1
|
McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Adjunctive Systemic Corticosteroids for Pulmonary Exacerbations of Cystic Fibrosis. Ann Am Thorac Soc 2024; 21:716-726. [PMID: 38096105 DOI: 10.1513/annalsats.202308-673oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale: Pulmonary exacerbations (PEx) remain the most common cause of morbidity, recurrent hospitalization, and diminished survival in people with cystic fibrosis (PWCF) and are characterized by excess inflammation. Corticosteroids are potent, widely available antiinflammatory drugs. However, corticosteroid efficacy data from randomized controlled trials in PWCF are limited. Objectives: To determine whether adjunctive systemic corticosteroid therapy is associated with improved outcomes in acute CF PEx. Methods: We performed a secondary analysis of Standardized Treatment of Pulmonary Exacerbations 2 (STOP2), a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx, that included the use of corticosteroids as a stratification criterion in its randomization protocol. Corticosteroid treatment effects were determined after propensity score matching for covariates including age, sex, baseline forced expiratory volume in 1 second (FEV1), genotype, and randomization arm. The primary outcome measure was the change in percentage predicted FEV1 (ppFEV1). Symptoms, time to next PEx, and the incidence of adverse events (AEs) and serious adverse events (SAEs) were assessed as secondary endpoints. Phenotypic factors associated with the clinical decision to prescribe steroids were also investigated. Results: Corticosteroids were prescribed for 168 of 982 PEx events in STOP2 (17%). Steroid prescription was associated with decreased baseline ppFEV1, increased age, and female sex. Cotreatment with corticosteroids was independent of treatment arm allocation and did not result in greater mean ppFEV1 response, longer median time to next PEx, or more substantial symptomatic improvement compared with propensity-matched PWCF receiving antibiotics alone. AEs were not increased in corticosteroid-treated PWCF. The total number of SAEs-but not the number of corticosteroid-related or PEx-related SAEs-was higher among patients receiving corticosteroids. Conclusions: Empiric, physician-directed treatment with systemic corticosteroids, although common, is not associated with improved clinical outcomes in PWCF receiving antibiotics for PEx. Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
Collapse
Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Patrick A Flume
- Department of Pediatrics and
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
| |
Collapse
|
2
|
Zemanick ET, Emerman I, McCreary M, Mayer-Hamblett N, Warden MN, Odem-Davis K, VanDevanter DR, Ren CL, Young J, Konstan MW. Heterogeneity of CFTR modulator-induced sweat chloride concentrations in people with cystic fibrosis. J Cyst Fibros 2024:S1569-1993(24)00015-8. [PMID: 38360461 DOI: 10.1016/j.jcf.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Sweat chloride (SC) concentrations in people with cystic fibrosis (PwCF) reflect relative CF transmembrane conductance regulator (CFTR) protein function, the primary CF defect. Populations with greater SC concentrations tend to have lesser CFTR function and more severe disease courses. CFTR modulator treatment can improve CFTR function within specific CF genotypes and is commonly associated with reduced SC concentration. However, SC concentrations do not necessarily fall to concentrations seen in the unaffected population, suggesting potential for better CFTR treatment outcomes. We characterized post-modulator SC concentration variability among CHEC-SC study participants by genotype and modulator. METHODS PwCF receiving commercially approved modulators for ≥90 days were enrolled for a single SC measurement. Clinical data were obtained from chart review and the CF Foundation Patient Registry (CFFPR). Variability of post-modulator SC concentrations was assessed by cumulative SC concentration frequencies. RESULTS Post-modulator SC concentrations (n = 3787) were collected from 3131 PwCF; most (n = 1769, 47 %) were collected after elexacaftor/tezacaftor/ivacaftor (ETI) treatment. Modulator use was associated with lower SC distributions, with post-ETI concentrations the lowest on average. Most post-ETI SC concentrations were <60 mmol/L (79 %); 26 % were <30 mmol/L. Post-ETI distributions varied by genotype. All genotypes containing at least one F508del allele had individuals with post-ETI SC ≥60 mmol/L, with the largest proportion being F508del/minimal function (31 %). CONCLUSIONS Post-modulator SC concentration heterogeneity was observed among all genotypes and modulators, including ETI. The presence of PwCF with post-modulator SC concentrations within the CF diagnostic range suggests room for additional treatment-associated CFTR restoration in this population.
Collapse
Affiliation(s)
- E T Zemanick
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA, United States
| | - M McCreary
- Seattle Children's Hospital, Seattle, WA, United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA, United States; University of Washington, Seattle, WA, United States
| | - M N Warden
- Seattle Children's Hospital, Seattle, WA, United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA, United States
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA, United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| |
Collapse
|
3
|
Nichols D, Gifford A, Russell R, Odem-Davis K, Young J, Amaro-Galvez R, Billings J, Mukadam Z, Mayer-Hamblett N. Assessing Safety of Discontinuing Hypertonic Saline in Those with Lower Forced Expiratory Volume in 1 Second after Elexacaftor/Tezacaftor/Ivacaftor. Ann Am Thorac Soc 2024; 21:360-362. [PMID: 38019099 DOI: 10.1513/annalsats.202308-735rl] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
| | | | - Renee Russell
- Seattle Children's Research Institute Seattle, Washington
| | | | - Julia Young
- Seattle Children's Research Institute Seattle, Washington
| | | | | | | | - Nicole Mayer-Hamblett
- University of Washington Seattle, Washington
- TDN Coordinating Center Seattle Children's Research Institute Seattle, Washington
| |
Collapse
|
4
|
McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Impact of lumacaftor/ivacaftor and tezacaftor/ivacaftor on treatment response in pulmonary exacerbations of F508del/F508del cystic fibrosis. J Cyst Fibros 2023; 22:875-879. [PMID: 37407341 PMCID: PMC10761587 DOI: 10.1016/j.jcf.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) remain a major cause of morbidity and mortality in people with cystic fibrosis (PWCF). Although the combination cystic fibrosis transmembrane conductance regulator (CFTR) modulators lumacaftor/ivacaftor and tezacaftor/ivacaftor have been shown to reduce PEx frequency, their influence on clinical and biochemical responses to acute PEx treatment is unknown. METHODS We performed a secondary analysis of STOP2, a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx. Propensity score matching was used to compare outcomes in antibiotic-treated F508del/F508del PWCF receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor with those observed in antibiotic-treated F508del/F508del controls not receiving CFTR modulator therapy. The primary outcome measure was the change in percent predicted FEV1 (ppFEV1) following completion of intravenous (IV) antibiotics, with post-antibiotic changes in symptoms, serum C-reactive protein (CRP) concentrations and weight included as secondary endpoints. RESULTS Among 982 PEx events in randomized PWCF, 480 were homozygous for F508del, of whom 289 were receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor at initiation of antibiotic therapy. Modulator-treated F508del/F508del PWCF did not demonstrate greater improvements in ppFEV1, symptoms, serum CRP or weight following antibiotic treatment compared to modulator-naïve controls matched for age, sex, baseline ppFEV1, genotype, body mass index, initial CRP, initial symptoms, exacerbation history, diabetic status, randomization arm and concomitant medical therapy. CONCLUSION In the acute setting, CFTR modulator therapy with lumacaftor/ivacaftor or tezacaftor/ivacaftor does not convey additional clinical or biochemical advantage above standardized PEx treatment in F508del/F508del PWCF.
Collapse
Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis IN, United States
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH, United States
| | - Patrick A Flume
- Department of Pediatrics, Medical University of South Carolina, Charleston SC, United States; Department of Medicine, Medical University of South Carolina, Charleston SC, United States
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States; Department of Pediatrics, University of Washington, Seattle WA, United States.
| |
Collapse
|
5
|
VanDevanter DR, Zemanick ET, Konstan MW, Ren CL, Odem-Davis K, Emerman I, Young J, Mayer-Hamblett N. Willingness of people with cystic fibrosis receiving elexacaftor/tezacaftor/ivacaftor (ETI) to participate in randomized modulator and inhaled antimicrobial clinical trials. J Cyst Fibros 2023; 22:652-655. [PMID: 37100705 PMCID: PMC10523954 DOI: 10.1016/j.jcf.2023.04.007] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To assess the feasibility of enrolling people with CF (pwCF) taking the CFTR modulator elexacaftor/tezacaftor/ivacaftor (ETI) in clinical trials of a new modulator. METHODS PwCF receiving ETI at CHEC-SC study (NCT03350828) enrollment were surveyed for interest in 2-week to 6-month placebo- (PC) and active-comparator (AC) modulator studies. Those taking inhaled antimicrobials (inhABX) were surveyed for interest in PC inhABX studies. RESULTS Of 1791 respondents, 75% [95% CI 73, 77] would enroll in a 2-week PC modulator study versus 51% [49, 54] for a 6-month study; 82% [81, 84] and 63% [61, 65] would enroll in 2-week and 6 month AC studies; 77% [74, 80] of 551 taking inhABX would enroll in a 2-week PC inhABX study versus 59% [55, 63] for a 6-month study. Previous clinical trial experience increased willingness. CONCLUSIONS Study designs will affect feasibility of future clinical trials of new modulators and inhABX in people receiving ETI.
Collapse
Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH United States.
| | - E T Zemanick
- University of Colorado, Anschutz Medical Campus, Aurora CO United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH United States; Rainbow Babies and Children's Hospital, Cleveland, OH United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA United States
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA United States; University of Washington, Seattle, WA United States
| |
Collapse
|
6
|
Mayer-Hamblett N, Ratjen F, Russell R, Donaldson SH, Riekert KA, Sawicki GS, Odem-Davis K, Young JK, Rosenbluth D, Taylor-Cousar JL, Goss CH, Retsch-Bogart G, Clancy JP, Genatossio A, O'Sullivan BP, Berlinski A, Millard SL, Omlor G, Wyatt CA, Moffett K, Nichols DP, Gifford AH. Discontinuation versus continuation of hypertonic saline or dornase alfa in modulator treated people with cystic fibrosis (SIMPLIFY): results from two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials. Lancet Respir Med 2023; 11:329-340. [PMID: 36343646 PMCID: PMC10065895 DOI: 10.1016/s2213-2600(22)00434-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reducing treatment burden is a priority for people with cystic fibrosis, whose health has benefited from using new modulators that substantially increase CFTR protein function. The SIMPLIFY study aimed to assess the effects of discontinuing nebulised hypertonic saline or dornase alfa in individuals using the CFTR modulator elexacaftor plus tezacaftor plus ivacaftor (ETI). METHODS The SIMPLIFY study included two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials at 80 participating clinics across the USA in the Cystic Fibrosis Therapeutics Development Network. We included individuals with cystic fibrosis aged 12-17 years with percent predicted FEV1 (ppFEV1) of 70% or more, or those aged 18 years or older with ppFEV1 of 60% or more, if they had been taking ETI and either (or both) mucoactive therapies (≥3% hypertonic saline or dornase alfa) for at least 90 days before screening. Participants on both hypertonic saline and dornase alfa were randomly assigned to one of the two trials, and those on a single therapy were assigned to the applicable trial. All participants were then randomly assigned 1:1 to continue or discontinue therapy for 6 weeks using permuted blocks of varying size, stratified by baseline ppFEV1 (week 0; ≥90% or <90%), single or concurrent use of hypertonic saline and dornase alfa, previous SIMPLIFY study participation (yes or no), and age (≥18 or <18 years). For participants randomly assigned to continue their therapy during a given trial, this therapy was instructed to be taken at least once daily according to each participant's pre-existing, clinically prescribed regimen. Hypertonic saline concentration was required to be at least 3%. The primary objective for each trial was to determine whether discontinuing was non-inferior to continuing, measured by the 6-week change in ppFEV1 in the per-protocol population. We established a non-inferiority margin of -3% for the difference between groups in the 6-week change in ppFEV1. Safety outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04378153. FINDINGS From Aug 25, 2020, to May 25, 2022, a total of 672 unique participants were screened for eligibility for one or both trials, resulting in 847 total random assignments across both trials with 594 unique participants. 370 participants were randomly assigned in the hypertonic saline trial and 477 in the dornase alfa trial. Participants across both trials had an average ppFEV1 of 96·9%. Discontinuing treatment was non-inferior to continuing treatment with respect to the absolute 6-week change in ppFEV1 in both the hypertonic saline trial (-0·19% [95% CI -0·85 to 0·48] in the discontinuation group [n=133] vs 0·14% [-0·51 to 0·78] in the continuation group [n=140]; between-group difference -0·32% [-1·25 to 0·60]) and dornase alfa trial (0·18% [-0·38 to 0·74] in the discontinuation group [n=199] vs -0·16% [-0·73 to 0·41] in the continuation group [n=193]; between-group difference 0·35% [-0·45 to 1·14]), with consistent results in the intention-to-treat populations. In the hypertonic saline trial, 64 (35%) of 184 in the discontinuation group versus 44 (24%) of 186 participants in the continuation group and, in the dornase alfa trial, 89 (37%) of 240 in the discontinuation group versus 55 (23%) of 237 in the continuation group had at least one adverse event. INTERPRETATION In individuals with cystic fibrosis on ETI with relatively well preserved pulmonary function, discontinuing daily hypertonic saline or dornase alfa for 6 weeks did not result in clinically meaningful differences in pulmonary function when compared with continuing treatment.
Collapse
Affiliation(s)
- Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
| | - Felix Ratjen
- Translational Medicine Research Institute, The Hospital for Sick Children, Toronto, ON, Canada; Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Renee Russell
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory S Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Julia K Young
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Daniel Rosenbluth
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jennifer L Taylor-Cousar
- Department of Internal Medicine, National Jewish Health, Denver, CO, USA; Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Christopher H Goss
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Brian P O'Sullivan
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Ariel Berlinski
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Susan L Millard
- Department of Pediatrics, Spectrum Health, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Gregory Omlor
- Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
| | - Colby A Wyatt
- Department of Pediatrics, The Barbara Bush Children's Hospital, Maine Medical Center, Portland, ME, USA
| | - Kathryn Moffett
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - David P Nichols
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alex H Gifford
- Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| |
Collapse
|
7
|
Mayer-Hamblett N, Zemanick ET, Odem-Davis K, VanDevanter D, Warden M, Rowe SM, Young J, Konstan MW, For-The-Chec-Sc-Study-Group. Characterizing CFTR modulated sweat chloride response across the cf population: Initial results from the CHEC-SC study. J Cyst Fibros 2023; 22:79-88. [PMID: 35871974 PMCID: PMC10103635 DOI: 10.1016/j.jcf.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/24/2022] [Accepted: 07/12/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND CHEC-SC is an ongoing epidemiologic study characterizing modulator-induced sweat chloride (SC) responses across the CF population, with interim results available prior to the availability of triple combination modulator therapy. METHODS Eligible participants had been prescribed a modulator for ≥90 days with re-enrollment allowed upon establishment of a new modulator. Pre-modulator SC values were obtained from chart review; post-modulator sweat was collected and analyzed locally. SC changes were descriptively summarized with biologic sex effects adjusted for age, weight, and CFTR genotype. Heterogeneity in ivacaftor SC response was characterized in relation to published CFTR functional responses. RESULTS 1848 participants provided 2004 SC measurements, 26.2% on ivacaftor, 39.1% on lumacaftor/ivacaftor, and 34.7% on tezacaftor/ivacaftor. Average SC changes for all modulators were consistent with those reported in previous clinical studies, with greater variation in SC response observed among rarer mutations and notable shifts in the proportion with SC <60mmol/L independent of the magnitude of SC change. Ivacaftor induced in vitro CFTR functional change was significantly correlated with ivacaftor-modulated SC response (Pearson correlation= ‒0.52, 95% CI: ‒0.773, ‒0.129). Average SC change from ivacaftor to tezacaftor/ivacaftor was ‒4.9 mmol/L (n=17,95% CI:‒9.3, ‒0.5) and differed from those switching from lumacaftor/ivacaftor (10.0 mmol/L, n=139, 95% CI:7.8,12.3). Sex at birth was not associated with SC response. CONCLUSIONS CHEC-SC is the largest study characterizing modulator-induced SC changes across the CF population. There was a strong association between ivacaftor induced in vitro CFTR function and SC response across a genotypically heterogenous cohort. Biological sex was not associated with SC response.
Collapse
Affiliation(s)
- N Mayer-Hamblett
- University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
| | - E T Zemanick
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA, United States
| | - D VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - M Warden
- Seattle Children's Hospital, Seattle, WA, United States
| | - S M Rowe
- University of Alabama at Birmingham, Birmingham, AL, England
| | - J Young
- Seattle Children's Hospital, Seattle, WA, United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | | |
Collapse
|
8
|
Solomon G, Suzuki S, Hathorne H, Barilla C, Wang B, Rab A, Manfredi C, Joshi D, Brewington J, Stecenko A, Driggers W, Bai S, Hunter E, Streby A, Hong J, Odem-Davis K, Davis B, Sorscher E, Linnemann R. 606 Focused clinical trials of modulator response for rare cystic fibrosis genotypes. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)01296-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
9
|
Guimbellot J, Natt J, Ryan K, Dowell A, Odem-Davis K, Konstan M, Zemanick E, Mayer-Hamblett N, Acosta E. 261 Concentrations of elexacaftor/tezacaftor/ivacaftor in the cystic fibrosis population: Interim analysis of the CHEC-Pharmacokinetics study. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00951-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
10
|
Zemanick ET, Konstan MW, VanDevanter DR, Rowe SM, Clancy JP, Odem-Davis K, Skalland M, Mayer-Hamblett N. Measuring the impact of CFTR modulation on sweat chloride in cystic fibrosis: Rationale and design of the CHEC-SC study. J Cyst Fibros 2021; 20:965-971. [PMID: 33573995 DOI: 10.1016/j.jcf.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Characterizing CFTR Modulated Changes in Sweat Chloride and their Association with Clinical Outcomes (CHEC-SC) study is a large epidemiologic study designed to determine the relationship between sweat chloride response and clinical outcomes in people with cystic fibrosis (CF) on commercially approved CFTR modulators. A challenge to study feasibility was capturing sweat chloride measurements before modulator initiation. We tested the hypothesis that historic sweat chloride approximated contemporary pre-modulator values to estimate CFTR modulator-induced changes, allowing a single-visit study design. METHODS GOAL and PROSPECT were multi-center prospective studies of individuals initiating ivacaftor or lumacaftor-ivacaftor. At enrollment, pre-modulator sweat chloride was measured and historic results recorded. Post-modulator sweat chloride was measured at 1, 3 and 6 months. For this analysis, differences between historic and pre-modulator sweat chloride were estimated. CFTR modulator-induced sweat chloride mean changes were compared using historic and pre-modulator sweat chloride. RESULTS Paired historic and pre-modulator sweat chloride (n=406 participants) revealed a non-significant mean change of -1.0 mmol/L (95% CI: -2.71, 0.66) over an average of 17.2 years. Calculating sweat response to ivacaftor or lumacaftor-ivacaftor using historic or pre-modulator values resulted in similar estimates of modulator response. Based on these results, the CHEC-SC study was designed with a single, post-modulator sweat chloride measurement. CONCLUSIONS Historic sweat chloride values provide a reliable estimate of pre-modulator sweat chloride for people starting on modulator therapy. The CHEC-SC study anticipates capturing approximately 5,000 sweat chloride values, providing an unprecedented understanding of sweat chloride across the CF population in the era of CFTR modulators.
Collapse
Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH USA; Rainbow Babies and Children's Hospital, Cleveland OH USA
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH USA
| | - Steven M Rowe
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL USA
| | - J P Clancy
- Cystic Fibrosis Foundation, Bethesda, MD USA
| | | | | | - Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA 98145, USA; Department of Biostatistics and Pediatrics, University of Washington, Seattle, WA 98195, USA
| |
Collapse
|
11
|
Nichols DP, Odem-Davis K, Cogen JD, Goss CH, Ren CL, Skalland M, Somayaji R, Heltshe SL. Pulmonary Outcomes Associated with Long-Term Azithromycin Therapy in Cystic Fibrosis. Am J Respir Crit Care Med 2020; 201:430-437. [PMID: 31661302 PMCID: PMC7049934 DOI: 10.1164/rccm.201906-1206oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: Chronic azithromycin is commonly used in cystic fibrosis based on short controlled clinical trials showing reductions in pulmonary exacerbations and improved FEV1. Long-term effects are unknown. Objectives: Examine pulmonary outcomes among chronic azithromycin users compared with matched controls over years of use and consider combined azithromycin use in cohorts using chronic inhaled tobramycin or aztreonam. Methods: This retrospective cohort study used the U.S. cystic fibrosis Foundation Patient Registry. Incident chronic azithromycin users were compared with matched controls by FEV1% predicted rate of decline and rates of intravenous antibiotic use to treat pulmonary exacerbations. Propensity score methods were utilized to address confounding by indication. Predefined sensitivity analyses based on lung function, Pseudomonas aeruginosa (PA) status, and follow-up time intervals were conducted. Measurements and Main Results: Across 3 years, FEV1% predicted per-year decline was nearly 40% less in those with PA using azithromycin compared with matched controls (slopes, −1.53 versus −2.41% predicted per yr; difference: 0.88; 95% confidence interval [CI], 0.30–1.47). This rate of decline did not differ based on azithromycin use in those without PA. Among all cohorts, use of intravenous antibiotics was no different between azithromycin users and controls. Users of inhaled tobramycin and azithromycin had FEV1% predicted per-year decline of −0.16 versus nonusers (95% CI, −0.44 to 0.13), whereas users of inhaled aztreonam lysine and azithromycin experienced a mean 0.49% predicted per year slower decline than matched controls (95% CI, −0.11 to 1.10). Conclusions: Results from this study provide additional rationale for chronic azithromycin use in PA-positive patients to reduce lung function decline.
Collapse
Affiliation(s)
- Dave P Nichols
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Department of Pediatrics, University of Washington, Seattle, Washington
| | - Clement L Ren
- Division of Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana; and
| | - Michelle Skalland
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
12
|
Gao P, Odem-Davis K. Assessing noninferiority: Evaluating efficacy of a new treatment without complete data. Pharm Stat 2019; 18:546-554. [PMID: 30977258 DOI: 10.1002/pst.1946] [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] [Received: 05/15/2018] [Revised: 01/15/2019] [Accepted: 03/05/2019] [Indexed: 11/12/2022]
Abstract
The FDA released the final guidance on noninferiority trials in November 2016. In noninferiority trials, validity of the assessment of the efficacy of the test treatment depends on the control treatment's efficacy. Therefore, it is critically important that there be a reliable estimate of the control treatment effect-which is generally obtained from historical trials, and often assumed to hold in the current setting (the assay constancy assumption). Validating the constancy assumption requires clinical data, which are typically lacking. The guidance acknowledges that "lack of constancy can occur for many reasons." We clarify the objectives of noninferiority trials. We conclude that correction for bias, rather than assay constancy, is critical to conducting valid noninferiority trials. We propose that assay constancy not be assumed and discounting or thresholds be used to address concern about loss of historical efficacy. Examples are provided for illustration.
Collapse
Affiliation(s)
- Ping Gao
- Brightech International, Somerset, New Jersey
| | | |
Collapse
|
13
|
Verdial FC, Madtes DK, Hwang B, Mulligan MS, Odem-Davis K, Waworuntu R, Wood DE, Farjah F. Prediction Model for Nodal Disease Among Patients With Non-Small Cell Lung Cancer. Ann Thorac Surg 2019; 107:1600-1606. [PMID: 30710518 DOI: 10.1016/j.athoracsur.2018.12.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 03/06/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND We characterized the performance characteristics of guideline-recommended invasive mediastinal staging (IMS) for lung cancer and developed a prediction model for nodal disease as a potential alternative approach to staging. METHODS We conducted a prospective cohort study of adults with suspected/confirmed non-small cell lung cancer without evidence of distant metastatic disease (by computed tomography/positron emission tomography) who underwent nodal evaluation by IMS and/or at the time of resection. The true-positive rate was the proportion of patients with true nodal disease selected to undergo IMS based on guideline recommendations, and the false-positive rate was the proportion of patients without true nodal disease selected to undergo IMS. Logistic regression was used to predict nodal disease using radiographic predictors. RESULTS Among 123 eligible subjects, 31 (25%) had pathologically confirmed nodal disease. A guideline-recommended invasive staging strategy had a true-positive rate and false-positive rate of 100% and 65%, respectively. The prediction model fit the data well (goodness-of-fit test, p = 0.55) and had excellent discrimination (optimism corrected c-statistic, 0.78; 95% confidence interval, 0.72 to 0.89). Exploratory analysis revealed that use of the prediction model could achieve a false-positive rate of 44% and a true-positive rate of 97%. CONCLUSIONS A guideline-recommended strategy for IMS selects all patients with true nodal disease and most patients without nodal disease for IMS. Our prediction model appears to maintain (within a margin of error) the sensitivity of a guideline-recommended invasive staging strategy and has the potential to reduce the use of invasive procedures.
Collapse
Affiliation(s)
- Francys C Verdial
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - David K Madtes
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Billanna Hwang
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington
| | - Michael S Mulligan
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington
| | | | - Rachel Waworuntu
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Center for Lung Biology, University of Washington, Seattle, Washington
| | - Douglas E Wood
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Farhood Farjah
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington.
| |
Collapse
|
14
|
Doll KM, Khor S, Odem-Davis K, He H, Wolff EM, Flum DR, Ramsey SD, Goff BA. Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer. Am J Obstet Gynecol 2018; 219:593.e1-593.e14. [PMID: 30291839 DOI: 10.1016/j.ajog.2018.09.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/24/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advanced stage at diagnosis is an independent, unexplained contributor to racial disparity in endometrial cancer. OBJECTIVE We sought to investigate whether, prior to diagnosis, provider recognition of the cardinal symptom of endometrial cancer, postmenopausal bleeding, differs by patient race. STUDY DESIGN Black and White women diagnosed with endometrial cancer (2001 through 2011) from Surveillance, Epidemiology, and End Results-Medicare who had at least 2 years of claims prior to diagnosis were identified. Bleeding diagnoses along with procedures done prior to diagnosis were captured via claims data. Multinomial logistic regression was used to evaluate the association of race with diagnostic workup and multivariate models built to determine the association of appropriate diagnostic procedures with stage at diagnosis. RESULTS In all, 4354 White and 537 Black women diagnosed with endometrial cancer were included. Compared to White women, Black women were less likely to have guideline-concordant care: postmenopausal bleeding and appropriate diagnostic evaluation (70% vs 79%, P < .001), with adjusted relative risk ratios of 1.12-1.73 for different nonguideline-concordant pathways: bleeding without diagnostic procedures, alternative bleeding descriptions, and neither bleeding nor procedures. These pathways were associated with higher odds of advanced stage at diagnosis (adjusted odds ratio, 1.90-2.88). CONCLUSION The lack of recognition and evaluation of postmenopausal bleeding is associated with advanced stage at diagnosis in endometrial cancer. Older Black women are at highest risk for the most aggressive histology types, yet they are less likely to have guideline-concordant evaluation of vaginal bleeding. Efforts aimed at improving recognition-among patients and providers-of postmenopausal bleeding in Black women could substantially reduce disparities in endometrial cancer.
Collapse
|
15
|
Thornblade LW, Mulligan MS, Odem-Davis K, Hwang B, Waworuntu RL, Wolff EM, Kessler L, Wood DE, Farjah F. Challenges in Predicting Recurrence After Resection of Node-Negative Non-Small Cell Lung Cancer. Ann Thorac Surg 2018; 106:1460-1467. [PMID: 30031845 DOI: 10.1016/j.athoracsur.2018.06.022] [Citation(s) in RCA: 11] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND One in 5 patients with completely resected early-stage non-small cell lung cancer will recur within 2 years. Risk stratification may facilitate a personalized approach to the use of adjuvant therapy and surveillance imaging. We developed a prediction model for recurrence based on five clinical variables (tumor size and grade, visceral pleural and lymphovascular invasion, and sublobar resection), and tested the hypothesis that the addition of several new molecular markers of poor long-term outcome (vascular endothelial growth factor C; microRNA precursors 486 and 30d) would enhance prediction. METHODS We performed a retrospective cohort study of patients with completely resected, node-negative non-small cell lung cancer from 2011 to 2014 (follow-up through 2016) using the Lung Cancer Biospecimen Resource Network. Cox regression was used to estimate the 2-year risk of recurrence. Our primary measure of model performance was the optimism-corrected C statistic. RESULTS Among 173 patients (mean tumor size, 3.6 cm; 12% sublobar resection, 32% poorly differentiated, 16% lymphovascular invasion, 26% visceral pleural invasion), the 2-year recurrence rate was 23% (95% confidence interval, 17% to 31%). A prediction model using five known risk factors for recurrence performed only slightly better than chance in predicting recurrence (optimism-corrected C statistic, 0.54; 95% confidence interval, 0.51 to 0.68). The addition of biomarkers did not improve the model's ability to predict recurrence (corrected C statistic, 0.55; 95% confidence interval, 0.52 to 0.71). CONCLUSIONS We were unable to predict lung cancer recurrence using a risk-prediction model based on five well-known clinical risk factors and several biomarkers. Further research should consider novel predictors of recurrence to stratify patients with completely resected early-stage non-small cell lung cancer according to their risk of recurrence.
Collapse
Affiliation(s)
| | | | - Katherine Odem-Davis
- Clinical & Translational Research, Seattle Children's Hospital, Seattle, Washington
| | - Billanna Hwang
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, Washington
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, Washington
| | - Douglas E Wood
- Department of Surgery, University of Washington, Seattle, Washington
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington.
| |
Collapse
|
16
|
Banerji JS, Odem-Davis K, Wolff EM, Nichols CR, Porter CR. Patterns of Care and Survival Outcomes for Malignant Sex Cord Stromal Testicular Cancer: Results from the National Cancer Data Base. J Urol 2016; 196:1117-22. [DOI: 10.1016/j.juro.2016.03.143] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- John S. Banerji
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | | | - Erika M. Wolff
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
- Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Craig R. Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, Washington
| | - Christopher R. Porter
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
17
|
Fu X, Felcyn JR, Odem-Davis K, Zimring JC. Bioactive lipids accumulate in stored red blood cells despite leukoreduction: a targeted metabolomics study. Transfusion 2016; 56:2560-2570. [DOI: 10.1111/trf.13748] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Xiaoyun Fu
- Bloodworks Northwest Research Institute
- School of Medicine, Department of Internal Medicine, Division of Hematology; University of Washington
| | | | | | - James C. Zimring
- Bloodworks Northwest Research Institute
- School of Medicine, Department of Internal Medicine, Division of Hematology; University of Washington
- Department of Laboratory Medicine; University of Washington School of Medicine; Seattle Washington
| |
Collapse
|
18
|
Zimring JC, Spitalnik SL, Odem-Davis K. Lost in translation: signal and frequency amplification in animal modeling. Transfusion 2016; 56:773-4. [PMID: 26954453 DOI: 10.1111/trf.13457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 12/29/2022]
Affiliation(s)
- James C Zimring
- BloodworksNW Research Institute, Seattle, WA.,Departments of Laboratory Medicine, and Internal Medicine, Division of Hematology, University of Washington, Seattle, WA
| | - Steven L Spitalnik
- Department of Pathology & Cell Biology, Laboratory of Transfusion Biology, Columbia University, New York, NY
| | | |
Collapse
|
19
|
Pham KN, Cullen J, Hurwitz LM, Wolff EM, Levie KE, Odem-Davis K, Banerji JS, Rosner IL, Brand TC, L’Esperance JO, Sterbis JR, Porter CR. Prospective Quality of Life in Men Choosing Active Surveillance Compared to Those Biopsied but not Diagnosed with Prostate Cancer. J Urol 2016; 196:392-8. [DOI: 10.1016/j.juro.2016.02.2972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 01/22/2023]
Affiliation(s)
| | - Jennifer Cullen
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lauren M. Hurwitz
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | | | - Katherine E. Levie
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Katherine Odem-Davis
- Center for Biomedical Statistics, Seattle, Washington
- Institute of Translational Health Sciences, Seattle, Washington
| | | | - Inger L. Rosner
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Urology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Timothy C. Brand
- Madigan Army Medical Center, Tacoma, Washington
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
| | - James O. L’Esperance
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Naval Medical Center San Diego, San Diego, California
| | - Joseph R. Sterbis
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
- Tripler Army Medical Center, Honolulu, Hawaii
| | - Christopher R. Porter
- Virginia Mason, Seattle, Washington
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
| |
Collapse
|
20
|
Zimring JC, Slichter S, Odem-Davis K, Felcyn JR, Kapp LM, Bell LN, Gunst PR, Corson J, Jones MK, Pellham E, Bailey SL, Fu X. Metabolites in stored platelets associated with platelet recoveries and survivals. Transfusion 2016; 56:1974-83. [DOI: 10.1111/trf.13631] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/03/2016] [Accepted: 03/05/2016] [Indexed: 01/19/2023]
Affiliation(s)
- James C. Zimring
- Bloodworks NW Research Institute; and
- Department of Laboratory Medicine and the; University of Washington School of Medicine; Seattle Washington
- Department of Internal Medicine, Division of Hematology; University of Washington School of Medicine; Seattle Washington
| | - Sherrill Slichter
- Bloodworks NW Research Institute; and
- Department of Internal Medicine, Division of Hematology; University of Washington School of Medicine; Seattle Washington
| | | | | | | | | | - P. Ross Gunst
- Metabolon, Inc.; Research Triangle Park North Carolina
| | | | | | | | | | - Xiaoyun Fu
- Bloodworks NW Research Institute; and
- Department of Internal Medicine, Division of Hematology; University of Washington School of Medicine; Seattle Washington
| |
Collapse
|
21
|
de Wolski K, Fu X, Dumont LJ, Roback JD, Waterman H, Odem-Davis K, Howie HL, Zimring JC. Metabolic pathways that correlate with post-transfusion circulation of stored murine red blood cells. Haematologica 2016; 101:578-86. [PMID: 26921359 DOI: 10.3324/haematol.2015.139139] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 02/15/2016] [Indexed: 12/22/2022] Open
Abstract
Transfusion of red blood cells is a very common inpatient procedure, with more than 1 in 70 people in the USA receiving a red blood cell transfusion annually. However, stored red blood cells are a non-uniform product, based upon donor-to-donor variation in red blood cell storage biology. While thousands of biological parameters change in red blood cells over storage, it has remained unclear which changes correlate with function of the red blood cells, as opposed to being co-incidental changes. In the current report, a murine model of red blood cell storage/transfusion is applied across 13 genetically distinct mouse strains and combined with high resolution metabolomics to identify metabolic changes that correlated with red blood cell circulation post storage. Oxidation in general, and peroxidation of lipids in particular, emerged as changes that correlated with extreme statistical significance, including generation of dicarboxylic acids and monohydroxy fatty acids. In addition, differences in anti-oxidant pathways known to regulate oxidative stress on lipid membranes were identified. Finally, metabolites were identified that differed at the time the blood was harvested, and predict how the red blood cells perform after storage, allowing the potential to screen donors at time of collection. Together, these findings map out a new landscape in understanding metabolic changes during red blood cell storage as they relate to red blood cell circulation.
Collapse
Affiliation(s)
| | - Xiaoyoun Fu
- Bloodworks NW Research Institute, Seattle, WA, USA University of Washington Department of Internal Medicine, Division of Hematology, Seattle, WA, USA
| | | | - John D Roback
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | - James C Zimring
- Bloodworks NW Research Institute, Seattle, WA, USA University of Washington Department of Internal Medicine, Division of Hematology, Seattle, WA, USA University of Washington Department of Laboratory Medicine and Department of Internal Medicine, Division of Hematology, Seattle, WA, USA
| |
Collapse
|
22
|
Banerji JS, Wolff EM, Massman JD, Odem-Davis K, Porter CR, Corman JM. Prostate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specific Antigen Based Screening. J Urol 2016; 195:66-73. [DOI: 10.1016/j.juro.2015.07.099] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Affiliation(s)
- John S. Banerji
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Erika M. Wolff
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - John D. Massman
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | | | | | - John M. Corman
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| |
Collapse
|
23
|
Waterman HR, Kapp LM, Munday A, Odem-Davis K, Zimring JC. Transfusion-induced alloimmunization and platelet refractoriness in a mouse model: mechanisms and interventions. Transfusion 2015; 56:91-100. [PMID: 26400622 DOI: 10.1111/trf.13270] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/08/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Platelet (PLT) transfusions can be an essential therapy for patients with thrombocytopenia to maintain hemostasis. However, some patients become alloimmunized to antigens on PLTs (typically HLA), which can prevent efficacy of PLT transfusion due to antibody-mediated clearance. In extreme cases, patients with alloimmunization to multiple HLAs can become "refractory" to PLT transfusion, such that insufficient compatible PLT units can be found to meet transfusion needs. MATERIALS AND METHODS An in vivo murine model of PLT-induced alloimmunization was refined so as to include both transfusion with allogeneic leukoreduced PLTs and studies of posttransfusion PLT recoveries, allowing assessment of alloimmunization and refractoriness. Basic mechanisms of antibody-mediated PLT clearance were investigated using recipients missing either the C3 complement gene or the common gamma chain for Fc receptors. In addition, the efficacy of using costimulatory blockade as a therapeutic intervention was assessed by testing CTLA4-Ig administration before PLT transfusion. RESULTS Fcγ receptors (but not complement C3) are required for alloantibody-mediated PLT refractoriness. In addition, levels of anti-MHC predict the extent of refractoriness in a given animal. Finally, costimulatory blockade as a therapeutic modality prevents transfusion-induced PLT refractoriness. CONCLUSIONS Together these findings introduce new experimental methods, basic mechanistic understanding, and a potential therapeutic intervention for alloimmunization to MHC-based antigens on transfused PLTs.
Collapse
Affiliation(s)
- Hayley R Waterman
- Bloodworks NW Research Institute, University of Washington School of Medicine, Seattle, Washington
| | - Linda M Kapp
- Bloodworks NW Research Institute, University of Washington School of Medicine, Seattle, Washington
| | - Adam Munday
- Bloodworks NW Research Institute, University of Washington School of Medicine, Seattle, Washington
| | - Katherine Odem-Davis
- Bloodworks NW Research Institute, University of Washington School of Medicine, Seattle, Washington
| | - James C Zimring
- Bloodworks NW Research Institute, University of Washington School of Medicine, Seattle, Washington.,Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, Washington.,Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
24
|
Abstract
The regulatory guidelines on noninferiority (NI) trials emphasize constancy not only in the treatment effect over time but also in the trial design, clinical practice, and quality of the trial conduct and execution. In practice, the constancy assumption is generally impossible to justify; often, there are clear reasons to expect a loss of efficacy over time. There are also concerns about the inherent and publication bias in the historical data, and various sources of selection bias in the NI trial design. Thus, a conservative NI margin is often considered. However, different NI margin approaches are largely evaluated under the assumption of constancy and absence of bias, and therefore, controversies arise and are unresolved on the necessary degree of conservativeness. We develop a framework to quantify the robustness of any NI margin approach against inherent and publication bias in historical data, selection bias in trial design, and nonconstancy in reference effects. We introduce a consistency principle to address variability in the historical data. We control across-trial conditional error rates given a final NI trial design over a design specific robust range for reference effects. Following a conditionality principle, we provide a theoretical justification of the framework and the conditions for controlling across-trial unconditional type 1 error rates. We raise the issue of inherent bias in historical data with an illustrative example.
Collapse
Affiliation(s)
- Qing Liu
- a AbacusCloud, LLC , Long Valley , New Jersey , USA
| | | | | |
Collapse
|
25
|
Jeldres C, Cullen J, Hurwitz LM, Wolff EM, Levie KE, Odem-Davis K, Johnston RB, Pham KN, Rosner IL, Brand TC, L'Esperance JO, Sterbis JR, Etzioni R, Porter CR. Prospective quality-of-life outcomes for low-risk prostate cancer: Active surveillance versus radical prostatectomy. Cancer 2015; 121:2465-73. [PMID: 25845467 DOI: 10.1002/cncr.29370] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/16/2015] [Accepted: 02/23/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND For patients with low-risk prostate cancer (PCa), active surveillance (AS) may produce oncologic outcomes comparable to those achieved with radical prostatectomy (RP). Health-related quality-of-life (HRQoL) outcomes are important to consider, yet few studies have examined HRQoL among patients with PCa who were managed with AS. In this study, the authors compared longitudinal HRQoL in a prospective, racially diverse, and contemporary cohort of patients who underwent RP or AS for low-risk PCa. METHODS Beginning in 2007, HRQoL data from validated questionnaires (the Expanded Prostate Cancer Index Composite and the 36-item RAND Medical Outcomes Study short-form survey) were collected by the Center for Prostate Disease Research in a multicenter national database. Patients aged ≤75 years who were diagnosed with low-risk PCa and elected RP or AS for initial disease management were followed for 3 years. Mean scores were estimated using generalized estimating equations adjusting for baseline HRQoL, demographic characteristics, and clinical patient characteristics. RESULTS Of the patients with low-risk PCa, 228 underwent RP, and 77 underwent AS. Multivariable analysis revealed that patients in the RP group had significantly worse sexual function, sexual bother, and urinary function at all time points compared with patients in the AS group. Differences in mental health between groups were below the threshold for clinical significance at 1 year. CONCLUSIONS In this study, no differences in mental health outcomes were observed, but urinary and sexual HRQoL were worse for patients who underwent RP compared with those who underwent AS for up to 3 years. These data offer support for the management of low-risk PCa with AS as a means for postponing the morbidity associated with RP without concomitant declines in mental health.
Collapse
Affiliation(s)
- Claudio Jeldres
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington.,University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jennifer Cullen
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lauren M Hurwitz
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Erika M Wolff
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Katherine E Levie
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Richard B Johnston
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Khanh N Pham
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington
| | - Inger L Rosner
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Urology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Timothy C Brand
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Madigan Army Medical Center, Tacoma, Washington
| | - James O L'Esperance
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Naval Medical Center San Diego, San Diego, California
| | - Joseph R Sterbis
- Center for Prostate Disease Research, Department of Defense, Rockville, Maryland.,Department of Urology, Tripler Army Medical Center, Honolulu, Hawaii
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Christopher R Porter
- Section of Urology and Renal Transplantation, Virginia Mason, Seattle, Washington.,Center for Prostate Disease Research, Department of Defense, Rockville, Maryland
| |
Collapse
|
26
|
Pham K, Odem-Davis K, Jeldres C, Porter C, Wei J, Morgan T. MP11-09 TRANSPERINEAL TEMPLATE-GUIDED PROSTATE BIOPSY IN PATIENTS INITIATING ACTIVE SURVEILLANCE: A MULTI-INSTITUTIONAL COMPARISON. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.390] [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: 10/23/2022]
|
27
|
Banerji JS, Hurwitz LM, Cullen J, Odem-Davis K, Wolff EM, Levie K, Pham KN, Porter CR. MP42-13 A PROSPECTIVE STUDY OF HEALTH-RELATED QUALITY OF LIFE OUTCOMES FOR LOW-RISK PROSTATE CANCER PATIENTS MANAGED BY ACTIVE SURVEILLANCE OR RADIATION THERAPY. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.1598] [Citation(s) in RCA: 2] [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: 11/29/2022]
|
28
|
Odem-Davis K, Fleming TR. A simulation study evaluating bio-creep risk in serial non-inferiority clinical trials for preservation of effect. Stat Biopharm Res 2015; 7:12-24. [PMID: 26052374 DOI: 10.1080/19466315.2014.1002627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In non-inferiority trials, acceptable efficacy of an experimental treatment is established by ruling out some defined level of reduced effect relative to an effective active control standard. Serial use of non-inferiority trials may lead to newly approved therapies that provide meaningfully reduced levels of benefit; this phenomenon is called bio-creep. Simulations were designed to facilitate understanding of bio-creep risk when approval of an experimental treatment with efficacy less than some proportion of the effect of the active control treatment would constitute harm, such as when new antibiotics that are meaningfully less effective than the most effective current antibiotic would be used for treatment of Community-Acquired Bacterial Pneumonia. In this setting, risk of approval of insufficiently effective therapies may be great, even when the standard treatment effect satisfies constancy across trials. Modifiable factors contributing to this manifestation of bio-creep included the active control selection method, the non-inferiority margin, and bias in the active control effect estimate. Therefore, when non-inferiority testing is performed, the best available treatment should be used as the standard, and margins should be based on the estimated effect of this control, accounting for the variability and for likely sources of bias in this estimate, and addressing the importance of preservation of some portion of the standard's effect.
Collapse
|
29
|
Beard C, Jeldres C, Odem-Davis K, Hoffman K, Martin N, Nguyen P, Porter C, Sweeney C, Kollmannsberger C, Nichols C. Variation in Patterns of Care in the United States for Clinical Stage I Seminoma: Results From the National Cancer Data Base (1998-2011). Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Wilson KS, Odem-Davis K, Shafi J, Kashonga F, Wanje G, Masese L, Mandaliya K, Jaoko W, McClelland RS. Association between alcohol use and sexually transmitted infection incidence among kenyan women engaged in transactional sex. AIDS Behav 2014; 18:1324-9. [PMID: 24179037 DOI: 10.1007/s10461-013-0648-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Few prospective studies have evaluated the association between alcohol use and STI acquisition among African women. We examined the association between baseline drinking frequency and STIs in a cohort of Kenyan women reporting transactional sex. The association between alcohol use and STI differed significantly by HIV status. Among 139 HIV-positive women, STI acquisition was significantly associated with consuming 1-7 drinks/week and marginally associated with ≥8 drinks/week in unadjusted analyses. However, no association between alcohol use and STIs was observed among 335 HIV-negative women. Addressing alcohol use within comprehensive HIV care may also reduce the burden of STIs among high-risk women.
Collapse
Affiliation(s)
- Kate S Wilson
- Department of Epidemiology, University of Washington, 325 Ninth Ave, Box 359909, Seattle, WA, 98104, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Jeldres C, Pham KN, Daneshmand S, Kollmannsberger CK, Hayes-Lattin BM, Wolff E, Odem-Davis K, Porter CR, Nichols CR. Association of higher institutional volume with improved overall survival in clinical stage III testicular cancer: Results from the National Cancer Data Base (1998-2011). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.4519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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)
| | | | - Siamak Daneshmand
- Institute of Urology, University of Southern California, Los Angeles, CA
| | | | | | | | | | | | | |
Collapse
|
32
|
Jeldres C, Nichols CR, Pham K, Daneshmand S, Kollmannsberger C, Hayes-Lattin B, Wolff E, Odem-Davis K, Porter CR. MP10-05 INFLUENCE OF RACE ON OUTCOMES IN TESTICULAR CANCER: ANALYSIS OF 75902 PATIENTS IN THE NATIONAL CANCER DATA BASE. J Urol 2014. [DOI: 10.1016/j.juro.2014.02.461] [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: 11/26/2022]
|
33
|
Pham K, Jeldres C, Corman J, Odem-Davis K, Wolff E, Porter C. MP12-18 FOCAL THERAPY FOR PROSTATE CANCER: THE UTILITY OF A CONFIRMATORY TRANSPERINEAL TEMPLATE GUIDED PROSTATE BIOPSY TO IDENTIFY APPROPRIATE CANDIDATES. J Urol 2014. [DOI: 10.1016/j.juro.2014.02.453] [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: 11/26/2022]
|
34
|
Jeldres C, Nichols CR, Pham K, Daneshmand S, Kollmannsberger C, Hayes-Lattin B, Wolff E, Odem-Davis K, Porter CR. PD5-04 UNITED STATES TRENDS IN PATTERNS OF CARE IN CLINICAL STAGE I TESTICULAR CANCER: RESULTS FROM THE NATIONAL CANCER DATA BASE (1998-2011). J Urol 2014. [DOI: 10.1016/j.juro.2014.02.407] [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: 10/25/2022]
|
35
|
Jeldres C, Pham K, Johnston RB, Cullen J, Odem-Davis K, Wolff E, Levie K, Hurwitz L, Porter CR. MP58-20 HEALTH-RELATED QUALITY OF LIFE IN MEN UNDERGOING ACTIVE SURVEILLANCE VS. RADICAL PROSTATECTOMY FOR LOW RISK PROSTATE CANCER: A PROSPECTIVE MULTI-INSTITUTIONAL STUDY. J Urol 2014. [DOI: 10.1016/j.juro.2014.02.1836] [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: 10/25/2022]
|
36
|
Cortez V, Odem-Davis K, Lehman DA, Mabuka J, Overbaugh J. Quotidian changes of genital tract cytokines in human immunodeficiency virus-1-infected women during the menstrual cycle. Open Forum Infect Dis 2014; 1:ofu002. [PMID: 25734076 PMCID: PMC4324201 DOI: 10.1093/ofid/ofu002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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] [Indexed: 01/24/2023] Open
Abstract
The role of hormonal changes throughout the menstrual cycle on genital tract inflammation during chronic human immunodeficiency virus (HIV) infection is not well defined, but it has implications for HIV prevention. We assessed daily levels of 26 vaginal cytokines and chemokines from 15 women infected with HIV-1. Taking into account coexisting sexually transmitted infections, behavioral factors, and menstruation, this study illustrates cyclic patterns of granulocyte macrophage colony-stimulating factor, interferon-α2, interleukin (IL)-6, IL-10, macrophage inflammatory protein (MIP)-1α, MIP-1β, and tumor necrosis factor (TNF)-α. Progesterone was associated with levels of granulocyte colony-stimulating factor, IL-1α, and monocyte chemoattractant protein-1. Interferon-α2, IL-6, MIP-1α, MIP-1β, and TNF-α levels predicted HIV shedding, but these associations were heavily influenced by the menstrual cycle.
Collapse
Affiliation(s)
- Valerie Cortez
- Program in Molecular and Cellular Biology, University of Washington
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Katherine Odem-Davis
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Dara A. Lehman
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jennifer Mabuka
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
37
|
Jeldres C, Nichols CR, Pham K, Daneshmand S, Kollmannsberger CK, Hayes-Lattin BM, Wolff E, Odem-Davis K, Porter CR. United States trends in patterns of care in clinical stage I testicular cancer: Results from the National Cancer Database (1998-2011). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.4_suppl.369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
369 Background: There has been significant evolution in worldwide guidelines for management of clinical stage I (CS1) testicular cancer where active surveillance (AS) strategies are now considered a first choice, especially for patients with lower recurrence risk after orchiectomy. Conversely, local therapies for CS1 such as primary retroperitoneal lymphadenectomy (RPLND) in non-seminoma and regional radiation in seminoma are phasing out of recommendations. In the US, there have been no comprehensive efforts to measure uptake of guideline recommendations and modern patterns of care for early-stage testicular cancer. Methods: Access to the testicular cancer data set within the National Cancer Data Base (NCDB) was granted to Virginia Mason Medical Center (A SWOG affiliated cancer research program) for this retrospective cohort study. We identified all patients with CS1 testicular cancer between 1998 and 2011. Management options after orchiectomy such as adjuvant radiotherapy, adjuvant chemotherapy, RPLND, or AS were analyzed using cross tabulation and trend analysis. Results: Within the NCDB, of 75,902 patients with testicular cancer, 31,208 and 13,301 were diagnosed with CS1 seminoma and non-seminoma, respectively. For CS1 seminoma, AS use increased from 25.2% in 1998 to 55.8% in 2011. Similarly adjuvant chemotherapy use also increased (1.9 % to 16.7%). Conversely, use of adjuvant radiation decreased from 72.9% to 27.5%. For CS1 non-seminoma, AS remained the main treatment modality ranging between 58.8% and 66.2%. The use of adjuvant chemotherapy increased (28.3% in 2011) and the rate of primary RPLND constantly decreased down to 12.9% that same year. Interestingly, 50.3% of patients with CS1 non-seminoma and negative lympho-vascular invasion status had chemotherapy rather than AS. Trends analyses were statistically significant for all treatment modalities (p<0.05). Conclusions: Active surveillance as a management strategy has increased and is currently the most common treatment modality used for both CS1 seminoma and non-seminoma in the US. Regional therapies in CSI seminoma and non-seminoma are decreasing but persist even in patients with a low risk of recurrence.
Collapse
Affiliation(s)
| | | | - Khanh Pham
- Virginia Mason Medical Center, Seattle, WA
| | | | | | | | | | | | | |
Collapse
|
38
|
Nichols CR, Jeldres C, Pham K, Daneshmand S, Kollmannsberger CK, Hayes-Lattin BM, Odem-Davis K, Wolff E, Porter CR. Influence of social demographics and African-American race on outcomes in testicular cancer: Analysis of 75,902 patients in the National Cancer database. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.4_suppl.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
391 Background: While there have been substantial advances in treatment and outcomes in testicular cancer, most of the data are derived from large institutionals or clinical trials. Testicular germ cell tumors are uncommon (8,000 new patients annually in US). The incidence among patients (pts) of African origins is extremely low. Most of the conclusions regarding outcomes are based on Caucasian pts from research institutions. Information about modern outcomes in non-Caucasian races is scant and little is known about the influence of various social demographic parameters on presentation patterns and survival. Using this population-based database available through the NCDB, we sought to better understand social and racial variations in outcomes. Methods: Within the NCDB, 75,902 testicular cancer pts were available for review. Tools available through the NCDB were utilized for analysis. Herein, we evaluated social demographics (insurance type, educational achievement, annual income, type of treating institution) and racial/ethnic characteristics as they pertained to stage at presentation and survival. Results: 75,902 pts were available from the timeframe of 1998 through 2011 for aggregation of social demographic features as well as racial/ethnic characteristics. Overall survival was available on 48573 pts through 2006. Racial-ethnic breakdown at presentation was 84.1% (n=63,867) Caucasian and African-American 2.7% (n=2,083). Overall, insurance type, education (% without high school degree), income (< $ 30000 to >$46,000) and type of treating hospital were analyzed using univariate and multivariate models. Full details will be presented. Conclusions: Unfavorable presentations and outcomes in testicular cancer are seen by race and social demographics. In depth analytics are being performed to characterize the variations as related to biological/genetic differences and/or differences in social demographics. In this very large cohort, the National Cancer database demonstrates a 2-fold risk increase in death in African American pts relative to Caucasian pts with similar stage at presentation.
Collapse
Affiliation(s)
| | | | - Khanh Pham
- Virginia Mason Medical Center, Seattle, WA
| | - Siamak Daneshmand
- University of Southern California Institute of Urology, Los Angeles, CA
| | | | | | | | | | | |
Collapse
|
39
|
Slyker J, Farquhar C, Atkinson C, Ásbjörnsdóttir K, Roxby A, Drake A, Kiarie J, Wald A, Boeckh M, Richardson B, Odem-Davis K, John-Stewart G, Emery V. Compartmentalized cytomegalovirus replication and transmission in the setting of maternal HIV-1 infection. Clin Infect Dis 2013; 58:564-72. [PMID: 24192386 DOI: 10.1093/cid/cit727] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is associated with adverse outcomes in human immunodeficiency virus (HIV)-exposed infants. Determinants of vertical CMV transmission in the setting of maternal HIV-1 infection are not well-defined. METHODS CMV and HIV-1 levels were measured in plasma, cervical secretions, and breast milk of 147 HIV-1-infected women to define correlates of maternal CMV replication and infant CMV acquisition. RESULTS Although few women had detectable CMV in plasma (4.8%), the majority had detectable CMV DNA in cervical secretions (66%) and breast milk (99%). There was a strong association between cervical CMV detection during pregnancy and later breast milk levels (β = 0.47; P = .005). Plasma HIV-1 level and CD4 counts were associated with CMV in the cervix and breast milk. However HIV-1 levels within the cervix and breast milk were not associated with CMV within these compartments. Maternal breast milk CMV levels (hazard ratio [HR], 1.4; P = .003) and maternal CD4 < 450 cells/mm(3) (HR, 1.8; P = .008) were independently associated with infant CMV acquisition; each log10 increase in breast milk CMV was associated with a 40% increase in infant infection. The breast milk CMV level required to attain a 50% probability of CMV transmission increased with higher maternal CD4 counts, increasing from 3.55 log10 CMV DNA copies/mL at a CD4 count of 350 cells/mm(3) to 5.50 log10 CMV DNA copies/mL at a CD4 count of 1000 cells/mm(3). CONCLUSIONS Breast milk CMV levels and maternal CD4 count are major determinants of CMV transmission in the setting of maternal HIV-1. Maternal immune reconstitution or lowering breast milk CMV levels may reduce vertical CMV transmission.
Collapse
|
40
|
Ronen K, McCoy CO, Matsen FA, Boyd DF, Emery S, Odem-Davis K, Jaoko W, Mandaliya K, McClelland RS, Richardson BA, Overbaugh J. HIV-1 superinfection occurs less frequently than initial infection in a cohort of high-risk Kenyan women. PLoS Pathog 2013; 9:e1003593. [PMID: 24009513 PMCID: PMC3757054 DOI: 10.1371/journal.ppat.1003593] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/19/2013] [Indexed: 11/18/2022] Open
Abstract
HIV superinfection (reinfection) has been reported in several settings, but no study has been designed and powered to rigorously compare its incidence to that of initial infection. Determining whether HIV infection reduces the risk of superinfection is critical to understanding whether an immune response to natural HIV infection is protective. This study compares the incidence of initial infection and superinfection in a prospective seroincident cohort of high-risk women in Mombasa, Kenya. A next-generation sequencing-based pipeline was developed to screen 129 women for superinfection. Longitudinal plasma samples at <6 months, >2 years and one intervening time after initial HIV infection were analyzed. Amplicons in three genome regions were sequenced and a median of 901 sequences obtained per gene per timepoint. Phylogenetic evidence of polyphyly, confirmed by pairwise distance analysis, defined superinfection. Superinfection timing was determined by sequencing virus from intervening timepoints. These data were combined with published data from 17 additional women in the same cohort, totaling 146 women screened. Twenty-one cases of superinfection were identified for an estimated incidence rate of 2.61 per 100 person-years (pys). The incidence rate of initial infection among 1910 women in the same cohort was 5.75 per 100 pys. Andersen-Gill proportional hazards models were used to compare incidences, adjusting for covariates known to influence HIV susceptibility in this cohort. Superinfection incidence was significantly lower than initial infection incidence, with a hazard ratio of 0.47 (CI 0.29-0.75, p = 0.0019). This lower incidence of superinfection was only observed >6 months after initial infection. This is the first adequately powered study to report that HIV infection reduces the risk of reinfection, raising the possibility that immune responses to natural infection are partially protective. The observation that superinfection risk changes with time implies a window of protection that coincides with the maturation of HIV-specific immunity.
Collapse
Affiliation(s)
- Keshet Ronen
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Connor O. McCoy
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Frederick A. Matsen
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - David F. Boyd
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Sandra Emery
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Katherine Odem-Davis
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Walter Jaoko
- Department of Medical Microbiology, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Kishor Mandaliya
- Coast Provincial General Hospital, Women's Health Project, Mombasa, Kenya
| | - R. Scott McClelland
- Department of Medical Microbiology, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Barbra A. Richardson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Julie Overbaugh
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
| |
Collapse
|
41
|
Abstract
Evaluation of non-inferiority is based on ruling out a threshold for what would constitute unacceptable loss of efficacy of an experimental treatment relative to an active comparator "Standard". This threshold, the "non-inferiority margin", is often based on preservation of a percentage of Standard's effect. To obtain an estimate of this effect to be used in the development of the "non-inferiority margin", data are needed from earlier trials comparing Standard to placebo if the non-inferiority trial does not have a placebo arm. This approach often provides a biased over-estimate of Standard's true effect in the setting of the current non-inferiority study. We describe two commonly used non-inferiority margin methods that adjust for this bias, the two-confidence interval (95-95) and the Synthesis margins. However, the added 'variance inflation' adjustment made by 95-95 margin diminishes with increasing information from historical trial(s), and the Synthesis margin is based on a strong assumption that the relative bias is known. We introduce an alternative "Bias-adjusted" margin addressing vulnerabilities of each by attenuating the estimate and by accounting for uncertainty in the true level of bias. Examples and asymptotic estimates of non-inferiority hypothesis rejection rates in the proportional hazards setting are used to compare methods.
Collapse
|
42
|
Wilson KS, Odem-Davis K, Kashonga F, Wanje G, Jaoko W, Estambale B, McClelland R. P3.181 The Association Between Alcohol Use and Sexually Transmitted Infection(STI) Incidence Among Kenyan Women Engaged in Transactional Sex. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
43
|
Day SL, Odem-Davis K, Mandaliya KN, Jerome KR, Cook L, Masese LN, Scott J, Kim HN, Graham SM, McClelland RS. Prevalence, clinical and virologic outcomes of hepatitis B virus co-infection in HIV-1 positive Kenyan women on antiretroviral therapy. PLoS One 2013; 8:e59346. [PMID: 23527168 PMCID: PMC3601052 DOI: 10.1371/journal.pone.0059346] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/13/2013] [Indexed: 12/17/2022] Open
Abstract
Background Sub-Saharan Africa carries a high burden of co-infection with HIV-1 and hepatitis B virus (HBV). In this region, individuals with HIV-1/HBV co-infection on antiretroviral therapy (ART) frequently receive lamivudine as the only agent active against HBV, raising concerns for development of HBV resistance to lamivudine. We aimed to determine the prevalence, clinical, and virologic outcomes of chronic HBV infection, including HBV resistance to lamivudine, in a cohort of HIV-1 seropositive Kenyan women on long-term ART. Methods In this prospective cohort study, HIV-1 seropositive women initiated three-drug ART regimens that included lamivudine as the single drug active against HBV. Archived samples were tested for HBsAg, with further testing to determine HBeAg seroprevalence, HBV DNA suppression, and lamivudine resistance. We estimated the prevalence of chronic HBV and examined associations between HBV co-infection and clinical and virologic outcomes with chi-square tests, logistic regression, Kaplan-Meier and Cox regression. Results In a cohort of 159 women followed for a median of 3.4 years (interquartile range 1.4–4.5), 11 (6.9%; 95% CI 3.1–10.7) had chronic HBV infection. Of these, 9 (82%) achieved undetectable plasma HBV DNA levels. One woman developed lamivudine resistance, for an incidence of 3 per 100 person-years. The HBV co-infected women were at greater risk for abnormal ALT elevations compared to HIV-1 mono-infected women (HR 2.37; 95% CI 1.1–5.3). There were no differences between HBV-infected and uninfected women in mortality, CD4 count, or HIV-1 RNA suppression. Conclusion The prevalence of chronic HBV in this cohort was similar to recent studies from other African populations. Given our long-term follow-up, lamivudine resistance was lower than expected for HIV-1/HBV co-infected patients. Improved screening for HBV and extended follow-up of HIV-1/HBV co-infected individuals are needed to better understand the impact of different ART regimens on clinical outcomes in this population.
Collapse
Affiliation(s)
- Summer L. Day
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Katherine Odem-Davis
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Fred Hutchison Cancer Research Center, Seattle, Washington, United States of America
| | | | - Keith R. Jerome
- Fred Hutchison Cancer Research Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Linda Cook
- Fred Hutchison Cancer Research Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Linnet N. Masese
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - John Scott
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - H. Nina Kim
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Susan M. Graham
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - R. Scott McClelland
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| |
Collapse
|
44
|
Mabuka J, Nduati R, Odem-Davis K, Peterson D, Overbaugh J. HIV-specific antibodies capable of ADCC are common in breastmilk and are associated with reduced risk of transmission in women with high viral loads. PLoS Pathog 2012; 8:e1002739. [PMID: 22719248 PMCID: PMC3375288 DOI: 10.1371/journal.ppat.1002739] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 04/23/2012] [Indexed: 01/25/2023] Open
Abstract
There are limited data describing the functional characteristics of HIV-1 specific antibodies in breast milk (BM) and their role in breastfeeding transmission. The ability of BM antibodies to bind HIV-1 envelope, neutralize heterologous and autologous viruses and direct antibody-dependent cell cytotoxicity (ADCC) were analyzed in BM and plasma obtained soon after delivery from 10 non-transmitting and 9 transmitting women with high systemic viral loads and plasma neutralizing antibodies (NAbs). Because subtype A is the dominant subtype in this cohort, a subtype A envelope variant that was sensitive to plasma NAbs was used to assess the different antibody activities. We found that NAbs against the subtype A heterologous virus and/or the woman's autologous viruses were rare in IgG and IgA purified from breast milk supernatant (BMS)--only 4 of 19 women had any detectable NAb activity against either virus. Detected NAbs were of low potency (median IC50 value of 10 versus 647 for the corresponding plasma) and were not associated with infant infection (p = 0.58). The low NAb activity in BMS versus plasma was reflected in binding antibody levels: HIV-1 envelope specific IgG titers were 2.2 log(10) lower (compared to 0.59 log(10) lower for IgA) in BMS versus plasma. In contrast, antibodies capable of ADCC were common and could be detected in the BMS from all 19 women. BMS envelope-specific IgG titers were associated with both detection of IgG NAbs (p = 0.0001) and BMS ADCC activity (p = 0.014). Importantly, BMS ADCC capacity was inversely associated with infant infection risk (p = 0.039). Our findings indicate that BMS has low levels of envelope specific IgG and IgA with limited neutralizing activity. However, this small study of women with high plasma viral loads suggests that breastmilk ADCC activity is a correlate of transmission that may impact infant infection risk.
Collapse
Affiliation(s)
- Jennifer Mabuka
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Program of Pathobiology, Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ruth Nduati
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Katherine Odem-Davis
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Dylan Peterson
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
| |
Collapse
|
45
|
Cortez V, Odem-Davis K, McClelland RS, Jaoko W, Overbaugh J. HIV-1 superinfection in women broadens and strengthens the neutralizing antibody response. PLoS Pathog 2012; 8:e1002611. [PMID: 22479183 PMCID: PMC3315492 DOI: 10.1371/journal.ppat.1002611] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 02/14/2012] [Indexed: 12/16/2022] Open
Abstract
Identifying naturally-occurring neutralizing antibodies (NAb) that are cross-reactive against all global subtypes of HIV-1 is an important step toward the development of a vaccine. Establishing the host and viral determinants for eliciting such broadly NAbs is also critical for immunogen design. NAb breadth has previously been shown to be positively associated with viral diversity. Therefore, we hypothesized that superinfected individuals develop a broad NAb response as a result of increased antigenic stimulation by two distinct viruses. To test this hypothesis, plasma samples from 12 superinfected women each assigned to three singly infected women were tested against a panel of eight viruses representing four different HIV-1 subtypes at matched time points post-superinfection (~5 years post-initial infection). Here we show superinfected individuals develop significantly broader NAb responses post-superinfection when compared to singly infected individuals (RR = 1.68, CI: 1.23-2.30, p = 0.001). This was true even after controlling for NAb breadth developed prior to superinfection, contemporaneous CD4+ T cell count and viral load. Similarly, both unadjusted and adjusted analyses showed significantly greater potency in superinfected cases compared to controls. Notably, two superinfected individuals were able to neutralize variants from four different subtypes at plasma dilutions >1∶300, suggesting that their NAbs exhibit elite activity. Cross-subtype breadth was detected within a year of superinfection in both of these individuals, which was within 1.5 years of their initial infection. These data suggest that sequential infections lead to augmentation of the NAb response, a process that may provide insight into potential mechanisms that contribute to the development of antibody breadth. Therefore, a successful vaccination strategy that mimics superinfection may lead to the development of broad NAbs in immunized individuals.
Collapse
Affiliation(s)
- Valerie Cortez
- Molecular and Cellular Biology Graduate Program, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Katherine Odem-Davis
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Walter Jaoko
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
| |
Collapse
|
46
|
Abstract
BACKGROUND Suppose a standard therapy (Standard) has been established to provide a clinically important reduction in risk of irreversible morbidity or mortality. In that setting, the safety and efficacy of an experimental intervention likely would be assessed in a clinical trial providing a comparison with Standard rather than a placebo arm. Such a trial often is designed to assess whether the efficacy of the experimental intervention is not unacceptably worse than that of Standard, and is called a non-inferiority trial. Formally, the non-inferiority trial usually is designed to rule out a non-inferiority margin, defined as the minimum threshold for what would constitute an unacceptable loss of efficacy. PURPOSE Even though the literature has many important articles identifying various approaches to the design and conduct of non-inferiority trials, confusion remains especially regarding key considerations for selecting the non-inferiority margin. The purpose of this article is to provide improved clarity regarding these considerations. METHODS We present scientific insights into many factors that should be addressed in the design and conduct of non-inferiority trials to enhance their integrity and reliability, and provide motivation for key considerations that guide the selection of non-inferiority margins. We also provide illustrations and insights from recent experiences. RESULTS Two considerations are essential, and should be addressed in separate steps, in the formulation of the non-inferiority margin. First, the margin should be formulated using adjustments to account for bias or lack of reliability in the estimate of the effect of Standard in the non-inferiority trial setting. Second, the non-inferiority margin should be formulated to achieve preservation of an appropriate percentage of the effect of Standard. LIMITATIONS The considerations, in particular regarding the importance of preservation of effect, might not apply to settings where it would be ethical as well as clinically relevant to include both Standard and placebo arms in the trial for direct comparisons with the experimental intervention arm. CONCLUSIONS Non-inferiority trials with non-rigorous margins allow substantial risk for accepting inadequately effective experimental regimens, leading to the risk of erosion in quality of health care. The design and conduct of non-inferiority trials, including selection of non-inferiority margins, should account for many factors that can induce bias in the estimated effect of Standard in the non-inferiority trial and thus lead to bias in the estimated effect of the experimental treatment, for the need to ensure the experimental treatment preserves a clinically acceptable fraction of Standard's effect, and for the particular vulnerability of the integrity of a non-inferiority trial to the irregularities in trial conduct. Due to the inherent uncertainties in non-inferiority trials, alternative designs should be pursued whenever possible.
Collapse
Affiliation(s)
- Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA 98195-7232, USA.
| | | | | | | |
Collapse
|