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Rosh JR, Turner D, Hyams JS, Dubinsky M, Griffiths AM, Cohen SA, Lo KH, Kim L, Volger S, Zhang R, Strauss R, Conklin LS. Outcomes in Adult Inflammatory Bowel Disease Clinical Trials: Assessment of Similarity Among Participants with Adolescent-Onset and Adult-Onset Disease. J Crohns Colitis 2024:jjae030. [PMID: 38408273 DOI: 10.1093/ecco-jcc/jjae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND AIMS Most pediatric IBD studies are performed after medications are approved in adults and the majority of participants in these studies are adolescents. We hypothesized that adolescent-onset IBD is not fundamentally different than adult-onset IBD. If this is correct, the value of delaying access to novel drugs in adolescents becomes questioned. METHODS Data from 11 randomized, double-blind, placebo-controlled adult phase 2 and 3 trials of 4 biologics were analyzed. Participants were categorized as having adolescent- or adult-onset disease (diagnosed 12 to <18, or ≥18 years). Multivariable modelling explored the association between age at diagnosis and response to treatment after adjustment for disease duration, extent, and severity at baseline. Data from dose arms were pooled to evaluate similarity of therapeutic response between adolescent- and adult-onset IBD within the same trial (not between doses or across trials). Ratios of odds ratios between the two groups were evaluated. RESULTS Data from 6,283 study participants (2,575 with Crohn's disease [CD], 3,708 with ulcerative colitis [UC]) were evaluated. Of 2,575 study participants with CD, 325 were 12-<18 years old at diagnosis; 836 participants (32.4%) received placebo. Of 3,708 participants with UC, 221 were 12-<18 years old at diagnosis; 1,212 (33%) were receiving placebo. The majority of the ratios of ORs were within two-fold, suggesting that responses in adolescent and adult-onset participants are generally similar. CONCLUSION Data presented lend support for extrapolating efficacy of biologics from adults to adolescents with IBD, which would facilitate earlier labeling and patient access.
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Affiliation(s)
- Joel R Rosh
- Division of Pediatric Gastroenterology, Cohen Children's Medical Center, New Hyde Park, USA
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Jeffrey S Hyams
- Division of Pediatric Gastroenterology, Connecticut Children's, Hartford, CT USA
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Mount Sinai Medical Center, New York, NY USA
| | - Anne M Griffiths
- Division of Pediatric Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Stanley A Cohen
- Division of Pediatric Gastroenterology, Children's Center for Digestive Health Care, Atlanta, GA USA
| | - Kim Hung Lo
- Statistics and Decision Sciences, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Lilianne Kim
- Statistics and Decision Sciences, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Sheri Volger
- Pediatric Development Team, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Renping Zhang
- Data Analytics, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Richard Strauss
- Pediatric Development Team, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Laurie S Conklin
- Child Health Innovation Leadership Department, Johnson & Johnson Innovative Medicine, New Brunswick, NJ USA
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Nabbout R, Zanello G, Baker D, Black L, Brambilla I, Buske OJ, Conklin LS, Davies EH, Julkowska D, Kim Y, Klopstock T, Nakamura H, Nielsen KG, Pariser AR, Pastor JC, Scarpa M, Smith M, Taruscio D, Groft S. Towards the international interoperability of clinical research networks for rare diseases: recommendations from the IRDiRC Task Force. Orphanet J Rare Dis 2023; 18:109. [PMID: 37161573 PMCID: PMC10169162 DOI: 10.1186/s13023-023-02650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 02/27/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Many patients with rare diseases are still lacking a timely diagnosis and approved therapies for their condition despite the tremendous efforts of the research community, biopharmaceutical, medical device industries, and patient support groups. The development of clinical research networks for rare diseases offers a tremendous opportunity for patients and multi-disciplinary teams to collaborate, share expertise, gain better understanding on specific rare diseases, and accelerate clinical research and innovation. Clinical Research Networks have been developed at a national or continental level, but global collaborative efforts to connect them are still lacking. The International Rare Diseases Research Consortium set a Task Force on Clinical Research Networks for Rare Diseases with the objective to analyse the structure and attributes of these networks and to identify the barriers and needs preventing their international collaboration. The Task Force created a survey and sent it to pre-identified clinical research networks located worldwide. RESULTS A total of 34 responses were received. The survey analysis demonstrated that clinical research networks are diverse in their membership composition and emphasize community partnerships including patient groups, health care providers and researchers. The sustainability of the networks is mostly supported by public funding. Activities and research carried out at the networks span the research continuum from basic to clinical to translational research studies. Key elements and infrastructures conducive to collaboration are well adopted by the networks, but barriers to international interoperability are clearly identified. These hurdles can be grouped into five categories: funding limitation; lack of harmonization in regulatory and contracting process; need for common tools and data standards; need for a governance framework and coordination structures; and lack of awareness and robust interactions between networks. CONCLUSIONS Through this analysis, the Task Force identified key elements that should support both developing and established clinical research networks for rare diseases in implementing the appropriate structures to achieve international interoperability worldwide. A global roadmap of actions and a specific research agenda, as suggested by this group, provides a platform to identify common goals between these networks.
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Affiliation(s)
- Rima Nabbout
- Department of Pediatric Neurology, Reference Center for Rare Epilepsies, Hôpital Necker-Enfants Malades, APHP, member of ERN EPICARE, Institut Imagine, INSERM U1163, Université Paris Cité, Paris, France.
| | - Galliano Zanello
- Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Dixie Baker
- Martin, Blanck, and Associates, Arlington, VA, USA
| | | | | | | | | | | | - Daria Julkowska
- Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Yeonju Kim
- Korea Disease Control and Prevention Agency, Cheongju-si, Chungcheongbuj-do, Korea
| | - Thomas Klopstock
- Friedrich-Baur-Institute, Department of Neurology, LMU Klinikum, Ludwig-Maximilians-Universität München, Ziemssenstr. 1, 80336, Munich, Germany
| | - Harumasa Nakamura
- Department of Clinical Research Support, Clinical Research and Education Promotion Division, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kim G Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Maurizio Scarpa
- Regional Coordinating Center for Rare Diseases, Udine University Hospital, Udine, Italy
- European Reference Network. For Hereditary Metabolic Diseases (MetabERN), Dublin, Ireland
| | - Maureen Smith
- Canadian Organization for Rare Disorders, Toronto, ON, Canada
| | - Domenica Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Stephen Groft
- Division of Rare Diseases Research Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
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3
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Zhang N, Liu C, Steiner SJ, Colletti RB, Baldassano R, Chen S, Cohen S, Kappelman MD, Saeed S, Conklin LS, Strauss R, Volger S, King E, Lo KH. Using multiple imputation of real-world data to estimate clinical remission in pediatric inflammatory bowel disease. J Comp Eff Res 2023; 12:e220136. [PMID: 36799351 PMCID: PMC10402781 DOI: 10.57264/cer-2022-0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Aim: To evaluate the performance of the multiple imputation (MI) method for estimating clinical effectiveness in pediatric Crohn's disease in the ImproveCareNow registry; to address the analytical challenge of missing data. Materials & methods: Simulation studies were performed by creating missing datasets based on fully observed data from patients with moderate-to-severe Crohn's disease treated with non-ustekinumab biologics. MI was used to impute sPCDAI remission statuses in each simulated dataset. Results: The true remission rate (75.1% [95% CI: 72.6%, 77.5%]) was underestimated without imputation (72.6% [71.8%, 73.3%]). With MI, the estimate was 74.8% (74.4%, 75.2%). Conclusion: MI reduced nonresponse bias and improved the validity, reliability, and efficiency of real-world registry data to estimate remission rate in pediatric patients with Crohn's disease.
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Affiliation(s)
- Nanhua Zhang
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- University of Cincinnati, Cincinnati, OH 45229, USA
| | - Chunyan Liu
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Steven J Steiner
- Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Richard B Colletti
- University of Vermont College of Medicine, Department of Pediatrics, Burlington, VT 05405, USA
| | - Robert Baldassano
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Shiran Chen
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Stanley Cohen
- GI Care For Kids, Atlanta, GA 30342, USA
- Morehouse School of Medicine, Atlanta, GA 30310, USA
| | | | - Shehzad Saeed
- Dayton Children's Hospital/Wright State University, Dayton, OH 45404, USA
| | - Laurie S Conklin
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Richard Strauss
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Sheri Volger
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
| | - Eileen King
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- University of Cincinnati, Cincinnati, OH 45229, USA
| | - Kim Hung Lo
- Janssen Research & Development, LLC, Spring House, PA 19477, USA
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Adler J, Colletti RB, Noonan L, Berzin TM, Cheifetz AS, Conklin LS, Hoops TC, Huang CS, Lewis B, Mishkin DS, Hung Lo K, Xiao Y, Volger S. Validating the Simplified Endoscopic Mucosal Assessment for Crohn's Disease: A Novel Method for Assessing Disease Activity. Inflamm Bowel Dis 2022:6682834. [PMID: 36049024 DOI: 10.1093/ibd/izac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND To demonstrate treatment efficacy in Crohn's disease (CD), regulatory authorities require that trials include an endoscopic remission/response end point; however, standardized endoscopic assessment of disease activity, such as the Simple Endoscopic Score for Crohn's Disease (SES-CD), is not typically recorded by clinicians in practice or outside of clinical trials. The novel Simplified Endoscopic Mucosal Assessment for Crohn's Disease (SEMA-CD) was developed to be easy to use in routine clinical practice and as a trial end point. We conducted a study to assess and validate the reliability and feasibility of SEMA-CD as a measure of endoscopic disease activity. METHODS Pre- and post-treatment ileocolonoscopy videos of pediatric (n = 36) and adult (n = 74) CD patients from 2 ustekinumab clinical trials were each scored with SEMA-CD by 2 to 3 professional central readers, blinded to clinical history and other video scorings; the correlation between SEMA-CD and SES-CD previously completed during the trials was assessed. Sensitivity to change, inter- and intrarater reliability, and comparative ease of scoring were also assessed. RESULTS The SEMA-CD strongly correlated with SES-CD (Spearman ρ = 0.89; 95% confidence interval, 0.86-0.92). Pre- to post-treatment changes in SEMA-CD vs in SES-CD were strongly correlated, and the correlation remained strong between the scores when compared by study population (pediatric, adult), disease severity, and video quality. Intra- and inter-rater reliability were good, and SEMA-CD was rated easier than SES-CD to score 63.0% of the time, although slightly more difficult than SES-CD to score <1.0% of the time. CONCLUSIONS The SEMA-CD is reliable, reproducible, sensitive to change, and easy to use in both pediatric and adult patients with CD.
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Affiliation(s)
- Jeremy Adler
- C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Lenore Noonan
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Division of Gastroenterology, Harvard Medical School, Boston, MA, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Division of Gastroenterology, Harvard Medical School, Boston, MA, USA
| | | | - Timothy C Hoops
- Immunology Global Medical Affairs, Janssen Pharmaceutical Companies (a subsidiary of Johnson & Johnson), Horsham, PA, USA
| | - Christopher S Huang
- Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Blair Lewis
- Division of Gastroenterology, Mount Sinai Health System, New York, NY, USA
| | | | - Kim Hung Lo
- Janssen Research & Development, LLC, Spring House, PA, USA
| | | | - Sheri Volger
- Janssen Research & Development, LLC, Spring House, PA, USA
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5
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Mulberg AE, Conklin LS, Croft NM. Pediatric Extrapolation of Adult Efficacy to Children Is Critical for Efficient and Successful Drug Development. Gastroenterology 2022; 163:77-83. [PMID: 35288113 DOI: 10.1053/j.gastro.2022.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Andrew E Mulberg
- University of Maryland School of Medicine, Baltimore, Maryland; Janssen; and Barts and the London School of Medicine and Dentistry.
| | - Laurie S Conklin
- University of Maryland School of Medicine, Baltimore, Maryland; Janssen; and Barts and the London School of Medicine and Dentistry
| | - Nicholas M Croft
- University of Maryland School of Medicine, Baltimore, Maryland; Janssen; and Barts and the London School of Medicine and Dentistry
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- University of Maryland School of Medicine, Baltimore, Maryland; Janssen; and Barts and the London School of Medicine and Dentistry
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6
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Dang UJ, Ziemba M, Clemens PR, Hathout Y, Conklin LS, Hoffman EP. Serum biomarkers associated with baseline clinical severity in young steroid-naïve Duchenne muscular dystrophy boys. Hum Mol Genet 2021; 29:2481-2495. [PMID: 32592467 PMCID: PMC7471506 DOI: 10.1093/hmg/ddaa132] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/28/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is caused by loss of dystrophin in muscle, and while all patients share the primary gene and biochemical defect, there is considerable patient–patient variability in clinical symptoms. We sought to develop multivariate models of serum protein biomarkers that explained observed variation, using functional outcome measures as proxies for severity. Serum samples from 39 steroid-naïve DMD boys 4 to <7 years enrolled into a clinical trial of vamorolone were studied (NCT02760264). Four assessments of gross motor function were carried out for each participant over a 6-week interval, and their mean was used as response for biomarker models. Weighted correlation network analysis was used for unsupervised clustering of 1305 proteins quantified using SOMAscan® aptamer profiling to define highly representative and connected proteins. Multivariate models of biomarkers were obtained for time to stand performance (strength phenotype; 17 proteins) and 6 min walk performance (endurance phenotype; 17 proteins) including some shared proteins. Identified proteins were tested with associations of mRNA expression with histological severity of muscle from dystrophinopathy patients (n = 28) and normal controls (n = 6). Strong associations predictive of both clinical and histological severity were found for ERBB4 (reductions in both blood and muscle with increasing severity), SOD1 (reductions in muscle and increases in blood with increasing severity) and CNTF (decreased levels in blood and muscle with increasing severity). We show that performance of DMD boys was effectively modeled with serum proteins, proximal strength associated with growth and remodeling pathways and muscle endurance centered on TGFβ and fibrosis pathways in muscle.
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Affiliation(s)
- Utkarsh J Dang
- Department of Health Outcomes and Administrative Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University-SUNY, Binghamton, NY 13902, USA
| | - Michael Ziemba
- Department of Biomedical Engineering, Watson School of Engineering, Binghamton University-SUNY, Binghamton, NY 13902, USA
| | - Paula R Clemens
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Veteran Affairs Medical Center, Pittsburgh, PA 15213, USA
| | - Yetrib Hathout
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University-SUNY, Binghamton, NY 13902, USA
| | | | | | - Eric P Hoffman
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University-SUNY, Binghamton, NY 13902, USA.,ReveraGen BioPharma, Rockville, MD 20850, USA
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7
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Constant BD, Khushal S, Jiang J, Bost JE, Chaisson E, Conklin LS. Early Inflammatory Markers are Associated With Inadequate Post-Induction Infliximab Trough in Pediatric Crohn's Disease. J Pediatr Gastroenterol Nutr 2021; 72:410-416. [PMID: 33439565 PMCID: PMC8258369 DOI: 10.1097/mpg.0000000000002975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES In pediatric Crohn's disease, infliximab trough concentrations after standard weight-based induction therapy are commonly below 7 μg/mL. Clinical treatment outcomes are associated with post-induction infliximab trough concentration. Markers of inflammation are associated with low infliximab concentrations during maintenance dosing. We sought to determine if early markers of disease activity are associated with inadequate post-induction infliximab trough concentrations in pediatric Crohn's disease. METHODS We performed a retrospective single-center case-control study of pediatric Crohn's disease patients to assess the association between baseline and week-2 biomarkers (albumin, C-reactive protein, and erythrocyte sedimentation rate) and inadequate post-induction infliximab trough concentration (<7 μg/mL) in patients treated with standard 5 mg/kg dosing. Baseline and week-2 biomarker values were coded as dichotomous variables at clinically useful thresholds. Univariable logistic regression was used to calculate odds ratios of developing an inadequate infliximab trough concentration for each threshold, as well as thresholds in combination. RESULTS Fifty-five patients were evaluated. Early biomarker thresholds significantly associated with inadequate post-induction infliximab trough concentrations included baseline C-reactive protein >1 mg/dL (odds ratio [OR] 4.58; 95% confidence interval [CI] 1.24--17.01), both baseline C-reactive protein >0.5 mg/dL and albumin <3.5 g/dL (OR 8.31; 95% CI 1.99--34.63), and week-2 C-reactive protein >0.5 mg/dL or albumin <3.5 mg/dL or erythrocyte sedimentation rate >25 mm/hour (OR 11.08; 95% CI 2.14--57.22). CONCLUSIONS Routine baseline and week-2 markers of disease activity at clinically useful thresholds were associated with inadequate post-induction infliximab trough concentration in pediatric Crohn's disease patients receiving standard weight-based induction dosing.
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Affiliation(s)
- Brad D. Constant
- Department of Pediatrics, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
| | - Salina Khushal
- Department of Pediatrics, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
| | - Jiji Jiang
- Department of Biostatistics, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
| | - James E. Bost
- Department of Biostatistics, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
| | - Ellen Chaisson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
| | - Laurie S. Conklin
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s National Hospital, George Washington University, Washington, DC
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8
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Conklin LS, Hoffman EP, van den Anker J. Developmental Pharmacodynamics and Modeling in Pediatric Drug Development. J Clin Pharmacol 2020; 59 Suppl 1:S87-S94. [PMID: 31502687 DOI: 10.1002/jcph.1482] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022]
Abstract
Challenges in pediatric drug development include small patient numbers, limited outcomes research, ethical barriers, and sparse biosamples. Increasingly, pediatric drug development is focusing on extrapolation: leveraging knowledge about adult disease and drug responses to inform projections of drug and clinical trial performance in pediatric subpopulations. Pharmacokinetic-pharmacodynamic (PK-PD) modeling and extrapolation aim to reduce the numbers of patients and data points needed to establish efficacy. Planning for PK-PD and biomarker studies should begin early in the adult drug development program. Extrapolation relies on the assumption that both the underlying disease and the mechanism of action of the drug used to treat that disease are similar in adults and pediatric subpopulations. Clearly, developmental changes in PK and PD need to be considered to enhance the quality of PK-PD modeling and, therefore, increase the success of extrapolation. This article focuses on the influence of differences in PD between adults and pediatric subpopulations that are highly relevant for the use of extrapolation.
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Affiliation(s)
- Laurie S Conklin
- Division of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA.,ReveraGen BioPharma, Rockville, MD, USA
| | - Eric P Hoffman
- ReveraGen BioPharma, Rockville, MD, USA.,Binghamton University-SUNY, School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
| | - John van den Anker
- ReveraGen BioPharma, Rockville, MD, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
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9
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Smith EC, Conklin LS, Hoffman EP, Clemens PR, Mah JK, Finkel RS, Guglieri M, Tulinius M, Nevo Y, Ryan MM, Webster R, Castro D, Kuntz NL, Kerchner L, Morgenroth LP, Arrieta A, Shimony M, Jaros M, Shale P, Gordish-Dressman H, Hagerty L, Dang UJ, Damsker JM, Schwartz BD, Mengle-Gaw LJ, McDonald CM. Efficacy and safety of vamorolone in Duchenne muscular dystrophy: An 18-month interim analysis of a non-randomized open-label extension study. PLoS Med 2020; 17:e1003222. [PMID: 32956407 PMCID: PMC7505441 DOI: 10.1371/journal.pmed.1003222] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Treatment with corticosteroids is recommended for Duchenne muscular dystrophy (DMD) patients to slow the progression of weakness. However, chronic corticosteroid treatment causes significant morbidities. Vamorolone is a first-in-class anti-inflammatory investigational drug that has shown evidence of efficacy in DMD after 24 weeks of treatment at 2.0 or 6.0 mg/kg/day. Here, open-label efficacy and safety experience of vamorolone was evaluated over a period of 18 months in trial participants with DMD. METHODS AND FINDINGS A multicenter, open-label, 24-week trial (VBP15-003) with a 24-month long-term extension (VBP15-LTE) was conducted by the Cooperative International Neuromuscular Research Group (CINRG) and evaluated drug-related effects of vamorolone on motor outcomes and corticosteroid-associated safety concerns. The study was carried out in Canada, US, UK, Australia, Sweden, and Israel, from 2016 to 2019. This report covers the initial 24-week trial and the first 12 months of the VBP15-LTE trial (total treatment period 18 months). DMD trial participants (males, 4 to <7 years at entry) treated with 2.0 or 6.0 mg/kg/day vamorolone for the full 18-month period (n = 23) showed clinical improvement of all motor outcomes from baseline to month 18 (time to stand velocity, p = 0.012 [95% CI 0.010, 0.068 event/second]; run/walk 10 meters velocity, p < 0.001 [95% CI 0.220, 0.491 meters/second]; climb 4 stairs velocity, p = 0.001 [95% CI 0.034, 0.105 event/second]; 6-minute walk test, p = 0.001 [95% CI 31.14, 93.38 meters]; North Star Ambulatory Assessment, p < 0.001 [95% CI 2.702, 6.662 points]). Outcomes in vamorolone-treated DMD patients (n = 46) were compared to group-matched participants in the CINRG Duchenne Natural History Study (corticosteroid-naïve, n = 19; corticosteroid-treated, n = 68) over a similar 18-month period. Time to stand was not significantly different between vamorolone-treated and corticosteroid-naïve participants (p = 0.088; least squares [LS] mean 0.042 [95% CI -0.007, 0.091]), but vamorolone-treated participants showed significant improvement compared to group-matched corticosteroid-naïve participants for run/walk 10 meters velocity (p = 0.003; LS mean 0.286 [95% CI 0.104, 0.469]) and climb 4 stairs velocity (p = 0.027; LS mean 0.059 [95% CI 0.007, 0.111]). The vamorolone-related improvements were similar in magnitude to corticosteroid-related improvements. Corticosteroid-treated participants showed stunting of growth, whereas vamorolone-treated trial participants did not (p < 0.001; LS mean 15.86 [95% CI 8.51, 23.22]). Physician-reported incidences of adverse events (AEs) for Cushingoid appearance, hirsutism, weight gain, and behavior change were less for vamorolone than published incidences for prednisone and deflazacort. Key limitations to the study were the open-label design, and use of external comparators. CONCLUSIONS We observed that vamorolone treatment was associated with improvements in some motor outcomes as compared with corticosteroid-naïve individuals over an 18-month treatment period. We found that fewer physician-reported AEs occurred with vamorolone than have been reported for treatment with prednisone and deflazacort, and that vamorolone treatment did not cause the stunting of growth seen with these corticosteroids. This Phase IIa study provides Class III evidence to support benefit of motor function in young boys with DMD treated with vamorolone 2.0 to 6.0 mg/kg/day, with a favorable safety profile. A Phase III RCT is underway to further investigate safety and efficacy. TRIAL REGISTRATION Clinical trials were registered at www.clinicaltrials.gov, and the links to each trial are as follows (as provided in manuscript text): VBP15-002 [NCT02760264] VBP15-003 [NCT02760277] VBP15-LTE [NCT03038399].
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Affiliation(s)
- Edward C. Smith
- Duke University, Durham, North Carolina, United States of America
| | - Laurie S. Conklin
- ReveraGen Biopharma, Rockville, Maryland, United States of America
- Children’s National Hospital, Washington, District of Columbia, United States of America
| | - Eric P. Hoffman
- ReveraGen Biopharma, Rockville, Maryland, United States of America
- Binghamton University–SUNY, Binghamton, New York, United States of America
| | - Paula R. Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Jean K. Mah
- Alberta Children’s Hospital, Calgary, Alberta, Canada
| | - Richard S. Finkel
- Nemours Children’s Hospital, Orlando, Florida, United States of America
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mar Tulinius
- Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Yoram Nevo
- Schneider Children’s Medical Center, Tel Aviv University, Petah Tikvah, Israel
| | - Monique M. Ryan
- Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Richard Webster
- The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Diana Castro
- University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Nancy L. Kuntz
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
| | | | | | | | - Maya Shimony
- TRiNDS, Pittsburgh, Pennsylvania, United States of America
| | - Mark Jaros
- Summit Analytical, Denver, Colorado, United States of America
| | - Phil Shale
- Summit Analytical, Denver, Colorado, United States of America
| | | | - Laura Hagerty
- ReveraGen Biopharma, Rockville, Maryland, United States of America
| | - Utkarsh J. Dang
- Binghamton University–SUNY, Binghamton, New York, United States of America
| | - Jesse M. Damsker
- ReveraGen Biopharma, Rockville, Maryland, United States of America
| | | | | | - Craig M. McDonald
- University of California, Davis, Davis, California, United States of America
- * E-mail:
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10
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Batra SK, Heier CR, Diaz-Calderon L, Tully CB, Fiorillo AA, van den Anker J, Conklin LS. Serum miRNAs Are Pharmacodynamic Biomarkers Associated With Therapeutic Response in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1597-1606. [PMID: 32793975 PMCID: PMC7500519 DOI: 10.1093/ibd/izaa209] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND We sought to identify microRNAs (miRNAs) associated with response to anti-TNF-α or glucocorticoids in children with inflammatory bowel disease (IBD) to generate candidate pharmacodynamic and monitoring biomarkers. METHODS Clinical response was assessed by Pediatric Crohn's Disease Activity Index and Pediatric Ulcerative Colitis Activity Index. Quantitative real-time polymerase chain reaction via Taqman Low-Density Array cards were used to identify miRNAs in a discovery cohort of responders (n = 11) and nonresponders (n = 8). Seven serum miRNAs associated with clinical response to treatment, along with 4 previously identified (miR-146a, miR-146b, miR-320a, miR-486), were selected for further study. Candidates were assessed in a validation cohort of serum samples from IBD patients pre- and post-treatment and from healthy controls. Expression of miRNA was also analyzed in inflamed mucosal biopsies from IBD patients and non-IBD controls. RESULTS Discovery cohort analysis identified 7 miRNAs associated with therapeutic response: 5 that decreased (miR-126, miR-454, miR-26b, miR-26a, let-7c) and 2 that increased (miR-636, miR-193b). In the validation cohort, 7 of 11 candidate miRNAs changed in the same direction with response to anti-TNF-α therapies, glucocorticoids, or both. In mucosal biopsies, 7 out of 11 miRNAs were significantly increased in IBD vs healthy controls. CONCLUSIONS Five candidate miRNAs associated with clinical response and mucosal inflammation in pediatric IBD patients were identified (miR-126, let-7c, miR-146a, miR-146b, and miR-320a). These miRNAs may be further developed as pharmacodynamic and response monitoring biomarkers for use in clinical care and trials.
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Affiliation(s)
- Suruchi K Batra
- Division of Gastroenterology, Hepatology and Nutrition, Children’s National Hospital, Washington, DC, USA
| | - Christopher R Heier
- Research Center for Genetic Medicine, Children’s National Hospital, Washington, DC, USA,Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Lina Diaz-Calderon
- Division of Gastroenterology, Hepatology and Nutrition, Children’s National Hospital, Washington, DC, USA
| | - Christopher B Tully
- Research Center for Genetic Medicine, Children’s National Hospital, Washington, DC, USA
| | - Alyson A Fiorillo
- Research Center for Genetic Medicine, Children’s National Hospital, Washington, DC, USA,Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children’s National Hospital, Washington, DC, USA
| | - Laurie S Conklin
- Division of Gastroenterology, Hepatology and Nutrition, Children’s National Hospital, Washington, DC, USA,Address correspondence to: Laurie S. Conklin, MD, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA. E-mail:
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11
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Li X, Conklin LS, van den Anker J, Hoffman EP, Clemens PR, Jusko WJ. Exposure-Response Analysis of Vamorolone (VBP15) in Boys With Duchenne Muscular Dystrophy. J Clin Pharmacol 2020; 60:1385-1396. [PMID: 32434278 DOI: 10.1002/jcph.1632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/09/2020] [Indexed: 12/12/2022]
Abstract
Exposure-response relationships of vamorolone, a novel dissociative steroidal anti-inflammatory drug, were investigated in clinical trials in boys with Duchenne muscular dystrophy. Variables were clinical outcome measures, Fridericia-corrected QT (QTcF) duration, and pharmacodynamic (PD) biomarkers. Exposure metrics were area under the plasma concentration time curve (AUC) and maximum plasma concentration (Cmax ), with a sigmoid Emax model applied. Significant improvement in clinical efficacy outcomes was observed after 24 weeks of daily dosing. The primary outcome, time to stand from supine velocity, exhibited the highest sensitivity to vamorolone, with the lowest AUC value providing 50% of maximum effect (E50 = 186 ng·h/mL), followed by time to climb 4 stairs (E50 = 478 ng·h/mL), time to run/walk 10 m (E50 = 1220 ng·h/mL), and 6-minute walk test (E50 = 1770 ng·h/mL). Week 2 changes of proinflammatory PD biomarkers showed exposure-dependent decreases. The E50 was 260 ng·h/mL for insulin-like growth factor-binding protein 2, 1200 ng·h/mL for matrix metalloproteinase 12, 1260 ng·h/mL for lymphotoxin α1/β2, 1340 ng·h/mL for CD23, 1420 ng·h/mL for interleukin-22-binding protein, and 1600 ng·h/mL for macrophage-derived chemokine/C-C motif chemokine 22. No relationship was found between QTcF interval changes from baseline and Cmax in week 2 or 24. This analysis showed that improvements in clinical efficacy end points in week 24 and PD biomarkers in week 2 were achieved at typical vamorolone exposure of 2 mg/kg daily dose with a median AUC dose of 6 mg/kg (3651 ng·h/mL), corresponding to approximately 95% of maximum effects for most response variables.
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Affiliation(s)
- Xiaonan Li
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Laurie S Conklin
- ReveraGen BioPharma, Rockville, Maryland, USA.,Children's National Hospital, Washington, District of Columbia, USA
| | - John van den Anker
- ReveraGen BioPharma, Rockville, Maryland, USA.,Children's National Hospital, Washington, District of Columbia, USA
| | - Eric P Hoffman
- ReveraGen BioPharma, Rockville, Maryland, USA.,Binghamton University-SUNY, Binghamton, New York, USA
| | - Paula R Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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12
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Hoffman EP, Schwartz BD, Mengle-Gaw LJ, Smith EC, Castro D, Mah JK, McDonald CM, Kuntz NL, Finkel RS, Guglieri M, Bushby K, Tulinius M, Nevo Y, Ryan MM, Webster R, Smith AL, Morgenroth LP, Arrieta A, Shimony M, Siener C, Jaros M, Shale P, McCall JM, Nagaraju K, van den Anker J, Conklin LS, Cnaan A, Gordish-Dressman H, Damsker JM, Clemens PR. Vamorolone trial in Duchenne muscular dystrophy shows dose-related improvement of muscle function. Neurology 2019; 93:e1312-e1323. [PMID: 31451516 PMCID: PMC7011869 DOI: 10.1212/wnl.0000000000008168] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 05/29/2019] [Indexed: 11/15/2022] Open
Abstract
Objective To study vamorolone, a first-in-class steroidal anti-inflammatory drug, in Duchenne muscular dystrophy (DMD). Methods An open-label, multiple-ascending-dose study of vamorolone was conducted in 48 boys with DMD (age 4–<7 years, steroid-naive). Dose levels were 0.25, 0.75, 2.0, and 6.0 mg/kg/d in an oral suspension formulation (12 boys per dose level; one-third to 10 times the glucocorticoid dose in DMD). The primary goal was to define optimal doses of vamorolone. The primary outcome for clinical efficacy was time to stand from supine velocity. Results Oral administration of vamorolone at all doses tested was safe and well tolerated over the 24-week treatment period. The 2.0–mg/kg/d dose group met the primary efficacy outcome of improved muscle function (time to stand; 24 weeks of vamorolone treatment vs natural history controls), without evidence of most adverse effects of glucocorticoids. A biomarker of bone formation, osteocalcin, increased in vamorolone-treated boys, suggesting possible loss of bone morbidities seen with glucocorticoids. Biomarker outcomes for adrenal suppression and insulin resistance were also lower in vamorolone-treated patients with DMD relative to published studies of glucocorticoid therapy. Conclusions Daily vamorolone treatment suggested efficacy at doses of 2.0 and 6.0 mg/kg/d in an exploratory 24-week open-label study. Classification of evidence This study provides Class IV evidence that for boys with DMD, vamorolone demonstrated possible efficacy compared to a natural history cohort of glucocorticoid-naive patients and appeared to be tolerated.
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Affiliation(s)
- Eric P Hoffman
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA.
| | - Benjamin D Schwartz
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Laurel J Mengle-Gaw
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Edward C Smith
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Diana Castro
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Jean K Mah
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Craig M McDonald
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Nancy L Kuntz
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Richard S Finkel
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Michela Guglieri
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Katharine Bushby
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Mar Tulinius
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Yoram Nevo
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Monique M Ryan
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Richard Webster
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Andrea L Smith
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Lauren P Morgenroth
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Adrienne Arrieta
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Maya Shimony
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Catherine Siener
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Mark Jaros
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Phil Shale
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - John M McCall
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Kanneboyina Nagaraju
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - John van den Anker
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Laurie S Conklin
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Avital Cnaan
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Heather Gordish-Dressman
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Jesse M Damsker
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
| | - Paula R Clemens
- From ReveraGen Biopharma (E.P.H., J.M.M., K.N., J.v.d.A., L.S.C., J.M.D.), Rockville, MD; Binghamton University-SUNY (E.P.H., K.N.), NY: Camden Group (B.D.S., L.J.M.-G.), LLC, St. Louis, MO; Duke University (E.C.S.), Durham, NC; University of Texas Southwestern (D.C.), Dallas; Alberta Children's Hospital (J.K.M.), Calgary, Canada; University of California Davis (C.M.M.), Sacramento; Ann & Robert H. Lurie Children's Hospital (N.L.K.), Chicago, IL; Nemours Children's Hospital (R.S.F.), Orlando, FL; John Walton Muscular Dystrophy Research Centre (M.G., K.B.), Newcastle University, Newcastle-Upon-Tyne, UK; Queen Silvia Children's Hospital (M.T.), Gothenburg, Sweden; Schneider Children's Medical Center (Y.N.), Tel Aviv University, Israel; Royal Children's Hospital and Murdoch Children's Research Institute (M.M.R.), Melbourne, Australia; The Children's Hospital at Westmead (R.W.), Sydney, Australia; TRiNDS LLC (A.L.S., L.P.M., A.A., M.S., C.S.), Kensington, MD; Summit Analytical (M.J., P.S.), Denver, CO; Children's National Health System (J.v.d.A., L.S.C., A.C., H.G.-D.), Washington, DC; and University of Pittsburgh and Department of Veterans Affairs Medical Center (P.R.C.), PA
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Mavroudis PD, van den Anker J, Conklin LS, Damsker JM, Hoffman EP, Nagaraju K, Clemens PR, Jusko WJ. Population Pharmacokinetics of Vamorolone (VBP15) in Healthy Men and Boys With Duchenne Muscular Dystrophy. J Clin Pharmacol 2019; 59:979-988. [PMID: 30742306 DOI: 10.1002/jcph.1388] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Abstract
Duchenne muscular dystrophy (DMD) is an inherited neuromuscular disorder occurring in boys and caused by mutations in the dystrophin gene. Vamorolone is a first-generation delta-9,11 compound that has favorable efficacy and side effect profiles relative to classical glucocorticoids. The pharmacokinetics (PK) of oral vamorolone were assessed in parallel-group studies in healthy men (phase 1, n = 86) and boys with DMD (phase 2a, n = 48) during 14 days of once-daily dosing with a range of doses. Vamorolone exhibited moderate variability in PK, with the maximum plasma concentration usually occurring at 2-4 hours and a half-life of approximately 2 hours for all doses and days examined. Population PK modeling of all data together indicated that the PK of vamorolone can be well described by a 1-compartment model with zero-order absorption. Both men and boys showed a dose-linearity of PK parameters for the doses examined, with no accumulation of the drug during daily dosing. Ingestion with food resulted in markedly enhanced absorption of the drug, as tested in healthy men. There were similar PK of vamorolone in healthy men and DMD boys with apparent clearance averaging 2.0 L/h/kg in men and 1.7 L/h/kg in boys. Overall, vamorolone exhibited well-behaved linear PK, with similar profiles in healthy men and boys with DMD, moderate variability in PK parameters, and absorption and disposition profiles similar to those of classical glucocorticoids.
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Affiliation(s)
- Panteleimon D Mavroudis
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - John van den Anker
- ReveraGen Biopharma, Rockville, MD, USA.,Children's National Health System, Washington, DC, USA
| | - Laurie S Conklin
- ReveraGen Biopharma, Rockville, MD, USA.,Children's National Health System, Washington, DC, USA
| | | | - Eric P Hoffman
- ReveraGen Biopharma, Rockville, MD, USA.,Binghamton University-SUNY, Binghamton, NY, USA
| | - Kanneboyina Nagaraju
- ReveraGen Biopharma, Rockville, MD, USA.,Binghamton University-SUNY, Binghamton, NY, USA
| | - Paula R Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
| | - William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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14
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Batra S, Conklin LS. Therapeutics for Inflammatory Bowel Diseases in Children and Adolescents: A Focus on Biologics and an Individualized Treatment Paradigm. Handb Exp Pharmacol 2019; 261:363-375. [PMID: 31342277 DOI: 10.1007/164_2019_255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pharmacologic treatment of children and adolescents with inflammatory bowel diseases (IBD) [Crohn's disease and ulcerative colitis] requires consideration of disease and medication effects on growth and nutrition, the importance of durability of biologics, and concerns for long-term sequelae of disease and therapies. Achieving early remission in children with Crohn's disease correlates with improved outcomes and therefore allows a window of opportunity for maximizing growth. Thus, there is a great need to treat children and adolescents with the right drug at the right time while achieving adequate exposure. Improved understanding of disease phenotypes, disease natural history, and risk stratification will play a critical role in treatment selection for children, particularly as more therapeutic options become available. Here we summarize data supporting newer concepts of treating the individual child with IBD through targeted early biologic treatment, including utilization of therapeutic drug monitoring to optimize treatment effects and the use of early antitumor necrosis factor (TNF)-α therapies to mitigate long-term sequelae of the disease. Recent inception cohort studies provide important data regarding the risk stratification of children and adolescents with IBD, which support a move toward a personalized therapeutic approach to IBD in children and adolescents.
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Affiliation(s)
- Suruchi Batra
- Division of Gastroenterology, Hepatology, and Nutrition, Children's National Medical Center, Washington, DC, USA
| | - Laurie S Conklin
- George Washington University School of Medicine, Children's National Medical Center, Washington, DC, USA.
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15
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Conklin LS, Merkel PA, Pachman LM, Parikh H, Tawalbeh S, Damsker JM, Cuthbertson DD, Morgan GA, Monach PA, Hathout Y, Nagaraju K, van den Anker J, McAlear CA, Hoffman EP. Serum biomarkers of glucocorticoid response and safety in anti-neutrophil cytoplasmic antibody-associated vasculitis and juvenile dermatomyositis. Steroids 2018; 140:159-166. [PMID: 30352204 PMCID: PMC6640634 DOI: 10.1016/j.steroids.2018.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 12/25/2022]
Abstract
Glucocorticoids are standard of care for many chronic inflammatory conditions, including juvenile dermatomyositis (JDM) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We sought to define pharmacodynamic biomarkers of therapeutic efficacy and safety concerns of glucocorticoid treatment for these two disorders. Previous proteomic profiling of patients with Duchenne muscular dystrophy (DMD) and inflammatory bowel disease (IBD) treated with glucocorticoids identified candidate biomarkers for efficacy and safety concerns of glucocorticoids. Serial serum samples from patients with AAV (n = 30) and JDM (n = 12) were obtained during active disease, and after treatment with glucocorticoids. For AAV, 8 of 11 biomarkers of the anti-inflammatory response to glucocorticoids were validated (P-value ≤0.05; CD23, macrophage-derived cytokine, interleukin-22 binding protein, matrix metalloproteinase-12, T lymphocyte surface antigen Ly9, fibrinogen gamma chain, angiopoietin-2 [all decreased], and protein C [increased]), as were 5 of 7 safety biomarkers (P-value ≤0.05; afamin, matrix metalloproteinase-3, insulin growth factor binding protein-5, angiotensinogen, leptin [all increased]). For JDM, 10 of 11 efficacy biomarkers were validated (P-value ≤0.05; all proteins except fibrinogen gamma chain) and 6 of 7 safety biomarkers (P-value ≤0.05; AAV proteins plus growth hormone binding protein). The identified efficacy biomarkers may be useful as objective outcome measures for early phase proof-of-concept studies when assessing novel anti-inflammatory drugs in JDM and AAV, and likely in other inflammatory disorders. Similarly, safety biomarkers may also be helpful assessing toxicity of alternatives to glucocorticoids.
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Affiliation(s)
- Laurie S Conklin
- ReveraGen BioPharma, 155 Gibbs St., Suite 433, Rockville, MD 20850, USA; Division of Gastroenterology, George Washington University School of Medicine and Health Sciences, Children's National Health System, 111 Michigan Avenue NW, Washington, DC 20010, USA.
| | - Peter A Merkel
- Division of Rheumatology and the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Lauren M Pachman
- Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, USA.
| | - Hemang Parikh
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Shefa Tawalbeh
- Department of Biomedical Engineering, Binghamton University - SUNY, 4400 Vestal Pkwy E, Binghamton, NY 13902, USA.
| | - Jesse M Damsker
- ReveraGen BioPharma, 155 Gibbs St., Suite 433, Rockville, MD 20850, USA.
| | - David D Cuthbertson
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Gabrielle A Morgan
- Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, USA.
| | - Paul A Monach
- Division of Rheumatology, Boston University School of Medicine, 75 E. Newton St., Boston, MA USA 02118, USA.
| | - Yetrib Hathout
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University - SUNY, 4400 Vestal Pkwy E, Binghamton, NY 13902, USA.
| | - Kanneboyina Nagaraju
- ReveraGen BioPharma, 155 Gibbs St., Suite 433, Rockville, MD 20850, USA; School of Pharmacy and Pharmaceutical Sciences, Binghamton University - SUNY, 4400 Vestal Pkwy E, Binghamton, NY 13902, USA.
| | - John van den Anker
- ReveraGen BioPharma, 155 Gibbs St., Suite 433, Rockville, MD 20850, USA; Department of Clinical Pharmacology, George Washington University School of Medicine and Health Sciences, Children's National Health System, 111 Michigan Avenue NW, Washington, DC 20010, USA.
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania School of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Eric P Hoffman
- ReveraGen BioPharma, 155 Gibbs St., Suite 433, Rockville, MD 20850, USA; School of Pharmacy and Pharmaceutical Sciences, Binghamton University - SUNY, 4400 Vestal Pkwy E, Binghamton, NY 13902, USA.
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16
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Conklin LS, Damsker JM, Hoffman EP, Jusko WJ, Mavroudis PD, Schwartz BD, Mengle-Gaw LJ, Smith EC, Mah JK, Guglieri M, Nevo Y, Kuntz N, McDonald CM, Tulinius M, Ryan MM, Webster R, Castro D, Finkel RS, Smith AL, Morgenroth LP, Arrieta A, Shimony M, Jaros M, Shale P, McCall JM, Hathout Y, Nagaraju K, van den Anker J, Ward LM, Ahmet A, Cornish MR, Clemens PR. Phase IIa trial in Duchenne muscular dystrophy shows vamorolone is a first-in-class dissociative steroidal anti-inflammatory drug. Pharmacol Res 2018; 136:140-150. [PMID: 30219580 PMCID: PMC6218284 DOI: 10.1016/j.phrs.2018.09.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [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] [Received: 07/12/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/24/2022]
Abstract
We report a first-in-patient study of vamorolone, a first-in-class dissociative steroidal anti-inflammatory drug, in Duchenne muscular dystrophy. This 2-week, open-label Phase IIa multiple ascending dose study (0.25, 0.75, 2.0, and 6.0 mg/kg/day) enrolled 48 boys with Duchenne muscular dystrophy (4 to <7 years), with outcomes including clinical safety, pharmacokinetics and pharmacodynamic biomarkers. The study design included pharmacodynamic biomarkers in three contexts of use: 1. Secondary outcomes for pharmacodynamic safety (insulin resistance, adrenal suppression, bone turnover); 2. Exploratory outcomes for drug mechanism of action; 3. Exploratory outcomes for expanded pharmacodynamic safety. Vamorolone was safe and well-tolerated through the highest dose tested (6.0 mg/kg/day) and pharmacokinetics of vamorolone were similar to prednisolone. Using pharmacodynamic biomarkers, the study demonstrated improved safety of vamorolone versus glucocorticoids as shown by reduction of insulin resistance, beneficial changes in bone turnover (loss of increased bone resorption and decreased bone formation only at the highest dose level), and a reduction in adrenal suppression. Exploratory biomarkers of pharmacodynamic efficacy showed an anti-inflammatory mechanism of action and a beneficial effect on plasma membrane stability, as demonstrated by a dose-responsive decrease in serum creatine kinase activity. With an array of pre-selected biomarkers in multiple contexts of use, we demonstrate the development of the first dissociative steroid that preserves anti-inflammatory efficacy and decreases steroid-associated safety concerns. Ongoing extension studies offer the potential to bridge exploratory efficacy biomarkers to clinical outcomes.
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Affiliation(s)
- Laurie S. Conklin
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | | | - Eric P. Hoffman
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | | | | | | | | | | | - Jean K. Mah
- University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | | | - Yoram Nevo
- Schneider Children’s Medical Center of Israel, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Kuntz
- Ann & Robert H. Lurie Children’s Hospital Chicago, IL, USA
| | | | - Mar Tulinius
- Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Monique M. Ryan
- Royal Children’s Hospital, University of Melbourne, Melbourne, Australia
| | | | - Diana Castro
- University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | | | | | | | | | | | | | - Kanneboyina Nagaraju
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | - John van den Anker
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | | | - Paula R. Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
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17
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Picoraro JA, Lee D, Heller CA, Weaver A, Hyams JS, Conklin LS, Otley A, Ziring D, Kugathasan S, Rosh JR, Mulberg A, Denson LA, Kappelman MD, Grossman AB, Bousvaros A, Park KT. Pediatric Inflammatory Bowel Disease Clinical Innovations Meeting of the Crohn's & Colitis Foundation: Charting the Future of Pediatric IBD. Inflamm Bowel Dis 2018; 25:27-32. [PMID: 29931102 PMCID: PMC8133504 DOI: 10.1093/ibd/izy205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Indexed: 12/30/2022]
Abstract
The Crohn's & Colitis Foundation has facilitated transformational research in pediatric inflammatory bowel disease (IBD), through the RISK and PROTECT studies, that has laid the groundwork for a comprehensive understanding of molecular mechanisms of disease and predictors of therapeutic response in children. Despite these advances, children have lacked timely and informed access to the latest therapeutic advancements in IBD. The Crohn's & Colitis Foundation convened a Pediatric Resource Organization for Kids with Inflammatory Intestinal Diseases (PRO-KIIDS) Clinical Innovations Meeting at the inaugural Crohn's and Colitis Congress in January 2018 to devise how to advance the care of children with IBD. The working group selected 2 priorities: (1) accelerating therapies to children with IBD and (2) stimulating investigator-initiated research while fostering sustainable collaboration; and proposed 2 actions: (a) the convening of a task force to specifically address how to accelerate pharmacotherapies to children with IBD and (b) the funding of a multicenter clinical and translational research study that incorporates the building of critical research infrastructure.10.1093/ibd/izy205_video1izy205.video15799266615001.
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Affiliation(s)
- Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Medical Center, New York, New York
| | - Dale Lee
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Jeffrey S Hyams
- Division of Gastroenterology, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Laurie S Conklin
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s National Medical Center, Washington, DC,ReveraGen Biopharma, LLC, Rockville, Maryland
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - David Ziring
- Pediatric Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, Georgia
| | - Joel R Rosh
- Pediatric Gastroenterology, Clinical Development and Research Affairs, Goryeb Children’s Hospital/Atlantic Health, Morristown, New Jersey
| | | | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Andrew B Grossman
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts,Address correspondence to: Athos Bousvaros, MD, MPH, Inflammatory Bowel Disease Center, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 ()
| | - K T Park
- Division of Gastroenterology, Hepatology and Nutrition, Stanford University School of Medicine, Palo Alto, California
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18
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Vaughns JD, Conklin LS, Long Y, Zheng P, Faruque F, Green DJ, van den Anker JN, Burckart GJ. Obesity and Pediatric Drug Development. J Clin Pharmacol 2018; 58:650-661. [PMID: 29350758 DOI: 10.1002/jcph.1054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/07/2017] [Indexed: 12/19/2022]
Abstract
There is a lack of dosing guidelines for use in obese children. Moreover, the impact of obesity on drug safety and clinical outcomes is poorly defined. The paucity of information needed for the safe and effective use of drugs in obese patients remains a problem, even after drug approval. To assess the current incorporation of obesity as a covariate in pediatric drug development, the pediatric medical and clinical pharmacology reviews under the Food and Drug Administration (FDA) Amendments Act of 2007 and the FDA Safety and Innovation Act (FDASIA) of 2012 were reviewed for obesity studies. FDA labels were also reviewed for statements addressing obesity in pediatric patients. Forty-five drugs studied in pediatric patients under the FDA Amendments Act were found to have statements and key words in the medical and clinical pharmacology reviews and labels related to obesity. Forty-four products were identified similarly with pediatric studies under FDASIA. Of the 89 product labels identified, none provided dosing information related to obesity. The effect of body mass index on drug pharmacokinetics was mentioned in only 4 labels. We conclude that there is little information presently available to provide guidance related to dosing in obese pediatric patients. Moving forward, regulators, clinicians, and the pharmaceutical industry should consider situations in drug development in which the inclusion of obese patients in pediatric trials is necessary to facilitate the safe and effective use of new drug products in the obese pediatric population.
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Affiliation(s)
- Janelle D Vaughns
- Department of Anesthesiology, Pain, and Perioperative Medicine, Children's National Health System, Washington, DC, USA.,Department of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Laurie S Conklin
- Department of Gastroenterology, Children's National Health System, Washington, DC, USA
| | - Ying Long
- School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Panli Zheng
- School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Fahim Faruque
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Dionna J Green
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - John N van den Anker
- Department of Clinical Pharmacology, Children's National Health System, Washington, DC, USA.,Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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19
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Shouval DS, Konnikova L, Griffith AE, Wall SM, Biswas A, Werner L, Nunberg M, Kammermeier J, Goettel JA, Anand R, Chen H, Weiss B, Li J, Loizides A, Yerushalmi B, Yanagi T, Beier R, Conklin LS, Ebens CL, Santos FGMS, Sherlock M, Goldsmith JD, Kotlarz D, Glover SC, Shah N, Bousvaros A, Uhlig HH, Muise AM, Klein C, Snapper SB. Enhanced TH17 Responses in Patients with IL10 Receptor Deficiency and Infantile-onset IBD. Inflamm Bowel Dis 2017; 23:1950-1961. [PMID: 29023267 DOI: 10.1097/mib.0000000000001270] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 01/22/2023]
Abstract
BACKGROUND IL10 receptor (IL10R) deficiency causes severe infantile-onset inflammatory bowel disease. Intact IL10R-dependent signals have been shown to be important for innate and adaptive immune cell functions in mice. We have previously reported a key role of IL10 in the generation and function of human anti-inflammatory macrophages. Independent of innate immune cell defects, the aim of the current study was to determine the role of IL10R signaling in regulating human CD4 T-cell function. METHODS Peripheral blood mononuclear cells and intestinal biopsies cells were collected from IL10/IL10R-deficient patients and controls. Frequencies of CD4 T-cell subsets, naive T-cell proliferation, regulatory T cell (Treg)-mediated suppression, and Treg and TH17 generation were determined by flow cytometry. Transcriptional profiling was performed by NanoString and quantitative real-time polymerase chain reaction. RNA in situ hybridization was used to determine the quantities of various transcripts in intestinal mucosa. RESULTS Analysis of 16 IL10- and IL10R-deficient patients demonstrated similar frequencies of peripheral blood and intestinal Tregs, compared with control subjects. In addition, in vitro Treg suppression of CD4 T-cell proliferation and generation of Treg were not dependent on IL10R signaling. However, IL10R-deficient T naive cells exhibited higher proliferative capacity, a strong TH17 signature, and an increase in polarization toward TH17 cells, compared with controls. Moreover, the frequency of TH17 cells was increased in the colon and ileum of IL10R-deficient patients. Finally, we show that stimulation of IL10R-deficient Tregs in the presence of IL1β leads to enhanced production of IL17A. CONCLUSIONS IL10R signaling regulates TH17 polarization and T-cell proliferation in humans but is not required for the generation and in vitro suppression of Tregs. Therapies targeting the TH17 axis might be beneficial for IL10- and IL10R-deficient patients as a bridge to allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Dror S Shouval
- 1Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; 4VEO-IBD Consortium; 5Department of Pediatrics and Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts; 6Harvard Medical School, Boston, Massachusetts; 7Great Ormond Street Hospital London, London, England; 8Translational Gastroenterology Unit, University of Oxford, Oxford, England; 9Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, Florida; 10Division of Gastroenterology and Nutrition, The Children's Hospital at Montefiore, Bronx, New York; 11Pediatric Gastroenterology Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 12Department of Pediatrics, Kurume University School of Medicine, Kurume, Japan; 13Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany; 14Department of Gastroenterology, Children's National Medical Center, Washington, DC; 15Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, Michigan; 16Hospital das Clınicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; 17Division of Gastroenterology, McMaster Children's Hospital, West Hamilton, Ontario, Canada; 18Dr von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; 19Division of Pathology, Boston Children's Hospital, Boston, Massachusetts; 20Department of Pediatrics, University of Oxford, Oxford, England; 21Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; 22Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada; 23Department of Biochemistry, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; and 24Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
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20
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Heier CR, Fiorillo AA, Chaisson E, Gordish-Dressman H, Hathout Y, Damsker JM, Hoffman EP, Conklin LS. Identification of Pathway-Specific Serum Biomarkers of Response to Glucocorticoid and Infliximab Treatment in Children with Inflammatory Bowel Disease. Clin Transl Gastroenterol 2016; 7:e192. [PMID: 27628422 PMCID: PMC5288595 DOI: 10.1038/ctg.2016.49] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Serum biomarkers may serve to predict early response to therapy, identify relapse, and facilitate drug development in inflammatory bowel disease (IBD). Biomarkers are particularly important in children, in whom achieving early remission and minimizing procedures are especially beneficial. METHODS We profiled protein and micro RNA (miRNA) in serum from patients pre- and post-therapy, to identify molecular markers of pharmacodynamic effect. Serum was obtained from children with IBD before and after treatment with either corticosteroids (prednisone; n=12) or anti-tumor necrosis factor-α biologic (infliximab; n=7). Over 1,100 serum proteins were assayed using aptamer-based SOMAscan proteomics, and 22 miRNAs analyzed by quantitative real time PCR. Concordance of longitudinal changes between the groups was used to identify markers responsive to treatment. Bioinformatic analysis was used to build insight into mechanisms of changes in response to treatment. RESULTS We identified 18 proteins and three miRNAs responsive to both prednisone and infliximab. Eight markers that decreased are associated with inflammation and have gene promoters regulated by nuclear factor (NF)-κB. Several that increased are associated with resolving inflammation and tissue damage. We also identified six markers that appear to be steroid-specific, three of which have glucocorticoid receptor binding elements in their promoter region. CONCLUSIONS Serum markers regulated by the inflammatory transcription factor NF-κB are potential candidates for pharmacodynamic biomarkers that, if correlated with later outcomes like endoscopic or histologic healing, could be used to monitor treatment, optimize dosing, and enhance drug development. The pharmacodynamic biomarkers identified here hold potential to improve both clinical care and drug development. Further studies are warranted to investigate these markers as early predictors of response, or possibly surrogate outcomes.
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Affiliation(s)
- Christopher R Heier
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Alyson A Fiorillo
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Ellen Chaisson
- Division of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA
| | - Heather Gordish-Dressman
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA.,Department of Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Yetrib Hathout
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA.,Department of Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jesse M Damsker
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA.,ReveraGen BioPharma, Rockville, MD, USA
| | - Eric P Hoffman
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA.,Department of Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,ReveraGen BioPharma, Rockville, MD, USA
| | - Laurie S Conklin
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA
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21
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Hathout Y, Conklin LS, Seol H, Gordish-Dressman H, Brown KJ, Morgenroth LP, Nagaraju K, Heier CR, Damsker JM, van den Anker JN, Henricson E, Clemens PR, Mah JK, McDonald C, Hoffman EP. Serum pharmacodynamic biomarkers for chronic corticosteroid treatment of children. Sci Rep 2016; 6:31727. [PMID: 27530235 PMCID: PMC4987691 DOI: 10.1038/srep31727] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/25/2016] [Indexed: 12/13/2022] Open
Abstract
Corticosteroids are extensively used in pediatrics, yet the burden of side effects is significant. Availability of a simple, fast, and reliable biochemical read out of steroidal drug pharmacodynamics could enable a rapid and objective assessment of safety and efficacy of corticosteroids and aid development of corticosteroid replacement drugs. To identify potential corticosteroid responsive biomarkers we performed proteome profiling of serum samples from DMD and IBD patients with and without corticosteroid treatment using SOMAscan aptamer panel testing 1,129 proteins in <0.1 cc of sera. Ten pro-inflammatory proteins were elevated in untreated patients and suppressed by corticosteroids (MMP12, IL22RA2, CCL22, IGFBP2, FCER2, LY9, ITGa1/b1, LTa1/b2, ANGPT2 and FGG). These are candidate biomarkers for anti-inflammatory efficacy of corticosteroids. Known safety concerns were validated, including elevated non-fasting insulin (insulin resistance), and elevated angiotensinogen (salt retention). These were extended by new candidates for metabolism disturbances (leptin, afamin), stunting of growth (growth hormone binding protein), and connective tissue remodeling (MMP3). Significant suppression of multiple adrenal steroid hormones was also seen in treated children (reductions of 17-hydroxyprogesterone, corticosterone, 11-deoxycortisol and testosterone). A panel of new pharmacodynamic biomarkers for corticosteroids in children was defined. Future studies will need to bridge specific biomarkers to mechanism of drug action, and specific clinical outcomes.
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Affiliation(s)
- Yetrib Hathout
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Laurie S Conklin
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Haeri Seol
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Heather Gordish-Dressman
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Kristy J Brown
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Lauren P Morgenroth
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Kanneboyina Nagaraju
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Christopher R Heier
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Jesse M Damsker
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - John N van den Anker
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
| | - Erik Henricson
- Department of Physical Medicine &Rehabilitation, University of California, Davis School of Medicine, Davis, CA 95618, USA
| | - Paula R Clemens
- Neurology Service, Department of Veterans Affairs Medical Center, Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean K Mah
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, T3B 6A8 Canada
| | - Craig McDonald
- Department of Physical Medicine &Rehabilitation, University of California, Davis School of Medicine, Davis, CA 95618, USA
| | - Eric P Hoffman
- Research Center for Genetic Medicine, Children's National Health Systems, Washington, DC 20010, USA
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Damsker JM, Conklin LS, Sadri S, Dillingham BC, Panchapakesan K, Heier CR, McCall JM, Sandler AD. VBP15, a novel dissociative steroid compound, reduces NFκB-induced expression of inflammatory cytokines in vitro and symptoms of murine trinitrobenzene sulfonic acid-induced colitis. Inflamm Res 2016; 65:737-43. [PMID: 27261270 DOI: 10.1007/s00011-016-0956-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE AND DESIGN The goal of this study was to assess the capacity of VBP15, a dissociative steroidal compound, to reduce pro-inflammatory cytokine expression in vitro, to reduce symptoms of colitis in the trinitrobenzene sulfonic acid-induced murine model, and to assess the effect of VBP15 on growth stunting in juvenile mice. MATERIALS In vitro studies were performed in primary human intestinal epithelial cells. Colitis was induced in mice by administering trinitrobenzene sulfonic acid. Growth stunting studies were performed in wild type outbred mice. TREATMENT Cells were treated with VBP15 or prednisolone (10 μM) for 24 h. Mice were subjected to 3 days of VBP15 (30 mg/kg) or prednisolone (30 mg/kg) in the colitis study. In the growth stunting study, mice were subjected to VBP15 (10, 30, 45 mg/kg) or prednisolone (10 mg/kg) for 5 weeks. METHODS Cytokines were measured by PCR and via Luminex. Colitis symptoms were evaluated by assessing weight loss, intestinal blood, and stool consistency. Growth stunting was assessed using an electronic caliper. RESULTS VBP15 significantly reduced the in vitro production of CCL5 (p < 0.001) IL-6 (p < 0.001), IL-8 (p < 0.05) and reduced colitis symptoms (p < 0.05). VBP15 caused less growth stunting than prednisolone (p < 0.001) in juvenile mice. CONCLUSION VBP15 may reduce symptoms of IBD, while decreasing or avoiding detrimental side effects.
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Affiliation(s)
- Jesse M Damsker
- ReveraGen BioPharma Inc., 155 Gibbs St. Suite 433, Rockville, MD, 20850, USA.
| | - Laurie S Conklin
- The Joseph E. Robert Center for Surgical Care, Children's National Health System, Washington, DC, 20010, USA.,The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, 20010, USA
| | - Soheil Sadri
- The Joseph E. Robert Center for Surgical Care, Children's National Health System, Washington, DC, 20010, USA.,The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, 20010, USA
| | - Blythe C Dillingham
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, 20010, USA
| | - Karuna Panchapakesan
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, 20010, USA
| | - Christopher R Heier
- Research Center for Genetic Medicine, Children's National Health System, Washington, DC, 20010, USA
| | - John M McCall
- ReveraGen BioPharma Inc., 155 Gibbs St. Suite 433, Rockville, MD, 20850, USA.,PharMac LLC, Boca Grande, FL, 33921, USA
| | - Anthony D Sandler
- The Joseph E. Robert Center for Surgical Care, Children's National Health System, Washington, DC, 20010, USA.,The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, 20010, USA
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Shouval DS, Biswas A, Goettel JA, McCann K, Conaway E, Redhu NS, Mascanfroni ID, Al Adham Z, Lavoie S, Ibourk M, Nguyen DD, Samsom JN, Escher JC, Somech R, Weiss B, Beier R, Conklin LS, Ebens CL, Santos FGMS, Ferreira AR, Sherlock M, Bhan AK, Müller W, Mora JR, Quintana FJ, Klein C, Muise AM, Horwitz BH, Snapper SB. Interleukin-10 receptor signaling in innate immune cells regulates mucosal immune tolerance and anti-inflammatory macrophage function. Immunity 2014; 40:706-19. [PMID: 24792912 DOI: 10.1016/j.immuni.2014.03.011] [Citation(s) in RCA: 385] [Impact Index Per Article: 38.5] [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] [Received: 09/30/2013] [Accepted: 03/18/2014] [Indexed: 12/13/2022]
Abstract
Intact interleukin-10 receptor (IL-10R) signaling on effector and T regulatory (Treg) cells are each independently required to maintain immune tolerance. Here we show that IL-10 sensing by innate immune cells, independent of its effects on T cells, was critical for regulating mucosal homeostasis. Following wild-type (WT) CD4(+) T cell transfer, Rag2(-/-)Il10rb(-/-) mice developed severe colitis in association with profound defects in generation and function of Treg cells. Moreover, loss of IL-10R signaling impaired the generation and function of anti-inflammatory intestinal and bone-marrow-derived macrophages and their ability to secrete IL-10. Importantly, transfer of WT but not Il10rb(-/-) anti-inflammatory macrophages ameliorated colitis induction by WT CD4(+) T cells in Rag2(-/-)Il10rb(-/-) mice. Similar alterations in the generation and function of anti-inflammatory macrophages were observed in IL-10R-deficient patients with very early onset inflammatory bowel disease. Collectively, our studies define innate immune IL-10R signaling as a key factor regulating mucosal immune homeostasis in mice and humans.
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MESH Headings
- Adoptive Transfer
- Animals
- Cell Differentiation/immunology
- Cell Proliferation
- Cells, Cultured
- Colitis, Ulcerative/genetics
- Colitis, Ulcerative/immunology
- DNA-Binding Proteins/deficiency
- DNA-Binding Proteins/genetics
- Humans
- Immune Tolerance/genetics
- Immune Tolerance/immunology
- Immunity, Innate/genetics
- Immunity, Innate/immunology
- Inflammation/immunology
- Interleukin-10/immunology
- Macrophages/immunology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Receptors, Interleukin-10/deficiency
- Receptors, Interleukin-10/genetics
- Receptors, Interleukin-10/immunology
- Signal Transduction/immunology
- T-Lymphocytes, Regulatory/immunology
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Affiliation(s)
- Dror S Shouval
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Amlan Biswas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Jeremy A Goettel
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Katelyn McCann
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Evan Conaway
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Naresh S Redhu
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Ivan D Mascanfroni
- Center of Neurological Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Ziad Al Adham
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Sydney Lavoie
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA
| | - Mouna Ibourk
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA
| | - Deanna D Nguyen
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Janneke N Samsom
- Laboratory of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, 3000 CA Rotterdam, the Netherlands; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Johanna C Escher
- Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, 3000 CA Rotterdam, the Netherlands; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Raz Somech
- Pediatric Immunology Service, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer 52661, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer 52661, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Rita Beier
- Department of Pediatric Hematology and Oncology, Hannover Medical School, 30625 Hannover, Germany; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Laurie S Conklin
- Department of Gastroenterology, Children's National Medical Center, Washington, D.C. 20010, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Christen L Ebens
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, MI 48109, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Fernanda G M S Santos
- Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais 30130-100, Brazil; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Alexandre R Ferreira
- Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais 30130-100, Brazil; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Mary Sherlock
- Division of Gastroenterology, McMaster Children's Hospital, West Hamilton, Ontario L8N 3Z5, Canada; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Atul K Bhan
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Harvard Medical School, Boston, MA 02115, USA
| | - Werner Müller
- Faculty of Life Sciences, University of Manchester, Manchester M13 9PL, UK
| | - J Rodrigo Mora
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Francisco J Quintana
- Center of Neurological Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Christoph Klein
- Dr von Hauner Children's Hospital, Ludwig-Maximilians-University, 80337 Munich, Germany; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Aleixo M Muise
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Bruce H Horwitz
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS)
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA; Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA 02115, USA; interNational Early Onset Paediatric IBD Cohort Study (NEOPICS).
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Dumont MF, Hoffman HA, Yoon PRS, Conklin LS, Saha SR, Paglione J, Sze RW, Fernandes R. Biofunctionalized gadolinium-containing prussian blue nanoparticles as multimodal molecular imaging agents. Bioconjug Chem 2013; 25:129-37. [PMID: 24328306 DOI: 10.1021/bc4004266] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Molecular imaging agents enable the visualization of phenomena with cellular and subcellular level resolutions and therefore have enormous potential in improving disease diagnosis and therapy assessment. In this article, we describe the synthesis, characterization, and demonstration of core-shell, biofunctionalized, gadolinium-containing Prussian blue nanoparticles as multimodal molecular imaging agents. Our multimodal nanoparticles combine the advantages of MRI and fluorescence. The core of our nanoparticles consists of a Prussian blue lattice with gadolinium ions located within the lattice interstices that confer high relaxivity to the nanoparticles providing MRI contrast. The relaxivities of our nanoparticles are nearly nine times those observed for the clinically used Magnevist. The nanoparticle MRI core is biofunctionalized with a layer of fluorescently labeled avidin that enables fluorescence imaging. Biotinylated antibodies are attached to the surface avidin and confer molecular specificity to the nanoparticles by targeting cell-specific biomarkers. We demonstrate our nanoparticles as multimodal molecular imaging agents in an in vitro model consisting of a mixture of eosinophilic cells and squamous epithelial cells. Our nanoparticles specifically detect eosinophilic cells and not squamous epithelial cells, via both fluorescence imaging and MRI in vitro. These results suggest the potential of our biofunctionalized Prussian blue nanoparticles as multimodal molecular imaging agents in vivo.
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Affiliation(s)
- Matthieu F Dumont
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center , 111 Michigan Avenue NW, Washington, DC 20010, United States
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Abstract
Nutrition is a critical part of the management of inflammatory bowel disease (IBD) in children and adults. Malnutrition and micronutrient deficiencies are common at the time of diagnosis and may persist throughout the course of the disease. There are a number of similarities with regards to the nutritional complications and the approach to nutritional management in IBD in both children and adults, but there are also important differences. Growth failure, pubertal delay and the need for corticosteroid-sparing regimens are of higher importance in pediatrics. In the pediatric population, exclusive enteral nutrition may be equivalent to corticosteroids in inducing remission in acute Crohn's disease, and may have benefits over corticosteroids in children. Adherence with exclusive enteral nutrition is better in children than in adults. Iron deficiency anemia is an important problem for adults and children with IBD. Intravenous iron administration may be superior to oral iron supplementation. Ensuring adequate bone health is another critical component of nutritional management in IBD, but guidelines for screening and therapeutic interventions for low bone mineral density are lacking in children.
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Conklin LS, Cohen B, Wilson L, Cuffari C, Oliva-Hemker M. Rash induced by anti-tumor necrosis factor agents in an adolescent with Crohn's disease. Nat Rev Gastroenterol Hepatol 2010; 7:174-7. [PMID: 20203680 DOI: 10.1038/nrgastro.2010.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [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: 02/08/2023]
Abstract
BACKGROUND A 17-year-old white male with Crohn's disease who was receiving maintenance infusions of the anti-tumor necrosis factor (TNF) agent, infliximab, presented with a new-onset psoriasiform skin rash. The rash was not responsive to topical or oral corticosteroids and worsened after infliximab infusions and after subsequent administration of a second anti-TNF drug, adalimumab. INVESTIGATIONS Full medical history and physical examination, including assessment of the morphology of rash and the temporal correlation with administration of anti-TNF agents. DIAGNOSIS Anti-TNF-agent induced psoriasiform skin rash. MANAGEMENT Discontinuation of anti-TNF therapy. The patient opted to have his gastrointestinal symptoms treated with oral mesalazine and metronidazole.
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Affiliation(s)
- Laurie S Conklin
- Division of Gastroenterology and Nutrition, Children's National Medical Center, 111 Michigan Avenue NW, West Wing 2.5, Suite 600, Washington DC 20010, USA
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Foerster BR, Conklin LS, Petrou M, Barker PB, Schwarz KB. Minimal hepatic encephalopathy in children: evaluation with proton MR spectroscopy. AJNR Am J Neuroradiol 2009; 30:1610-3. [PMID: 19509075 DOI: 10.3174/ajnr.a1652] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [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: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Minimal hepatic encephalopathy (MHE) in children is difficult to evaluate because of lack of standardized neuropsychological tests for all age ranges. The purpose of this retrospective study of children with clinically suspected MHE was to investigate relationships between brain MR spectroscopy metabolites and biochemical markers of encephalopathy as well as measures of liver disease severity. MATERIALS AND METHODS A total of 12 children (age range, 9-19 years; 8 female) with clinically suspected MHE were studied by short TE brain MR spectroscopy on a 1.5T magnet. We estimated gray matter (GM) and white matter (WM) metabolite concentrations using "LCModel" software. Regional metabolite concentrations were examined for correlation with various parameters, including plasma ammonia, the ratio of branched-chain to aromatic amino acids (BCAA/AAA), model for end stage liver disease/pediatric end stage liver disease (MELD/PELD) and Child-Pugh scores, bilirubin, albumin, and platelet counts. RESULTS Myo-inositol (mIns) levels correlated with BCAA/AAA ratios (r = 0.86; P = .002 for GM and r = 0.77; P = .01 for WM). WM choline (Cho) levels and GM mIns levels showed significant negative correlation with ammonia levels (r = -0.58; P = .04 and r = -0.65; P = .02, respectively). A positive significant correlation trend was present for GM glutamine/glutamate (Glx) and ammonia levels (r = 0.66; P = .05). There was no correlation of brain MR spectroscopy parameters and severity of liver disease. CONCLUSIONS Brain MR spectroscopy metabolites in children with suspected MHE show significant correlations with plasma ammonia levels and BCAA/AAA. As in adults, brain MR spectroscopy in children may be helpful in establishing a diagnosis of MHE.
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Affiliation(s)
- B R Foerster
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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29
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Foerster BR, Conklin LS, Petrou M, Barker PB, Schwarz KB. Minimal hepatic encephalopathy in children: evaluation with proton MR spectroscopy. AJNR Am J Neuroradiol 2009. [PMID: 19509075 DOI: 10.3174/ajnr.a165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Minimal hepatic encephalopathy (MHE) in children is difficult to evaluate because of lack of standardized neuropsychological tests for all age ranges. The purpose of this retrospective study of children with clinically suspected MHE was to investigate relationships between brain MR spectroscopy metabolites and biochemical markers of encephalopathy as well as measures of liver disease severity. MATERIALS AND METHODS A total of 12 children (age range, 9-19 years; 8 female) with clinically suspected MHE were studied by short TE brain MR spectroscopy on a 1.5T magnet. We estimated gray matter (GM) and white matter (WM) metabolite concentrations using "LCModel" software. Regional metabolite concentrations were examined for correlation with various parameters, including plasma ammonia, the ratio of branched-chain to aromatic amino acids (BCAA/AAA), model for end stage liver disease/pediatric end stage liver disease (MELD/PELD) and Child-Pugh scores, bilirubin, albumin, and platelet counts. RESULTS Myo-inositol (mIns) levels correlated with BCAA/AAA ratios (r = 0.86; P = .002 for GM and r = 0.77; P = .01 for WM). WM choline (Cho) levels and GM mIns levels showed significant negative correlation with ammonia levels (r = -0.58; P = .04 and r = -0.65; P = .02, respectively). A positive significant correlation trend was present for GM glutamine/glutamate (Glx) and ammonia levels (r = 0.66; P = .05). There was no correlation of brain MR spectroscopy parameters and severity of liver disease. CONCLUSIONS Brain MR spectroscopy metabolites in children with suspected MHE show significant correlations with plasma ammonia levels and BCAA/AAA. As in adults, brain MR spectroscopy in children may be helpful in establishing a diagnosis of MHE.
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Affiliation(s)
- B R Foerster
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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Alex P, Zachos NC, Nguyen T, Gonzales L, Chen TE, Conklin LS, Centola M, Li X. Distinct cytokine patterns identified from multiplex profiles of murine DSS and TNBS-induced colitis. Inflamm Bowel Dis 2009; 15:341-52. [PMID: 18942757 PMCID: PMC2643312 DOI: 10.1002/ibd.20753] [Citation(s) in RCA: 567] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The cytokine network in inflammatory bowel disease (IBD) is a complex, dynamic system that plays an important role in regulating mucosal innate and adaptive immune responses. While several studies have been done to evaluate immunomodulatory profiles in murine IBD, they have been limited to a relatively small number of cytokines that do not take into account its dependency of the interplay of multiple factors, and therefore the diagnostic potential of their cytokine profiles have been inconclusive. METHODS A novel approach of comprehensive serum multiplex cytokine profiling with biometric immunosandwich ELISA's was used to describe the modulation of 16 Th1, Th2, Th17 cytokines and chemokines in both acute and chronic murine models of DSS and TNBS-induced colitis. Advanced multivariate discriminant functional analyses (DFA) was used to identify statistically interrelated sets of variables with the most significant power to discriminate among the groups. Profiles of multiple cytokines seen systemically were also validated locally in colonic mucosa using Western blot analysis and fluorescent immunohistochemistry. RESULTS Distinctive disease-specific cytokine profiles were identified with significant correlations to disease activity and duration of disease. TNBS colitis exhibits heightened Th1-Th17 response (increased IL-12 and IL-17) as the disease becomes chronic. In contrast, DSS colitis switches from a Th1-Th17-mediated acute inflammation (increased TNF-alpha, IL6, IL-17, and KC) to a predominant Th2-mediated inflammatory response (increase in IL-4 and IL-10 and concomitant decrease in TNF-alpha, IL6, IL-17, and KC) in the chronic state. Moreover, DFA identified discriminatory cytokine profiles that can be sufficiently used to distinguish unaffected controls from diseases, and one disease type from another. IL-6 and IL-12 stratified gender-associated disease activity in chronic colitis. CONCLUSIONS Our studies provide insight into disease immunopathogenesis and illustrate the significant potential of utilizing multiplex cytokine profiles and bioinformatics as diagnostic tools in IBD.
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Affiliation(s)
- Philip Alex
- Div of Gastroenterology, Dept of Medicine, Johns Hopkins University, Baltimore, MD, Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Nicholas C. Zachos
- Div of Gastroenterology, Dept of Medicine, Johns Hopkins University, Baltimore, MD
| | - Thuan Nguyen
- Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Liberty Gonzales
- Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Tian E. Chen
- Div of Gastroenterology, Dept of Medicine, Johns Hopkins University, Baltimore, MD
| | - Laurie S. Conklin
- Div of Gastroenterology, Dept of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michael Centola
- Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Xuhang Li
- Div of Gastroenterology, Dept of Medicine, Johns Hopkins University, Baltimore, MD,Address correspondence to: Xuhang Li, Ph.D. Gastroenterology, Dept of Medicine, Johns Hopkins University, 1120 Ross, 720 Rutland Avenue, Baltimore, MD 21205, Tel: 443-287-4804, Fax: 410-955-9677
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Abstract
BACKGROUND & AIMS Gastroenterologists commonly perceive themselves to be at increased legal risk because they perform invasive procedures. However, there is little published information about gastroenterology (GI) malpractice claims. The goal of this study was to evaluate available malpractice claim data within GI. METHODS This study was a database analysis of GI claims submitted by insurance companies to the Physician Insurers Association of America Data Sharing Project from January 1, 1985, to December 31, 2005. Another analysis from 2005 compared GI claims with other subspecialties. RESULTS Sixty-six percent of physicians involved in claims had previous claims experience. The most common reasons for claims were errors in diagnosis (28%) and improper performance of a procedure (25%). Seventy-two percent of reported closed claims were settled out of court. Of 12,367 total claims in 2005, only 233 (1.8%) were within GI. GI ranked below other procedurally based subspecialties in numbers of claims per physician. CONCLUSIONS GI does not rank highly among subspecialties in malpractice claims and only a minority of claims are procedure-related. Physicians with claims experience are likely to have further claims against them and should consider evaluating their practices.
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Affiliation(s)
- Laurie S Conklin
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Chi SN, Conklin LS, Qin J, Meyers PA, Huvos AG, Healey JH, Gorlick R. The patterns of relapse in osteosarcoma: the Memorial Sloan-Kettering experience. Pediatr Blood Cancer 2004; 42:46-51. [PMID: 14752794 DOI: 10.1002/pbc.10420] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [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: 11/12/2022]
Abstract
BACKGROUND With the introduction of intensive high-dose chemotherapy for the treatment of osteosarcoma, changes in the pattern of metastases observed at relapse have been reported. To further investigate this hypothesis, the relapse patterns among groups receiving chemotherapy regimens of variable intensity at Memorial Sloan-Kettering Cancer Center were analyzed. PROCEDURE All patients treated with the protocols T4, T5, T7, T10, and T12 were included. Patients were divided into two groups, one including those patients treated with less intense therapy (T4, T5, and T7) and the other, those treated with current regimens (T10 and T12). RESULTS Of the 25 patients who relapsed on the earlier protocols, 76% relapsed to the lungs, 8% had local recurrences, and 16% distant metastases to the bone. The median time to first relapse was 12 months. Of the 69 patients who relapsed on the T10 and T12 protocols, 75% relapsed in the lungs, 9% had local recurrences, and 16% distant bone metastases. The median time to first relapse was 17 months. There was no statistically significant difference in the timing of relapse between the two groups studied, although a longer median time to relapse was observed for patients treated on the later protocols. The range of time to relapse was also wider in the later protocols. CONCLUSIONS These data do not support the hypothesis that patterns of relapse are changing with alterations in osteosarcoma treatment. This limited single institutional experience can be explored further in the context of a multi-institutional effort.
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Affiliation(s)
- Susan N Chi
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Abstract
Vasopressin (AVP) receptor binding within hypothalamic sites was compared between cycling and lactating female golden hamsters. The density of AVP receptor binding was analyzed by quantitative autoradiography within the ventrolateral hypothalamus and dorsomedial hypothalamic nucleus. Lactation was correlated with a disappearance of AVP receptor binding within the ventrolateral hypothalamus. In contrast, lactation was associated with a two- to three-fold increase in the density of AVP receptor binding within the dorsomedial hypothalamic nucleus. These results suggest that AVP receptor binding within the ventrolateral hypothalamus is responsive to gonadal hormones in female golden hamsters. However, the increase in binding observed within the dorsomedial hypothalamus may be related to other neurobiological changes associated with lactation.
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Affiliation(s)
- Y Delville
- Psychiatry Department, University of Massachusetts Medical Center, Worcester 01655, USA
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