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Ware J, Allen JM, Boughton C, Cezar A, Hartnell S, Wilinska M, Thankamony A, Deakin M, Leyland H, Phelan K, Thornborough K, Hovorka R. Hybrid closed-loop with faster insulin aspart compared with standard insulin aspart in very young children with type 1 diabetes: A double-blind, multicenter, randomized, crossover study. Diabetes Technol Ther 2023. [PMID: 36880866 DOI: 10.1089/dia.2023.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
We evaluated the use of hybrid closed-loop (HCL) insulin delivery with faster insulin aspart (Fiasp) in very young children with type 1 diabetes (T1D). In a double-blind, multicenter, randomized, crossover study, children aged 2-6 years with T1D underwent two 8-week periods of HCL using CamAPS FX with Fiasp and standard insulin aspart (IAsp), in random order. Primary endpoint was between-treatment difference in time in target range 3.9-10.0mmol/L. We randomized 25 participants: mean(±SD) age 5.1±1.3 years, baseline HbA1c 55±9mmol/mol. Time in range was not significantly different between interventions (64±9% vs 65±9% for HCL with Fiasp vs IAsp; mean difference -0.33% [95% CI -2.13, 1.47; p=0.71]). There was no significant difference in time with glucose <3.9mmol/L. No post-randomization severe hypoglycemia or DKA events occurred. Use of Fiasp with CamAPS FX hybrid closed-loop demonstrated no significant difference in glycemic outcomes compared with IAsp in very young children with T1D. Clinical trials registration: NCT04759144.
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Affiliation(s)
- Julia Ware
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
- University of Cambridge Department of Paediatrics, 151909, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Janet M Allen
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Charlotte Boughton
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
- Cambridge University Hospitals NHS Foundation Trust, 2153, Department of Diabetes and Endocrinology, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Alina Cezar
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Sara Hartnell
- Cambridge University Hospitals NHS Foundation Trust, 2153, Department of Diabetes and Endocrinology, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Malgorzata Wilinska
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
- University of Cambridge Department of Paediatrics, 151909, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Ajay Thankamony
- University of Cambridge Department of Paediatrics, 151909, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
| | - Mark Deakin
- Alder Hey Children's NHS Foundation Trust, 4593, Department of Diabetes, Liverpool, Merseyside, United Kingdom of Great Britain and Northern Ireland;
| | - Hannah Leyland
- NIHR Alder Hey Clinical Research Facility, 475754, Alder Hey Children's NHS Foundation Trust, Liverpool, LIverpool, United Kingdom of Great Britain and Northern Ireland;
| | - Karen Phelan
- NIHR Alder Hey Clinical Research Facility, 475754, Alder Hey Children's NHS Foundation Trust, Liverpool, LIverpool, United Kingdom of Great Britain and Northern Ireland;
| | - Keith Thornborough
- Alder Hey Children's NHS Foundation Trust, 4593, Department of Diabetes, Liverpool, Merseyside, United Kingdom of Great Britain and Northern Ireland;
| | - Roman Hovorka
- Wellcome-MRC Institute of Metabolic Science, 151918, University of Cambridge, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
- University of Cambridge Department of Paediatrics, 151909, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland;
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Ware J, Boughton CK, Allen JM, Wilinska ME, Tauschmann M, Denvir L, Thankamony A, Campbell FM, Wadwa RP, Buckingham BA, Davis N, DiMeglio LA, Mauras N, Besser REJ, Ghatak A, Weinzimer SA, Hood KK, Fox DS, Kanapka L, Kollman C, Sibayan J, Beck RW, Hovorka R, Hovorka R, Acerini CL, Thankamony A, Allen JM, Boughton CK, Dovc K, Dunger DB, Ware J, Musolino G, Tauschmann M, Wilinska ME, Hayes JF, Hartnell S, Slegtenhorst S, Ruan Y, Haydock M, Mangat J, Denvir L, Kanthagnany SK, Law J, Randell T, Sachdev P, Saxton M, Coupe A, Stafford S, Ball A, Keeton R, Cresswell R, Crate L, Cripps H, Fazackerley H, Looby L, Navarra H, Saddington C, Smith V, Verhoeven V, Bratt S, Khan N, Moyes L, Sandhu K, West C, Wadwa RP, Alonso G, Forlenza G, Slover R, Towers L, Berget C, Coakley A, Escobar E, Jost E, Lange S, Messer L, Thivener K, Campbell FM, Yong J, Metcalfe E, Allen M, Ambler S, Waheed S, Exall J, Tulip J, Buckingham BA, Ekhlaspour L, Maahs D, Norlander L, Jacobson T, Twon M, Weir C, Leverenz B, Keller J, Davis N, Kumaran A, Trevelyan N, Dewar H, Price G, Crouch G, Ensom R, Haskell L, Lueddeke LM, Mauras N, Benson M, Bird K, Englert K, Permuy J, Ponthieux K, Marrero-Hernandez J, DiMeglio LA, Ismail H, Jolivette H, Sanchez J, Woerner S, Kirchner M, Mullen M, Tebbe M, Besser REJ, Basu S, London R, Makaya T, Ryan F, Megson C, Bowen-Morris J, Haest J, Law R, Stamford I, Ghatak A, Deakin M, Phelan K, Thornborough K, Shakeshaft J, Weinzimer SA, Cengiz E, Sherr JL, Van Name M, Weyman K, Carria L, Steffen A, Zgorski M, Sibayan J, Beck RW, Borgman S, Davis J, Rusnak J, Hellman A, Cheng P, Kanapka L, Kollman C, McCarthy C, Chalasani S, Hood KK, Hanes S, Viana J, Lanning M, Fox DS, Arreaza-Rubin G, Eggerman T, Green N, Janicek R, Gabrielson D, Belle SH, Castle J, Green J, Legault L, Willi SM, Wysham C. Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial. Lancet Digit Health 2022; 4:e245-e255. [PMID: 35272971 DOI: 10.1016/s2589-7500(22)00020-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/10/2021] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population. METHODS In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299. FINDINGS Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis. INTERPRETATION The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases.
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Fose C, Jones L, Phelps J, Phelan K. Development of an Innovative Learning Model for Dietetic Interns Utilizing Gross Anatomy Lab Resources. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.06.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Schenkel LC, Aref-Eshghi E, Rooney K, Kerkhof J, Levy MA, McConkey H, Rogers RC, Phelan K, Sarasua SM, Jain L, Pauly R, Boccuto L, DuPont B, Cappuccio G, Brunetti-Pierri N, Schwartz CE, Sadikovic B. DNA methylation epi-signature is associated with two molecularly and phenotypically distinct clinical subtypes of Phelan-McDermid syndrome. Clin Epigenetics 2021; 13:2. [PMID: 33407854 PMCID: PMC7789817 DOI: 10.1186/s13148-020-00990-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/09/2020] [Indexed: 12/31/2022] Open
Abstract
Background Phelan-McDermid syndrome is characterized by a range of neurodevelopmental phenotypes with incomplete penetrance and variable expressivity. It is caused by a variable size and breakpoint microdeletions in the distal long arm of chromosome 22, referred to as 22q13.3 deletion syndrome, including the SHANK3 gene. Genetic defects in a growing number of neurodevelopmental genes have been shown to cause genome-wide disruptions in epigenomic profiles referred to as epi-signatures in affected individuals. Results In this study we assessed genome-wide DNA methylation profiles in a cohort of 22 individuals with Phelan-McDermid syndrome, including 11 individuals with large (2 to 5.8 Mb) 22q13.3 deletions, 10 with small deletions (< 1 Mb) or intragenic variants in SHANK3 and one mosaic case. We describe a novel genome-wide DNA methylation epi-signature in a subset of individuals with Phelan-McDermid syndrome. Conclusion We identified the critical region including the BRD1 gene as responsible for the Phelan-McDermid syndrome epi-signature. Metabolomic profiles of individuals with the DNA methylation epi-signature showed significantly different metabolomic profiles indicating evidence of two molecularly and phenotypically distinct clinical subtypes of Phelan-McDermid syndrome.
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Affiliation(s)
- L C Schenkel
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, ON, N6A3K7, Canada
| | - E Aref-Eshghi
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - K Rooney
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - J Kerkhof
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - M A Levy
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - H McConkey
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - R C Rogers
- Greenville Office, Greenwood Genetic Center, Greenville, SC, 29605, USA
| | - K Phelan
- Genetics Laboratory, Florida Cancer Specialists and Research Institute, Fort Myers, FL, 33816, USA
| | | | - L Jain
- Greenwood Genetic Center, Greenwood, SC, 29646, USA.,Clemson University, Clemson, SC, 29634, USA
| | - R Pauly
- Greenwood Genetic Center, Greenwood, SC, 29646, USA
| | - L Boccuto
- Greenwood Genetic Center, Greenwood, SC, 29646, USA.,Clemson University, Clemson, SC, 29634, USA
| | - B DuPont
- Greenwood Genetic Center, Greenwood, SC, 29646, USA
| | - G Cappuccio
- Department of Translational Medicine, University Federico II, 80131, Naples, NA, Italy.,Telethon Institute of Genetics and Medicine, Pozzuoli, NA, Italy
| | - N Brunetti-Pierri
- Department of Translational Medicine, University Federico II, 80131, Naples, NA, Italy.,Telethon Institute of Genetics and Medicine, Pozzuoli, NA, Italy
| | - C E Schwartz
- Greenwood Genetic Center, Greenwood, SC, 29646, USA.
| | - B Sadikovic
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre, London, ON, N6A5W9, Canada. .,Department of Pathology and Laboratory Medicine, Western University, London, ON, N6A3K7, Canada.
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Abstract
The 22q13.3 deletion syndrome, also known as Phelan-McDermid syndrome, is a contiguous gene disorder resulting from deletion of the distal long arm of chromosome 22. In addition to normal growth and a constellation of minor dysmorphic features, this syndrome is characterized by neurological deficits which include global developmental delay, moderate to severe intellectual impairment, absent or severely delayed speech, and neonatal hypotonia. In addition, more than 50% of patients show autism or autistic-like behavior, and therefore it can be classified as a syndromic form of autism spectrum disorders (ASD). The differential diagnosis includes Angelman syndrome, velocardiofacial syndrome, fragile X syndrome, and FG syndrome. Over 600 cases of 22q13.3 deletion syndrome have been documented. Most are terminal deletions of ∼100 kb to >9 Mb, resulting from simple deletions, ring chromosomes, and unbalanced translocations. Almost all of these deletions include the gene SHANK3 which encodes a scaffold protein in the postsynaptic densities of excitatory synapses, connecting membrane-bound receptors to the actin cytoskeleton. Two mouse knockout models and cell culture experiments show that SHANK3 is involved in the structure and function of synapses and support the hypothesis that the majority of 22q13.3 deletion syndrome neurological defects are due to haploinsufficiency of SHANK3, although other genes in the region may also play a role in the syndrome. The molecular connection to ASD suggests that potential future treatments may involve modulation of metabotropic glutamate receptors.
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Affiliation(s)
- K Phelan
- Hayward Genetics Center and Department of Pediatrics, Tulane University School of Medicine, New Orleans, La., USA
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Abstract
BACKGROUND Few data exist on the effect of maternal depression on child injury outcomes and mediators of this relationship. OBJECTIVE To examine the relationship between mothers' depressive symptoms and medically attended injuries in their children and the potential mediating role of child behavior. DESIGN/METHODS A cohort of mother-child dyads from the National Longitudinal Study of Youth followed from 1992 to 1994. The primary exposure variable was maternal depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale in 1992. Child behavior was assessed by the Behavior Problems Index externalizing subscale. Logistic regression was used to examine the relationship between depressive symptoms, child behavior, and injury reported in the prior year in 1994. RESULTS 94 medically attended injuries were reported in the 1106 children (8.5%); two-thirds were sustained in the home environment. Maternal depressive symptoms significantly increased the risk of child injury; injury risk increased 4% for every 1-point increase in depressive symptoms (adjusted OR 1.04, 95% CI 1.01 to 1.08, p=0.02). Increasing maternal depressive symptoms also increased the risk of externalizing behavior problems (adjusted OR 1.06, 95% CI 1.03 to 1.09), but externalizing behavior problems did not significantly mediate the relationship between maternal symptoms and child injury. CONCLUSIONS Increasing depressive symptoms in mothers was associated with an increased risk of child injury. Child behavior did not significantly mediate the association between maternal depressive symptoms and child injury in this cohort. Greater recognition, referral, and treatment of depressive symptoms in mothers may have effects on child behavior and injury risk.
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Affiliation(s)
- K Phelan
- Division of Health Policy & Clinical Effectiveness, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229-3039, USA.
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Hoppensteadt D, Walenga J, Fareed J, Phelan K. Evaluation of “Statsep,” a Semiautomated Device to Prepare Plasma Samples for Coagulation Analysis. Semin Thromb Hemost 2008. [DOI: 10.1055/s-2007-1005033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Du Q, Jovanović S, Clelland A, Sukhodub A, Budas G, Phelan K, Murray-Tait V, Malone L, Jovanović A. Overexpression of SUR2A generates a cardiac phenotype resistant to ischemia. FASEB J 2006; 20:1131-41. [PMID: 16770012 PMCID: PMC2121651 DOI: 10.1096/fj.05-5483com] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ATP-sensitive K+ (K(ATP)) channels are present in the sarcolemma of cardiac myocytes where they link membrane excitability with the cellular bioenergetic state. These channels are in vivo composed of Kir6.2, a pore-forming subunit, SUR2A, a regulatory subunit, and at least four accessory proteins. In the present study, real-time RT-PCR has demonstrated that of all six sarcolemmal K(ATP) channel-forming proteins, SUR2A was probably the least expressed protein. We have generated mice where the SUR2A was under the control of a cytomegalovirus promoter, a promoter that is more efficient than the native promoter. These mice had an increase in SUR2A mRNA/protein levels in the heart whereas levels of mRNAs of other channel-forming proteins were not affected at all. Imunoprecipitation/Western blot and patch clamp electrophysiology has shown an increase in K(ATP) channel numbers in the sarcolemma of transgenic mice. Cardiomyocytes from transgenic mice responded to hypoxia with shortening of action membrane potential and were significantly more resistant to this insult than cardiomyocytes from the wild-type. The size of myocardial infarction in response to ischemia-reperfusion was much smaller in hearts from transgenic mice compared to those in wild-type. We conclude that overexpression of SUR2A generates cardiac phenotype resistant to hypoxia/ischemia/reperfusion injury due at least in part to increase in levels of sarcolemmal K(ATP) channels.
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Affiliation(s)
- Qingyou Du
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Sofija Jovanović
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Allyson Clelland
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Andrey Sukhodub
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Grant Budas
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Karen Phelan
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
| | - Victoria Murray-Tait
- Division of Cell Biology and Immunology, School of Life Sciences, MSI/WTB Complex, University of Dundee, Dundee, UK
| | - Lorraine Malone
- Division of Cell Biology and Immunology, School of Life Sciences, MSI/WTB Complex, University of Dundee, Dundee, UK
| | - Aleksandar Jovanović
- Maternal and Child Health Sciences, Ninewells Hospital and Medical School, University of Dundee, Dundee UK
- Correspondence: Maternal and Child Health Sciences, Ninewells Hospital & Medical School, University of Dundee, Dundee, DD1 9SY Scotland, UK. E-mail:
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Abstract
BACKGROUND Omalizumab is a recombinant humanised monoclonal antibody directed against immunoglobulin E (anti-IgE) to inhibit the immune system's response to allergen exposure. Omalizumab is directed against the binding site of IgE for its high affinity Fc receptor. It prevents free serum IgE from attaching to mast cells and other effector cells and prevents IgE mediated inflammatory changes. OBJECTIVES To determine the efficacy of anti-IgE compared with placebo in patients with allergic asthma SEARCH STRATEGY We searched the Cochrane Airways Group Asthma trials register for potentially relevant studies (February 2006). SELECTION CRITERIA Randomised controlled trials examining anti-IgE administered in any manner for any duration. Trials with co-interventions were included as long as they were the same in each arm. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed study quality and extracted and entered data. Three modes of administration were identified from the published literature (inhaled, intravenous and subcutaneous injection). Subgroup analysis was performed by asthma severity. Data were extracted from published and unpublished sources. MAIN RESULTS Fourteen trials (15 group comparisons) were included in the review, contributing a total of 3143 mild to severe allergic asthmatic participants with high levels of IgE. Treatment with intravenous and subcutaneous Omalizumab significantly reduced free IgE compared with placebo. Omalizumab led to a significant reduction in inhaled steroid (ICS) consumption compared with placebo (-119 mcg/day (95% CI -154 to -83, three trials)). There were significant increases in the number of participants who were able to reduce ICS by over 50% (odds ratio (OR) 2.50, 95% confidence interval (CI) 2.02 to 3.10 (four trials)); or completely withdraw their daily ICS intake (OR 2.50 (95%CI 2.00 to 3.13; four trials)). Participants treated with Omalizumab were less likely to suffer an asthma exacerbation with treatment as an adjunct to ICS (OR 0.52, 95%CI 0.41 to 0.65, five trials), or as an ICS tapering agent (OR 0.47, 95% CI 0.37 to 0.60, four trials). AUTHORS' CONCLUSIONS Omalizumab was significantly more effective than placebo at increasing the numbers of patients who were able to reduce or withdraw their inhaled steroids, but the clinical value of the reduction in steroid consumption has be considered in the light of the high cost of Omalizumab. The impressive placebo effects observed in control groups bring into question the true effect of Omalizumab. Omalizumab was effective in reducing asthma exacerbations as an adjunctive therapy to inhaled steroids, and during steroid tapering phases of clinical trials. Omalizumab was generally well tolerated, although there were more injection site reactions with Omalizumab. Patient and physician assessments of the drug were positive. Further assessment in paediatric populations is necessary, as is direct double-dummy comparison with ICS.
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Affiliation(s)
- S Walker
- National Respiratory Training Centre, The Athenaeum, 10 Church Street, Warwick, UK, CV34 4AB.
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Abstract
BACKGROUND Omalizumab is a recombinant humanised monoclonal antibody directed against immunoglobulin E (IgE) to inhibit the immune system's response to allergen exposure. Omalizumab is directed against the binding site of IgE for its high affinity Fc receptor. It prevents free serum IgE from attaching to mast cells and other effector cells and prevents IgE mediated inflammatory changes. OBJECTIVES To determine the efficacy of anti-IgE in patients with allergic asthma SEARCH STRATEGY We searched the Cochrane Airways Group Asthma trials register (February 2003) for potentially relevant studies. SELECTION CRITERIA Randomised controlled trials examining anti-IgE administered in any manner for any duration. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed study quality and extracted and entered data. Three modes of administration were identified from the published literature (inhaled, intravenous and subcutaneous injection). Subgroup analysis was performed by asthma severity. Data were extracted from published and unpublished sources. MAIN RESULTS Eight trials were included in the review, contributing a total of 2037 mild to severe allergic asthmatic participants with high levels of IgE. Treatment with intravenous and subcutaneous Omalizumab significantly reduced free IgE compared with placebo. Omalizumab led to a significant reduction in inhaled steroid consumption compared with placebo: -114 mcg/day (95% CI -150 to -78.13, two trials). There were significant increases in the number of participants who were able to reduce steroids by over 50%: odds ratio (OR) 2.50, 95% confidence interval (CI) 2.02 to 3.10 (four trials); or completely withdraw their daily steroid intake: OR 2.50, 95%CI 2.00 to 3.13 (four trials). Participants treated with Omalizumab were less likely to suffer an asthma exacerbation with treatment as an adjunct to steroids (OR 0.49, 95%CI 0.38 to 0.64, four trials), or as a steroid tapering agent (OR 0.47, 95% CI 0.37 to 0.60, four trials). REVIEWERS' CONCLUSIONS Omalizumab was significantly more effective than placebo at increasing the numbers of patients who were able to reduce or withdraw their inhaled steroids, but the mean difference in steroid consumption achieved with Omalizumab was of debatable clinical value. The impressive effects observed in control groups bring into question the true effect of Omalizumab. Omalizumab was effective in reducing asthma exacerbations as an adjunctive therapy to inhaled steroids. Omalizumab was well tolerated, although the safety profile requires longer term assessment. Patient and physician assessment of the drug was positive. Further assessment in paediatric and severe adult populations is necessary, as is double-dummy comparison with inhaled corticosteroids.
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Affiliation(s)
- S Walker
- National Respiratory Training Centre, The Athenaeum, 10 Church Street, Warwick, UK, CV34 4AB
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Faghih R, Phelan K, Esbenshade TA, Miller TR, Kang CH, Krueger KM, Yao BB, Fox GB, Bennani YL, Hancock AA. D-alanine piperazine-amides: novel non-imidazole antagonists of the histamine H3 receptor. Inflamm Res 2003; 52 Suppl 1:S47-8. [PMID: 12755406 DOI: 10.1007/s000110300049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- R Faghih
- Neuroscience Research, Global Pharmaceutical Research and Development, Abbott Laboratories, AP-9A, R4MN, Abbott Park, IL 60064-6123, USA.
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12
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Abstract
BACKGROUND Omalizumab is a recombinant humanised monoclonal antibody directed against immunoglobulin E (IgE) to inhibit the immune system's response to allergen exposure. Omalizumab is directed against the binding site of IgE for its high affinity Fc receptor. It prevents free serum IgE from attaching to mast cells and other effector cells and prevents IgE mediated inflammatory changes. The complexes of Omalizumab and IgE formed as a result of treatment are small and not thought to be able to trigger complement activation or give rise to immune complex mediated pathology. OBJECTIVES To determine the efficacy of anti-IgE in patients with allergic asthma. SEARCH STRATEGY We searched the Cochrane Airways Group Asthma trials register (February 2003) for potentially relevant studies. SELECTION CRITERIA Randomised control trials examining anti-IgE administered in any manner for any duration. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed study quality and extracted and entered data. Three modes of administration were identified from the published literature (inhaled, intravenous and subcutaneous injection). Subgroup analysis was performed by asthma severity. Data were extracted from published and unpublished sources. MAIN RESULTS Eight trials were included in the review, contributing a total of 2037 mild to severe allergic asthmatic participants with high levels of IgE. Treatment with intravenous and subcutaneous Omalizumab resulted in a 98 to 99% reduction in free IgE, reductions which were not observed following placebo treatment. Significant increases in the number of participants who were able to reduce (> 50% reduction in daily corticosteroid usage (four trials): odds ratio (OR) 2.50, 95% confidence interval (CI) 2.02 to 3.10; or completely withdraw their daily steroid intake (four trials): OR 2.50, 95%CI 2.00 to 3.13, were observed. Participants treated with Omalizumab were less likely to suffer an asthma exacerbation (stable steroid phase (three trials): OR 0.46, 95%CI 0.35 to 0.61; steroid reduction phase (three trials) OR 0.46, 95% CI 0.36 to 0.59). REVIEWER'S CONCLUSIONS Omalizumab was significantly more effective than placebo at increasing the numbers of patients who were able to reduce or withdraw their inhaled steroids and was effective in reducing asthma exacerbations. Omalizumab was well tolerated, although the safety profile requires longer term assessment. Patient and physician assessment of the drug was positive. Further assessment in paediatric and severe adult populations is necessary, as is comparison with inhaled corticosteroids.
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Affiliation(s)
- S Walker
- National Respiratory Training Centre, The Athenaeum, 10 Church Street, Warwick, UK, CV34 4AB
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Heinrich SD, Gallagher D, Warrior R, Phelan K, George VT, MacEwen GD. The prognostic significance of the skeletal manifestations of acute lymphoblastic leukemia of childhood. J Pediatr Orthop 1994; 14:105-11. [PMID: 8113359 DOI: 10.1097/01241398-199401000-00021] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The variety and distribution of skeletal pathology in children with acute lymphoblastic leukemia is rarely seen in other disease states. Skeletal radiographic changes associated with and/or suggestive of acute leukemia include diffuse osteopenia, metaphyseal bands, periosteal new bone formation, geographic lytic lesions, sclerosis, mixed sclerosis/lysis, and permeative destruction. This retrospective analysis of 83 children with acute lymphoblastic leukemia suggests that children without radiographic skeletal abnormalities have an "aggressive" form of leukemia. Children with one to four lesions have an "indolent" form of leukemia that is of short duration. Children with five or more lesions have an indolent form of leukemia that is of longer duration. The longer duration of symptoms before diagnosis reduces the survival rate to that of the aggressive form of leukemia. It is therefore imperative that physicians who treat children recognize the orthopaedic/radiographic manifestations of acute leukemia (the most common pediatric malignancy) to facilitate diagnosis, and, thereby, improve survival.
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Affiliation(s)
- S D Heinrich
- Department of Orthopaedics, Children's Hospital, Louisiana State University Medical School, New Orleans
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Thomson DM, Halliday WJ, Phelan K. Leukocyte adherence inhibition to myelin basic protein by cancer patients' T-lymphocytes in association with class II major histocompatibility antigens on monocytes. J Natl Cancer Inst 1985; 75:995-1003. [PMID: 2415744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patients' leukocytes were shown to react consistently in tube leukocyte adherence inhibition (LAI) assays with myelin basic protein (MBP) at optimal concentration, whereas control leukocytes were nonreactive. Mononuclear cells from patients with cancer gave positive LAI reactions with MBP, but separated T-lymphocytes, monocytes, and neutrophils did not. The mononuclear cell LAI responses were blocked by monoclonal antibody (MAb) to monomorphic determinant of class II major histocompatibility complex (MHC) antigens and to T4+ (Leu-3a+) and T3+ (Leu-4+) T-cell differentiation antigens but not by antibody to class I MHC antigens or T8+ (Leu-2a+) antigens. MBP was thus recognized by helper T-cells, requiring presentation in association with class II MHC determinants on monocytes. MAb to class I and class II MHC antigens and to T8+ (Leu-2a+), T4+ (Leu-3a+), and T3+ (Leu-4+) differentiation antigens did not negate LAI mediated by peripheral blood lymphocytes to organ-specific cancer neoantigens (OSN) of crude extracts of allogeneic cancer, which had previously been shown to react with cytophilic antibody on allogeneic monocytes. When membrane OSN and leukocytes were autologous, T8+ (Leu-2a+) phenotypic T-cells also mediated LAI that was blocked by anti-T8 (Leu-2a) and anti-T3 (Leu-4). LAI induced by MBP was also negated by drugs that antagonize thromboxane-leukotriene biosynthesis, indicating that, in common with other LAI reactions, the terminal mediators of nonadherence are oxidative metabolites of arachidonic acid. In addition to clarifying the role of MBP in the cellular in vitro immunoreactivity of cancer patients, the present observations have important implications for theories of LAI. Sensitized leukocytes have different mechanisms for the recognition of antigens in different forms, and the antigen-stimulated leukocytes produce mediators that in a final common pathway induce nonadherence of surrounding cells through leukotriene-like metabolites.
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Phelan K. Do HMOs mean lower health care costs? Pers J 1985; 64:66-71. [PMID: 10311035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Hoppensteadt D, Walenga JM, Fareed J, Phelan K. Evaluation of "Statsep," a semiautomated device to prepare plasma samples for coagulation analysis. Semin Thromb Hemost 1983; 9:334-40. [PMID: 6658464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Thomson DM, Phelan K, Scanzano R. Oxidative metabolism, cytoskeletal system, and calcium entry of leukocytes in the phenomenon of sensitizing cancer extract-induced leukocyte adherence inhibition. Cancer Res 1983; 43:1066-73. [PMID: 6681728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
We examined some of the metabolic events that regulate sensitizing cancer extract-induced leukocyte adherence inhibition and found that human leukocytes adhere in a comparatively passive manner to glass in serum-free medium. Adherence of leukocytes to glass did not require oxidative metabolism, microtubules, microfilaments, or calcium entry, whereas leukocyte mobility excited by sensitizing cancer extract did. Calcium antagonists, lanthanum chloride, cromolyn sodium, nifedipine, trifluoperazine, and lidocaine, prevented sensitizing cancer extract-induced leukocyte mobility. Calcium agonist, ionophore A23187, excited leukocyte mobility. Ouabain, which inhibits Na+-K+-adenosine triphosphatase and may increase intracellular Ca2+ as a result, also excited leukocyte mobility. Monocytes, armed with serum from patients with early cancer and challenged with the same sensitizing tumor antigen, generated a leukotriene mediator that excited leukocyte mobility; cromolyn sodium, nifedipine, and trifluoperazine antagonized the synthesis of the mediator. The calcium antagonists inhibited the leukotriene mediator and authentic leukotrienes B4, C4, and D4 from exciting leukocyte mobility. The results showed that leukocyte mobility, excited by sensitizing cancer extract, is an active process depending upon immunologically triggered release of a leukotriené mediator from armed monocytes. Leukocyte adherence inhibition requires many of the same physiological events that chemokinesis and chemotaxis do and is thus an assay to study either immunologically released chemoattractants or chemoattractants themselves on leukocyte locomotion.
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Thomson DM, Phelan K, Scanzano R, Fink A. Modulation of antigen-induced leukocyte adherence inhibition by metabolites of arachidonic acid and intracellular nucleotides. Int J Cancer 1982; 30:311-9. [PMID: 6752047 DOI: 10.1002/ijc.2910300310] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
After binding a sensitizing tumor antigen, human leukocytes undergo a series of changes that lead to a loss of their glass-adherent properties; a phenomenon called leukocyte adherence inhibition (LAI). After surgery or when patients have a large tumor burden, their test results become negative. This study shows that in vitro incubation of the leukocytes for 5 min with PGE2 converted to positive the negative test, in an immunologically specific manner. The effect was critically dose-dependent, too little or too much did not alter the result. The same effect was achieved with PGE2, PGI2, aminophylline or other drugs that raise intracellular nucleotides, including dibutyryl cyclic AMP and dibutyryl cyclic GMP. Dibutyryl cyclic AMP stimulated a stronger response and 100 times less was needed than of dibutyryl cyclic GMP. Prostaglandins did not mediate LAI since Indomethacin failed to inhibit a positive test. Nonetheless, arachidonate metabolites were critical for the LAI phenomenon since BPB and mepacrine, inhibitors of phospholipase A2, negated the LAI response. Moreover, ETYA, phenidone and NDGA, inhibitors of the lipoxygenase metabolic pathway, all negated the positive LAI response. The positive response was especially sensitive to nullification by ETYA. Although the last-named drugs inhibit other arachidonate metabolic pathways too, conclusive evidence that the metabolites of the lipoxygenase pathway, and leukotrienes in particular, mediate the LAI response was the fact that FPL 55712, a competitive antagonist of SRS, nullified a positive response at levels as low as 10(-13) M. The results imply that prostaglandins were able to modulate the expression of LAI by affecting intracellular nucleotides, but leukotrienes, it seems, were the metabolites that mediated leukocyte nonadherence after monocytes recognized and bound tumor antigen.
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Thomson DM, Phelan K, Morton DG, Bach MK. Armed human monocytes challenged with a sensitizing cancer extract release substances pharmacologically similar to leukotrienes. Int J Cancer 1982; 30:299-306. [PMID: 7129679 DOI: 10.1002/ijc.2910300308] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Human peripheral blood monocytes were highly enriched by adherence to plastic, armed with serum from cancer patients, and challenged separately and simultaneously with the sensitizing and unrelated cancer extracts. The response of the monocytes was to release a factor that inhibited leukocyte adherence (LAI) to glass. The macrophage-like cell line U937 released a similar factor when it was armed and challenged with the sensitizing cancer extract. The production of the factor was blocked by 10(-6) M ETYA and 10(-6) M NDGA but not by 10(-6) M indomethacin. Moreover, a competitive inhibitor of leukotriene function, 10(-6) M FPL 55712, blocked the LAI reaction mediated by the factor. Arylsulfatase destroyed its activity while depletion of the monocytes' cellular glutathione pool with CyH or Et2Mal stopped production of the mediator. Pure leukotrienes (C and D) in a dose-response fashion prevented the adherence of leukocytes to glass; the nonadherence of mononuclear cells was equal to that of polymorphonuclear cells. PGE2, if added to the leukocytes immediately before challenge with LTC or LTD, increased 1,000-fold the leukocytes' sensitivity to the leukotrienes. Paradoxically, if leukocytes were washed and exposed to PGE2 15 min after being challenged with leukotrienes, their normal glass-adherence property and the ability to respond again to LTD were restored. FPL 55712 blocked the effect of LTC and LTD from inhibiting the adherence of leukocytes to glass. The present study shows that human monocytes armed with cytophilic anti-tumor antibody, when challenged with the sensitizing cancer extract, release leukotriene(s) as shown by pharmacologic evidence, implying that monocytes may play an important inflammatory role in human cancer.
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Abstract
The tube LAI assay measures accurately antitumor immunity in patients with early cancer but fails to detect up to 75% of patients with advanced cancer due to excess circulating organ-specific neoantigen (OSN). Substances such as prostaglandin E2 (PGE2) or aminophylline, which increase intracellular nucleotides in leukocytes of patients with advanced cancer reversed this nonreactivity and greatly increased the sensitivity of the assay without any loss of specificity. Antitumor immunity can now be detected in advanced cancer, and a combination of the two assays gives prognostic potential to the assay: a positive test with PGE2 and negative test without indicates the patient has a large tumor burden. The specificity of the assay for each cancer was high and in most instances was greater than or equal to 95%. The PGE2 stimulated assay retained the high specificity. The sensitivity of the regular tube assay was often low, 33-56% because of the many advanced cancer patients tested, whereas the PGE2 stimulated assay showed almost a two-fold increase in sensitivity, 67-93%. The diagnostic value of the assay was estimated by calculating the predictive value for different prevalences of cancer. It was found that at low prevalences of cancer as found in the general population, the assay had a low diagnostic value since few patients with a positive test would have the cancer tested for. With prevalences of cancer of 5% or greater as might be found in a tertiary care clinical setting, the assay would seem to have diagnostic value since one half or more patients with a positive test would have the cancer tested for. Most false positives, but not all, are found in patients who have lesions that are often considered to increase their risk for cancer: severe dysplasia of the breast, colon adenomas, chronic atrophic gastritis and chronic pancreatitis, suggesting that the assay predicts oncogenesis.
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Thomson DM, Phelan K, Scanzano R, Fink A. The regulation of the human antitumor immune response to organ-specific neoantigens. Transplant Proc 1981; 13:1952-4. [PMID: 6277060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Thomson DM, Neville AM, Phelan K, Scanzano RS, Vandevoorde JP. Human cancers transplanted in nude mice retain the expression of their organ-specific neoantigens. Eur J Cancer Clin Oncol 1981; 17:1191-7. [PMID: 7199466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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