1
|
Erstad BL, Davis LE. Fixed Versus Body-Sized-Based Dosing of Monoclonal Antibodies. Ann Pharmacother 2024; 58:91-95. [PMID: 37129243 DOI: 10.1177/10600280231170650] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Monoclonal antibody products are an increasing portion of novel drug approvals. The labeling of initial drug approvals frequently involves body-size-based rather than fixed-dose administration regimens for adults without clear rationale for doing so. This presents challenges when prescribing these products for patients with extremes of body habitus who constitute a small portion of enrollment in pre-approval investigations. Fixed-dose regimens allow for standardized preparation with the potential to reduce the risk of calculation errors, drug waste, and make home administration more practical. Fixed-dose rather than body-size-based monoclonal antibody regimens should serve as the initial approach in early phase 1 clinical trials.
Collapse
Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice & Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Lisa E Davis
- Department of Pharmacy Practice & Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| |
Collapse
|
2
|
Finnes HD, Kennedy L, Buie LW, Lawson AP, Seung AH, Davis LE, Mackler E, Iannucci A, Hough S. Hematology‐oncology pharmacists: We hear you, we see you, we support you. J Am Coll Clin Pharm 2022. [DOI: 10.1002/jac5.1707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Heidi D. Finnes
- Mayo Clinic Comprehensive Cancer Center Rochester Minnesota USA
| | - LeAnne Kennedy
- Atrium Health Wake Forest Baptist Winston‐Salem North Carolina USA
| | - Larry W. Buie
- Health Systems Liaison, Bristol Myers Squibb Plainfield New Jersey USA
| | | | - Amy H. Seung
- Scientific Affairs, Pharmacy Times, Continuing Education Cranbury New Jersey USA
| | - Lisa E. Davis
- R. Ken Coit College of Pharmacy The University of Arizona Tucson Arizona USA
| | - Emily Mackler
- Michigan Oncology Quality Consortium and Michigan Institute of Care Management and Transformation University of Michigan Ann Arbor Michigan USA
| | - Andrea Iannucci
- UC Davis Health, UC Davis School of Medicine, UCSF School of Pharmacy Sacramento California USA
| | - Shannon Hough
- The US Oncology Network, McKesson Specialty Health The Woodlands Texas USA
| |
Collapse
|
3
|
Garland LL, Guillen-Rodriguez J, Hsu CH, Davis LE, Szabo E, Husted CR, Liu H, LeClerc A, Alekseyev YO, Liu G, Bauman JE, Spira AE, Beane J, Wojtowicz M, Chow HHS. Clinical Study of Aspirin and Zileuton on Biomarkers of Tobacco-Related Carcinogenesis in Current Smokers. Cancers (Basel) 2022; 14:2893. [PMID: 35740559 PMCID: PMC9221101 DOI: 10.3390/cancers14122893] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 12/04/2022] Open
Abstract
The chemopreventive effect of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) on lung cancer risk is supported by epidemiologic and preclinical studies. Zileuton, a 5-lipoxygenase inhibitor, has additive activity with NSAIDs against tobacco carcinogenesis in preclinical models. We hypothesized that cyclooxygenase plus 5-lipoxygenase inhibition would be more effective than a placebo in modulating the nasal epithelium gene signatures of tobacco exposure and lung cancer. We conducted a randomized, double-blinded study of low-dose aspirin plus zileuton vs. double placebo in current smokers to compare the modulating effects on nasal gene expression and arachidonic acid metabolism. In total, 63 participants took aspirin 81 mg daily plus zileuton (Zyflo CR) 600 mg BID or the placebo for 12 weeks. Nasal brushes from the baseline, end-of-intervention, and one-week post intervention were profiled via microarray. Aspirin plus zilueton had minimal effects on the modulation of the nasal or bronchial gene expression signatures of smoking, lung cancer, and COPD but favorably modulated a bronchial gene expression signature of squamous dysplasia. Aspirin plus zileuton suppressed urinary leukotriene but not prostaglandin E2, suggesting shunting through the cyclooxygenase pathway when combined with 5-lipoxygenase inhibition. Continued investigation of leukotriene inhibitors is needed to confirm these findings, understand the long-term effects on the airway epithelium, and identify the safest, optimally dosed agents.
Collapse
Affiliation(s)
- Linda L. Garland
- Department of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA; (J.G.-R.); (C.-H.H.); (H.-H.S.C.)
| | - José Guillen-Rodriguez
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA; (J.G.-R.); (C.-H.H.); (H.-H.S.C.)
| | - Chiu-Hsieh Hsu
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA; (J.G.-R.); (C.-H.H.); (H.-H.S.C.)
| | - Lisa E. Davis
- College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA;
| | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesa, MD 20892, USA; (E.S.); (M.W.)
| | - Christopher R. Husted
- Section of Computational Biomedicine, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (C.R.H.); (H.L.); (G.L.); (A.E.S.); (J.B.)
| | - Hanqiao Liu
- Section of Computational Biomedicine, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (C.R.H.); (H.L.); (G.L.); (A.E.S.); (J.B.)
| | - Ashley LeClerc
- Department of Pathology and Laboratory Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (A.L.); (Y.O.A.)
| | - Yuriy O. Alekseyev
- Department of Pathology and Laboratory Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (A.L.); (Y.O.A.)
| | - Gang Liu
- Section of Computational Biomedicine, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (C.R.H.); (H.L.); (G.L.); (A.E.S.); (J.B.)
| | - Julie E. Bauman
- Department of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA; (J.G.-R.); (C.-H.H.); (H.-H.S.C.)
- Division of Hematology/Oncology, Department of Medicine, George Washington (GW) University and GW Cancer Center, Washington, DC 20037, USA
| | - Avrum E. Spira
- Section of Computational Biomedicine, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (C.R.H.); (H.L.); (G.L.); (A.E.S.); (J.B.)
| | - Jennifer Beane
- Section of Computational Biomedicine, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA; (C.R.H.); (H.L.); (G.L.); (A.E.S.); (J.B.)
| | - Malgorzata Wojtowicz
- Division of Cancer Prevention, National Cancer Institute, Bethesa, MD 20892, USA; (E.S.); (M.W.)
| | - H.-H. Sherry Chow
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ 85724, USA; (J.G.-R.); (C.-H.H.); (H.-H.S.C.)
| |
Collapse
|
4
|
Nix DE, Davis LE, Matthias KR. Response to Rybak et al. Am J Health Syst Pharm 2022; 79:1308-1311. [PMID: 35511826 DOI: 10.1093/ajhp/zxac126] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Collapse
Affiliation(s)
- David E Nix
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
| | - Lisa E Davis
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
| |
Collapse
|
5
|
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Prior to the 2020 release of a joint consensus guideline on monitoring of vancomycin therapy for serious methicillin-resistant Staphylococcus aureus (MRSA) infections, clinicians had escalated vancomycin doses for 2 decades while targeting trough concentrations of 15 to 20 µg/mL, leading to an increased frequency of nephrotoxicity. For MRSA infections, the 2020 guideline recommends adjusting doses to achieve a 24-hour area under the concentration-time curve (AUC) of 400 to 600 µg · h/mL; however, monitoring of trough concentrations has been entrenched for 3 decades. Calculating dose regimens based on AUC will require obtaining an increased number of vancomycin serum concentrations and, possibly, advanced software. The aim of this investigation was to determine the relationship between AUC and trough concentration and the influence of dosing regimen on goal achievement. METHODS The relationship between trough concentration and AUC was explored through derivation of an equation based on a 1-compartment model and simulations. RESULTS 24-hour AUC is related to dosing interval divided by half-life in a nonlinear fashion. The target trough concentration can be individualized to achieve a desired AUC range, and limiting use of large doses (>15-20 mg/kg) can protect against excessive 24-hour AUC with trough-only monitoring. CONCLUSION After initially determining pharmacokinetic parameters, subsequent monitoring of AUC can be accomplished using trough concentrations only. Trough concentration may be used as a surrogate for AUC, although the acceptable target trough concentration will vary depending on dosing interval and elimination rate constant. This work included development of an AUC-trough equation to establish a patient-specific target for steady-state trough concentration.
Collapse
Affiliation(s)
- David E Nix
- Department of Pharmacy Practice & Science and Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Lisa E Davis
- Department of Pharmacy Practice & Science, University of Arizona, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice & Science, University of Arizona, Tucson, AZ, USA
| |
Collapse
|
6
|
Anderson EJ, Mollon LE, Dean JL, Warholak TL, Aizer A, Platt EA, Tang DH, Davis LE. A Systematic Review of the Prevalence and Diagnostic Workup of PIK3CA Mutations in HR+/HER2- Metastatic Breast Cancer. Int J Breast Cancer 2020; 2020:3759179. [PMID: 32637176 PMCID: PMC7322582 DOI: 10.1155/2020/3759179] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/28/2020] [Indexed: 12/13/2022] Open
Abstract
PIK3CA mutation frequency varies among breast cancer (BC) subtypes. Recent evidence suggests combination therapy with the PI3K inhibitor (PI3Ki) alpelisib and endocrine therapy (ET) improves response rates and progression-free survival (PFS) in PIK3CA-mutant, hormone receptor positive (HR+) BC versus ET alone; thus, better understanding the clinical and epidemiologic elements of these mutations is warranted. This systematic review characterizes the PIK3CA mutation epidemiology, type of testing approaches (e.g., liquid or tissue tumor biopsy), and stability/concordance (e.g., consistency in results by liquid versus solid tumor sample, by the same method over time) in patients with HR+/HER2- advanced (locally unresectable) or metastatic disease (HR+/HER2- mBC) and explores performance (e.g., pairwise concordance, sensitivity, specificity, or predictive value) of respective mutation findings. A comprehensive search of PubMed/MEDLINE, EMBASE, Cochrane Central, and select conference abstracts (i.e., AACR, ASCO, SABCS, ECCO, and ESMO conferences between 2014 and 2017) identified 39 studies of patients with HR+, HER2- mBC. The median prevalence of PIK3CA mutation was 36% (range: 13.3% to 61.5%); identified testing approaches more commonly used tissue over liquid biopsies and primarily utilized next-generation sequencing (NGS), polymerase chain reaction (PCR), or Sanger sequencing. There was concordance and stability between tissues (range: 70.4% to 94%) based on limited data. Given the clinical benefit of the PI3Ki alpelisib in patients with PIK3CA mutant HR+/HER2- mBC, determination of tumor PIK3CA mutation status is of importance in managing patients with HR+/HER2- mBC. Prevalence of this mutation and utility of test methodologies likely warrants PIK3CA mutation testing in all patients with this breast cancer subtype via definitive assessment of PIK3CA mutational status.
Collapse
Affiliation(s)
| | - Lea E. Mollon
- University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Joni L. Dean
- University of Arizona College of Pharmacy, Tucson, AZ, USA
| | | | | | | | | | - Lisa E. Davis
- University of Arizona College of Pharmacy, Tucson, AZ, USA
| |
Collapse
|
7
|
Garland LL, Guillen-Rodriguez J, Hsu CH, Yozwiak M, Zhang HH, Alberts DS, Davis LE, Szabo E, Merenstein C, Lel J, Zhang X, Liu H, Liu G, Spira AE, Beane JE, Wojtowicz M, Chow HHS. Effect of Intermittent Versus Continuous Low-Dose Aspirin on Nasal Epithelium Gene Expression in Current Smokers: A Randomized, Double-Blinded Trial. Cancer Prev Res (Phila) 2019; 12:809-820. [PMID: 31451521 PMCID: PMC7485120 DOI: 10.1158/1940-6207.capr-19-0036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/23/2019] [Revised: 05/23/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022]
Abstract
A chemopreventive effect of aspirin (ASA) on lung cancer risk is supported by epidemiologic and preclinical studies. We conducted a randomized, double-blinded study in current heavy smokers to compare modulating effects of intermittent versus continuous low-dose ASA on nasal epithelium gene expression and arachidonic acid (ARA) metabolism. Fifty-four participants were randomized to intermittent (ASA 81 mg daily for one week/placebo for one week) or continuous (ASA 81 mg daily) for 12 weeks. Low-dose ASA suppressed urinary prostaglandin E2 metabolite (PGEM; change of -4.55 ± 11.52 from baseline 15.44 ± 13.79 ng/mg creatinine for arms combined, P = 0.02), a surrogate of COX-mediated ARA metabolism, but had minimal effects on nasal gene expression of nasal or bronchial gene-expression signatures associated with smoking, lung cancer, and chronic obstructive pulmonary disease. Suppression of urinary PGEM correlated with favorable changes in a smoking-associated gene signature (P < 0.01). Gene set enrichment analysis (GSEA) showed that ASA intervention led to 1,079 enriched gene sets from the Canonical Pathways within the Molecular Signatures Database. In conclusion, low-dose ASA had minimal effects on known carcinogenesis gene signatures in nasal epithelium of current smokers but results in wide-ranging genomic changes in the nasal epithelium, demonstrating utility of nasal brushings as a surrogate to measure gene-expression responses to chemoprevention. PGEM may serve as a marker for smoking-associated gene-expression changes and systemic inflammation. Future studies should focus on NSAIDs or agent combinations with broader inhibition of pro-inflammatory ARA metabolism to shift gene signatures in an anti-carcinogenic direction.
Collapse
Affiliation(s)
| | | | - Chiu-Hsieh Hsu
- University of Arizona Cancer Center, University of Arizona
| | | | | | | | - Lisa E Davis
- University of Arizona Cancer Center, University of Arizona
| | - Eva Szabo
- Division of Cancer Prevention, NCI/NIH, Boston, Massachusetts
| | | | - Julian Lel
- Boston University School of Medicine, Boston, Massachusetts
| | - Xiaohui Zhang
- Boston University School of Medicine, Boston, Massachusetts
| | - Hanqiao Liu
- Boston University School of Medicine, Boston, Massachusetts
| | - Gang Liu
- Boston University School of Medicine, Boston, Massachusetts
| | - Avrum E Spira
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | | |
Collapse
|
8
|
Tung S, Coburn NG, Davis LE, Mahar AL, Myrehaug S, Zhao H, Earle CC, Nathens A, Hallet J. Population-based study of the prevalence and management of self-reported high pain scores in patients with non-resected pancreatic adenocarcinoma. Br J Surg 2019; 106:1666-1675. [PMID: 31639208 DOI: 10.1002/bjs.11330] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/09/2019] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pain is a common debilitating symptom in pancreatic adenocarcinoma. This cohort study examined the use of, and factors associated with, pain-directed interventions for a high pain score in patients with non-curable pancreatic adenocarcinoma. METHODS Administrative databases were linked and patients with non-resected pancreatic adenocarcinoma diagnosed between 2010 and 2016, who reported one or more Edmonton Symptom Assessment System (ESAS) score, were identified. A high pain score was defined as an ESAS score of at least 4. Outcomes were pain-directed interventions: opiates (in patients aged 65 years or more with universal drug coverage), nerve block and radiation therapy for a high pain score. Reduction in pain score of at least 1 point after pain-directed intervention was also evaluated. Modified Poisson regression was used to examine factors associated with pain-directed intervention. RESULTS Among 2623 patients with a median age of 67 years, 1223 (46·6 per cent) were women, and 1621 (61·8 per cent) reported a high pain score at a median of 38 days after diagnosis. Of those with a high pain score, 75·6 per cent (688 of 910) received opiates, 13·5 per cent (219 of 1621) radiation and 1·2 per cent (19 of 1621) nerve block. The pain score decreased in 62·1 per cent of patients after administration of opiates, 73·4 per cent after radiation and all patients after nerve block. In multivariable analysis, no patient factor (age, sex, co-morbidity burden, rurality, income quintile) was associated with receipt of non-opiate pain-directed intervention for a high pain score. In patients aged at least 65 years, advanced age was associated with lower odds of opiate use. CONCLUSION Opiates are the most common pain-directed intervention for non-curable pancreatic adenocarcinoma, whereas radiation therapy and nerve blocks are seldom used. The lack of association between pain-directed interventions and patient factors points toward practice-driven patterns.
Collapse
Affiliation(s)
- S Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - L E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Myrehaug
- Divisions of Radiation Oncology, Odette Cancer Centre, Toronto, Canada
| | - H Zhao
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - C C Earle
- Divisions of Medical Oncology, Odette Cancer Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - J Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Mollon LE, Anderson EJ, Dean JL, Warholak TL, Aizer A, Platt EA, Tang DH, Davis LE. A Systematic Literature Review of the Prognostic and Predictive Value of PIK3CA Mutations in HR +/HER2 - Metastatic Breast Cancer. Clin Breast Cancer 2019; 20:e232-e243. [PMID: 32234362 DOI: 10.1016/j.clbc.2019.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 11/18/2022]
Abstract
PIK3CA mutations may have prognostic value for patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative metastatic breast cancer, representing an important potential target for systemic therapy. Prognostic and predictive values associated with PIK3CA mutations are not well understood. A comprehensive search of PubMed/MEDLINE, EMBASE, Cochrane Central, and conference abstracts was performed for English-language articles published January 1993 through April 2019. Articles were categorized by treatment arms based on experimental and treatment drug classes. Information on progression-free survival (PFS), hazard ratios, overall survival, response rate, and clinical benefit rate was obtained. A total of 17 studies were included. Among those evaluating non-PI3Ki based therapies, 91% showed numerically shorter median PFS, ranging from 1.5 to 19.2 months and 1.8 to 29.6 months for the mutant versus non-mutant subgroups, respectively. Where reported (n = 13 studies), PFS was shorter between those arms offering endocrine monotherapy (range, 1.6-14.7 months) compared with a corresponding targeted therapy + endocrine monotherapy (range, 3.9-29.6 months). Of 5 PI3Ki-based arms comparing PFS, higher median PFS in PIK3CA mutant versus non-mutant cases was demonstrated. PFS was shorter for patients with PIK3CA mutant (range, 1.6-19.2 months) compared with PIK3CA wild-type (range, 1.8-29.6 months) in 10 (71%) of 14 treatment arms reporting PFS. Studies (n = 4) not reporting PFS reported response rate, but there were no clear directional trends. The presence of PIK3CA mutations may be associated with worse clinical outcomes in patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative metastatic breast cancer. Clinical outcomes such as PFS may be improved using a combination of PI3Ki-based therapies and endocrine therapies among this population. However, more research is warranted to fully elucidate this association.
Collapse
MESH Headings
- Antineoplastic Agents, Hormonal/pharmacology
- Antineoplastic Agents, Hormonal/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Breast/pathology
- Breast/surgery
- Breast Neoplasms/genetics
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Chemotherapy, Adjuvant/methods
- Class I Phosphatidylinositol 3-Kinases/antagonists & inhibitors
- Class I Phosphatidylinositol 3-Kinases/genetics
- Drug Resistance, Neoplasm/genetics
- Female
- Humans
- Mastectomy
- Mutation
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/prevention & control
- Predictive Value of Tests
- Prognosis
- Progression-Free Survival
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Receptor, ErbB-2/analysis
- Receptors, Estrogen/analysis
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/analysis
- Receptors, Progesterone/metabolism
- Risk Assessment/methods
Collapse
Affiliation(s)
- Lea E Mollon
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ.
| | - Elizabeth J Anderson
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Joni L Dean
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Terri L Warholak
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Ayal Aizer
- Radiation Oncology, Harvard Medical School, Boston, MA
| | | | | | - Lisa E Davis
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| |
Collapse
|
10
|
Davis LE, Nicholls LA, Babiker HM, Liau J, Mahadevan D. PD-1 Inhibition Achieves a Complete Metabolic Response in a Patient with Malignant Peripheral Nerve Sheath Tumor. Cancer Immunol Res 2019; 7:1396-1400. [PMID: 31383651 DOI: 10.1158/2326-6066.cir-19-0072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/01/2019] [Accepted: 07/29/2019] [Indexed: 11/16/2022]
Abstract
High-grade malignant peripheral nerve sheath tumors (MPNST) have a poor prognosis with limited responsiveness to systemic therapy. We document a case of a complete metabolic response to pembrolizumab monotherapy in metastatic disease. Tumor molecular profiling identified programmed-death ligand-1 (PD-L1) positivity. This characteristic provided a rationale for immune-checkpoint therapy. Treatment with pembrolizumab resulted in a complete metabolic response after four cycles of therapy. Patients with PD-L1-positive, metastatic MPNST may be candidates for immune-checkpoint therapy, which may produce a durable complete remission. Future study of anti-PD-1/PD-L1 therapy is warranted.
Collapse
Affiliation(s)
- Lisa E Davis
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona.,The University of Arizona Cancer Center, Tucson, Arizona
| | | | - Hani M Babiker
- The University of Arizona Cancer Center, Tucson, Arizona.,Department of Medicine, College of Medicine, University of Arizona, Tucson, Arizona
| | - Joy Liau
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, Arizona
| | - Daruka Mahadevan
- The University of Arizona Cancer Center, Tucson, Arizona. .,Department of Medicine, College of Medicine, University of Arizona, Tucson, Arizona
| |
Collapse
|
11
|
Mahar AL, Davis LE, Bubis LD, Li Q, Sutradhar R, Coburn NG, Barbera L. Factors associated with receipt of symptom screening in the year after cancer diagnosis in a universal health care system: a retrospective cohort study. ACTA ACUST UNITED AC 2019; 26:e8-e16. [PMID: 30853804 DOI: 10.3747/co.26.4160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/08/2023]
Abstract
Purpose Patient-reported symptom data are collected prospectively by a provincial cancer agency to mitigate the significant symptom burden that patients with cancer experience. However, an assessment of whether such symptom screening occurs uniformly for those patients has yet to be performed. In the present study, we investigated patient, disease, and health system factors associated with receipt of symptom screening in the year after a cancer diagnosis. Methods Patients diagnosed with cancer between 2007 and 2014 were identified. We measured whether 1 or more symptom screenings were recorded in the year after diagnosis. A multivariable modified Poisson regression with robust error variance was used to identify predictors [age, comorbidity, rurality, socioeconomic status, immigration status, cancer site, registration at a regional cancer centre (cc), and year of diagnosis] of being screened for symptoms. Results Of 425,905 patients diagnosed with cancer, 163,610 (38%) had 1 or more symptom screening records in the year after diagnosis, and 75% survived at least 1 year. We identified variability in symptom screening by primary cancer site, regional cc, age, sex, comorbidity, material deprivation, rurality of residence, and immigration status. Patients who had been diagnosed with melanoma or endocrine cancers, who were not registered at a regional cc, who lived in the most urban areas, who were elderly, and who were immigrants were least likely to undergo symptom screening after diagnosis. Conclusions Our evaluation of the implementation of a population-based symptom screening program in a universal health care system identified populations who are at risk for not receiving screening and who are therefore future targets for improvements in population symptom screening and better management of cancer-related symptoms at diagnosis.
Collapse
Affiliation(s)
- A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
| | - L E Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON
| | - L D Bubis
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | | | - R Sutradhar
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,ICES, Toronto, ON
| | - N G Coburn
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,ICES, Toronto, ON.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON
| | - L Barbera
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,ICES, Toronto, ON.,Department of Radiation Oncology, University of Toronto, Toronto, ON
| |
Collapse
|
12
|
Haas NB, Appleman LJ, Stein M, Redlinger M, Wilks M, Xu X, Onorati A, Kalavacharla A, Kim T, Zhen CJ, Kadri S, Segal JP, Gimotty PA, Davis LE, Amaravadi RK. Autophagy Inhibition to Augment mTOR Inhibition: a Phase I/II Trial of Everolimus and Hydroxychloroquine in Patients with Previously Treated Renal Cell Carcinoma. Clin Cancer Res 2019; 25:2080-2087. [PMID: 30635337 DOI: 10.1158/1078-0432.ccr-18-2204] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/12/2018] [Accepted: 01/08/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Everolimus inhibits the mTOR, activating cytoprotective autophagy. Hydroxychloroquine inhibits autophagy. On the basis of preclinical data demonstrating synergistic cytotoxicity when mTOR inhibitors are combined with an autophagy inhibitor, we launched a clinical trial of combined everolimus and hydroxychloroquine, to determine its safety and activity in patients with clear-cell renal cell carcinoma (ccRCC). PATIENTS AND METHODS Three centers conducted a phase I/II trial of everolimus 10 mg daily and hydroxychloroquine in patients with advanced ccRCC. The objectives were to determine the MTD of hydroxychloroquine with daily everolimus, and to estimate the rate of 6-month progression-free survival (PFS) in patients with ccRCC receiving everolimus/hydroxychloroquine after 1-3 prior treatment regimens. Correlative studies to identify patient subpopulations that achieved the most benefit included population pharmacokinetics, measurement of autophagosomes by electron microscopy, and next-generation tumor sequencing. RESULTS No dose-limiting toxicity was observed in the phase I trial. The recommended phase II dose of hydroxychloroquine 600 mg twice daily with everolimus was identified. Disease control [stable disease + partial response (PR)] occurred in 22 of 33 (67%) evaluable patients. PR was observed in 2 of 33 patients (6%). PFS ≥ 6 months was achieved in 15 of 33 (45%) of patients who achieved disease control. CONCLUSIONS Combined hydroxychloroquine 600 mg twice daily with 10 mg daily everolimus was tolerable. The primary endpoint of >40% 6-month PFS rate was met. Hydroxychloroquine is a tolerable autophagy inhibitor in future RCC or other trials.
Collapse
Affiliation(s)
- Naomi B Haas
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Leonard J Appleman
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Stein
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Maryann Redlinger
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Melissa Wilks
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Xiaowei Xu
- Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angelique Onorati
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anusha Kalavacharla
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Taehyong Kim
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chao Jie Zhen
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Sabah Kadri
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Jeremy P Segal
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Phyllis A Gimotty
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa E Davis
- Department of Pharmacy Practice & Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Ravi K Amaravadi
- Abramson Cancer Center and the Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Anderson EJ, Mollon L, Dean JL, Aguilar A, Davis LE, Warholak TL, Aizer AA, Platt E, Bardia A, Tang D. A systematic literature review of the clinical prognosis of HR+/HER2- advanced or metastatic breast cancer with and without PIK3CA mutation. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e13037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Lea Mollon
- University of Arizona College of Pharmacy, Tucson, AZ
| | - Joni L Dean
- University of Arizona College of Pharmacy, Tucson, AZ
| | | | | | | | | | - Emma Platt
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Derek Tang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| |
Collapse
|
14
|
Davis LE. The evolution of biomarkers to guide the treatment of metastatic colorectal cancer. Am J Manag Care 2018; 24:S107-S117. [PMID: 30207665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the United States, colon cancer is one of the leading causes of death and cancer-related death. There is a critical need to improve clinical outcomes in patients with metastatic colorectal cancer (mCRC), as current survival rates are unsatisfactory. There have been significant advances in the treatment of mCRC over the past decade. Molecular characteristics of mCRC and identification of mutations can serve predictive and prognostic indicators of disease response to treatment. These biomarkers can be incorporated into clinical decision making when developing an individualized treatment plan. Targeted therapies have improved the survival of patients with mCRC. As we learn about the various molecular alterations in this disease, additional emerging therapies can be developed to improve clinical outcomes in patients with mCRC.
Collapse
Affiliation(s)
- Lisa E Davis
- Professor, Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ.
| |
Collapse
|
15
|
Rangwala R, Leone R, Chang YC, Fecher LA, Schuchter LM, Kramer A, Tan KS, Heitjan DF, Rodgers G, Gallagher M, Piao S, Troxel AB, Evans TL, DeMichele AM, Nathanson KL, O'Dwyer PJ, Kaiser J, Pontiggia L, Davis LE, Amaravadi RK. Phase I trial of hydroxychloroquine with dose-intense temozolomide in patients with advanced solid tumors and melanoma. Autophagy 2014; 10:1369-79. [PMID: 24991839 PMCID: PMC4203514 DOI: 10.4161/auto.29118] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Blocking autophagy with hydroxychloroquine (HCQ) augments cell death associated with alkylating chemotherapy in preclinical models. This phase I study evaluated the maximum tolerated dose (MTD), safety, preliminary activity, pharmacokinetics, and pharmacodynamics of HCQ in combination with dose-intense temozolomide (TMZ) in patients with advanced solid malignancies. Forty patients (73% metastatic melanoma) were treated with oral HCQ 200 to 1200 mg daily with dose-intense oral TMZ 150 mg/m2 daily for 7/14 d. This combination was well tolerated with no recurrent dose-limiting toxicities observed. An MTD was not reached for HCQ and the recommended phase II dose was HCQ 600 mg twice daily combined with dose-intense TMZ. Common toxicities included grade 2 fatigue (55%), anorexia (28%), nausea (48%), constipation (20%), and diarrhea (20%). Partial responses and stable disease were observed in 3/22 (14%) and 6/22 (27%) patients with metastatic melanoma. In the final dose cohort 2/6 patients with refractory BRAF wild-type melanoma had a near complete response, and prolonged stable disease, respectively. A significant accumulation in autophagic vacuoles (AV) in peripheral blood mononuclear cells was observed in response to combined therapy. Population pharmacokinetics (PK) modeling, individual PK simulations, and PK-pharmacodynamics (PD) analysis identified a threshold HCQ peak concentration that predicts therapy-associated AV accumulation. This study indicates that the combination of high-dose HCQ and dose-intense TMZ is safe and tolerable, and is associated with autophagy modulation in patients. Prolonged stable disease and responses suggest antitumor activity in melanoma patients, warranting further studies of this combination, or combinations of more potent autophagy inhibitors and chemotherapy in melanoma.
Collapse
Affiliation(s)
- Reshma Rangwala
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Robert Leone
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Yunyoung C Chang
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Leslie A Fecher
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Lynn M Schuchter
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Amy Kramer
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Kay-See Tan
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Daniel F Heitjan
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Glenda Rodgers
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Maryann Gallagher
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Shengfu Piao
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Andrea B Troxel
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Tracey L Evans
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Angela M DeMichele
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Katherine L Nathanson
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Peter J O'Dwyer
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Jonathon Kaiser
- Philadelphia College of Pharmacy; University of the Sciences; Philadelphia, PA USA
| | - Laura Pontiggia
- Department of Mathematics, Physics and Statistics; University of the Sciences; Philadelphia, PA USA
| | - Lisa E Davis
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA; Philadelphia College of Pharmacy; University of the Sciences; Philadelphia, PA USA
| | - Ravi K Amaravadi
- Department of Medicine and Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| |
Collapse
|
16
|
Vogl DT, Stadtmauer EA, Tan KS, Heitjan DF, Davis LE, Pontiggia L, Rangwala R, Piao S, Chang YC, Scott EC, Paul TM, Nichols CW, Porter DL, Kaplan J, Mallon G, Bradner JE, Amaravadi RK. Combined autophagy and proteasome inhibition: a phase 1 trial of hydroxychloroquine and bortezomib in patients with relapsed/refractory myeloma. Autophagy 2014; 10:1380-90. [PMID: 24991834 DOI: 10.4161/auto.29264] [Citation(s) in RCA: 285] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The efficacy of proteasome inhibition for myeloma is limited by therapeutic resistance, which may be mediated by activation of the autophagy pathway as an alternative mechanism of protein degradation. Preclinical studies demonstrate that autophagy inhibition with hydroxychloroquine augments the antimyeloma efficacy of the proteasome inhibitor bortezomib. We conducted a phase I trial combining bortezomib and hydroxychloroquine for relapsed or refractory myeloma. We enrolled 25 patients, including 11 (44%) refractory to prior bortezomib. No protocol-defined dose-limiting toxicities occurred, and we identified a recommended phase 2 dose of hydroxychloroquine 600 mg twice daily with standard doses of bortezomib, at which we observed dose-related gastrointestinal toxicity and cytopenias. Of 22 patients evaluable for response, 3 (14%) had very good partial responses, 3 (14%) had minor responses, and 10 (45%) had a period of stable disease. Electron micrographs of bone marrow plasma cells collected at baseline, after a hydroxychloroquine run-in, and after combined therapy showed therapy-associated increases in autophagic vacuoles, consistent with the combined effects of increased trafficking of misfolded proteins to autophagic vacuoles and inhibition of their degradative capacity. Combined targeting of proteasomal and autophagic protein degradation using bortezomib and hydroxychloroquine is therefore feasible and a potentially useful strategy for improving outcomes in myeloma therapy.
Collapse
Affiliation(s)
- Dan T Vogl
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | | | - Kay-See Tan
- Department of Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia, PA USA
| | - Daniel F Heitjan
- Department of Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia, PA USA
| | - Lisa E Davis
- Department of Pharmacy Practice and Pharmacy Administration; University of the Sciences in Philadelphia; Philadelphia, PA USA
| | - Laura Pontiggia
- Department of Mathematics, Physics and Statistics; University of the Sciences in Philadelphia; Philadelphia, PA USA
| | - Reshma Rangwala
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Shengfu Piao
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Yunyoung C Chang
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Emma C Scott
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Thomas M Paul
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Charles W Nichols
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - David L Porter
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Janeen Kaplan
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - Gayle Mallon
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| | - James E Bradner
- Division of Hematologic Neoplasia; Dana-Farber Cancer Institute; Boston, MA USA
| | - Ravi K Amaravadi
- Abramson Cancer Center; University of Pennsylvania; Philadelphia, PA USA
| |
Collapse
|
17
|
Rosenfeld MR, Ye X, Supko JG, Desideri S, Grossman SA, Brem S, Mikkelson T, Wang D, Chang YC, Hu J, McAfee Q, Fisher J, Troxel AB, Piao S, Heitjan DF, Tan KS, Pontiggia L, O'Dwyer PJ, Davis LE, Amaravadi RK. A phase I/II trial of hydroxychloroquine in conjunction with radiation therapy and concurrent and adjuvant temozolomide in patients with newly diagnosed glioblastoma multiforme. Autophagy 2014; 10:1359-68. [PMID: 24991840 PMCID: PMC4203513 DOI: 10.4161/auto.28984] [Citation(s) in RCA: 379] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Preclinical studies indicate autophagy inhibition with hydroxychloroquine (HCQ) can augment the efficacy of DNA-damaging therapy. The primary objective of this trial was to determine the maximum tolerated dose (MTD) and efficacy of HCQ in combination with radiation therapy (RT) and temozolomide (TMZ) for newly diagnosed glioblastoma (GB). A 3 + 3 phase I trial design followed by a noncomparative phase II study was conducted in GB patients after initial resection. Patients received HCQ (200 to 800 mg oral daily) with RT and concurrent and adjuvant TMZ. Quantitative electron microscopy and immunoblotting were used to assess changes in autophagic vacuoles (AVs) in peripheral blood mononuclear cells (PBMC). Population pharmacokinetic (PK) modeling enabled PK-pharmacodynamic correlations. Sixteen phase I subjects were evaluable for dose-limiting toxicities. At 800 mg HCQ/d, 3/3 subjects experienced Grade 3 and 4 neutropenia and thrombocytopenia, 1 with sepsis. HCQ 600 mg/d was found to be the MTD in this combination. The phase II cohort (n = 76) had a median survival of 15.6 mos with survival rates at 12, 18, and 24 mo of 70%, 36%, and 25%. PK analysis indicated dose-proportional exposure for HCQ. Significant therapy-associated increases in AV and LC3-II were observed in PBMC and correlated with higher HCQ exposure. These data establish that autophagy inhibition is achievable with HCQ, but dose-limiting toxicity prevented escalation to higher doses of HCQ. At HCQ 600 mg/d, autophagy inhibition was not consistently achieved in patients treated with this regimen, and no significant improvement in overall survival was observed. Therefore, a definitive test of the role of autophagy inhibition in the adjuvant setting for glioma patients awaits the development of lower-toxicity compounds that can achieve more consistent inhibition of autophagy than HCQ.
Collapse
Affiliation(s)
- Myrna R Rosenfeld
- Adult Brain Tumor Consortium; Department of Neurology; University of Pennsylvania; Philadelphia, PA USA
| | - Xiaobu Ye
- Adult Brain Tumor Consortium; Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University; Baltimore, MD USA
| | - Jeffrey G Supko
- Adult Brain Tumor Consortium; Massachusetts General Hospital; Harvard Medical School; Boston, MA USA
| | - Serena Desideri
- Adult Brain Tumor Consortium; Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University; Baltimore, MD USA
| | - Stuart A Grossman
- Adult Brain Tumor Consortium; Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University; Baltimore, MD USA
| | - Steven Brem
- Adult Brain Tumor Consortium; H Lee Moffitt Cancer Center Department of Neurosurgery; Tampa, FL USA
| | - Tom Mikkelson
- Adult Brain Tumor Consortium; Henry Ford Hospital Hermelin Brain Tumor Center/Neurology; Detroit, MI USA
| | - Daniel Wang
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA
| | - Yunyoung C Chang
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA
| | - Janice Hu
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA
| | - Quentin McAfee
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA
| | - Joy Fisher
- Adult Brain Tumor Consortium; Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University; Baltimore, MD USA
| | - Andrea B Troxel
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Shengfu Piao
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA
| | - Daniel F Heitjan
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Kay-See Tan
- Center for Clinical Epidemiology and Biostatistics; University of Pennsylvania; Philadelphia, PA USA
| | - Laura Pontiggia
- Department of Mathematics, Physics, and Statistics; University of the Sciences
| | - Peter J O'Dwyer
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA; Abramson Cancer Center, University of Pennsylvania; Philadelphia, PA USA
| | - Lisa E Davis
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA; Philadelphia College of Pharmacy; University of the Sciences; Philadelphia, PA USA
| | - Ravi K Amaravadi
- Division of Hematology-Oncology; Department of Medicine; Perelman School of Medicine; Philadelphia, PA USA; Abramson Cancer Center, University of Pennsylvania; Philadelphia, PA USA
| |
Collapse
|
18
|
Rangwala R, Chang YC, Hu J, Algazy KM, Evans TL, Fecher LA, Schuchter LM, Torigian DA, Panosian JT, Troxel AB, Tan KS, Heitjan DF, DeMichele AM, Vaughn DJ, Redlinger M, Alavi A, Kaiser J, Pontiggia L, Davis LE, O'Dwyer PJ, Amaravadi RK. Combined MTOR and autophagy inhibition: phase I trial of hydroxychloroquine and temsirolimus in patients with advanced solid tumors and melanoma. Autophagy 2014; 10:1391-402. [PMID: 24991838 PMCID: PMC4203516 DOI: 10.4161/auto.29119] [Citation(s) in RCA: 328] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The combination of temsirolimus (TEM), an MTOR inhibitor, and hydroxychloroquine (HCQ), an autophagy inhibitor, augments cell death in preclinical models. This phase 1 dose-escalation study evaluated the maximum tolerated dose (MTD), safety, preliminary activity, pharmacokinetics, and pharmacodynamics of HCQ in combination with TEM in cancer patients. In the dose escalation portion, 27 patients with advanced solid malignancies were enrolled, followed by a cohort expansion at the top dose level in 12 patients with metastatic melanoma. The combination of HCQ and TEM was well tolerated, and grade 3 or 4 toxicity was limited to anorexia (7%), fatigue (7%), and nausea (7%). An MTD was not reached for HCQ, and the recommended phase II dose was HCQ 600 mg twice daily in combination with TEM 25 mg weekly. Other common grade 1 or 2 toxicities included fatigue, anorexia, nausea, stomatitis, rash, and weight loss. No responses were observed; however, 14/21 (67%) patients in the dose escalation and 14/19 (74%) patients with melanoma achieved stable disease. The median progression-free survival in 13 melanoma patients treated with HCQ 1200mg/d in combination with TEM was 3.5 mo. Novel 18-fluorodeoxyglucose positron emission tomography (FDG-PET) measurements predicted clinical outcome and provided further evidence that the addition of HCQ to TEM produced metabolic stress on tumors in patients that experienced clinical benefit. Pharmacodynamic evidence of autophagy inhibition was evident in serial PBMC and tumor biopsies only in patients treated with 1200 mg daily HCQ. This study indicates that TEM and HCQ is safe and tolerable, modulates autophagy in patients, and has significant antitumor activity. Further studies combining MTOR and autophagy inhibitors in cancer patients are warranted.
Collapse
Affiliation(s)
- Reshma Rangwala
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Yunyoung C Chang
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Janice Hu
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Kenneth M Algazy
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Tracey L Evans
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Leslie A Fecher
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Lynn M Schuchter
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Drew A Torigian
- Department of Radiology Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Jeffrey T Panosian
- Department of Radiology Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Andrea B Troxel
- Center for Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia, PA USA
| | - Kay-See Tan
- Center for Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia, PA USA
| | - Daniel F Heitjan
- Center for Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia, PA USA
| | - Angela M DeMichele
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - David J Vaughn
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Maryann Redlinger
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Abass Alavi
- Department of Radiology Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Jonathon Kaiser
- Department of Pharmacy Practice and Pharmacy Administration; Philadelphia College of Pharmacy; University of the Sciences; Philadelphia, PA USA
| | - Laura Pontiggia
- Department of Mathematics, Physics, and Statistics; University of the Sciences; Philadelphia, PA USA
| | - Lisa E Davis
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA; Department of Pharmacy Practice and Pharmacy Administration; Philadelphia College of Pharmacy; University of the Sciences; Philadelphia, PA USA
| | - Peter J O'Dwyer
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Ravi K Amaravadi
- Department of Medicine and the Abramson Cancer Center; Perelman School of Medicine; University of Pennsylvania; Philadelphia, PA USA
| |
Collapse
|
19
|
Mahalingam D, Mita M, Sarantopoulos J, Wood L, Amaravadi RK, Davis LE, Mita AC, Curiel TJ, Espitia CM, Nawrocki ST, Giles FJ, Carew JS. Combined autophagy and HDAC inhibition: a phase I safety, tolerability, pharmacokinetic, and pharmacodynamic analysis of hydroxychloroquine in combination with the HDAC inhibitor vorinostat in patients with advanced solid tumors. Autophagy 2014; 10:1403-14. [PMID: 24991835 DOI: 10.4161/auto.29231] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [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: 01/06/2023] Open
Abstract
We previously reported that inhibition of autophagy significantly augmented the anticancer activity of the histone deacetylase (HDAC) inhibitor vorinostat (VOR) through a cathepsin D-mediated mechanism. We thus conducted a first-in-human study to investigate the safety, preliminary efficacy, pharmacokinetics (PK), and pharmacodynamics (PD) of the combination of the autophagy inhibitor hydroxychloroquine (HCQ) and VOR in patients with advanced solid tumors. Of 27 patients treated in the study, 24 were considered fully evaluable for study assessments and toxicity. Patients were treated orally with escalating doses of HCQ daily (QD) (d 2 to 21 of a 21-d cycle) in combination with 400 mg VOR QD (d one to 21). Treatment-related adverse events (AE) included grade 1 to 2 nausea, diarrhea, fatigue, weight loss, anemia, and elevated creatinine. Grade 3 fatigue and/or myelosuppression were observed in a minority of patients. Fatigue and gastrointestinal AE were dose-limiting toxicities. Six-hundred milligrams HCQ and 400 mg VOR was established as the maximum tolerated dose and recommended phase II regimen. One patient with renal cell carcinoma had a confirmed durable partial response and 2 patients with colorectal cancer had prolonged stable disease. The addition of HCQ did not significantly impact the PK profile of VOR. Treatment-related increases in the expression of CDKN1A and CTSD were more pronounced in tumor biopsies than peripheral blood mononuclear cells. Based on the safety and preliminary efficacy of this combination, additional clinical studies are currently being planned to further investigate autophagy inhibition as a new approach to increase the efficacy of HDAC inhibitors.
Collapse
Affiliation(s)
- Devalingam Mahalingam
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Monica Mita
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA; Cedars-Sinai Medical Center; University of California, Los Angeles; Los Angeles CA USA
| | - John Sarantopoulos
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Leslie Wood
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Ravi K Amaravadi
- Abramson Cancer Center and Department of Medicine; University of Pennsylvania; Philadelphia, PA USA
| | - Lisa E Davis
- University of the Sciences; Philadelphia, PA USA
| | - Alain C Mita
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA; Cedars-Sinai Medical Center; University of California, Los Angeles; Los Angeles CA USA
| | - Tyler J Curiel
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Claudia M Espitia
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Steffan T Nawrocki
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA
| | - Francis J Giles
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA; Robert H Lurie Comprehensive Cancer Center; Northwestern University; Chicago, IL USA
| | - Jennifer S Carew
- Cancer Therapy and Research Center at the University of Texas Health Science Center; San Antonio, TX USA; Taussig Cancer Institute; Cleveland Clinic; Cleveland, OH USA
| |
Collapse
|
20
|
Davis LE. Book Review: Stockley's Drug Interactions Pocket Companion 2012. Ann Pharmacother 2012. [DOI: 10.1345/aph.1r125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lisa E Davis
- Clinical Pharmacy, Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
| |
Collapse
|
21
|
Algazy KM, Schuchter LM, Demichele AM, David VJ, Torigian DA, Chang CY, Redlinger M, Davis LE, O'Dwyer PJ, Amaravadi RK. Abstract 4500: Combined mTOR inhibition and autophagy inhibition: Phase I trial of temsirolimus and hydroxchloroquine in patients with advanced solid tumors. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-4500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Therapy-induced autophagy may be a key resistance mechanism that explains the low rates of clinical benefit observed in trials of mTOR inhibitors in multiple cancers. For example, the mTOR inhibitor temsirolimus produced a 0% stable disease rate in a prior phase II trial in patients with metastatic melanoma. Hydroxychloroquine (HCQ) is an autophagy inhibitor that augments the antitumor efficacy of a number of anticancer therapies including mTOR inhibitors in preclinical models. To determine the safety and pharmacodynamic (PD) effects of combining an mTOR inhibitor with an autophagy inhibitor, we report the results of a phase I clinical trial of temsirolimus and HCQ in patients with advanced solid tumors. Methods: We conducted a traditional 3+3 phase I dose escalation clinical trial in which patients were treated with 1 week single agent temsirolimus 25 mg IV weekly followed by combined weekly temsirolimus with increasing doses of daily continuous HCQ. Patients with advanced solid tumors with any number of prior therapies were eligible. The primary objective was to determine the maximal tolerated dose (MTD) of HCQ in this combination. Secondary objectives included toxicity rate, response rate, measurement of therapy-induced accumulation of autophagic vesicles (AV) in serial peripheral blood mononuclear cells (PBMC) and tumor tissue, and pharmacokinetic (PK) analysis of temsirolimus, sirolimus and HCQ to explore drug interactions and establish a PK-PD relationship. A 12 patient expansion at the MTD or HCQ 600 mg bid (final planned dose level) in patients with metastatic melanoma with serial FDG-PET scans is planned. Results: 23 patients were enrolled with 14 evaluable for response and toxicity. The median number of prior treatments was 4. HCQ was successfully dose escalated from 200 mg daily to 600 mg bid in 4 cohorts. There was one dose limiting toxicity (DLT) at 200 mg HCQ, grade 4 thrombocytopenia with bleeding, that lead to dose expansion. The 800 mg dose cohort was also expanded due to a death from streptococcal pneumonia in month 3 of treatment. No additional bleeding, infections, or other DLTs were observed. Anorexia, nausea, and fatigue were common grade 2 toxicities. Stable disease was achieved in 10/14 evaluable patients, including 4/5 patients with metastatic melanoma. After 6 weeks of treatment, a significant accumulation of AV was observed in PBMC of patients treated with this combination compared to pretreatment samples providing PD evidence of consistent autophagy inhibition. Conclusions: The combination of temsirolimus and HCQ demonstrated significant clinical activity, and a manageable safety profile in a highly treatment-refractory patient population. PD evidence of autophagy inhibition was observed. The recommended phase II dose, PK-PD analysis, response rate, and FDG-PET results in the melanoma expansion will be presented.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4500. doi:10.1158/1538-7445.AM2011-4500
Collapse
|
22
|
Burton ME, Munger MA, Bednarczyk EM, Davis LE, Davis GA, Elliott ME, Maurey JO, Seaton TL, Touchette DR, Zimmer-Young J. Update: The Clinical Pharmacist as Principal Investigator. Pharmacotherapy 2010. [DOI: 10.1592/phco.30.12.1314] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
23
|
McCluggage LK, Davis LE. Book Review: Stockley's Drug Interactions 2010: Pocket Companion. Ann Pharmacother 2010. [DOI: 10.1345/aph.1p048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lauren K McCluggage
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, Philadelphia, PA
| | - Lisa E Davis
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, Philadelphia, PA
| |
Collapse
|
24
|
Faber JJ, Brace RA, Davis LE, Anderson DF. Ovine amniotic fluid volume response to intra-amniotic balloon filling. Placenta 2008; 30:201-2. [PMID: 19095300 DOI: 10.1016/j.placenta.2008.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 11/19/2008] [Accepted: 11/20/2008] [Indexed: 10/21/2022]
|
25
|
Yang Q, Hohimer AR, Giraud GD, Van Winkle DM, Underwood MJ, He GW, Davis LE. Effect of fetal anaemia on myocardial ischaemia-reperfusion injury and coronary vasoreactivity in adult sheep. Acta Physiol (Oxf) 2008; 194:325-34. [PMID: 18729844 DOI: 10.1111/j.1748-1716.2008.01892.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [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: 12/01/2022]
Abstract
AIMS We investigated whether chronic fetal anaemia affects myocardial infarct in adulthood and elicits functional modifications in adult coronary vasoreactivity. METHODS Seven-month-old sheep that were made anaemic in utero and transfused to normal haematocrit before birth were studied. Infarct size was determined by tetrazolium after 1-h ischaemia (occlusion of the mid of left anterior descending artery) and 2-h reperfusion. The dose-response to vasoconstrictors and vasodilators was assessed in small resistance coronary arteries. RESULTS There were no significant differences between the animals previously subjected to in utero anaemia and the control animals regarding the percentage infarct size and the area-at-risk to the left ventricle. The ventricular function (dP/dt) was preserved. The percentage infarct size of the area-at-risk (70.7 +/- 3.5%) was larger than that in the controls (49.8 +/- 4.5%) (P = 0.006). The vascular responses were not altered. Endothelium-dependent relaxation to bradykinin (96.0 +/- 2.6% vs. 98.8 +/- 1.0%) was not affected by PGI(2) inhibitor (94.6 +/- 2.6% vs. 98.5 +/- 1.0%) but significantly reduced by the inhibition of nitric oxide (NO) in both anaemic (P < 0.05) and control (P < 0.001) groups with a significant right shift of EC(50) (P < 0.01). The non-NO-non-PGI(2)-mediated relaxation was slightly potentiated in anaemic animals. CONCLUSIONS Exposing fetal sheep to in utero anaemia in late gestation for 3 weeks may increase the susceptibility of adult hearts to ischaemia-reperfusion injury without major alterations in coronary vasomotor responsiveness. The impact of in utero anaemia at earlier period of pregnancy and on the earlier or later life of the adult is yet to be further investigated.
Collapse
Affiliation(s)
- Q Yang
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Two anaesthetic protocols were compared using pregnant sheep. In both groups of animals, anaesthesia was induced using an intravenous (i.v.) injection of diazepam and ketamine. The ewes were then intubated for positive pressure ventilation using 0.8 L/min of nitrous oxide and 2 L/min oxygen with 1.1-1.8% halothane. If the ewe showed any signs of awakening, one of two protocols was followed. First, the halothane concentration was increased to 2-3% until the ewe was completely anaesthetized. Second, the halothane concentration was not altered, but the ewe was given doses of i.v. diazepam (0.1 mg/kg) and ketamine (1 mg/kg) until again completely anaesthetized. At the completion of surgery, maternal recovery was rapid and similar between the two groups. However, five days after surgery, the fetal arterial Po(2) and oxygen content of the fetuses receiving additional halothane (1.9 +/- 0.2 kPa and 4.4 +/- 1.0 mL/100 mL) were statistically significantly depressed when compared with the fetuses receiving additional diazepam and ketamine (2.9 +/- 0.1 kPa and 7.0 +/- 0.5 mL/100 mL). These results led us to conclude that certain anaesthetic protocols, in spite of good maternal recovery, can lead to deleterious effects upon the fetus that persist for at least five days after surgery.
Collapse
Affiliation(s)
- S S Jonker
- Department of Physiology and Pharmacology, Oregon Health and Science University, Portland, OR, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Faber JJ, Anderson DF, Jonker SS, Davis LE, Giraud GD. Fetal infusions of plasma cause an increase in umbilical vascular resistance in sheep. Placenta 2005; 27:876-81. [PMID: 16289267 DOI: 10.1016/j.placenta.2005.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Revised: 07/12/2005] [Accepted: 09/19/2005] [Indexed: 11/27/2022]
Abstract
Earlier studies suggested that the fetal placental circulation is relatively inert with fetal placental flow increasing or decreasing with perfusion pressure. Subsequent studies have demonstrated that the placenta may not be an unreactive vascular bed. The present study was undertaken to determine if plasma infusion-induced hypertension increased fetal placental flow in proportion to the driving pressure across the fetal placental circulation. Six fetal sheep were operated on at 118-122 days to place intravascular catheters and a flow sensor on the common umbilical artery. Starting 6 days later, the fetuses were infused with adult sheep plasma. During the 7-day-long infusion period, they received a total of 1515+/-217 (SD) ml of fluid and 93.2+/-12.0 g of protein. Fetal plasma protein concentrations increased from 34.2+/-2.3 to 77.0+/-9.7 g/l (P<0.0001). Fetal arterial blood pressures rose from 42+/-3 to 59+/-4 mmHg (P<0.01) and venous pressures rose from 2.2+/-0.5 to 4.8+/-0.8 mmHg (P<0.01). In spite of the large increase in driving pressure, fetal placental blood flow remained (statistically) constant (627+/-299 ml/min and 552+/-221 ml/min) while fetal umbilical resistance increased from 0.077+/-0.038 to 0.115+/-0.053 mmHg min/ml (P<0.01). On day 7, plasma renin activity had fallen from 6.7+/-4.2 ng/(ml/h) at preinfusion control to 0.6+/-0.6 ng/(ml/h) (P<0.05) and plasma angiotensin-II concentration had fallen from 33.2+/-26.6 to 6.2+/-3.9 pg/ml, although this fall was not statistically significant (P=0.07). Fetal placental flow did not increase with increased driving pressure across the fetal placental circulation. The increase in fetal placental resistance may be a response to the increase in arterial pressure since there was no increase in flow.
Collapse
Affiliation(s)
- J J Faber
- Department of Physiology and Pharmacology, School of Medicine, Oregon Health and Sciences University, Portland, 97239, USA
| | | | | | | | | |
Collapse
|
28
|
Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, Arbeit RD, Simberkoff MS, Gershon AA, Davis LE, Weinberg A, Boardman KD, Williams HM, Zhang JH, Peduzzi PN, Beisel CE, Morrison VA, Guatelli JC, Brooks PA, Kauffman CA, Pachucki CT, Neuzil KM, Betts RF, Wright PF, Griffin MR, Brunell P, Soto NE, Marques AR, Keay SK, Goodman RP, Cotton DJ, Gnann JW, Loutit J, Holodniy M, Keitel WA, Crawford GE, Yeh SS, Lobo Z, Toney JF, Greenberg RN, Keller PM, Harbecke R, Hayward AR, Irwin MR, Kyriakides TC, Chan CY, Chan ISF, Wang WWB, Annunziato PW, Silber JL. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005; 352:2271-84. [PMID: 15930418 DOI: 10.1056/nejmoa051016] [Citation(s) in RCA: 1500] [Impact Index Per Article: 78.9] [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: 12/20/2022]
Abstract
BACKGROUND The incidence and severity of herpes zoster and postherpetic neuralgia increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV). We tested the hypothesis that vaccination against VZV would decrease the incidence, severity, or both of herpes zoster and postherpetic neuralgia among older adults. METHODS We enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine ("zoster vaccine"). Herpes zoster was diagnosed according to clinical and laboratory criteria. The pain and discomfort associated with herpes zoster were measured repeatedly for six months. The primary end point was the burden of illness due to herpes zoster, a measure affected by the incidence, severity, and duration of the associated pain and discomfort. The secondary end point was the incidence of postherpetic neuralgia. RESULTS More than 95 percent of the subjects continued in the study to its completion, with a median of 3.12 years of surveillance for herpes zoster. A total of 957 confirmed cases of herpes zoster (315 among vaccine recipients and 642 among placebo recipients) and 107 cases of postherpetic neuralgia (27 among vaccine recipients and 80 among placebo recipients) were included in the efficacy analysis. The use of the zoster vaccine reduced the burden of illness due to herpes zoster by 61.1 percent (P<0.001), reduced the incidence of postherpetic neuralgia by 66.5 percent (P<0.001), and reduced the incidence of herpes zoster by 51.3 percent (P<0.001). Reactions at the injection site were more frequent among vaccine recipients but were generally mild. CONCLUSIONS The zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.
Collapse
Affiliation(s)
- M N Oxman
- Shingles Prevention Study (Mail code 111F-1), VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161,USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
|
30
|
Davis LE, Eisen SA, Murphy FM, Alpern R, Parks BJ, Blanchard M, Reda DJ, King MK, Mithen FA, Kang HK. Clinical and laboratory assessment of distal peripheral nerves in Gulf War veterans and spouses. Neurology 2004; 63:1070-7. [PMID: 15452300 DOI: 10.1212/01.wnl.0000138426.88460.cb] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The prevalence of symptoms suggesting distal symmetric polyneuropathy (DSP) was reported to be higher among deployed veterans (DV) to the Persian Gulf in 1990-1991 than to control non-deployed veterans (NDV). The authors therefore compared the prevalence of DSP by direct examination of DV and their spouses to control NDV and spouses. METHODS The authors performed standardized neurologic examinations on 1,061 DV and 1,128 NDV selected from a cohort of veterans who previously participated in a national mail and telephone survey. Presence of DSP was evaluated by history, physical examination, and standardized electrophysiologic assessment of motor and sensory nerves. Similar examinations were performed without electrophysiologic tests in 484 DV spouses and 533 NDV spouses. Statistical analyses were performed with appropriate adjustments for the stratified sampling scheme. RESULTS No differences between adjusted population prevalence of DSP in DV and NDV were found by electrophysiology (3.7% vs 6.3%, p = 0.07), by neurologic examination (3.1% vs 2.6%, p = 0.60), or by the methods combined (6.3% vs 7.3%, p = 0.47). Excluding veterans with non-military service related diseases that may cause DSP did not alter outcomes. DV potentially exposed to neurotoxins from the Khamisiyah ammunition depot explosion did not significantly differ in DSP prevalence compared to non-exposed DV. The prevalence of DSP in DV spouses did not differ from NDV spouses (2.7% vs 3.2%, p = 0.64). CONCLUSIONS Neither veterans deployed during the Gulf War era nor their spouses had a higher prevalence of DSP compared to NDV and spouses.
Collapse
Affiliation(s)
- L E Davis
- Neurology Service, New Mexico VA Health Care System, 1501 San Pedro Dr. SE, Albuquerque, NM 87108, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Jonker S, Davis LE, van der Bilt JDW, Hadder B, Hohimer AR, Giraud GD, Thornburg KL. Anaemia stimulates aquaporin 1 expression in the fetal sheep heart. Exp Physiol 2004; 88:691-8. [PMID: 14603367 DOI: 10.1113/eph8802626] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Interstitial fluid fluxes are much greater in the fetus than in the adult, and filtration rates are increased over control in most tissues of the anaemic fetus. Increased capillary filtration may lead to cardiac oedema which, in turn, severely impacts cardiac function. Mechanisms that underlie these differences in flux are incompletely understood. One possible mechanism is an increase in capillary water permeability. Therefore, the goal of our study was to determine the level of expression of the water channel aquaporin 1 (AQP1) during cardiac development and in the anaemic fetal sheep heart. Hearts from chronically instrumented anaemic sheep fetuses and hearts from normal early fetal, late fetal, neonatal and adult sheep were used for Northern and Western analyses and immunohistochemistry. We found that AQP1 mRNA levels were lower in the young fetal left ventricle than in the adult left ventricle (P < 0.05). We also found that cardiac AQP1 expression was increased in anaemic fetuses compared to age-matched controls (P < 0.05). Expression of AQP1 in all groups was greatest in the microvascular endothelium. These data suggest that AQP1 plays an important role in the physiological accommodation to fetal anaemia.
Collapse
Affiliation(s)
- S Jonker
- Departments of Physiology and Pharmacology, Obstetrics, Medicine (Cardiology), and Heart Research Center, Oregon Health and Science University, Portland, OR 97239, USA
| | | | | | | | | | | | | |
Collapse
|
32
|
Huang M, Davis LE, Aine C, Weisend M, Harrington D, Christner R, Stephen J, Edgar JC, Herman M, Meyer J, Paulson K, Martin K, Lee RR. MEG response to median nerve stimulation correlates with recovery of sensory and motor function after stroke. Clin Neurophysiol 2004; 115:820-33. [PMID: 15003762 DOI: 10.1016/j.clinph.2003.11.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [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] [Accepted: 11/17/2003] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Hemiparesis due to damage by stroke in primary motor cortex (MI) or its underlying projections presents a problem for functional neuroimaging technologies that attempt to evaluate the neurophysiological basis for restoration of motor function. Traditional assessments of MI function require patients to move their fingers, hands, or limbs, which can be either impossible or markedly compromised after stroke. We recently demonstrated in normal subjects that magnetoencephalography (MEG), a non-invasive neuromagnetic functional imaging technique, detects neuronal response elicited by electrical median nerve stimulation in MI, as well as primary somatosensory cortex (SI). In the present study, we used the MEG response from median nerve stimulation to investigate the recovery of primary motor and somatosensory in acute ischemic stroke patients. METHODS Twelve patients with unilateral ischemic strokes that affected sensorimotor functions of their hand were studied in the acute stage (4.4+/-1.2 days, mean+/-SD) and during a 1-month follow-up (38.6+/-5.6 days, except for one patient's follow-up done 6 month after stroke). RESULTS Among the multiple cortical sources localized after median nerve stimulation, one source localized to SI and another localized to the vicinity of MI. Changes in the source strengths of the first component post-stimulus of MI and SI correlated with the extent of recovery of sensorimotor functions as determined by neurological exams. CONCLUSIONS This study provides a novel way of indirectly assessing MI function using MEG during the acute stroke phase, when many patients often cannot perform motor tasks due to paralysis.
Collapse
Affiliation(s)
- M Huang
- Center for Functional Brain Imaging, Building 49 (114M), New Mexico VA Health Care System, and Department of Radiology, School of Medicine, Health Sciences Center, University of New Mexico, Albequerque, 87108, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Davis LE. Book Review: Fluoropyrimidines in Cancer Therapy. Ann Pharmacother 2003. [DOI: 10.1345/aph.1d047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lisa E Davis
- Associate Professor of Clinical Pharmacy Philadelphia College of Pharmacy University of the Sciences in Philadelphia Philadelphia, Pennsylvania
| |
Collapse
|
34
|
Abstract
BACKGROUND Inhibition of bone resorption using bisphosphonates is an important step in palliation of complications of advanced cancer, such as hypercalcemia and metastatic bone disease. OBJECTIVE The goal of this article was to describe the pharmacologic properties of zoledronic acid (zoledronate) and discuss findings from preclinical and clinical studies of its use in skeletal disorders. METHODS Relevant English-language literature was identified using the terms zoledronic acid, zoledronate, Zometa, and 118072-93-8 through searches of MEDLINE (1966-June 2003) and International Pharmaceutical Abstracts (1970-June 2003), and abstract proceedings from the American Society of Clinical Oncology (1997-2002). RESULTS Zoledronic acid is a nitrogen-containing bisphosphonate that inhibits bone resorption. It is indicated for the treatment of hypercalcemia of malignancy and for the treatment of patients with multiple myeloma or documented metastasis from solid tumors, in conjunction with standard antineoplastic therapy. The recommended dosage is 4 mg via IV over >or= 15 minutes every 3 or 4 weeks. Compared with pamidronate 90 mg, zoledronic acid 4 and 8 mg provided a higher complete response rate for hypercalcemia of malignancy by day 10 (88.4% and 86.7% vs 69.7%; P = 0.002 and P = 0.015) and longer duration of action (median time to relapse, 30 and 40 days vs 17 days; P = 0.001 and P = 0.007). In patients with breast cancer or multiple myeloma, zoledronic acid was as effective as pamidronate in delaying time to a first skeletal-related event (373 days vs 363 days). In patients with hormone-refractory prostate cancer and bone metastases, zoledronic acid 4 mg reduced the proportion of patients who experienced a skeletal-related event (33% vs 44% with placebo; P = 0.021) or a skeletal fracture (13% vs 22% with placebo; P = 0.015). In patients with bone metastases from solid tumors, zoledronic acid delayed the median time to a first skeletal-related event (230 days vs 163 days with placebo; P = 0.023). Common adverse events include fever, nausea, constipation, fatigue, and bone pain. CONCLUSION Zoledronic acid is an effective and generally well-tolerated treatment for hypercalcemia of malignancy and skeletal complications of metastatic bone disease.
Collapse
Affiliation(s)
- Edward C Li
- Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | | |
Collapse
|
35
|
Weber Nielsen MS, Domecq JJ, Davis LE, Beede DK, Budine M, Martsolf F. A partnership of universities and agri-business for an effective dairy herd management learning experience for undergraduates: the Dairy Challenge. J Dairy Sci 2003; 86:1029-35. [PMID: 12703640 DOI: 10.3168/jds.s0022-0302(03)73686-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The Dairy Challenge contest allows undergraduate students to apply knowledge gained in the classroom in an evaluation of the management practices of commercial dairy farms. University faculty partnered with industry representatives to develop the competition. Participants in the Dairy Challenge do the following: 1) critically evaluate dairy herd management practices and make recommendations for improvements; 2) visit local dairy farms and gain knowledge of different farms' management practices; 3) meet and interact with potential employers from the dairy industry during the contest; 4) evaluate herd records and utilize knowledge of dairy herd management software and computer presentation tools; 5) test their speaking, presentation, and problem-solving skills; and 6) work as a team to build consensus and tag-team speaking formats. Teams of four undergraduate students critically evaluate a commercial dairy farm using herd records, a description of farm operations, and tour of the farm facilities. The farmer answers questions pertaining to management of the farm in a group interview with all teams and in a separate interview with each individual team. Teams give a 20-min presentation that is scored on the description and assessment of the management practices and recommendations for improvements in management and facilities. Additionally, scoring is based on apparent level of preparation, speaking, presentation skills, and responses to judges' questions. The judges are university specialists and dairy industry professionals. This capstone experience allows students to interact with dairy farmers and representatives from the dairy industry and expands their knowledge and skills gained during their academic career.
Collapse
Affiliation(s)
- M S Weber Nielsen
- Department of Animal Science, Michigan State University, East Lansing, 48824, USA.
| | | | | | | | | | | |
Collapse
|
36
|
Abstract
CONTEXT Oculopharyngeal muscular dystrophy (OPMD) is a rare myopathy caused by polyalanine triplet repeat expansion in the gene for poly(A) binding protein 2 (PABP2) and is found in isolated cohorts throughout the world. We have observed numerous cases of OPMD in New Mexico. OBJECTIVE To characterize the clinical, genetic, and demographic features of the OPMD population in New Mexico. DESIGN, SETTING, AND PARTICIPANTS Cohort study with analysis of outpatient clinic medical records from 1965 to 2001 at the University of New Mexico Hospital and the New Mexico VA Health Care System in Albuquerque, which serve the entire state. MAIN OUTCOME MEASURES Clinical phenotype, supplemented with genetic confirmation (n = 10 patients) and in-depth clinical evaluations (n = 49 patients). RESULTS We identified 216 cases of OPMD (99 women and 117 men) from 39 kindreds of New Mexicans spanning up to 4 generations. All patients were Hispanic, and the majority of probands came from northern New Mexico. In patients who had both ocular and pharyngeal muscle weakness, ptosis was just as likely to occur before or concurrent with dysphagia. Proximal limb muscle weakness and gait abnormalities were common and occurred later than ocular or pharyngeal weakness. The clinical expression of OPMD caused marked debility, although life-table analysis showed no decrease in life expectancy compared with unaffected family members (P =.81). Ten individuals from different kindreds were found to have an identical polyalanine triplet repeat expansion ([GCG](9)) in the PABP2 gene. CONCLUSIONS Individuals in this cohort had clinical and genetic characteristics of classic OPMD. Longevity was not affected, but patients experienced considerable morbidity. The origin of the PABP2 mutation in New Mexican OPMD patients is unclear, although the geographic and genetic isolation of northern New Mexicans with a long ancestry in this region may have contributed to the development of this cohort. This disease cohort represents a large and previously unrecognized health care issue in the state of New Mexico and should serve to raise the awareness of this disorder among clinicians who treat Hispanics in the Southwest and throughout the United States.
Collapse
Affiliation(s)
- M W Becher
- Department of Cell Biology and Physiology, University of New Mexico HSC, BMSB 149, 915 Camino de Salud NE, Albuquerque, NM 87131, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
To investigate the pathogenesis of influenza myositis in animals, juvenile BALB/c mice were inoculated with influenza B/Lee virus intramuscularly into the right quadriceps muscle. Chicken normal allantoic fluid (NAF) or phosphate-buffered saline (PBS) was injected into the left quadriceps of control mice and in some virus-infected mice. Serum creatinine phosphokinase (CPK) levels rose significantly on days 1 and 2 post-inoculation (PI) in only virus-inoculated mice. On days 2 and 3 PI, right quadriceps muscles developed scattered foci of a predominantly mononuclear inflammation in the perimysial connective tissue often adjacent to degenerating or necrotic muscle fibers. Immunofluorescent staining with specific anti-influenza B virus antisera showed muscle fibers that contained specific staining in nuclei and adjacent cytoplasm. Skip areas of staining within muscle fibers suggested that not all muscle nuclei within an individual muscle fiber were infected. A continuous fall in infectious virus titer in the right quadriceps muscles suggested the initial virus inoculum became inactivated and progeny virions were not produced. Left quadriceps muscle never had muscle necrosis or endomysial inflammation, specific staining of viral antigen, virus isolation, or viral RNA detected by the reverse transcriptase polymerase chain reaction assay. These findings support the hypothesis that a non-permissive influenza viral infection can develop in murine skeletal muscle that can damage specific nuclear domains of muscle fibers producing muscle degeneration or necrosis. A similar type of muscle infection may develop in humans that occasionally develop focal myositis during influenza.
Collapse
Affiliation(s)
- L E Davis
- Neurology Service, New Mexico VA Health Care System, University of New Mexico School of Medicine, 1501 San Pedro Drive SE, Albuquerque, NM 87108, USA.
| | | |
Collapse
|
38
|
Massung RF, Davis LE, Slater K, McKechnie DB, Puerzer M. Epidemic typhus meningitis in the southwestern United States. Clin Infect Dis 2001; 32:979-82. [PMID: 11247722 DOI: 10.1086/319351] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2000] [Revised: 07/24/2000] [Indexed: 11/03/2022] Open
Abstract
A patient residing in New Mexico had murine typhus diagnosed. A novel molecular assay was performed at the Centers for Disease Control and Prevention, and Rickettsia prowazekii, the agent of epidemic typhus, was found, rather than R. typhi. To our knowledge, this is the first reported case of epidemic typhus confirmed by means of polymerase chain reaction--based testing of cerebrospinal fluid, and it introduces a novel assay for the molecular diagnosis of both epidemic and murine typhus.
Collapse
Affiliation(s)
- R F Massung
- Centers for Disease Control and Prevention, Division of Viral and Rickettsial Diseases, Atlanta, GA, 30333 USA.
| | | | | | | | | |
Collapse
|
39
|
Abstract
To determine whether some constitutional symptoms of influenza, such as headache, myalgia and nausea, could represent a viral infection of brain, muscle, and liver, we inoculated juvenile Balb/c mice intranasally with 103 plaque forming units of influenza B/Lee virus. Blood, brain, liver, skeletal muscle, and lung tissues were removed aseptically and assayed for infectivity by a plaque assay, viral RNA by reverse transcriptase-polymerase chain reaction (RT - PCR), viral antigen by immunoperoxidase staining, and histologic changes by light microscopy. Mice became ill 2 - 3 days post inoculation (PI). A productive viral infection of the lungs developed from days 1 - 8 with maxima of virus titers, pneumonia, and the number of immunoperoxidase staining lung cells occurring on days 2 - 6 PI. Virus isolation from blood was rare and viral RNA was detected intermittently in blood by RT - PCR. In many animals, a non-permissive or abortive infection of brain occurred from days 1 - 8 and peaked on days 3 - 4 PI. Viral RNA was detected in brain tissue and viral antigen was seen in cerebral endothelial cells but infectious virus was rarely isolated from brain. In liver, viral RNA was detected and viral antigen was seen occasionally in hepatocytes. In skeletal muscle, viral RNA was detected but neither infectious virus nor viral antigen was seen. A correlation existed between the severity of the illness, pneumonia, lung virus titer, viral antigen in lung cells, and extent of a non-permissive viral infection of brain and liver but not muscle. These studies demonstrate that following intranasal infection of influenza virus in mice, a viral pneumonia develops with subsequent intermittent viremia and non-permissive or abortive infection of brain, liver and muscle.
Collapse
Affiliation(s)
- L E Davis
- Neurology Service, New Mexico Veterans Affairs Healthcare System, 1501 San Pedro Dr., SE, Albuquerque, NM 87108, USA
| | | | | | | |
Collapse
|
40
|
Becher MW, Kotzuk JA, Davis LE, Bear DG. Intranuclear inclusions in oculopharyngeal muscular dystrophy contain poly(A) binding protein 2. Ann Neurol 2000; 48:812-5. [PMID: 11079550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Intranuclear inclusions are one of the ultrastructural hallmarks of oculopharyngeal muscular dystrophy (OPMD), a disorder caused by small polyalanine (GCG) expansions in the gene that codes for a ubiquitous nuclear protein called poly(A) binding protein 2 (PABP2). We studied OPMD skeletal muscle and found that 1.0 to 10.0% of myocyte nuclei contained discreet PABP2 immunoreactive intranuclear inclusions, providing the first direct evidence of the relation between the proposed gene for OPMD and the pathology of OPMD.
Collapse
Affiliation(s)
- M W Becher
- Department of Pathology, University of New Mexico, Health Sciences Center, Albuquerque 87131, USA
| | | | | | | |
Collapse
|
41
|
Affiliation(s)
- LE Davis
- Neurology Service New Mexico Veterans Affairs Health Care System 1501 San Pedro Dr SE Albuquerque, NM 87108, USA
| |
Collapse
|
42
|
Abstract
This review discusses a practical approach to the patient with possible fungal infection of the central nervous system (CNS). Difficulties in establishing the diagnosis come from the nonspecific clinical syndromes (subacute meningitis, meningoencephalitis, and brain abscess) and the low isolation rate of fungi from cerebrospinal fluid (CSF). Helpful diagnostic clues often come from knowledge of the patient's geographic travels, risk factors, evidence of systemic organ infection, and fungal serologic tests. Standard and new antifungal agents are evaluated and the initial and suppressive drug management of the common fungal infections is presented.
Collapse
Affiliation(s)
- L E Davis
- Neurology Service, Veterans Affairs Medical Center, Albuquerque, New Mexico 87108, USA
| |
Collapse
|
43
|
Grubb TL, Benson GJ, Foreman JH, Constable PD, Thurmon JC, Olson WO, Tranquilli WJ, Davis LE. Hemodynamic effects of ionized calcium in horses anesthetized with halothane or isoflurane. Am J Vet Res 1999; 60:1430-5. [PMID: 10566822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVES To evaluate the effects of halothane and isoflurane on cardiovascular function and serum total and ionized calcium concentrations in horses, and to determine whether administration of calcium gluconate would attenuate these effects. ANIMALS 6 clinically normal adult Thoroughbreds. PROCEDURE Catheters were inserted for measurement of arterial blood pressures, pulmonary arterial blood pressures, right ventricular pressure (for determination of myocardial contractility), right atrial pressure, and cardiac output and for collection of arterial blood samples. Anesthesia was then induced with xylazine hydrochloride and ketamine hydrochloride and maintained with halothane or isoflurane. An i.v. infusion of calcium gluconate was begun 75 minutes after anesthetic induction; dosage of calcium gluconate was 0.1 mg/kg of body weight/min for the first 15 minutes, 0.2 mg/kg/min for the next 15 minutes, and 0.4 mg/kg/min for an additional 15 minutes. Data were collected before, during, and after administration of calcium gluconate. RESULTS Halothane and isoflurane decreased myocardial contractility, cardiac index, and mean arterial pressure, but halothane caused greater depression than isoflurane. Calcium gluconate attenuated the anesthetic-induced depression in cardiac index, stroke index, and maximal rate of increase in right ventricular pressure when horses were anesthetized with isoflurane. When horses were anesthetized with halothane, a higher dosage of calcium gluconate was required to attenuate the depression in stroke index and maximal rate of increase in right ventricular pressure; cardiac index was not changed with calcium administration. CONCLUSIONS AND CLINICAL RELEVANCE I.v. administration of calcium gluconate may support myocardial function in horses anesthetized with isoflurane.
Collapse
Affiliation(s)
- T L Grubb
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Champaign-Urbana 61801, USA
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Chronic fetal anemia produces large compensatory increases in coronary blood flow in the near-term fetal lamb. To determine if increased coronary flow in anemic fetuses is associated with decreased coronary flow reserve or, alternatively, an increase in coronary conductance, we measured maximal coronary artery conductance during adenosine infusion before and during anemia. Isovolemic hemorrhage over 7 days reduced hematocrit from 30.6 +/- 2. 7 to 15.8 +/- 2.4% (P < 0.02) and the oxygen content from 7.3 +/- 1. 4 to 2.6 +/- 0.4 ml/dl (P < 0.001). Coronary blood flow increased from control (202 +/- 60) to 664 +/- 208 ml. min(-1). 100 g(-1) with adenosine to 726 +/- 169 ml. min(-1). 100 g(-1) during anemia and to 1,162 +/- 250 ml. min(-1). 100 g(-1) (left ventricle) during anemia with adenosine infusion (all P < 0.001). Coronary conductance, determined during maximal vasodilation, was 18.2 +/- 7.7 before and 32.8 +/- 11.9 ml. min(-1). 100 g(-1). mmHg(-1) during anemia (P < 0. 001). Coronary reserve, the difference between resting and maximal myocardial blood flow interpolated at 40 mmHg, was unchanged in control and anemic fetuses (368 +/- 142 and 372 +/- 201 ml/min). Because hematocrit affects viscosity, anemic fetuses were transfused with blood to acutely increase the hematocrit back to control, and conductance was remeasured. Coronary blood flow decreased 57.3 +/- 18.9% but was still 42.6 +/- 18.9% greater than control. We conclude that in chronically anemic fetal sheep coronary conductance is increased and coronary reserve is maintained, and this is attributed in part to angiogenesis as well as changes in viscosity.
Collapse
Affiliation(s)
- L E Davis
- Departments of Obstetrics and Internal Medicine (Cardiology) and Congenital Heart Center, Oregon Health Sciences University, Portland, Oregon 97201-3098, USA.
| | | | | |
Collapse
|
45
|
Grubb TL, Constable PD, Benson GJ, Foreman JH, Olson WO, Thurmon JC, Tranquilli WJ, Davis LE. Techniques for evaluation of right ventricular relaxation rate in horses and effects of inhalant anesthetics with and without intravenous administration of calcium gluconate. Am J Vet Res 1999; 60:872-9. [PMID: 10407482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
OBJECTIVES To determine the most repeatable method for evaluating right ventricular relaxation rate in horses and to determine and compare effects of isoflurane or halothane with and without the added influence of intravenously administered calcium gluconate on right ventricular relaxation rates in horses. ANIMALS 6 Thoroughbred horses from 2 to 4 years old. PROCEDURE 6 models (2 for monoexponential decay with zero asymptote, 3 for monoexponential decay with variable asymptote, and 1 for biexponential decay) for determining right ventricular relaxation rate were assessed in conscious and anesthetized horses. The 2 methods yielding the most repeatable results then were used to determine right ventricular relaxation rates in horses anesthetized with isoflurane or halothane before, during, and after i.v. administration of calcium gluconate. Right ventricular pressure was measured, using a catheter-tip high-fidelity pressure transducer, and results were digitized at 500 Hz from minimum rate of change in ventricular pressure. RESULTS 2 models that used monoexponential decay with zero asymptote repeatedly produced an estimate for relaxation rate and were used to analyze effects of anesthesia and calcium gluconate administration on relaxation rate. Isoflurane and halothane each prolonged right ventricular relaxation rate, with greater prolongation evident in halothane-anesthetized horses. Calcium gluconate attenuated the anesthesia-induced prolongation in right ventricular relaxation rate, with greater response obtained in isoflurane-anesthetized horses. CONCLUSIONS AND CLINICAL RELEVANCE Right ventricular relaxation rate in horses is assessed best by use of a monoexponential decay model with zero asymptote and nonlinear regression. Intravenous administration of calcium gluconate to isoflurane-anesthetized horses best preserves myocardial relaxant function.
Collapse
Affiliation(s)
- T L Grubb
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana 61801, USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Affiliation(s)
- L E Davis
- Department of Neurology, Veterans Affairs Medical Center, University of New Mexico, School of Medicine, Albuquerque 87108, USA
| | | |
Collapse
|
47
|
Davis LE. Differentiation of atrioventricular blocks. J Perianesth Nurs 1998; 13:31-4. [PMID: 9543968 DOI: 10.1016/s1089-9472(98)80078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In closing, it has been the purpose of this article to present and elaborate on the types of AV blocks, their clinical significance and causes, nursing interventions, and treatments associated with their management. The nurse that has knowledge of these heart blocks will be well equipped and prepared to promptly treat a patient suffering from AV block.
Collapse
Affiliation(s)
- L E Davis
- Presbyterian Hospital, Albuquerque, New Mexico, USA
| |
Collapse
|
48
|
Adair JC, Hart BL, Kornfeld M, Graham GD, Swanda RM, Ptacek LJ, Davis LE. Autosomal dominant cerebral arteriopathy: neuropsychiatric syndrome in a family. Neuropsychiatry Neuropsychol Behav Neurol 1998; 11:31-9. [PMID: 9560826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Though familial vascular leukoencephalopathy was described two decades ago, recent studies focus on a disorder termed Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), a dominantly inherited disorder causing recurrent strokes and eventual dementia. The phenotypic boundaries of CADASIL remain indistinct and novel clinical features continue to arise in the literature. However, the associated histopathology is fairly consistent, typically demonstrating granular thickening of cerebral arterioles. The authors evaluated a 38-year-old man who suffered from progressive change in personality and intellect. His father, paternal aunt, and older sister had succumbed to a similar disorder. The authors examined relatives from three generations, including another sister with transient focal symptoms followed by persisting psychiatric disorder, and reviewed the radiographic studies from the propositus and his siblings. All the siblings showed diffuse white matter signal change on magnetic resonance imaging. Brain biopsy from the propositus revealed normal cortex and white matter but granular sclerosis of leptomeningeal arterioles. While the family's illness likely represents another instance of CADASIL, their presentation is unique because neuropsychiatric disorders predominate over focal ischemic symptoms.
Collapse
Affiliation(s)
- J C Adair
- Neurology Service, Albuquerque Veterans Affairs Medical Center, New Mexico 87108, USA
| | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
A study was undertaken in an urgent clinical setting to determine whether the use of a cerebrospinal fluid (CSF) to blood glucose ratio is appropriate for describing the relationships between CSF glucose and blood glucose in patients who had not fasted. Blood glucose levels were obtained before a lumbar puncture in 79 adults who had normal CSF findings. Regression analysis of CSF glucose and blood glucose levels of these patients who had not fasted, as well as data from four published studies of normal blood and CSF glucose levels, indicated that a ratio was not a valid measure of the normal relationship between CSF and blood. Only when the blood glucose level was between 89 and 115 mg/dL was the relationship within the expected "ratio" of 0.60 to 0.70. In hyperglycemic states, the normal relationship may be substantially lower than 0.50. a nomogram is presented which is useful in determining hypoglycorrhachia when the patient is hyperglycemic.
Collapse
Affiliation(s)
- B J Skipper
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | | |
Collapse
|
50
|
Abstract
Vasectomy is a safe, permanent, and inexpensive method of surgical sterilization for men. No-scalpel vasectomy is an innovative approach for exposing the vas deferens that is associated with fewer complications than the standard technique of vasectomy (incisional). It has been used in this country since 1986. The no-scalpel vasectomy, preoperative counseling, management of complications, and evaluation of the postvasectomy semen specimen are described.
Collapse
Affiliation(s)
- L E Davis
- Department of Family Medicine, University of Tennessee Graduate School of Medicine at Knoxville, Knoxville, Tennessee 37920, USA
| | | |
Collapse
|