AAV8 gene therapy reverses cardiac pathology and prevents early mortality in a mouse model of Friedreich's ataxia

Friedreich's ataxia (FRDA) is an autosomal-recessive disorder primarily attributed to biallelic GAA repeat expansions that reduce expression of the mitochondrial protein frataxin (FXN). FRDA is characterized by progressive neurodegeneration, with many patients developing cardiomyopathy that progresses to heart failure and death. The potential to reverse or prevent progression of the cardiac phenotype of FRDA was investigated in a mouse model of FRDA, using an adeno-associated viral vector (AAV8) containing the coding sequence of the FXN gene. The Fxnflox/null::MCK-Cre conditional knockout mouse (FXN-MCK) has an FXN gene ablation that prevents FXN expression in cardiac and skeletal muscle, leading to cardiac insufficiency, weight loss, and morbidity. FXN-MCK mice received a single intravenous injection of an AAV8 vector containing human (hFXN) or mouse (mFXN) FXN genes under the control of a phosphoglycerate kinase promoter. Compared to vehicle-treated FXN-MCK control mice, AAV-treated FXN-MCK mice displayed increases in body weight, reversal of cardiac deficits, and increases in survival without apparent toxicity in the heart or liver for up to 12 weeks postdose. FXN protein expression in heart tissue was detected in a dose-dependent manner, exhibiting wide distribution throughout the heart similar to wild type, but more speckled. These results support an AAV8-based approach to treat FRDA-associated cardiomyopathy.

The FGFR1 V561M Gatekeeper Mutation Drives AZD4547 Resistance through STAT3 Activation and EMT

FGFR1 has been implicated in numerous cancer types including squamous cell lung cancer, a subset of non-small cell lung cancer with a dismal 5-year survival rate. Small-molecule inhibitors targeting FGFR1 are currently in clinical trials, with AZD4547 being one of the furthest along; however, the development of drug resistance is a major challenge for targeted therapies. A prevalent mechanism of drug resistance in kinases occurs through mutation of the gatekeeper residue, V561M in FGFR1; however, mechanisms underlying V561M resistance to AZD4547 are not fully understood. Here, the cellular consequences of the V561M gatekeeper mutation were characterized, and it was found that although AZD4547 maintains nanomolar affinity for V561M FGFR1, based on in vitro binding assays, cells expressing V561M demonstrate dramatic resistance to AZD4547 driven by increased STAT3 activation downstream of V561M FGFR1. The data reveal that the V561M mutation biases cells toward a more mesenchymal phenotype, including increased levels of proliferation, migration, invasion, and anchorage-independent growth, which was confirmed using CyTOF, a novel single-cell analysis tool. Using shRNA knockdown, loss of STAT3 restored sensitivity of cancer cells expressing V561M FGFR1 to AZD4547. Thus, the data demonstrate that combination therapies including FGFR and STAT3 may overcome V561M FGFR1-driven drug resistance in the clinic. IMPLICATIONS: The V561M FGFR1 gatekeeper mutation leads to devastating drug resistance through activation of STAT3 and the epithelial-mesenchymal transition; this study demonstrates that FGFR1 inhibitor sensitivity can be restored upon STAT3 knockdown.

Illuminating the molecular mechanisms of tyrosine kinase inhibitor resistance for the FGFR1 gatekeeper mutation: the Achilles' heel of targeted therapy

Human fibroblast growth factor receptors (FGFRs) 1-4 are a family of receptor tyrosine kinases that can serve as drivers of tumorigenesis. In particular, FGFR1 gene amplification has been implicated in squamous cell lung and breast cancers. Tyrosine kinase inhibitors (TKIs) targeting FGFR1, including AZD4547 and E3810 (Lucitanib), are currently in early phase clinical trials. Unfortunately, drug resistance limits the long-term success of TKIs, with mutations at the "gatekeeper" residue leading to tumor progression. Here we show the first structural and kinetic characterization of the FGFR1 gatekeeper mutation, V561M FGFR1. The V561M mutation confers a 38-fold increase in autophosphorylation achieved at least in part by a network of interacting residues forming a hydrophobic spine to stabilize the active conformation. Moreover, kinetic assays established that the V561M mutation confers significant resistance to E3810, while retaining affinity for AZD4547. Structural analyses of these TKIs with wild type (WT) and gatekeeper mutant forms of FGFR1 offer clues to developing inhibitors that maintain potency against gatekeeper mutations. We show that AZD4547 affinity is preserved by V561M FGFR1 due to a flexible linker that allows multiple inhibitor binding modes. This is the first example of a TKI binding in distinct conformations to WT and gatekeeper mutant forms of FGFR, highlighting adaptable regions in both the inhibitor and binding pocket crucial for drug design. Exploiting inhibitor flexibility to overcome drug resistance has been a successful strategy for combatting diseases such as AIDS and may be an important approach for designing inhibitors effective against kinase gatekeeper mutations.

Discovery, synthesis, and molecular pharmacology of selective positive allosteric modulators of the δ-opioid receptor

Allosteric modulators of G protein-coupled receptors (GPCRs) have a number of potential advantages compared to agonists or antagonists that bind to the orthosteric site of the receptor. These include the potential for receptor selectivity, maintenance of the temporal and spatial fidelity of signaling in vivo, the ceiling effect of the allosteric cooperativity which may prevent overdose issues, and engendering bias by differentially modulating distinct signaling pathways. Here we describe the discovery, synthesis, and molecular pharmacology of δ-opioid receptor-selective positive allosteric modulators (δ PAMs). These δ PAMs increase the affinity and/or efficacy of the orthosteric agonists leu-enkephalin, SNC80 and TAN67, as measured by receptor binding, G protein activation, β-arrestin recruitment, adenylyl cyclase inhibition, and extracellular signal-regulated kinases (ERK) activation. As such, these compounds are useful pharmacological tools to probe the molecular pharmacology of the δ receptor and to explore the therapeutic potential of δ PAMs in diseases such as chronic pain and depression.

A Probabilistic Estimation of Fluoride Intake by Infants up to the Age of 4 Months from Infant Formula Reconstituted with Tap Water in the Fluoridated Regions of Ireland

Two probabilistic models were developed to estimate the acute and chronic exposure to fluoride of exclusively formula-fed infants aged 0-4 months as a result of the consumption of infant formula reconstituted with fluoridated tap water in Ireland. The estimates were based on calculated infant formula consumption and accepted body weight standards, together with reported concentrations of fluoride in infant formula powder and measured values for the fluoride content of water in Ireland. The mean acute exposure of infants to fluoride on any single day in areas served by 387 fluoridated water supplies was estimated to be between 0.11 and 0.14 mg/kg body weight depending on age group (95th percentiles 0.2 and 0.26 mg/kg b.w., respectively). These predicted intakes were well below the intake of fluoride associated with acute toxic effects, which is considered to be 5 mg fluoride (F(-))/kg body weight. The mean chronic exposure of infants to fluoride was estimated to be between 0.106 and 0.170 mg/kg b.w./day depending on body weight (95th percentiles 0.108 and 0.172 mg/kg b.w./day, respectively). This estimate described the average daily fluoride intake of infants during the first 4 months of life residing in the areas served by 226 water supplies that achieved an average yearly fluoride concentration below 1.03 mg/l. Dental fluorosis may be considered to be the only risk at these low doses and from our work it is estimated that there is a very low risk of moderate dental fluorosis of the permanent dentition in infants exposed to fluoride at these levels.

A review of cytologic findings in neuroendocrine carcinomas including carcinoid tumors with histologic correlation

BACKGROUND

The nosology of neuroendocrine neoplasia has evolved substantially in recent years. The aim of this study was to review the authors' institutional experience and diagnostic accuracy for cytologic specimens of neuroendocrine carcinoma (NEC) and to identify features most suggestive of neuroendocrine differentiation.

METHODS

The cytologic and histologic findings of 29 archival NEC in which cytology preceded biopsy or resection were compared. The study was comprised of 6 carcinoid tumors, 3 atypical carcinoid tumors, 17 high grade NEC (5 small cell, 9 large cell, and 3 mixed small/large cell), and 3 combined NEC/nonneuroendocrine carcinomas. Cytologic material was derived from 21 fine-needle aspirates (FNA), 6 bronchial brushing/washings, and 2 gastrointestinal tract brushings.

RESULTS

Of the 29 cases, the correct cytologic diagnosis was rendered in 11. Two cases were identified as NEC but were graded incorrectly. The remaining 16 cases were interpreted as nonsmall cell carcinoma (8 cases); diagnostic or suspicious of carcinoma, not otherwise specified (7 cases); and atypical, indeterminate for malignancy (1 case). On review, neuroendocrine features were identified in 14 of the latter 16 cases.

CONCLUSIONS

The cytologic diagnosis of NEC, both high and low grade, can be difficult. Because of acinus-like formations and columnar cell shapes, low grade NEC may be mistaken for adenocarcinoma. Small cell carcinomas, especially in bronchial brush and wash preparations, may be difficult to classify beyond malignant. Large cell NEC may be confused with nonneuroendocrine carcinomas because of abundant cytoplasm and nucleoli. Attention to the presence of loose cell aggregates in a background of singly dispersed cells; feathery patterns created by tumor cells clinging to capillaries; rosette formations; delicate, granular cytoplasm; inconspicuous nucleoli; molding in high grade tumors; and, most important, speckled or dusty chromatin patterns are useful in identifying neuroendocrine differentiation in cytologic specimens.

A randomized controlled trial to assess the incidence of new onset hypertension in patients after shock wave lithotripsy for asymptomatic renal calculi

PURPOSE

To answer the question of whether extracorporeal shock wave lithotripsy (ESWL*) induces hypertension, a prospective, randomized controlled trial of normotensive patients with asymptomatic renal calculi was designed.

MATERIALS AND METHODS

Patients were randomized to receive immediate ESWL versus observation, reserving ESWL for the onset of symptoms. The rates of new onset hypertension were evaluated for both groups.

RESULTS

There was no observed difference in the incidence of hypertension between the treatment and observation groups.

CONCLUSIONS

The risk of hypertension in patients undergoing ESWL therapy is similar to that of a control cohort of initially observed asymptomatic patients.

The cytopathology of synovial sarcoma: a study of six cases, with emphasis on architecture and histopathologic correlation

BACKGROUND

In this article, the architectural and cytologic features of synovial sarcoma are described.

METHODS

Romanowsky- and Papanicolaou-stained fine-needle aspiration smears and corresponding hematoxylin and eosin sections were retrieved from archival material and examined by light microscopy.

RESULTS

Microtissue fragments comprised of spindle cells dominated smears and correlated with fibrosarcoma-like areas prevalent in tissue sections. Characteristic fascicular and whorled patterns were apparent, and matrix material representing collagenous stroma varied from fibrillary to hyalinized. Epithelial components included polygonal and rectangular cells isolated from spindle cells, gland-like formations occurring within otherwise spindle cell microtissue fragments, and clubbed, spindle cell collections lined by flattened epithelial cells.

CONCLUSIONS

Features of synovial sarcoma as defined previously by histopathology were apparent in cytologic preparations, facilitating a primary diagnosis by cytology.

Biosensor for neurotransmitter L-glutamic acid designed for efficient use of L-glutamate oxidase and effective rejection of interference

An amperometric biosensor for L-glutamic acid (Glu) was constructed by the adsorption and dip coating of L-glutamate oxidase (GluOx, 200 U ml-1 phosphate buffer, pH 7.4) onto 60-micron radius Teflon-coated Pt wire (1 mm exposed length). The enzyme was then trapped on the surface by electropolymerisation of o-phenylenediamine that also served to block electroactive interference. This procedure afforded electrodes with similar substrate sensitivity compared with the classical approach of immobilising enzyme from a solution of monomer, and represents an approximately 10,000-fold increase in the yield of biosensors from a batch of enzyme. A number of strategies were examined to enhance the sensitivity and selectivity of the Pt/PPD/GluOx sensors operating at 0.7 V versus SCE. Pre-coating the Pt with lipid and incorporation of the protein bovine serum albumin into the polymer matrix were found to improve the performance of the electrode. The sensors had a fast response time, high sensitivity to Glu, with an LOD of about 0.3 mumol l-1, and possessed selectivity characteristics suggesting that monitoring Glu in biological tissues in vivo may be feasible.

PAPNET-directed rescreening of cervicovaginal smears: a study of 101 cases of atypical squamous cells of undetermined significance

Many women having cervicovaginal smears interpreted as atypical squamous cells of undetermined significance (ASCUS) ultimately prove to harbor squamous intraepithelial lesions (SIL). The question is whether rare cells diagnostic of SIL are present in so-called "atypical" smears, but simply go undetected. To test whether the PAPNET Cytological Screening System, an automated system, can detect the (assumed) presence of such cells, six reviewers independently evaluated PAPNET video images generated for 101 cases conventionally diagnosed as ASCUS. Using PAPNET-identified microscopic coordinates, selected cases were then manually reviewed and reclassified according to consensus opinion. Overall, 35 cases were reclassified as SIL (22 low grade; 13 high grade). Histologic correlations showed 37 of the 101 cases conventionally interpreted as ASCUS carried tissue diagnoses of SIL, (28 low grade; 8 high grade, 1 ungraded). Using PAPNET, 24 of the 37 (65%) corresponding smears were reclassified as SIL (15 low grades; 9 high grade).

Laboratory detection of anaerobic bacteremia

The possibility that mycobacteria may be found in blood cultures is a relatively recent discovery. Immunocompromised patients, especially those with advanced HIV infection, are often mycobacteremic with Mycobacterium tuberculosis or M. avium complex. Laboratory methods provide sensitive detection options for these pathogens.

Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy

The potential for variability among observers interpreting diagnostic tests is well known but has not been well established for radiological imaging of urolithiasis. We measured the inter-observer and intra-observer variability in the reporting of plain abdominal films and tomograms from patients who had undergone extracorporeal shock wave lithotripsy (ESWL). Unlabeled copies of the plain abdominal films and tomograms for 58 patients were individually submitted to 3 different radiologists. Selected films from 25 patients were resubmitted to the same radiologists. We found differences among radiologists reporting plain abdominal films alone 52% of the time and even by the same radiologist rereading the films 24% of the time. Tomograms alone decreased the uncertainty but differences still occurred among radiologists 24% of the time and with themselves 16% of the time. When plain abdominal films and tomograms were read together there were differences among radiologists 28% of the time and with themselves 7% of the time but these were usually minor. We concluded from this study that the plain abdominal film alone was frequently difficult to interpret, resulting in uncertainty about the presence or absence of residual stone fragments. Tomograms alone or a plain abdominal film plus tomograms is superior to a plain abdominal film alone. Finally, radiological assessment with all modalities probably overestimates stone-free rates after ESWL even without consideration of the potential for reporting variability among observers.

The pharmacy technician--an occupation in search of consensus

These are some of the issues that warrant consideration as we examine the development of a more efficient manpower model for pharmacy. We all realize that we have reached a point in the delivery of health services where inefficiency will have a very direct impact on economic viability. It is imperative that we develop a more rational manpower model that takes advantage of appropriately trained supportive personnel who will be functioning in an environment greatly influenced by advancing technology. As we develop our manpower model, we should also understand that pharmacy is still evolving as a profession. It, too, has problems in identifying uniform standards of practice. We in academia have not yet reached agreement on the appropriate degree required to prepare individuals for the present and future practice of pharmacy. In spite of our inability to reach consensus on a number of important issues, we continue to realize an expansion of our professional roles. As these gains in professionalization continue, we will most likely see a concomitant need for growth in the support base required by pharmacists. This need will be met by either technicians or technology. One of my favorite quotes is taken from a book title by humorist and author Lewis Grizzard: Shoot Low Boys--They're Riding Shetland Ponies. Just as the imaginary speaker above was telling his companions to change their frame of reference, I believe we, too, must change our frame of reference.

Current and future delegation of pharmacy activities to technicians in Tennessee

Pharmacists in charge of community and institutional pharmacies in Tennessee were surveyed to identify which activities they currently delegate to technicians and which activities they might consider delegating in the future. Survey questionnaires were mailed to all pharmacists-in-charge registered with the board of pharmacy. Respondents were asked to indicate which of 38 listed pharmacy activities were currently delegated to technicians and which currently undelegated activities would be delegated in the future if legal and policy barriers were removed and if technician training programs were available. Respondents also ranked six types of technician training programs in order of preference and were asked whether they thought technicians should receive official recognition through certification or licensure. A total of 947 questionnaires were returned, for a response rate of 62%. Of the 24 activities that were delegated by significantly different numbers of pharmacists in community and institutional settings, 23 were delegated more frequently by institutional pharmacists. Activities related to drug therapy were delegated least frequently by either group, although community pharmacists delegated the task of recommending nonprescription drugs more often than did institutional pharmacists. If barriers were removed and training programs were available, more pharmacists would delegate activities to technicians than currently do. Most respondents preferred a formal, in-house training program for technicians; more than 65% of pharmacists favored certification of technicians. Pharmacists in Tennessee currently delegate a number of activities to technicians, and more pharmacists would do so if barriers toward technician use were removed and if more trained technicians were available.

Intraspinal opiates for treatment of intractable pain in the terminally ill cancer patient

The discovery of opiate receptors and then their endogenous ligands in 1974 (Snyder et al., 1974) has elucidated a vast pharmacology of opiates providing a basis for their diverse clinical applications. With the awareness of quality of life as a primary goal in terminal cancer patients, widespread attention has been drawn to the direct delivery of long-term intraspinal analgesics to cancer patients for who all medical pain control regimens have failed (Coombs & Saunders, 1974). Intraspinal administration of opiates and nonopiate analgesics is not only appealing on theoretical grounds but provides a minimally invasive method to insure otherwise unobtainable pain relief while eliminating obtundation and systemic side-effects associated with conventional therapy (Cobb et al., 1984; Harbaugh et al., 1982; Leavens et al., 1982; Malone et al., 1985; Onofrie et al., 1981; Poletti et al., 1981). Although intraspinal opiates have been used in the treatment of postoperative and benign-pain syndromes (Asari et al., 1981; Cousins & Mather, 1984), in our discussion we review the basic science, current techniques and possible future improvements in spinal analgesia in the control of chronic cancer pain.

Hospital pharmacists' evaluation of drug wholesaler services

Services provided by drug wholesalers were evaluated by hospital pharmacists. A survey was mailed to 1500 randomly selected pharmacy directors. Respondents indicated availability and use of 26 customer services. Pharmacists rated the services that they used on the basis of importance of the service and satisfaction with the service. The 644 returned questionnaires indicated that most services were available to a large majority of respondents. Most services used were rated as important or essential. Most respondents were satisfied with wholesaler services; the service with which the most respondents were dissatisfied was stocking of pharmaceuticals in single-unit packaging. Of other services that were widely used and rated important, prompt crediting for delivery errors, few out-of-stock items, frequent pickup of return merchandise, and stocking of injectable pharmaceuticals received low satisfaction ratings. Same-day delivery service and emergency delivery of prescription items were unavailable to more than 40% of respondents. Hospital pharmacists were generally satisfied with services provided by drug wholesalers. Wholesalers should be aware of the particular service needs of hospital pharmacists, and further studies of these needs should be conducted.

The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators

The use of an improper technique with metered-dose inhalers decreases the efficacy of the bronchodilators being administered. There is evidently a need for patients to watch a demonstration. Twenty-nine adult asthmatic patients from an allergy clinic were divided into three groups, each receiving a different form of instruction: an information sheet, personal instruction or a videotape presentation. Subsequently each patient was tested for correct use of the inhaler. There was no difference in mean scores for inhalation technique between the groups instructed in person and by videotape, but both were significantly better than the mean score of the group given only an information sheet. There was also no significant change in the scores at a follow-up test in the groups who saw the technique demonstrated. These results indicate the need for and value of the demonstration of proper technique with pressurized inhalers. A pharmacy-generated education system using videotape equipment or personal instruction by a pharmacist could readily solve the problem.

Content and retention evaluation of an audiovisual patient-education program on bronchodilators

A study was conducted to: (1) evaluate the effect of a slide-tape program on patients' short-term and long-term knowledge about their bronchodilator medications; and (2) determine it any differences exist in learning or retention patterns for different content areas of drug information. The knowledge of 30 patients was measured using a randomized sequence of three comparable 15-question tests. The first test was given before the slide-tape program was presented, the second test within 24 hours, and the last test one to six months (mean = 2.8 months) later. Scores attained on the first posttest were significantly higher (p less than 0.001) than pretest scores. Learning differences among drug-information-content areas were not evidenced on the first posttest. No significant difference was demonstrated between scores on pretest and last posttest (p = 0.100). However, retention patterns among content areas were found to differ significantly (p less than 0.05). Carefully designed audiovisual programs can impart drug information to patients. Medication counseling should be repeated at appropriate opportunities because patients lose drug knowledge over time.

Long-term effects of a cancer awareness program for community pharmacists

A continuing education program resulted in a 52% improvement in the specified professional behaviors of community pharmacists within one month. However, surveyed effects were not permanent and decreased significantly within 18 months. Following a simple mailing of specially designed literature, desired behaviors again underwent significant improvement comparable to that attributed to the original continuing education program. A better understanding of professional behaviors as functions of time and different educational modes would be invaluable to educators in both academic and postgraduate programs.

Bid purchasing of pharmaceuticals

The effects of bid purchasing of drug products by hospitals and the factors to consider in bid purchasing of pharmaceuticals are reviewed; further, the prices available with bid purchasing to a specific hospital in 1974 and 1977 are presented. Factors important for a successful bid purchasing system of pharmaceuticals are: (1) use of a formulary policy, (2) an effective procedure for handling bid purchasing and (3) criteria for evaluation of drug products. Significant differences were found between prices available with and without bid purchasing for 50 nonproprietary drug products in 1974 and for 19 products in 1977. Although monetary savings to hospitals do exist with bid purchasing of pharmaceuticals, the degree of savings is dependent upon the drug usage for that hospital.

Taste preference test for oral liquid theophylline preparations

Taste preferences among three oral liquid theophylline preparations were evaluated in 54 males. The products tested, and their theophylline concentrations, were Elixophyllin Pediatric Suspension (Cooper Laboratories, Inc.), 100 mg/5 ml; Somophyllin Oral Liquid (Fisons Corporation), 90 mg/5 ml; and Theophyl-225 Elixir (Knoll Pharmaceutical Company), 37.5 mg/5 ml. Generally-recommended procedures for taste tests were followed. The results indicated a taste preference for Theophyl-225 Elixir, followed by Elixophyllin Pediatric Suspension, followed by Somophyllin Oral Liquid. The results were statistically significant (p = 0.05). Product concentration and formulation were suggested to be major factors in determining taste preference.

Nursing attitudes toward oral liquid unit dose packaging

Nurses' attitudes toward three types of oral liquid unit dose packages--glass, plastic and aluminum--were determined. Thirty nurses who previously had not used unit dose packaging on their units were asked to evaluate the three types of packaging. The nurses preferred both aluminum and plastic over the glass containers; there was no significant difference in attitude toward the plastic and aluminum packages.

Potential economic effets of a brand standardization policy in a 1000-bed hospital

The potential economic effects of a brand standardization policy on 50 multiple source, nonproprietary drugs in a 1000-bed hospital which uses a unit dose drug distribution system were studied. Inpatient drug usage cost and inpatient drug inventory cost for the year 1974 were compared under the existing nonformulary system and a simulated formulary system of brand standardization. Drug usage cost was defined as expenditures made by the study hospital for drugs which were administered. Drug inventory cost was defined as the dollar value of drug inventory being stored for use in the hospital. Potential saving in excess of $35,000 for drug usage cost and $9,000 for drug inventory cost could have been realized with a brand standardization policy on 50 nonprietary drugs. The differences in costs were significant at the 0.005 level. It is concluded that a brand standardization policy can be effective means of reducing drug usage cost and drug inventory cost in a large hospital.

Pharmacist and physician evaluation of drug information sources

A survey was conducted to compare how pharmacists and physicians in Tennessee rated six sources of drug information (journals, textbooks, physicians, pharmacists, the Physicians' Desk Reference and detail men) in nine different categories. A one-page questionnaire was mailed to a 10% random sample of pharmacists and physicians. The physicians rated professional journals and the PDR consistently good and rated the pharmacist poor as a source of drug information. Pharmacists rated textbooks good and rated physicians poor for some categories of information. Both groups found the available information in certain categories to be inadequate.