurodegeneration and death. Susceptibility to prion infections, including CWD,
can be dependent on the amino acid sequence of the host prion protein (PrP).
Here, CWD agent obtained from a deer expressing the 96SS genotype, associated
with partial resistance to CWD, was used to infect transgenic (tg) mice
expressing either 96GG or 96SS deer PrP. Transgenic mice expressing 96GG deer
PrP succumbed to this agent, but tg mice expressing 96SS deer PrP did not.
Additional studies using inocula from 96GG deer showed no transmission to 96SS
PrP mice and delayed disease in 96GS mice. Thus, 96S PrP played an inhibitory
role in disease progression in tg mice. Chronic wasting disease (CWD) is an evolving prion disease of cervids (deer, elk
and moose) that has been recognized in North America and Korea. Infection of
non-cervid reservoir or transport species in nature is not reported. However,
the ferret (Mustela putorius furo) is susceptible to CWD after experimental
inoculation. Here, we report that infection of ferrets with either of two ferret
CWD isolates by various routes of exposure has revealed biologically distinct
strain-like properties distinguished by different clinical progression and
survival period. The isolates of ferret CWD were also differentiated by the
distribution of the infectious prion protein (PrP(CWD)) in the brain and
periphery, and by the proteinase K sensitivity of PrP(CWD). These findings
suggest that diversity in prion conformers exists in CWD-infected cervids. Chronic wasting disease (CWD) is a transmissible spongiform encephalopathy
affecting North American cervids. Because it is uniformly fatal, the disease is
a major concern in the management of white-tailed deer populations. Management
programs to control CWD require improved knowledge of deer interaction,
movement, and population connectivity that could influence disease transmission
and spread. Genetic methods were employed to evaluate connectivity among
populations in the CWD management zone of southern Wisconsin. A 576-base-pair
region of the mitochondrial DNA of 359 white-tailed deer from 12 sample
populations was analyzed. Fifty-eight variable sites were detected within the
sequence, defining 43 haplotypes. While most sample populations displayed
similar levels of haplotype diversity, individual haplotypes were clustered on
the landscape. Spatial clusters of different haplotypes were apparent in
distinct ecoregions surrounding CWD outbreak areas. The spatial distribution of
mtDNA haplotypes suggests that clustering of the deer matrilineal groups and
population connectivity are associated with broad-scale geographic landscape
features. These landscape characteristics may also influence the contact rates
between groups and therefore the potential spread of CWD; this may be especially
true of local disease spread between female social groups. Our results suggest
that optimal CWD management needs to be tailored to fit gender-specific
dispersal behaviors and regional differences in deer population connectivity.
This information will help wildlife managers design surveillance and monitoring
efforts based on population interactions and potential deer movement among
CWD-affected and unaffected areas. Chronic wasting disease (CWD) is an emergent, rapidly spreading prion disease of
cervids. Shedding of infectious prions in saliva and urine is thought to be an
important factor in CWD transmission. To help to elucidate this issue, we
applied an in vitro amplification assay to determine the onset, duration, and
magnitude of prion shedding in longitudinally collected saliva and urine samples
from CWD-exposed white-tailed deer. We detected prion shedding as early as 3
months after CWD exposure and sustained shedding throughout the disease course.
We estimated that the 50% lethal dose (LD50) for cervidized transgenic mice
would be contained in 1 ml of infected deer saliva or 10 ml of urine. Given the
average course of infection and daily production of these body fluids, an
infected deer would shed thousands of prion infectious doses over the course of
CWD infection. The direct and indirect environmental impacts of this magnitude
of prion shedding on cervid and noncervid species are surely significant.
IMPORTANCE: Chronic wasting disease (CWD) is an emerging and uniformly fatal
prion disease affecting free-ranging deer and elk and is now recognized in 22
U.S. states and 2 Canadian provinces. It is unique among prion diseases in that
it is transmitted naturally through wild populations. A major hypothesis to
explain CWD's florid spread is that prions are shed in excreta and transmitted
via direct or indirect environmental contact. Here we use a rapid in vitro assay
to show that infectious doses of CWD prions are in fact shed throughout the
multiyear disease course in deer. This finding is an important advance in
assessing the risks posed by shed CWD prions to animals as well as humans. BACKGROUND: Chronic wasting disease (CWD) is a contagious, fatal prion disease
affecting cervids in a growing number of regions across North America. Projected
deer population declines and concern about potential spread of CWD to other
species warrant strategies to manage this disease. Control efforts to date have
been largely unsuccessful, resulting in continuing spread and increasing
prevalence. This systematic review summarizes peer-reviewed published reports
describing field-applicable CWD control strategies in wild deer populations in
North America using systematic review methods. Ten databases were searched for
peer-reviewed literature. Following deduplication, relevance screening,
full-text appraisal, subject matter expert review and qualitative data
extraction, nine references were included describing four distinct management
strategies.
RESULTS: Six of the nine studies used predictive modeling to evaluate control
strategies. All six demonstrated one or more interventions to be effective but
results were dependant on parameters and assumptions used in the model. Three
found preferential removal of CWD infected deer to be effective in reducing CWD
prevalence; one model evaluated a test and slaughter strategy, the other
selective removal of infected deer by predators and the third evaluated
increased harvest of the sex with highest prevalence (males). Three models
evaluated non-selective harvest of deer. There were only three reports that
examined primary data collected as part of observational studies. Two of these
studies supported the effectiveness of intensive non-selective culling; the
third study did not find a difference between areas that were subjected to
culling and those that were not. Seven of the nine studies were conducted in the
United States.
CONCLUSIONS: This review highlights the paucity of evaluated, field-applicable
control strategies for CWD in wild deer populations. Knowledge gaps in the
complex epidemiology of CWD and the intricacies inherent to prion diseases
currently pose significant challenges to effective control of this disease in
wild deer in North America. Chronic wasting disease (CWD) is an invariably fatal transmissible spongiform
encephalopathy of white-tailed deer, mule deer, elk, and moose. Despite a 100%
fatality rate, areas of high prevalence, and increasingly expanding geographic
endemic areas, little is known about the population-level effects of CWD in
deer. To investigate these effects, we tested the null hypothesis that high
prevalence CWD did not negatively impact white-tailed deer population
sustainability. The specific objectives of the study were to monitor
CWD-positive and CWD-negative white-tailed deer in a high-prevalence CWD area
longitudinally via radio-telemetry and global positioning system (GPS) collars.
For the two populations, we determined the following: a) demographic and disease
indices, b) annual survival, and c) finite rate of population growth (λ). The
CWD prevalence was higher in females (42%) than males (28.8%) and hunter harvest
and clinical CWD were the most frequent causes of mortality, with CWD-positive
deer over-represented in harvest and total mortalities. Survival was
significantly lower for CWD-positive deer and separately by sex; CWD-positive
deer were 4.5 times more likely to die annually than CWD-negative deer while
bucks were 1.7 times more likely to die than does. Population λ was 0.896
(0.859-0.980), which indicated a 10.4% annual decline. We show that a chronic
disease that becomes endemic in wildlife populations has the potential to be
population-limiting and the strong population-level effects of CWD suggest
affected populations are not sustainable at high disease prevalence under
current harvest levels. Chronic wasting disease (CWD) is a fatal neurodegenerative disease affecting
free-ranging and captive cervids that now occurs in 24 U.S. states and two
Canadian provinces. Despite the potential threat of CWD to deer populations,
little is known about the rates of infection and mortality caused by this
disease. We used epidemiological models to estimate the force of infection and
disease-associated mortality for white-tailed deer in the Wisconsin and Illinois
CWD outbreaks. Models were based on age-prevalence data corrected for bias in
aging deer using the tooth wear and replacement method. Both male and female
deer in the Illinois outbreak had higher corrected age-specific prevalence with
slightly higher female infection than deer in the Wisconsin outbreak. Corrected
ages produced more complex models with different infection and mortality
parameters than those based on apparent prevalence. We found that adult male
deer have a more than threefold higher risk of CWD infection than female deer.
Males also had higher disease mortality than female deer. As a result, CWD
prevalence was twofold higher in adult males than females. We also evaluated the
potential impacts of alternative contact structures on transmission dynamics in
Wisconsin deer. Results suggested that transmission of CWD among male deer
during the nonbreeding season may be a potential mechanism for producing higher
rates of infection and prevalence characteristically found in males. However,
alternatives based on high environmental transmission and transmission from
females to males during the breeding season may also play a role. Prion diseases, such as Creutzfeldt-Jakob disease in humans, bovine spongiform
encephalopathy in cattle, chronic wasting disease in cervids (i.e., deer, elk,
moose, and reindeer), and sheep scrapie, are caused by the misfolding of the
cellular prion protein (PrPC) into a disease-causing conformer (PrPSc). PrPC is
a normal, GPI-anchored protein that is expressed on the surface of neurons and
other cell types. The structure of PrPC is well understood, based on studies of
recombit PrP, which closely mimics the structure of native PrPC. In contrast,
PrPSc is prone to aggregate into a variety of quaternary structures, such as
oligomers, amorphous aggregates, and amyloid fibrils. The propensity of PrPSc to
assemble into these diverse forms of aggregates is also responsible for our
limited knowledge about its structure. Then again, the repeating nature of
certain regular PrPSc aggregates has allowed (lower resolution) insights into
the structure of the infectious conformer, establishing a four-rung β-solenoid
structure as a key element of its architecture. A number of prion diseases affect humans, including Creutzfeldt-Jakob disease;
most of these are due to genetic mutations in the affected individual and occur
sporadically, but some result from transmission of prion proteins from external
sources. Of the known animal prion diseases, only bovine spongiform
encephalopathy prions have been shown to be transmissible from animals to humans
under non-experimental conditions. Chronic wasting disease (CWD) is a prion
disease that affects cervids (e.g., deer and elk) in North America and isolated
populations in Korea and Europe. Systematic review methodology was used to
identify, select, critically appraise and analyse data from relevant research.
Studies were evaluated for adherence to good conduct based on their study design
following the Cochrane collaboration's approach to grading the quality of
evidence and the strength of recommendations (GRADE). Twenty-three studies were
included after screening 800 citations from the literature search and evaluating
78 full papers. Studies examined the transmissibility of CWD prions to humans
using epidemiological study design, in vitro and in vivo experiments. Five
epidemiological studies, two studies on macaques and seven studies on humanized
transgenic mice provided no evidence to support the possibility of transmission
of CWD prions to humans. Ongoing surveillance in the United States and Canada
has not documented CWD transmission to humans. However, two studies on squirrel
monkeys provided evidence that transmission of CWD prions resulting in prion
disease is possible in these monkeys under experimental conditions and seven
in vitro experiments provided evidence that CWD prions can convert human prion
protein to a misfolded state. Therefore, future discovery of CWD transmission to
humans cannot be entirely ruled out on the basis of current studies,
particularly in the light of possible decades-long incubation periods for CWD
prions in humans. It would be prudent to continue CWD research and epidemiologic
surveillance, exercise caution when handling potentially contaminated material
and explore CWD management opportunities. Prion disease epidemics, which have been unpredictable recurrences, are of
significant concern for animal and human health. Examples include kuru, once the
leading cause of death among the Fore people in Papua New Guinea and caused by
mortuary feasting; bovine spongiform encephalopathy (BSE) and its subsequent
transmission to humans in the form of variant Creutzfeldt-Jakob disease (vCJD),
and repeated examples of large-scale prion disease epidemics in animals caused
by contaminated vaccines. The etiology of chronic wasting disease (CWD), a
relatively new and burgeoning prion epidemic in deer, elk, and moose (members of
the cervid family), is more enigmatic. The disease was first described in
captive and later in wild mule deer and subsequently in free-ranging as well as
captive Rocky Mountain elk, white-tailed deer, and most recently moose. It is
therefore the only recognized prion disorder of both wild and captive animals.
In addition to its expanding range of hosts, CWD continues to spread to new
geographical areas, including recent cases in Norway. The unparalleled
efficiency of the contagious transmission of the disease combined with high
densities of deer in certain areas of North America complicates strategies for
controlling CWD and raises concerns about its potential spread to new species.
Because there is a high prevalence of CWD in deer and elk, which are commonly
hunted and consumed by humans, the possibility of zoonotic transmission is
particularly concerning. Here, we review the current status of naturally
occurring CWD and describe advances in our understanding of its molecular
pathogenesis, as shown by studies of CWD prions in novel in vivo and in vitro
systems. Among prion infections, two scenarios of prion spread are generally observed:
(i) early lymphoid tissue replication or (ii) direct neuroinvasion without
substantial antecedent lymphoid amplification. In nature, cervids are infected
with chronic wasting disease (CWD) prions by oral and nasal mucosal exposure,
and studies of early CWD pathogenesis have implicated pharyngeal lymphoid tissue
as the earliest sites of prion accumulation. However, knowledge of chronological
events in prion spread during early infection remains incomplete. To investigate
this knowledge gap in early CWD pathogenesis, we exposed white-tailed deer to
CWD prions by mucosal routes and performed serial necropsies to assess PrPCWD
tissue distribution by real-time quaking-induced conversion (RT-QuIC) and
tyramide signal amplification immunohistochemistry (TSA-IHC). Although PrPCWD
was not detected by either method in the initial days (1 and 3) postexposure, we
observed PrPCWD seeding activity and follicular immunoreactivity in
oropharyngeal lymphoid tissues at 1 and 2 months postexposure (MPE). At 3 MPE,
PrPCWD replication had expanded to all systemic lymphoid tissues. By 4 MPE, the
PrPCWD burden in all lymphoid tissues had increased and approached levels
observed in terminal disease, yet there was no evidence of nervous system
invasion. These results indicate the first site of CWD prion entry is in the
oropharynx, and the initial phase of prion amplification occurs in the
oropharyngeal lymphoid tissues followed by rapid dissemination to systemic
lymphoid tissues. This lymphoid replication phase appears to precede
neuroinvasion.IMPORTANCE Chronic wasting disease (CWD) is a universally fatal
transmissible spongiform encephalopathy affecting cervids, and natural infection
occurs through oral and nasal mucosal exposure to infectious prions. Terminal
disease is characterized by PrPCWD accumulation in the brain and lymphoid
tissues of affected animals. However, the initial sites of prion accumulation
and pathways of prion spread during early CWD infection remain unknown. To
investigate the chronological events of early prion pathogenesis, we exposed
deer to CWD prions and monitored the tissue distribution of PrPCWD over the
first 4 months of infection. We show CWD uptake occurs in the oropharynx with
initial prion replication in the draining oropharyngeal lymphoid tissues,
rapidly followed by dissemination to systemic lymphoid tissues without evidence
of neuroinvasion. These data highlight the two phases of CWD infection: a robust
prion amplification in systemic lymphoid tissues prior to neuroinvasion and
establishment of a carrier state. Chronic wasting disease (CWD) is a fatal transmissible spongiform encephalopathy
affecting white-tailed deer (Odocoileus virginianus), mule deer (Odocoileus
hemionus), Rocky Mountain elk (Cervus elaphus nelsoni), and moose (Alces alces
shirasi) in North America. In southeastern Wyoming average annual CWD prevalence
in mule deer exceeds 20% and appears to contribute to regional population
declines. We determined the effect of CWD on mule deer demography using
age-specific, female-only, CWD transition matrix models to estimate the
population growth rate (λ). Mule deer were captured from 2010-2014 in southern
Converse County Wyoming, USA. Captured adult (≥ 1.5 years old) deer were tested
ante-mortem for CWD using tonsil biopsies and monitored using radio telemetry.
Mean annual survival rates of CWD-negative and CWD-positive deer were 0.76 and
0.32, respectively. Pregcy and fawn recruitment were not observed to be
influenced by CWD. We estimated λ = 0.79, indicating an annual population
decline of 21% under current CWD prevalence levels. A model derived from the
demography of only CWD-negative individuals yielded; λ = 1.00, indicating a
stable population if CWD were absent. These findings support CWD as a
significant contributor to mule deer population decline. Chronic wasting disease
is difficult or impossible to eradicate with current tools, given significant
environmental contamination, and at present our best recommendation for control
of this disease is to minimize spread to new areas and naïve cervid populations. |
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