Improved Screening of Monoclonal Gammopathy Patients by MALDI-TOF Mass Spectrometry

Monoclonal gammopathies are a group of blood diseases characterized by presence of abnormal immunoglobulins in peripheral blood and/or urine of patients. Multiple myeloma and plasma cell leukemia are monoclonal gammopathies with unclear etiology, caused by malignant transformation of bone marrow plasma cells. Mass spectrometry with matrix-assisted laser desorption/ionization and time-of-flight detection is commonly used for investigation of the peptidome and small proteome of blood plasma with high accuracy, robustness, and cost-effectivity. In addition, mass spectrometry coupled with advanced statistics can be used for molecular profiling, classification, and diagnosis of liquid biopsies and tissue specimens in various malignancies. Despite the fact there have been fully optimized protocols for mass spectrometry of normal blood plasma available for decades, in monoclonal gammopathy patients, the massive alterations of biophysical and biochemical parameters of peripheral blood plasma often limit the mass spectrometry measurements. In this paper, we present a new two-step extraction protocol and demonstrated the enhanced resolution and intensity (>50×) of mass spectra obtained from extracts of peripheral blood plasma from monoclonal gammopathy patients. When coupled with advanced statistics and machine learning, the mass spectra profiles enabled the direct identification, classification, and discrimination of multiple myeloma and plasma cell leukemia patients with high accuracy and precision. A model based on PLS-DA achieved the best performance with 71.5% accuracy (95% confidence interval, CI = 57.1-83.3%) when the 10× repeated 5-fold CV was performed. In summary, the two-step extraction protocol improved the analysis of monoclonal gammopathy peripheral blood plasma samples by mass spectrometry and provided a tool for addressing the complex molecular etiology of monoclonal gammopathies.

The endoplasmic reticulum and its signaling pathways - a novel target for multiple myeloma treatment

BACKGROUND

The endoplasmic reticulum (ER), an organelle composed of a system of cisternae and tubules, is essential for many cellular processes, including protein synthesis and transport. When misfolded proteins accumulate in the ER lumen, ER stress is induced, and the subsequent response to the disruption of homeostasis is the activation of the unfolded protein response (UPR). The purpose of this process is to restore homeostasis by increasing the capacity of the ER and its ability to fold proteins. Activation of the homeostatic UPR occurs via one of three transmembrane proteins, inositol-requiring enzyme 1a (IRE1a), protein kinase R-like ER kinase (PERK) and activating transcription factor 6 (ATF6). Failure of the attempt to restore homeostasis, on the other hand, leads to the development of terminal UPR and apoptosis via hyperactivation of the same proteins. Activation of UPR has been described in many malignancies, including multiple myeloma (MM), which is characterized by malignant transformation of plasma cells and increased monoclonal immunoglobulin synthesis, where the role of the ER is of particular importance. Despite advances in the treatment of MM, the disease remains difficult to treat and targeting signaling pathways associated with the UPR could, for example, enhance the effect of proteasome inhibitors.

PURPOSE

This review intends to present the molecular response to ER stress under physiological circumstances and in the context of cancer, particularly with regard to potential therapeutic targets in MM.

Therapeutic Drug Monitoring of Protein Kinase Inhibitors in the Treatment of Non-small Cell Lung Cancer

Targeted therapy with protein kinase inhibitors (PKIs) represents one of the important treatment options for non-small cell lung cancer (NSCLC). It has contributed to improve patients' survival and quality of life significantly. These anticancer drugs are administrated orally in flat-fixed doses despite the well-known large interpatient pharmacokinetic variability and the possible need for dose individualization. To optimize and individualize dosing of PKIs, and thereby increasing the effectiveness and safety of the treatment, therapeutic drug monitoring (TDM) is the most frequently mentioned method. Unlike other areas of medicine, TDM has been rather exceptional in oncological practise since there is a little evidence or no data for concentration-effect relationships of PKIs. Therefore, the aim of this review is to summarize the pharmacokinetic characteristics of PKIs and provide the evidence supporting the use of TDM for personalised treatment of patients with NSCLC.

Involvement of Small Non-Coding RNA and Cell Antigens in Pathogenesis of Extramedullary Multiple Myeloma

Extramedullary multiple myeloma (EMD) is an aggressive disease; malignant plasma cells lose their dependence in the bone marrow microenvironment and migrate into tissues. EMD is a negative prognostic factor of survival. Using flow cytometry and next-generation sequencing, we aimed to identify antigens and microRNAs (miRNAs) involved in EMD pathogenesis. Flow cytometry analysis revealed significant differences in the level of clonal plasma cells between MM and EMD patients, while the expression of CD markers was comparable between these two groups. Further, miR-26a-5p and miR-30e-5p were found to be significantly down-regulated in EMD compared to MM. Based on the expression of miR-26a-5p, we were able to distinguish these two groups of patients with high sensitivity and specificity. In addition, the involvement of deregulated miRNAs in cell cycle regulation, ubiquitin-mediated proteolysis and signaling pathways associated with infections or neurological disorders was observed using GO and KEGG pathways enrichment analysis. Subsequently, a correlation between the expression of analyzed miRNAs and the levels of CD molecules was observed. Finally, clinicopathological characteristics as well as CD antigens associated with the prognosis of MM and EMD patients were identified. Altogether, we identified several molecules possibly involved in the transformation of MM into EMD.

ELECTROMAGNETIC ABSORPTION CHARACTERISTICS OF MANGANESE–ZINC FERRITE AND MULTIWALLED CARBON NANOTUBE–FILLED COMPOSITES BASED ON NBR

Composites based on acrylonitrile–butadiene rubber, carbon nanotubes, and manganese–zinc ferrite were fabricated and tested for electromagnetic interference (EMI) absorption shielding. First, carbon nanotubes and ferrite were solely used for the preparation of rubber composites. Then, carbon nanotubes were combined with magnetic filler and incorporated into the rubber matrix. The results revealed that carbon nanotubes act as reinforcing filler and significantly enhance the physical–mechanical properties of composites. The presence of carbon nanotubes in the rubber matrix also results in an outstanding increase in electrical conductivity and permittivity of composite materials, as a consequence of which the EMI absorption shielding was poor in the tested frequency range of 1 MHz to 3 GHz. On the other hand, ferrite-filled composites are able to efficiently absorb electromagnetic radiation emitted from various electronic and radiation sources. However, the tensile strength of the composites showed a decreasing trend with increasing content of ferrite. The combination of carbon nanotubes with manganese–zinc ferrite resulted in an improvement in the physical–mechanical properties of hybrid composites. As the permittivity of hybrid composites was still much higher in comparison with those filled only with ferrite, only the composite filled with 5 phr of carbon nanotubes and 100 phr of ferrite showed a slight EMI absorption shielding ability over the tested frequency range.

[Fever of unknown origin: case reports from routine clinical practice and a review]

Fever of unknown origin represents a clinical syndrome characterized by a fever of over 38.3 °C documented on several occasions during a period of at least 3 weeks, etiology of which remains unexplained after obtaining a detailed history, conducting a thorough physical exam, and an array of basic laboratory tests and diagnostic imaging. Most cases of this syndrome are caused by infections, non-infectious inflammatory diseases, and neoplasms. In addition, drug fevers and internal medicine diseases should be included in the differential diagnostic work-up in all patients. This article presents five case reports of fever of unknown origin managed at an outpatient clinic of a tertiary care center for infectious diseases. This case series emphasizes the need for a consistent, broad and interdisciplinary diagnostic work-up. In addition, we present a review of the etiology and clinical management of fever of unknown origin.

Neurotoxic side effects of acyclovir: two case reports

Acyclovir is an antiviral drug frequently used in clinical practice. It is indicated for the treatment of infections caused by herpes simplex virus and varicella zoster virus. The drug has a good safety profile; however, severe side effects may rarely occur during therapy. These include renal failure as a major risk factor for neurotoxic side effects potentially developing within 24-48 hours of therapy initiation. The paper presents the cases of two patients developing neurotoxic side effects while treated for herpes zoster. The aim of the authors is to highlight the potential for developing neurotoxic side effects in high-risk groups such as the elderly, patients with impaired renal function or multiple comorbidities on polypharmacy, or those using nephrotoxic drugs. Acyclovir use could lead to renal impairment and an increase in its plasma and CNS concentrations with severe neuropsychiatric side effects. The neurotoxic side effects are reversible after therapy withdrawal. Thus, in patients developing mental impairment or showing other neurological symptoms during acyclovir therapy, the patient should be promptly assessed for potential drug neurotoxicity, their therapy should be discontinued and drug elimination with forced diuresis or hemodialysis considered. Early recognition of acyclovir neurotoxic side effects can significantly improve a patient's prognosis.

Waldenström macroglobulinemia

BACKGROUND

Waldenström macroglobulinemia (WM) is a hematological malignancy; it is a monoclonal gammopathy, a disease characterized by presence of a monoclonal immunoglobulin in serum and/or urine. The median age at dia-gnosis is 71 years. WM is not an aggres-sive disease and patients with this dia-gnosis can live for several years. Infiltration of the bone marrow with lymphoplasmacytoid cells causes anemia, leading to various problems, mainly fatigue. Hepatomegaly, splenomegaly and lymphadenopathy can also occur. Hyperviscosity syndrome can appear and is caused by excessive production of immunoglobulin M. A mutation in MYD88 gene is detected in almost every WM patient, and in almost one third of them, a mutation in CXCR4 gene is detected. The detection of MYD88 mutation is important for a correct therapeutic strategy, since a Brutons tyrosine kinase inhibitor, ibrutinib, is most effective in patients with mutated MYD88 and wt CXCR4. The therapy is started when first symptoms occur.

PURPOSE

The aim of this study is to summarize current knowledge about this disease, its dia-g-nostics, molecular basis and treatment.

Erdheim-Chester disease

Erdheim-Chester disease is a rare inflammatory myeloid clonal disease which is classified into histiocytoses. It is characterized by excessive production and accumulation of foamy histiocytes and Touton giant cells in various tissues and organs. Foamy histiocytes and Touton giant cells produce proinflammatory cytokines and chemokines and contain somatic mutations in genes activating the MAPK/ERK signaling pathway, but also in genes activating the PI3K/AKT signaling pathway. BRAFV600E is the most common somatic mutation. Furthermore, somatic mutations in the MAP2K1, KRAS, NRAS, ARAF or PIK3CA genes are abundant. Erdheim-Chester dis-ease is a multisystemic disease in which any organ can be affected, especially the long bones of the lower extremities, but also the cardiovascular system, retroperitoneum, endocrine system, central nervous system, lungs, skin or orbit. The dia-gnosis is difficult because of the various manifestations of this disease. The disease occurs mainly in adults and is more common in men than in women. Targeted treatment by kinase inhibitors, interferon a, cytokine blockers or cladribine is used for the treatment.

Fever of unknown origin

Fever of unknown origin is a rare clinical syndrome, that represents a significant diagnostic challenge. There have been described more than 200 potential diseases, that can manifest as a fever of unknown origin. These are classically divided into following categories: infections, non-infectious inflammatory diseases, malignancies, and other miscellaneous disorders. Each of the disease type is associated with rather characteristic symptoms, clinical signs and laboratory findings, which are individually non-specific, but may provide helpful clues for a further focused diagnostic work-up. The clinicians task is to be able to identify these hallmark clinical features and to correctly interpret their significance and limitations in the appropriate differential diagnostic context. The aim of this review is to provide up-to-date clinical research evidence and to propose a  concise clue-oriented diagnostic approach.

Role of exosomes in malignancies

BACKGROUND

Extracellular vesicles are closed structured surrounded by a lipid membrane that are secreted by almost all types of cells; their function is information delivery during cell-to-cell communication. They are most commonly divided into three categories - exosomes, microvesicles and apoptotic bodies. Exosomes are small vesicles with the size of 30-100 nm, and they are found in almost all body fluids, including peripheral blood, urine, breast milk, saliva and others. They are able to deliver their content to target cells and change their behavior. Cancer cells are able to secrete more exosomes and also contain different proteins and RNA species than the exosomes from healthy cells. Due to their specific composition that is connected to the cell of origin, exosomes could be used as bio-markers of various diseases in the future.

PURPOSE

The aim of this work is to summarize current knowledge about exosomes and their role in various processes connected to resistance in tumors. This work was supported by grant of the Ministry of Health of the Czech Republic AZV 17-29343A. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.

Perioperative management of metformin: is there something new?

Metformin is the drug of choice in the treatment of type 2 diabetes mellitus. Diabetic patients treated with metformin, who are scheduled for surgery, have always been subjects to discussion regarding the perioperative management of metformin because of the risk of developing lactic acidosis. The article presents the basic informations about this adverse event, describes new approach to the metformin treatment in the perioperative period, and summarizes the recommendations of professional societies and expert groups.

A novel coronavirus (SARS-CoV-2) and COVID-19

By the end of 2019 the first cases of severe pneumonia of unknown origin were reported in Wuhan, China. The causative agent was identified as a novel b-coronavirus SARS-CoV-2 and the disease was named COVID-19. Since the beginning of 2020, the infection has spread worldwide, which led the WHO to declare COVID-19 a public health emergency of international concern and to characterize the current situation as a pandemic. The transmission occurs mainly via respiratory droplets and the incubation period ranges from 2 to 14 days. Most cases are mild, but some patients develop severe pneumonia with acute respiratory distress, septic shock and multi-organ failure. The most common symptoms include fever, dry cough, myalgia and shortness of breath. Characteristic laboratory findings are normal white blood cell count or mild leukopenia, marked lymphopenia, in severe cases elevated CRP, procalcitonin, LDH, and D-dimer are commonly found. Typical imaging findings include multifocal peripherally distributed ground-glass opacities or consolidations, interlobular septal thickening, crazy paving appearance and cystic changes. The overall case fatality rate is estimated to range from 1 to 3 %, however, it is dependent on age and underlying medical comorbidities. Current potential treatment options include hydroxychloroquine, remdesivir, lopinavir/ritonavir and convalescent plasma.

Specialization in clinical pharmacy

Specialization in clinical pharmacy is necessary to providing clinical pharmacy services in Czech Republic. Clinical pharmacy knowledge has to be further developed within the framework of continuous education system.

Management of metabolic adverse effects of everolimus in patients with renal carcinoma

Everolimus is administered to patients with metastatic renal cell carcinoma in full daily dose of 10 mg or in reduced daily dose of 5 mg in case adverse effect occurred. These include metabolic adverse effects, mucositis, anorexia, and non-infectious pneumonitis and lead to increase in morbidity and decrease in the quality of life of the patient. Our goal was to evaluate the administration of fenofibrate and metformin in everolimus induced hypertriglyceridemia and hyperglycemia. The role of mTOR in lipid and glucose metabolism was researched in literature. The effect of including fenofibrate and metformin into metabolic adverse effect management guidelines in metastatic renal cell carcinoma patients who are administered everolimus was evaluated. Fenofibrate, metformin, and everolimus have several similar effects on intracellular level, therefore the effect of fenofibrate and metformin in treating everolimus induced metabolic adverse effects in metastatic renal cell carcinoma patients may be limited. The manifestation of metabolic adverse effects in patients treated with everolimus is not identical with metabolic syndrome or type II diabetes in standard population.

Clinical pharmacy in the Czech Republic

Currently there is an effort to move towards more service pharmacy to the physician and the patient in both inpatient and outpatient care. In the Czech Republic they are gradually created conditions for the daily work of clinical pharmacist. They are defined activities of clinical pharmaceutical care, which constitutes the work of emerging clinical pharmacy department. Contribution of the clinical pharmaceutical care has been repeatedly confirmed by both patients and the healthcare system as a whole.

Is safe pharmacotherapy worthwhile?

The safety of pharmacotherapy can be monitored at different levels of the health system and the quality of health care provided can be assessed from different points of view. The Ministry of Health, the health insurance companies, the State Institute for Drug Control, the Institute of Health Information and Statistics, and the health care facilities themselves fulfill their roles. Safety is assessed differently at each level. Based on current knowledge, it follows that the monitoring of adverse effects is not only of safety but also of economic importance for health care facilities. At this point the proactive way of working of clinical pharmacist can play a major role specifically when they get involved in direct care of the patient.

Intrapleural alteplase therapy: what are the knowns and unknowns?

In pneumology, enzymatic properties of plasmin are used to disrupt fibrin adhesions and septations formed during pathological conditions of the pleural cavity. In that case, fibrinolytics are administrated locally via a chest tube in the pleural cavity to evacuate pathological effusion. Although the first intrapleural administration of fibrinolytic occurred seventy years ago, there has been no consensus on dosing or a uniform procedure of their application. The aim of the article is to summarize current knowledge of alteplase usage in pneumology and discuss practical aspects of its intrapleural application regarding specific possibilities in the Czech Republic.

[MicroRNA Analysis for Extramedullary Multiple Myeloma Relapse]

INTRODUCTION AND AIMS

Multiple myeloma (MM) is the second most common hematooncological disease. Patient survival has been greatly improved by the introduction of new drugs into clinical practice, but survival is negatively affected by the so-called extramedullary relapse (EM), caused by the loss of plasma cell dependence on the bone marrow microenvironment and their migration out of the bone marrow. The nature and causes of this process are currently unclear. MicroRNAs (miRNAs) are short, non-coding RNA molecules involved in many physiological and pathological processes. Their significance in the pathogenesis of MM has been demonstrated by several studies. We assume that they are also involved in the development of the EM. The aim of this study was to analyze different miRNA expression between MM and EM patients.

MATERIAL AND METHODS

Using next generation sequencing, we analyzed 39 samples of bone marrow cells from MM patients at diagnosis and 9 bone marrow plasma samples of EM patients.

RESULTS

In total, 2,278 miRNA were sequenced, but only 658 miRNAs were analyzed as they were expressed in all samples and had at least 20 reads. Expression data were generated using the Chimira tool from fastq data. All sequences were mapped using miRBase v20. Further analyses were performed using the R/Bioconductor package. The Bayesian procedure was used for normalization of expression. P values were adjusted using the Benjamini-Hochberg method. Analysis found 10 miRNA (p < 0.0005) that are statistically significantly expressed in EM vs. MM patients - these are miR-26a-5p, miR-26b-5p, miR-30e-5p, miR-424-3p, miR-503-5p, miR-767-5p, miR-105-5p, miR-5695-5p, miR-450b-5p and miR-92b-3p. These miRNAs will be further verified by qPCR method on a larger set of MM and EM patients.

CONCLUSION

Our pilot study has shown that there are differentially expressed miRNAs between MM and EM patients.Key words: multiple myeloma - microRNA - carcinogenesis - next generation sequencing The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papersThis work was supported by grant MZ ČR AZV 17- 29343A. Submitted: 17. 3. 2018Accepted: 20. 3. 2018.

Standardization of clinical pharmacist's activities: Methodology

Study objectives

Establishing standardized and controlled system of work at a clinical pharmacy department and establishing effective recording of activities of a group of four clinical pharmacist when providing clinical pharmaceutical care (CPC) in a hospital.

Methods

The duration of evaluated period is 5.5 years. The first part was defining the purpose, methods and activities of clinical pharmaceutical care, the next part was designing the software for recording patient’s data and CPC activities. To verify the functionality of our system the third part was conducted (from January 1, 2015 to June 30, 2015).

Results

CPC activities were defined precisely. During the 6 months period, 3946 patients were reviewed (17% of patients admitted), in this group, 41% patients was labeled as risk (these patients had one or more risk factor). 1722 repeated reviews were performed, 884 drug therapy recommendations were recorded. The calculated average time necessary for one CPC activity is 28 min.

Conclusion

During the 5 year period, standardized system of work in clinical pharmacy department was established. This system is based on clearly defined activities and it enables external control. Our results supply data for negotiations with health insurance companies.

Evaluation of Clinical Pharmacists' Interventions in the Czech Republic

STUDY OBJECTIVES

To determine the frequency of interventions, categorized by type of intervention and therapeutic class, made by a team of four clinical pharmacists over a 1-year period, and to assess the potential economic impact of these interventions.

DESIGN

Prospective analysis.

SETTING

Large medical center in Prague, Czech Republic.

PATIENTS

A total of 9153 adults who were admitted to the general surgery, infectious diseases, oncology, orthopedics, and thoracic surgery and respiratory medicine services between January 1, 2014, and December 31, 2014.

INTERVENTION

Four clinical pharmacists reviewed patients' medication profiles, participated in medical and surgical rounds, and made drug therapy-related recommendations to physicians.

MEASUREMENTS AND MAIN RESULTS

Clinical pharmacists' interventions were categorized by therapeutic class and divided into eight types: introduction of a drug, discontinuation of a drug, dosage change, route of administration change, recommendation to continue therapy, recommendation to perform further evaluation (e.g., laboratory assessment), reintroduction of a missing medication, and therapeutic drug monitoring (request to measure a drug concentration and provide its interpretation). All interventions accepted by the attending physicians were recorded by using a software application. For the evaluation of the economic impact of the interventions, published statistical data were used from the Institute of Health Information and Statistics of the Czech Republic. During the 1-year period, the clinical pharmacists performed 1916 interventions. The most frequent intervention was drug discontinuation (27.9% of all interventions), and the drug category with the highest frequency of interventions was central nervous system drugs (25.1%). All interventions were accepted by the physicians. For the evaluation of potential economic impact, a select group of drugs was used, representing 14.4% of the interventions. The benefit:cost ratio was 3:1.

CONCLUSION

All interventions made by clinical pharmacists were accepted by the physicians. Drug discontinuation was the most frequent intervention. The analysis of potential economic savings showed the positive impact of these interventions, with a benefit:cost ratio of 3:1.

Dermatitis toxica faciei after boric acid

An adverse toxic reaction to the topical application of a 2% boric acid solution is described in a 2-year-old girl. Topical boric acid is licensed for use in children above the age of 10 in the Czech Republic. However, it can be bought over the counter and it is very often used in younger children. Due to its fast absorption and slow elimination, there is a high risk of systemic side effects. On the other hand, topical side effects are not reported in the present literature.

Isolation of quaternary benzo[c]phenanthridine alkaloids from Macleaya microcarpa (MAXIM.) FEDDE: comparison of maceration, Soxhlet extraction and pressurised liquid extraction

INTRODUCTION

Macleaya microcarpa (Papaveraceae family) has been of considerable interest in recent years as a prospective source of quaternary benzo[c]phenanthridine alkaloids (QBAs) related to many pharmaceutical beneficial effects. For this purpose, a quantitative, efficient and fast method to isolate the QBAs from the plant material is required.

OBJECTIVE

To optimise and compare pressurised liquid extraction (PLE) with Soxhlet extraction and maceration in order to estimate extraction conditions for fast and efficient isolation of QBAs contained in the roots of Macleaya microcarpa.

METHODOLOGY

The QBAs were extracted by PLE, Soxhlet extraction and maceration at different conditions (solvent, time, etc.). Reversed phase HPLC with diode-array detector was utilised for their determination and quantification. To optimise the PLE procedure, the variable parameters, including temperature (40-150 °C), sample-to-inert material ratio, extraction time (5-30 min) and number of extraction cycles (1-4), were also tested.

RESULTS

Quantitative determination of QBAs resulted in 0.2-2.8 mg/g, 0.3-2.5 mg/g and 0.3-3.1 mg/g for PLE, Soxhlet extraction and maceration. To produce the yields mentioned above, PLE required only up to 30 min compared with 21 h for Soxhlet extraction and 49 days for maceration.

CONCLUSION

PLE provided an effective and fast extraction of QBAs from M. microcarpa roots and can be recommended as an alternative isolation method to conventional techniques for QBAs from the plant sources.

Inhibition of aromatic amino acid decarboxylase by a group of non-steroidal anti-inflammatory drugs

In vitro inhibition of aromatic amino acid decarboxylase (AAD) by eight nonsteroidal anti-inflammatory drugs (NSAIDs) was studied. The most potent inhibitors were fenamates (IC50 for tolfenamate was 4.4 x 10(-5) M), while fluorinated biphenylic compounds (flobufen and 2',4'-difluorobiphenyl-4-yl acetate) and propionic acid derivatives (ibuprofen, ketoprofen, fenoprofen) were one order weaker. The in vitro inhibition of AAD by the compounds studied is probably not strong enough to contribute to their in vivo anti-inflammatory effects.