N-of-1 medicine

ABSTRACT

The fields of precision and personalised medicine have led to promising advances in tailoring treatment to individual patients. Examples include genome/molecular alteration-guided drug selection, single-patient gene therapy design and synergy-based drug combination development, and these approaches can yield substantially diverse recommendations. Therefore, it is important to define each domain and delineate their commonalities and differences in an effort to develop novel clinical trial designs, streamline workflow development, rethink regulatory considerations, create value in healthcare and economics assessments, and other factors. These and other segments are essential to recognise the diversity within these domains to accelerate their respective workflows towards practice-changing healthcare. To emphasise these points, this article elaborates on the concept of digital health and digital medicine-enabled N-of-1 medicine, which individualises combination regimen and dosing using a patient's own data. We will conclude with recommendations for consideration when developing novel workflows based on emerging digital-based platforms.

Elevated serum antibodies against insulin-like growth factor-binding protein-2 allow detecting early-stage cancers: evidences from glioma and colorectal carcinoma studies

BACKGROUND

Tumor-specific immunity of insulin-like growth factor-binding protein-2 (IGFBP-2) has been reported in several cancers. We aimed to assess the role of serum IGFBP-2 antibodies (IGFBP-2 Abs) in early cancer detection.

PATIENTS AND METHODS

Glioma and colorectal carcinoma (CRC) were used as models. Serum IGFBP-2 and IGFBP-2 Abs were measured in 260 tumor patients (145 gliomas, 45 colorectal polyps, and 70 CRCs) and 141 controls. Receiver operating characteristic curves were applied.

RESULTS

Serum IGFBP-2 Ab levels were significantly elevated in tumors (mean: 82 ng/ml, median: 17 ng/ml, range: 0-1387 ng/ml) compared with controls (11, 0, 0-212 ng/ml) (P < 0.0001) and higher in early than advanced cancers opposite of serum IGFBP-2 levels. IGFBP-2 Abs effectively discriminated between controls and grade II and III gliomas [area under the curve (AUC): 0.821-0.864; 95% confidence interval (CI) = 0.762-0.936; P < 0.0001], and CRC I-II (AUC: 0.668; 95% CI = 0.566-0.770; P = 0.002) as well as indicative of advanced polyps at high risk of CRC (AUC: 0.72; 95% CI = 0.630-0.811; P < 0.0001). The sensitivity and specificity for diagnosing grade II-III gliomas reached 66%-84% and 81%. Combined serum IGFBP-2 and IGFBP-2 Abs augmented the discriminative power of all stage tumors (AUC: 0.823), gliomas (AUC: 0.800), and CRCs (AUC = 0.917).

CONCLUSION

Our results first demonstrate IGFBP-2 Abs for early cancer detection and in combination of serum IGFBP-2 for improved cancer diagnosis.

Clinical Feasibility of Multiplanar Reconstruction Images of Temporal Bone CT in the Diagnosis of Temporal Bone Fracture with Otic-Capsule-Sparing Facial Nerve Paralysis

The aim of this study is to evaluate the feasibility of multiplanar reconstructive (MPR) imaging of temporal bone CT in the diagnosis of temporal bone fracture with oticcapsule-sparing facial nerve paralysis. Twelve patients with traumatic facial nerve paralysis with otic-capsule sparing and temporal bone fractures were selected. Multiplanar reconstruction images were obtained with the V-works 4.0 software program (Cybermed, Seoul, Korea) using axial scanning of high-resolution temporal bone CT of the fracture line. The clinical profiles of the patients displaying temporal bone fractures were examined in relation to the findings. Multiplanar images of the fracture line provided information regarding the direction of the external force that fractured the temporal bone. The fracture line was more continuous in the MPR images than in the axial view. All patients showed an imaginary extended fracture line directed toward the otic capsule. The direction of the fracture line toward the middle ear cavity is important, as it may suggest insult to the otic capsule. The MPR image parallel to the fracture line of the temporal bone provides a guideline for the vector of the force that induced the fracture. Thorough investigation of the critical organs during surgical exploration is recommended if the direction of the fracture in the MPR image points toward the otic capsule in the middle ear even if the fracture line relative to the otic capsule is not well defined in the axial or CT view.

Pretreatment with calcitonin gene-related peptide attenuates hepatic ischemia/reperfusion injury in rats

OBJECTIVE

Oxygen free radicals and apoptosis play important roles in liver ischemia/reperfusion (I/R) injury. We sought to investigate the protective effect of calcitonin gene-related peptide (CGRP) to attenuate liver I/R injury due to oxygen free radicals and apoptosis.

MATERIALS AND METHODS

Harvested rat livers were perfused via the portal vein with 60 mL of 4 degrees C histidine-tryptophan-ketoglutarate (HTK) solution alone in the control group, or with the same solution containing CGRP (3 microg/10 g body weight) in the experimental group. After 24 hours of cold storage, hepatic enzyme leakage, portal venous pressure, oxygen consumption, total adenine nucleotides (TAN), bile production, lipoperoxide (LPO) release, apoptosis, and histochemical changes were evaluated upon 45 minutes of isolated reperfusion.

RESULTS

Compared with control livers, CGRP-treated organs showed significantly decreased alanine aminotransferase (ALT) and glutamate-lactate dehydrogenase (GLDH) leakage and portal venous pressure (2.0 +/- 0.3 vs 4.0 +/- 0.4 mmHg; P < .01), with significantly increased bile production (8.56 +/- 0.76 vs 3.34 +/- 0.68 microL/g/45 min; P < .01), oxygen consumption (5.14 +/- 0.4 vs 2.57 +/- 0.2 microL/g/min; P < .01), and total adenine nucleotides (TAN) (11.1 +/- 0.71 vs 7.02 +/- 0.53 micromol/g; P < .01) upon reperfusion as signs of recovered viability. We observed infrequent positive terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end labeling (TUNEL) staining, especially in sinusoidal lining cells (SLC). The percentage of TUNEL-positive cells in the CGRP group was significantly decreased compared with the control group: (4.1 +/- 0.67 vs 8.0 +/- 1.27; P < .05). Perfusate levels of low molecular weight (LMW) histone-associated DNA fragments (0.36 +/- 0.04 vs 0.53 +/- 0.06 AU; P < .05) were also decreased, coupled with strong 5'-nucleotidase (5'-NT) and LDH activity staining concentrated on the endothelial cells. LPO release in the perfusate was largely decreased: (0.12 +/- 0.02 vs 0.36 +/- 0.04 nmoL/g, P < .01).

CONCLUSION

CGRP ameliorated liver I/R injury due to reactive oxygen species and apoptosis.

Exogenous superoxide dismutase prevents peroxynitrite-induced apoptosis in non-heart-beating donor livers

OBJECTIVE

To investigate the role of oxygen free radicals in the induction of apoptosis in non-heart-beating donor (NHBD) livers, and if superoxide dismutase (SOD) ameliorates these alterations.

METHODS

Rat livers were perfused via the portal vein with histidine/tryptophan/alpha-ketoglutarate solution from heart-beating donors (HBD) or 60-min warm ischemia from NHBD, with or without the addition of SOD. After 24 h, cold storage livers were evaluated by isolated reperfusion.

RESULTS

NHBD showed significantly higher enzyme leakage and elevated portal venous pressure (PVP) versus HBD. Bile and total adenine nucleotides (TAN) were significantly decreased. Apoptosis was prominent in sinusoidal lining cells, coupled with strong nitrotyrosine staining (NTR). The concentrations of nitric oxide and lipoperoxides were largely increased. SOD medication reduced hepatic enzyme release by 30% and lipoperoxides by nearly 50%. Apoptosis and NTR were significantly decreased, and PVP was strikingly reduced to normal values. A 3-fold enhancement in bile production and 1.5-fold increase in TAN of the liver tissue were also observed.

CONCLUSION

NHBD livers are prone to severe reoxygenation injury promoted by oxygen free radicals, massive nitrite oxide production and peroxynitrite-induced apoptosis within the sinusoids. Antioxidant medication with SOD should be considered as a useful means of preserving NHBD livers.

Autoimmune dacryoadenitis and keratoconjunctivitis induced in rabbits by subcutaneous injection of autologous lymphocytes activated ex vivo against lacrimal antigens

Autologous peripheral blood lymphocytes (PBL), activated in a mixed cell reaction when co-cultured with purified rabbit lacrimal epithelial cells, are known to induce a Sjögren's-like autoimmune dacryoadenitis and keratoconjunctivitis when injected directly back into the donor animal's inferior lacrimal gland (LG). This study shows that autoreactive lymphocytes injected subcutaneously in a site away from the LG is capable of inducing an autoimmune disease in a rabbit. Induced disease (ID) develops more slowly, taking 4weeks as compared to 2weeks in the direct injection model. Initially, both clinical symptoms and histopathology are less pronounced than in the direct injection ID model, but later the immunocytochemistry shows the same CD4+/CD8+ ratio of 4:1 for both injection methods. The finding that lymphocytes activated against lacrimal antigens can travel or home from the injection site back to the inferior and superior LG, as well as the conjunctiva, suggests that these anatomical sites may have common epitopes that induce pathogenic CD4+ T cells that produce a Sjögren's-like syndrome.

Immunohistochemical detection of galectin-3 in canine gastric carcinomas

Galectin-3 was detected immunohistochemically in nine canine gastric carcinomas. In normal gastric tissue adjacent to the neoplasms, the gastric epithelial cells showed faint immunolabelling for galectin-3, but in all the tumours the neoplastic cells showed moderate to strong immunolabelling. Galectin-3 was localized in the cytoplasm of the normal mucosal cells, whereas it was found in both the cytoplasm and the nucleus of the neoplastic cells. Positive cells typically exhibited dark brown coloration of the nucleus or cytoplasm, without background labelling. The results suggest that galactin-3 has a pathophysiological role in canine gastric carcinoma.

Multifocal phototherapeutic keratectomy for the treatment of persistent epithelial defect

PURPOSE

To evaluate the use of multifocal phototherapeutic keratectomy (PTK) for the treatment of indolent and persistent epithelial defect (PED).

SETTING

Department of Ophthalmology, Kangnam St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea.

METHODS

Fifteen eyes diagnosed with PED were treated with Summit excimer laser PTK. In all patients (N = 15), the epithelium had previously failed to cover with at least 1 method of medical or surgical treatment. Multifocal ablations were delivered to the elevated margin surrounding the epithelial defect area using PTK with a diameter of 1.0 mm and depth of 150 to 200 pulse ablations. The mean follow-up was 17.7 months (range 9 to 37 months).

RESULTS

Complete reepithelialization occurred within 7 days in 13 eyes and within 11 days and 12 days in 1 eye each. All corneas except 1 remained healed for at least 9 months of follow-up. One eye had a recurrence 3 months after PTK and was retreated. Postoperative visual acuity improved in 8 eyes and was unaltered in 7.

CONCLUSION

Multifocal PTK with the 193 nm excimer laser is a safe, effective treatment for PED that is unresponsive to conventional therapy.

Comparison between of the attenuated BR-Oka and the wild type strain of Varicella Zoster Virus (VZV) on the DNA level

Oka strain VR-795 (Varicella Zoster Virus, VZV) of American Type Culture Collection (ATCC) has been used for chickenpox vaccine production. In order to use this strain for vaccine production, the strain must be identified and its stability must be confirmed. The identification of the Oka strain has been confirmed using Restriction Fragment Length Polymorphism (RFLP) and DNA sequence analysis of glycoprotein-II (gp-II). The amino acid sequences of Oka deduced from the DNA sequence of gp-II have changed at three amino acids against Ellen and at one amino acid against Webster. To prove the stability of the Oka strain during the passage, RFLP and DNA sequence analyses were also used with 11, 15 and 23 times of virus passage. We found that the Oka strain was stable at passages of up to 23 times, based on the RFLP and DNA sequence analyses. The confirmed Oka strain was renamed as BR-Oka for the purposes of chickenpox vaccine production.

Kinematics and laxity of the Souter-Strathclyde total elbow prosthesis

The motion pattern and laxity of 8 cadaveric elbows were recorded with a 3-dimensional electromagnetic tracking device before and after the Souter-Strathclyde total elbow prosthesis was implanted. The Souter-Strathclyde prosthesis replicates the valgus-varus motion pattern of the intact elbow but causes a significant internal rotation of the ulnar shaft of 8.9 degrees +/- 4.1 degrees (P < .0005) at 110 degrees of elbow flexion. One of the reasons for this unphysiological motion pattern is positioning of the humeral component in a mean of 5.4 degrees +/- 6.4 degrees of external rotation compared with the intact elbow (P = .05). This positioning is related to the design of this device. The Souter-Strathclyde elbow prosthesis has a mean maximum valgus-varus laxity of 6.5 degrees +/- 1.5 degrees compared with 4.3 degrees +/- 2.3 degrees for the intact elbow (P = .004). This implant is more constrained than previously tested devices, which may explain its relatively higher loosening rate.

Simultaneous determination of flupyrazofos and its metabolite 1-phenyl-3-trifluoromethyl-5-hydroxypyrazole and flupyrazofos oxon in rat plasma by high-performance liquid chromatography with ultraviolet absorbance detection

An isocratic high-performance liquid chromatography (HPLC) system with UV detection was developed for simultaneous determination of flupyrazofos and its metabolites, 1-phenyl-3-trifluoromethyl-5-hydroxypyrazole and flupyrazofos oxon, in rat plasma. Optimal analytical conditions involved an analytical cartridge column consisting of a phenyl bonded phase, a mobile phase of 50 mM phosphate buffer (pH3.0)-acetonitrile (40:60, v/v) and a UV detection wavelength of 232 nm. Under these conditions the peaks of flupyrazofos and its metabolites were all well separated and the total time for complete separation was less than 12 min. The limit of quantitation was 40 ng/ml for flupyrazofos and 20 ng/ml for PTMHP. Recoveries from rat plasma were higher than 90%. Following intravenous administration of flupyrazofos, the method has been successfully applied in a toxicokinetic study in rats involving plasma samples. Therefore, the current method is a valuable analytical tool for investigating the metabolism and toxicokinetics of flupyrazofos.

Enhancing effects of captafol on the development of GST-P-positive liver cell foci in a medium-term bioassay, and protection by L-cysteine of the enhancement in rats

The modifying effects of captafol and protective effects of L-cysteine on the development of glutathione S-transferase placental form-positive (GST-P +) foci of the liver and expression of proliferating cell nuclear antigen (PCNA) in the kidney were investigated in a medium-term bioassay using D-galactosamine (DGA) in rats. Male 6-week-old F344 rats were initially given a single i.p. injection (200 mg/kg) of diethylnitrosamine (DEN) and after 2 weeks on basal diet, received two i.p. injections of DGA (300 mg/kg) at the ends of weeks 2 and 5, and were fed a diet supplemented with test chemicals for weeks 3-8. Animals in group 1 were given 1500 ppm captafol in the diet, while group 2 received 1500 ppm captafol in diet as well as 1500 ppm L-cysteine in drinking water, animals in control group being given basal diet alone. Positive results regarding increased numbers and areas of GST-P + liver cell foci were obtained in rats treated with captafol alone. On the other hand, significant reduction by L-cysteine in the areas of GST-P + liver cell foci initiated by DEN and promoted by captafol was observed. In addition, the PCNA-labelling indices of renal tubule cells were elevated in rats treated with captafol alone and significantly reduced in rats treated simultaneously with L-cysteine. The protocol used in the present study therefore allowed the in vivo determination of promoting effects of captafol and inhibitory influence of L-cysteine by analyzing GST-P + foci in the livers as marker lesions, within a relatively short period of 8 weeks. Thus, this bioassay protocol could have applicability as a new in vivo assay system for the screening of hepatic carcinogenic or anti-carcinogenic agents.

A thermally induced alteration in lysosome membranes: salt permeability at 0 and 37 degrees C

Preparations of radioactive lysosomes were obtained from mouse kidney after injection of radioactive iodine-labeled bovine ribonuclease. Stability of these lysosomes in various media was estimated from measurements of proteolytic activity towards the ribonuclease, and of ribonuclease retention in particles. The lysosomes were stable at 37 degrees C in isotonic, sucrose-free solutions of KCl, NaCl, and potassium acetate, and in mixtures of these with MgCl2, showing that these salts are relatively impermeant through the lysosomal membranes. The membranes were less permeable to Na+ than to K+. Both KCl and NaCl exerted their optimal protective effects over a broad concentration range above 0.125 M in 0.025 M acetate buffer. Mg2+ enhanced the protective effect of both K4 and Na+; the osmotic effect of 0.075 M NaC1-0.05 M MgCl2 was indistinguishable during the entire course of ribonuclease digestion from that of isotonic sucrose. Osmotic protection by KC1-MgC12 was demonstrated over the H range5.5-7.0. A marked alteration in membrane properties occurs at lower temperatures in 0.11 M KC1-0.01 M MgCl2 such that, at 0 degrees C, K+ permeability is much higher than at 37 degrees C, as shown by a several-fold decrease in stability at the lower temperature.