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Archive for the ‘Regulated Clinical Trials: Design, Methods, Components and IRB related issues’ Category

Premature Ventricular Contraction percentage predicts new Systolic Dysfunction and clinically diagnosed CHF and overall Mortality

Posted in Acute Myocardial Infarction, Cardiomyopathy, Electrophysiology, Epigenetics and Cardiovascular Risks, FDA Regulatory Affairs, Frontiers in Cardiology and Cardiovascular Disorders, Myocardial metabolism, Myocardial ischemia, myocardial perfusion, Myocardial adenine nucleotide metabolism, Regulated Clinical Trials: Design, Methods, Components and IRB related issues on July 14, 2015| Leave a Comment »

Premature Ventricular Contraction percentage predicts new Systolic Dysfunction and clinically diagnosed CHF and overall Mortality

Reporter: Aviva Lev-Ari, PhD, RN

 

Cardiovascular Health Study (CHS)

This study has been completed. ClinicalTrials.gov processed this record on July 13, 2015
Sponsor:
National Heart, Lung, and Blood Institute (NHLBI)
Information provided by:
National Heart, Lung, and Blood Institute (NHLBI)
ClinicalTrials.gov Identifier:
NCT00005133
First received: May 25, 2000
Last updated: May 1, 2009
Last verified: May 2009
History of Changes
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  Purpose

To determine the extent to which known risk factors predict coronary heart disease and stroke in the elderly, to assess the precipitants of coronary heart disease and stroke in the elderly, and to identify the predictors of mortality and functional impairments in clinical coronary disease or stroke.

SOURCE

https://clinicaltrials.gov/ct2/show/NCT00005133?term=Cardiovascular+Health+Study&rank=2

Although links between frequent PVCs and ongoing heart failure have been observed, the current analysis, based on a cohort from the Cardiovascular Health Study (CHS), provides “the first evidence that PVC percentage predicts new systolic dysfunction, as well as clinically diagnosed CHF and overall mortality,” say the authors in their report, published in the July 14, 2015 issue of the Journal of the American College of Cardiology. It also raises the issue of whether PVCs might sometimes be an appropriate target for treatments aimed at preventing heart failure.

The observational study can’t demonstrate causality, note the authors, led by Dr Jonathan W Dukes (University of California, San Francisco). But overall, the findings “suggest that PVCs might be an important cause of occult or ‘idiopathic’ cardiomyopathy and might be an important determinant of incident CHF among those with other established CHF risk factors.”

Ablate PVCs in HF, LVEF Can Improve

“There’s this general notion that PVCs are very benign, which is certainly what I was taught, even in my general cardiology fellowship, before the more recent data that came out of the electrophysiology labs,” senior author Dr Gregory M Marcus (UCSF) said in an interview with heartwire from Medscape.

In recent years, he said, it’s been appreciated that ablation of PVCs in patients with lots of them can improve quality of life by alleviating symptoms such as syncope. And there are series of patients with PVCs and primarily nonischemic cardiomyopathy in the EP literature suggesting that “if you ablate those PVCs, their heart failure improves and often their reduced ejection fraction normalizes,” according to Marcus. “Many of us have seen that and witnessed it firsthand in many of our own patients.”

Although the analysis tried to control for such factors, she said, the question remains “whether PVCs are causing deterioration in EF and HF or if they are simply a marker of underlying disease. If the former is true, then treating PVCs would help. But if the latter is true, then treating PVCs may not make a difference.”

Marcus acknowledges that PVCs may be simply a risk marker in people with sick hearts. “But even if that’s the case, I think it’s potentially a very useful marker.” He said he hopes the report will help “motivate future research in potentially two different directions. One, might ablation be an effective therapy to prevent heart failure in the right patients? Alternatively, could this be used to help predict heart failure and implement other strategies, such as beta-blockers, to prevent heart failure in those patients?”

CASTing a New Light on Treatment of PVCs

The Cardiac Arrhythmia Suppression Trial (CAST), Marcus noted, “taught us a lot of important lessons. More generally, it was a great example of the need to look at hard outcomes rather than secondary or surrogate outcomes.”

As cardiology textbooks have since noted, CAST randomized about 2300 patients who had asymptomatic or only mildly symptomatic PVCs after acute MI to receive one of three antiarrhythmic agents or placebo. The drugs, which included the class Ic agents encainide and flecainide, were mostly effective at suppressing PVCs. But over a mean 10 months of follow-up, patients who had received those drugs showed steep rise in rate of arrhythmic death (the primary end point) as well as nonfatal cardiac arrest, almost certainly due to proarrhythmic effects.

The widely learned lesson: post-MI suppression of PVCs, a surrogate for the pathology behind sudden cardiac death in ischemic heart disease, doesn’t lower its risk; in fact, treatment of surrogate markers can make things a lot worse. (Importantly, CAST was conducted in the early days of arrhythmia ablation and implantable defibrillators, which were not options for its patients.)

As a result, according to Marcus, class Ic agents are generally avoided in patients with structural heart disease. “I think that while the proarrhythmic effects of those drugs were known, they weren’t fully appreciated, and CAST taught us to be wary of them.”

 

The CHS is sponsored by the National Heart, Lung, and Blood Institute. Dukes and Marcus report that they have no relevant financial relationships; disclosures for the other authors are in the report. Santangeli and Marchlinski report that they have no relevant financial relationships. Al-Khatib says she has no relevant financial relationships with industry.

 

SOURCE

http://www.medscape.com/viewarticle/847859?nlid=84244_2562&src=wnl_edit_medp_card&uac=93761AJ&spon=2&impID=760872&faf=1

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Male Infertility and Genomics: Fertile men carried a complete set of the sperm RNA elements; however, most of the infertile men did not

Posted in Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Reproductive Andrology, Embryology, Genomic Endocrinology, Preimplantation Genetic Diagnosis and Reproductive Genomics, Reproductive Biology & Bio Instrumentation on July 8, 2015| Leave a Comment »

Male Infertility and Genomics: Fertile men carried a complete set of the sperm RNA elements; however, most of the infertile men did not

Reporter: Aviva Lev-Ari, PhD, RN

Absence of sperm RNA elements correlates with idiopathic male infertility

  1. Meritxell Jodar1,2,
  2. Edward Sendler1,2,
  3. Sergey I. Moskovtsev3,4,
  4. Clifford L. Librach3,4,5,
  5. Robert Goodrich1,2,
  6. Sonja Swanson3,
  7. Russ Hauser6,7,
  8. Michael P. Diamond8 and
  9. Stephen A. Krawetz1,2,*

+ Author Affiliations

  1. ↵*Corresponding author. E-mail: steve@compbio.med.wayne.edu

Science Translational Medicine  08 Jul 2015:
Vol. 7, Issue 295, pp. 295re6
DOI: 10.1126/scitranslmed.aab1287

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Abstract

Semen parameters are typically used to diagnose male infertility and specify clinical interventions. In idiopathic infertile couples, an unknown male factor could be the cause of infertility even when the semen parameters are normal. Next-generation sequencing of spermatozoal RNAs can provide an objective measure of the paternal contribution and may help guide the care of these couples. We assessed spermatozoal RNAs from 96 couples presenting with idiopathic infertility and identified the final reproductive outcome and sperm RNA elements (SREs) reflective of fecundity status. The absence of required SREs reduced the probability of achieving live birth by timed intercourse or intrauterine insemination from 73 to 27%. However, the absence of these same SREs does not appear to be critical when using assisted reproductive technologies such as in vitro fertilization with or without intracytoplasmic sperm injection. About 30% of the idiopathic infertile couples presented an incomplete set of required SREs, suggesting a male component as the cause of their infertility. Conversely, analysis of couples that failed to achieve a live birth despite presenting with a complete set of SREs suggested that a female factor may have been involved, and this was confirmed by their diagnosis. The data in this study suggest that SRE analysis has the potential to predict the individual success rate of different fertility treatments and reduce the time to achieve live birth.

SOURCE

http://stm.sciencemag.org/content/7/295/295re6

The authors said that nine of the 648 SREs corresponded to intergenic regions, while 12 corresponded to sperm-specific intronic elements, and 42 were within 24 different non-coding RNAs, “all of which are likely regulatory.” They added that most of the SREs, 585, were within exonic regions of 262 different genes. Of those genes, 40 percent were “ontologically classified as associated with spermatogenesis, sperm physiology, fertility, and early embryogenesis before implantation.”

They noted that approximately 13 percent of all couples of reproductive age have problems of infertility, and while physical examination of men can reveal lowered sperm count, shape, or motility, in some cases there’s no apparent cause of infertility. RNA sequencing could help resolve those unknown cases.

The scientists found that fertile men carried a complete set of the sperm RNA elements; however, most of the infertile men did not. Men whose sperm lacked the full transcriptional profile were less successful at impregnating their partner. Men with the whole package of required SREs were able to achieve live births without the aid of reproductive assistance in 22 of 30 cases, but men with at least one missing required SRE were only able to do so in 3 of 11 cases.

The authors acknowledged that their biomarkers need validation in a larger, prospective, blinded, controlled study, which would “clarify which are essential for diagnosis and may contribute to the birth of a healthy child.” But they noted the decreasing cost of NGS and said RNA sequencing could produce a clinical benefit.

RNA sequencing could help identify the most effective fertility treatments for couples struggling to conceive. In the study, 14 men with at least one critical SRE absent from their sperm RNA profile attempted to conceive with their partner using assisted reproductive technologies such as in vitro fertilization. Of those, 11 were successful.

The authors noted that women are more likely to bear the burden of extensive evaluation in the case of failure and that non-invasive RNA sequencing of sperm might reduce risks associated with that evaluation. “This may permit an informed choice of a treatment paradigm that would help the female partner avoid undergoing invasive procedures such as egg collection,” the authors wrote.

SOURCE

https://www.genomeweb.com/gene-expression-research/sperm-rna-seq-study-reveals-potential-biomarkers-diagnosing-male?utm_source=SilverpopMailing&utm_medium=email&utm_campaign=Daily%20News:%20Sperm%20RNA-seq%20Study%20Reveals%20Potential%20Biomarkers%20for%20Diagnosing%20Male%20Infertility%20-%2007/08/2015%2004:30:00%20PM

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Allogeneic Stem Cell Transplantation [9.3]

Posted in Acute lymphocytic leukemia, Acute myelocytic leukemia, Bone marrow derived cells, Cancer and Current Therapeutics, Clinical & Translational, Curation, Cytoskeleton, Developmental biology, Diagnostic Immunology, Drug Toxicity, Embryology, Genetics & Innovations in Treatment, Hematopoiesis, Human Immune System in Health and in Disease, Immuno-Oncology & Genomics, Immunodiagnostics, Lymphoma, Myelodysplasia, Myelofibrosis, Personalized and Precision Medicine & Genomic Research, Pharmaceutical Analytics, Pharmacologic toxicities, Regenerative Biology and Medicine, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Umbilical cord cells, tagged allograft, Aspergillus fumigatus, autograft, failure to take, Graft-versus-host disease (GVHD), host-versus-graft disease, stem cell transplant, syngeneic transplant donor on May 14, 2015| Leave a Comment »

Allogeneic Stem Cell Transplantation

Writer and Curator: Larry H. Bernstein, MD, FCAP

This article has the following structure:

9.3.1  Cell based immunotherapy

9.3.2  Photodynamic therapy (PDT)

9.3.3  Small molecules targeted therapy drugs; Tyrosine kinase inhibitors; imatinib (Gleevec/Glivec) and gefitinib (Iressa).

9.3.4 Graft versus Host Disease

9.3.5 Aspergillus Complicating Allogeneic Transplantation

Introduction

9.3.1 Allogeneic Stem Cell Treatment

http://www.lls.org/treatment/types-of-treatment/stem-cell-transplantation/allogeneic-stem-cell-transplantation

Allogeneic stem cell transplantation involves transferring the stem cells from a healthy person (the donor) to your body after high-intensity chemotherapy or radiation.

Allogeneic stem cell transplantation is used to cure some patients who:

  • Are at high risk of relapse
  • Don’t respond fully to treatment
  • Relapse after prior successful treatment

Allogeneic stem cell transplantation can be a high-risk procedure. The high-conditioning regimens are meant to severely or completely impair your ability to make stem cells and you will likely experience side effects during the days you receive high-dose conditioning radiation or chemotherapy. The goals of high-conditioning therapy are to:

treat the remaining cancer cells intensively, thereby making a cancer recurrence less likely
inactivate the immune system to reduce the chance of stem cell graft rejection
enable donor cells to travel to the marrow (engraftment), produce blood cells and bring about graft versus tumor effect

Possible Adverse Effects

The immune system and the blood system are closely linked and can’t be separated from each other. Because of this, allogeneic transplantation means that not only the donor’s blood system but also his or her immune system is transferred. As a result, these adverse effects are possible:

  • Immune rejection of the donated stem cells by the recipient (host-versus-graft effect)
  • Immune reaction by the donor cells against the recipient’s tissues (graft-versus-host disease [GVHD])

The immune reaction, or GVHD, is treated by administering drugs to the patient after the transplant that reduce the ability of the donated immune cells to attack and injure the patient’s tissues. See Graft Versus Host Disease.

Allogeneic stem cell transplants for patients who are older or have overall poor health are relatively uncommon. This is because the pre-transplant conditioning therapy is generally not well tolerated by such patients, especially those with poorly functioning internal organs. However, reduced intensity allogeneic stem cell transplants may be an appropriate treatment for some older or sicker patients.

T-Lymphocyte Depletion

One goal of allogeneic stem cell transplant is to cause the T lymphocytes in the donor’s blood or marrow to take hold (engraft) and grow in the patient’s marrow. Sometimes the T lymphocytes attack the cancer cells. When this happens, it’s called graft versus tumor (GVT) effect (also called graft versus cancer effect). The attack makes it less likely that the disease will return. This effect is more common in myeloid leukemias than it is in other blood cancers.

Unfortunately, T lymphocytes are the same cells that cause graft versus host disease (GVHD). Because of this serious and sometimes life-threatening side effect, doctors in certain cases want to decrease the number of T lymphocytes to be infused with the stem cells. This procedure, called T-lymphocyte depletion, is currently being studied by researchers. The technique involves treating the stem cells collected for transplant with agents that reduce the number of T lymphocytes.

The aim of T-lymphocyte depletion is to lessen GVHD’s incidence and severity. However, it can also cause increased rates of graft rejection, a decreased GVT effect and a slower immune recovery. Doctors must be careful about the number of T lymphocytes removed when using this technique.

Stem Cell Selection

Stem cell selection is another technique being studied in clinical trials that can reduce the number of T lymphocytes that a patient receives. Because of specific features on the outer coat of stem cells, doctors can selectively remove stem cells from a cell mixture. This technique produces a large number of stem cells and fewer other cells, including T lymphocytes.

9.3.2 Defining Characteristics of  Stem Cells

http://stemcells.nih.gov/info/basics/pages/basics1.aspx

Stem cells have the remarkable potential to develop into many different cell types in the body during early life and growth. In addition, in many tissues they serve as a sort of internal repair system, dividing essentially without limit to replenish other cells as long as the person or animal is still alive. When a stem cell divides, each new cell has the potential either to remain a stem cell or become another type of cell with a more specialized function, such as a muscle cell, a red blood cell, or a brain cell.

Stem cells are distinguished from other cell types by two important characteristics. First, they are unspecialized cells capable of renewing themselves through cell division, sometimes after long periods of inactivity. Second, under certain physiologic or experimental conditions, they can be induced to become tissue- or organ-specific cells with special functions. In some organs, such as the gut and bone marrow, stem cells regularly divide to repair and replace worn out or damaged tissues. In other organs, however, such as the pancreas and the heart, stem cells only divide under special conditions.

Until recently, scientists primarily worked with two kinds of stem cells from animals and humans: embryonic stem cells and non-embryonic “somatic” or “adult” stem cells. The functions and characteristics of these cells will be explained in this document. Scientists discovered ways to derive embryonic stem cells from early mouse embryos more than 30 years ago, in 1981. The detailed study of the biology of mouse stem cells led to the discovery, in 1998, of a method to derive stem cells from human embryos and grow the cells in the laboratory. These cells are called human embryonic stem cells. The embryos used in these studies were created for reproductive purposes through in vitro fertilization procedures.

When they were no longer needed for that purpose, they were donated for research with the informed consent of the donor. In 2006, researchers made another breakthrough by identifying conditions that would allow some specialized adult cells to be “reprogrammed” genetically to assume a stem cell-like state. This new type of stem cell is called induced pluripotent stem cells (iPSCs).

Stem cells differ from other kinds of cells in the body. All stem cells—regardless of their source—have three general properties: they are capable of dividing and renewing themselves for long periods; they are unspecialized; and they can give rise to specialized cell types.

Stem cells are capable of dividing and renewing themselves for long periods. Unlike muscle cells, blood cells, or nerve cells—which do not normally replicate themselves—stem cells may replicate many times, or proliferate. A starting population of stem cells that proliferates for many months in the laboratory can yield millions of cells. If the resulting cells continue to be unspecialized, like the parent stem cells, the cells are said to be capable of long-term self-renewal.

Scientists are trying to understand two fundamental properties of stem cells that relate to their long-term self-renewal:

  1. Why can embryonic stem cells proliferate for a year or more in the laboratory without differentiating, but most adult stem cells cannot; and
  2. What are the factors in living organisms that normally regulate stem cell proliferation and self-renewal?

Discovering the answers to these questions may make it possible to understand how cell proliferation is regulated during normal embryonic development or during the abnormal cell division that leads to cancer.

Stem cells are unspecialized. One of the fundamental properties of a stem cell is that it does not have any tissue-specific structures that allow it to perform specialized functions. For example, a stem cell cannot work with its neighbors to pump blood through the body (like a heart muscle cell), and it cannot carry oxygen molecules through the bloodstream (like a red blood cell). However, unspecialized stem cells can give rise to specialized cells, including heart muscle cells, blood cells, or nerve cells.

Stem cells can give rise to specialized cells. When unspecialized stem cells give rise to specialized cells, the process is called differentiation. While differentiating, the cell usually goes through several stages, becoming more specialized at each step. Scientists are just beginning to understand the signals inside and outside cells that trigger each step of the differentiation process. The internal signals are controlled by a cell’s genes, which are interspersed across long strands of DNA and carry coded instructions for all cellular structures and functions. The external signals for cell differentiation include chemicals secreted by other cells, physical contact with neighboring cells, and certain molecules in the microenvironment. The interaction of signals during differentiation causes the cell’s DNA to acquire epigenetic marks that restrict DNA expression in the cell and can be passed on through cell division.

Adult stem cells typically generate the cell types of the tissue in which they reside. For example, a blood-forming adult stem cell in the bone marrow normally gives rise to the many types of blood cells. It is generally accepted that a blood-forming cell in the bone marrow—which is called a hematopoietic stem cell—cannot give rise to the cells of a very different tissue, such as nerve cells in the brain.

Through years of experimentation, scientists have established some basic protocols or “recipes” for the directed differentiation of embryonic stem cells into some specific cell types (Figure 1). (For additional examples of directed differentiation of embryonic stem cells, refer to the NIH stem cell report available at

http://stemcells.nih.gov/info/scireport/pages/2006report.aspx.)

stem cell differentiation figure1_sm

stem cell differentiation figure1_sm

http://stemcells.nih.gov/StaticResources/images/figure1_sm.jpg

9.3.3 Types of Stem Cell Transplants for Treating Cancer

http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/bonemarrowandperipheralbloodstemcelltransplant/stem-cell-transplant-types-of-transplant

In a typical stem cell transplant for cancer very high doses of chemo are used, often along with radiation therapy, to try to destroy all the cancer cells. This treatment also kills the stem cells in the bone marrow. Soon after treatment, stem cells are given to replace those that were destroyed. These stem cells are given into a vein, much like a blood transfusion. Over time they settle in the bone marrow and begin to grow and make healthy blood cells. This process is called engraftment.

There are 3 basic types of transplants. They are named based on who gives the stem cells.

  • Autologous (aw-tahl-uh-gus)—the cells come from you
  • Allogeneic (al-o-jen-NEE-ick or al-o-jen-NAY-ick)—the cells come from a matched related or unrelated donor
  • Syngeneic (sin-jen-NEE-ick or sin-jen-NAY-ick)—the cells come from your identical twin or triplet
hematopoietic stem cell transplant

hematopoietic stem cell transplant

Autologous stem cell transplants

These stem cells come from you alone. In this type of transplant, your stem cells are taken before you get cancer treatment that destroys them. Your stem cells are removed, or harvested, from either your bone marrow or your blood and then frozen. To find out more about that process, please see the section “What’s it like to donate stem cells?” After you get high doses of chemo and/or radiation the stem cells are thawed and given back to you.

One advantage of autologous stem cell transplant is that you are getting your own cells back. When you donate your own stem cells you don’t have to worry about the graft attacking your body (graft-versus-host disease) or about getting a new infection from another person. But there can still be graft failure, and autologous transplants can’t produce the “graft-versus-cancer” effect.

This kind of transplant is mainly used to treat certain leukemias, lymphomas, and multiple myeloma. It’s sometimes used for other cancers, like testicular cancer and neuroblastoma, and certain cancers in children.

Getting rid of cancer cells in autologous transplants

A possible disadvantage of an autologous transplant is that cancer cells may be picked up along with the stem cells and then put back into your body later. Another disadvantage is that your immune system is still the same as before when your stem cells engraft. The cancer cells were able to grow despite your immune cells before, and may be able to do so again. The need to remove cancer cells from transplants or transplant patients and the best way to do it is being researched.

Doing 2 autologous transplants in a row is known as a tandem transplant or a double autologous transplant. In this type of transplant, the patient gets 2 courses of high-dose chemo, each followed by a transplant of their own stem cells. All of the stem cells needed are collected before the first high-dose chemo treatment, and half of them are used for each transplant. Most often both courses of chemo are given within 6 months, with the second one given after the patient recovers from the first one.

Allogeneic stem cell transplants

In the most common type of allogeneic transplant, the stem cells come from a donor whose tissue type closely matches the patient’s. (This is discussed later under “HLA matching” in the section called “ Donor matching for allogeneic transplant.”) The best donor is a close family member, usually a brother or sister. If you do not have a good match in your family, a donor might be found in the general public through a national registry. This is sometimes called a MUD (matched unrelated donor) transplant. Transplants with a MUD are usually riskier than those with a relative who is a good match.

Blood taken from the placenta and umbilical cord of newborns is a newer source of stem cells for allogeneic transplant. Called cord blood, this small volume of blood has a high number of stem cells that tend to multiply quickly. But the number of stem cells in a unit of cord blood is often too low for large adults, so this source of stem cells is limited to small adults and children. Doctors are now looking at different ways to use cord blood for transplant in larger adults, such as using cord blood from 2 donors.

Pros of allogeneic stem cell transplant: The donor stem cells make their own immune cells, which could help destroy any cancer cells that remain after high-dose treatment. This is called the graft-versus-cancer effect. Other advantages are that the donor can often be asked to donate more stem cells or even white blood cells if needed, and stem cells from healthy donors are free of cancer cells.

Cons to allogeneic stem cell transplants: The transplant, also known as the graft, might not take — that is, the donor cells could die or be destroyed by the patient’s body before settling in the bone marrow. Another risk is that the immune cells from the donor may not just attack the cancer cells – they could attack healthy cells in the patient’s body. This is called graft-versus-host disease (described in the section called “Problems that may come up shortly after transplant”). There is also a very small risk of certain infections from the donor cells, even though donors are tested before they donate. A higher risk comes from infections you have had, and which your immune system has under control. These infections often surface after allogeneic transplant because your immune system is held in check (suppressed) by medicines called immunosuppressive drugs. These infections can cause serious problems and even death.

Allogeneic transplant is most often used to treat certain types of leukemia, lymphomas, multiple myeloma,myelodysplastic syndrome, and other bone marrow disorders such as aplastic anemia.

Mini transplants (non-myeloablative transplants)

For some people, age or certain health conditions make it more risky to wipe out all of their bone marrow before a transplant. For those people, doctors can use a type of allogeneic transplant that’s sometimes called a mini-transplant. Compared with a standard allogeneic transplant, this one uses less chemo and/or radiation to get the patient ready for the transplant. Your doctor might refer to it as a non-myeloablative transplant or mention reduced-intensity conditioning (RIC). The idea here is to kill some of the cancer cells along with some of the bone marrow, and suppress the immune system just enough to allow donor stem cells to settle in the bone marrow.

Unlike the standard allogeneic transplant, cells from both the donor and the patient exist together in the patient’s body for some time after a mini-transplant. But slowly, over the course of months, the donor cells take over the bone marrow and replace the patient’s own bone marrow cells. These new cells can then develop an immune response to the cancer and help kill off the patient’s cancer cells — the graft-versus-cancer effect.

Syngeneic stem cell transplants – for those with an identical sibling

This is a special kind of allogeneic transplant that can only be used when the recipient has an identical sibling (twin or triplet) who can donate — someone who will have the same tissue type. An advantage of syngeneic stem cell transplant is that graft-versus-host disease will not be a problem. There are no cancer cells in the transplant, either, as there would be in an autologous transplant.

A disadvantage is that because the new immune system is so much like the recipient’s immune system, there is no graft-versus-cancer effect, either. Every effort must be made to destroy all the cancer cells before the transplant is done to help keep the cancer from relapsing (coming back).

9.3.4 Graft versus Host Disease

http://bethematch.org/For-Patients-and-Families/Life-after-transplant/Graft-versus-host-disease–GVHD-/

Graft-versus-host disease(GVHD) occurs because of differences between the cells of your body and the donated cells and is a common side effect of an allogeneic bone marrow transplant.

An allogeneic transplant uses blood cells from a family member, unrelated donor or cord blood unit. GVHD can affect many different parts of the body including the skin, eyes, mouth, stomach, and intestines.

There are two types of GVHD:

  • Acute GVHD: Develops in the first 100 days or so after transplant but can occur later. This primarily affects the skin, stomach, intestines, and liver.
  • Chronic GVHD: Usually develops 3-6 months after transplant, but signs can appear earlier or later. If you have had or currently have acute GVHD, you are more likely to have chronic GVHD.

The severity of acute and chronic GVHD can range from mild to life-threatening.

Doctors often see mild GVHD as a good thing after an allogeneic transplant when the transplant was done for a blood cancer. It is a sign that the donor’s immune system is working to destroy any remaining cancer cells. Patients who experience some GVHD have a lower risk of the cancer returning after transplant than patients who do not develop GVHD. If the transplant was to treat a disease other than cancer disease, like aplastic anemia, then the doctor may want to treat even mild GVHD.

Graft-versus-Host Disease

JLM Ferrara, JE Levine, P Reddy, and E Holler
Lancet. 2009 May 2; 373(9674): 1550–1561.
http://dx.doi.org:/10.1016/S0140-6736(09)60237-3

The number of allogeneic hematopoietic cell transplantations (HCT) continues to increase with more than 25,000 allogeneic transplantations performed annually. The graft-versus-leukemia / tumor (GVL) effect during allogeneic HCT effectively eradicates many hematological malignancies.1 The development of novel strategies that use donor leukocyte infusions, non-myeloablative conditioning and umbilical cord blood (UCB) transplantation have helped expand the indications for allogeneic HCT over the last several years, especially among older patients.2 Improvements in infectious prophylaxis, immunosuppressive medications, supportive care and DNA-based tissue typing have also contributed to improved outcomes after allogeneic HCT.1 Yet the major complication of allogeneic HCT, graft-versus-host disease (GVHD), remains lethal and limits the use of this important therapy.2 Given current trends, the number of transplants from unrelated donors is expected to double within the next five years, significantly increasing the population of patients with GVHD. In this seminar we review advances made in identifying the genetic risk factors and pathophysiology of this major HCT complication, as well as its prevention, diagnosis and treatment.

Etiology and Clinical Features

Fifty years ago Billingham formulated three requirements for the development of GVHD: the graft must contain immunologically competent cells; the recipient must express tissue antigens that are not present in the transplant donor; and the recipient must be incapable of mounting an effective response to eliminate the transplanted cells.3 We know now that the immunologically competent cells are T cells, and that GVHD can develop in various clinical settings when tissues containing T cells (blood products, bone marrow, and solid organs) are transferred from one person to another who is not able to eliminate those cells.4, 5 Patients, whose immune systems are suppressed, and who receive white blood cells from another individual, are at particularly high risk for GVHD.

GVHD occurs when donor T cells respond to genetically defined proteins on host cells. The most important proteins are Human Leukocyte Antigens (HLA)2, 6, 7, which are highly polymorphic and are encoded by the major histocompatibility complex (MHC). Class I HLA (A, B, and C) proteins are expressed on almost all nucleated cells of the body at varying densities. Class II proteins (DR, DQ, and DP) are primarily expressed on hematopoietic cells (B cells, dendritic cells, monocytes), but their expression can be induced on many other cell types following inflammation or injury. High-resolution DNA typing of HLA genes with polymerase chain reaction (PCR)-based techniques have now largely replaced earlier methods. The incidence of acute GVHD is directly related to the degree of mismatch between HLA proteins8, 9 and thus ideally, donors and recipients are matched at HLA-A, -B, -C, and -DRB1, (“8/8 matches”), but mismatches may be tolerated for UCB grafts (see below).10–12

Non-HLA Genetics

Despite HLA identity between a patient and donor, approximately 40% of patients receiving HLA-identical grafts develop acute GVHD due to genetic differences that lie outside the HLA loci, or “minor” histocompatibility antigens (HA). Some minor HAs, such as HY and HA-3, are expressed on all tissues and are targets for both GVHD and GVL.13 Other minor HAs, such as HA-1 and HA-2, are expressed most abundantly on hematopoietic cells (including leukemic cells) and may therefore induce a greater GVL effect with less GVHD.13, 14

Polymorphisms in both donors and recipients for cytokines that are involved in the classical `cytokine storm’ of GVHD (discussed below) have been implicated as risk factors for GVHD.15 Tumor Necrosis Factor (TNF)-α, Interleukin 10 (IL-10), Interferon-γ (IFNγ) variants have correlated with GVHD in some, but not all, studies.16–18 Genetic polymorphisms of proteins involved in innate immunity, such as nucleotide oligomerization domain 2 and Keratin 18 receptors, have also been associated with GVHD.19–22 Future strategies to identify the best possible transplant donor will probably incorporate both HLA and non-HLA genetic factors.

Clinical Features of Acute GVHD

Based on an early Seattle experience, acute GVHD was defined to occur prior to day 100, whereas chronic GVHD occurred after that time.23–25 This definition is far from satisfactory, and a recent National Institutes of Health classification includes late-onset acute GVHD (after day 100) and an overlap syndrome with features of both acute and chronic GVHD.26 Late-onset acute GVHD and the overlap syndrome occur with greater frequency after reduced-intensity conditioning (RIC), an increasingly widespread technique (see below). As shown in Table 1, the clinical manifestations of acute GVHD occur in the skin, gastrointestinal tract and liver.27 In a comprehensive review, Martin et al found that at the onset of acute GVHD, 81% of patients had skin involvement, 54% had GI involvement, and 50% had liver involvement.23 Recent data suggest that lungs might also be targets of experimental GVHD.28

Acute GVHD Symptoms

Table 1

Pathophysiology of Acute GVHD

Two important principles are important to consider regarding the pathophysiology of acute GVHD. First, acute GVHD reflects exaggerated but normal inflammatory mechanisms mediated by donor lymphocytes infused into the recipient where they function appropriately, given the foreign environment they encounter. Second, the recipient tissues that stimulate donor lymphocytes have usually been damaged by underlying disease, prior infections, and the transplant conditioning regimen.29 As a result, these tissues produce molecules (sometimes referred to as “danger” signals) that promote the activation and proliferation of donor immune cells.42–45 Mouse models havebeen central to our identification and understanding of the pathophysiologic mechanisms of GVHD, and canine models have been critical to the development of clinically useful strategies for GVHD prophylaxis and treatment and to the development of donor leukocyte infusions.36, 46, 47 Based largely on these experimental models, the development of acute GVHD can be conceptualized in three sequential steps or phases: (1) activation of the APCs; (2) donor T cell activation, proliferation, differentiation and migration; and (3) target tissue destruction (Figure 3).

Figure 3

GVHD Pathophysiology

In Phase I, the recipient conditioning regimen damages host tissues and causes release of inflammatory cytokines such as TNFα, IL-1 and IL-6. Increased levels of these cytokines leads to activation of host antigen presenting cells (APCs). In Phase II, host APCs activate mature donor cells. The subsequent proliferation and differentiation of these activated T cells produces additional effectors that mediate the tissue damage, including Cytotoxic T Lymphocytes, Natural Killer (NK) cells, TNFα and IL-1. Lipopolysaccharide (LPS) that has leaked through the damaged intestinal mucosa triggers additional TNFα production. TNFα can damage tissue directly by inducing necrosis and apoptosis in the skin and GI tract through either TNF receptors or the Fas pathway. TNFα plays a direct role in intestinal GVHD damage which further amplifies damage in the skin, liver and lung in a “cytokine storm.”

GVHD pathophysiology nihms-115970-f0003

GVHD pathophysiology nihms-115970-f0003

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735047/bin/nihms-115970-f0003.jpg

Phase I: Activation of Antigen Presenting Cells (APCs)

The first step involves the activation of APCs by the underlying disease and the HCT conditioning regimen. Damaged host tissues respond by producing “danger” signals, including proinflammatory cytokines (e.g., TNF-α), chemokines, and increased expression of adhesion molecules, MHC antigens and costimulatory molecules on host APCs.42, 48–50 A recent report demonstrated that at one week after HCT, increased levels of TNF-α receptor I, a surrogate marker for TNF-α, strongly correlated with the later development of GVHD.51 Damage to the GI tract from the conditioning is particularly important because it allows for systemic translocation of additional inflammatory stimuli such as microbial products including lipopolysaccaride (LPS) or other pathogen-associated molecular patterns that further enhance the activation of host APCs.49 The secondary lymphoid tissue in the GI tract is likely the initial site of interaction between activated APCs and donor T cells.52 These observations have led an important clinical strategy to reduce acute GVHD by reducing the intensity of the conditioning regimen. Experimental GVHD can also be reduced by manipulating distinct subsets of APCs.53,54 In addition, non-hematopoietic stem cells, such as mesenchymal stem cells or stromal cells, can reduce allogeneic T cell responses, although the mechanism for such inhibition remains unclear.2

The concept that enhanced activation of host APCs increases the risk for acute GVHD unifies a number of seemingly disparate clinical associations with that risk, such as advanced stages of malignancy, more intense transplant conditioning regimens and histories of viral infections. APCs detect infections by recognizing conserved molecular patterns that are unique to microbes, called pathogen-associated molecular patterns (PAMPs). Among the classes of receptors that recognize such patterns, the Toll-like receptors (TLR) are the best characterized.55 For example, TLR4 recognizes LPS55 and mice with mutant TLR4 receptors that do not respond to LPS cause less GVHD when used as donors.56 Other TLRs that recognize viral DNA or RNA also activate APCs and may enhance GVHD, providing a potential mechanistic basis for increased GVHD associated with viral infections such as cytomegalovirus (CMV).57

Phase II: Donor T Cell Activation

The core of the GVH reaction is Step 2, where donor T cells proliferate and differentiate in response to host APCs. The “danger” signals generated in Phase I augment this activation at least in part by increasing the expression of costimulatory molecules.58 Blockade of co-stimulatory pathways to prevent GVHD is successful in animal models, but this approach has not yet been tested in large clinical trials.2

In mouse models, where genetic differences between donor and recipient strains can be tightly controlled, CD4+ cells induce acute GVHD to MHC class II differences, and CD8+ cells induce acute GVHD to MHC class I differences.59–61 In the majority of HLA-identical HCTs, both CD4+ and CD8+ subsets respond to minor histocompatibility antigens and can cause GVHD in HLA-identical HCT.

Regulatory T cells can suppress the proliferation of conventional T cells and prevent GVHD in animal models when added to donor grafts containing conventional T cells.62 In mice, the Foxp3 protein functions as a master switch in the development of regulatory T cells, which normally constitute 5% of the CD4+ T cell population.62 Regulatory T cells secrete anti-inflammatory cytokines IL-10 and Transforming Growth Factor(TGF)-β and can also act through contact-dependent inhibition of APCs.62 It is likely that the use of regulatory T cells in clinical acute GVHD will require improved techniques to identify and expand them.

Natural Killer T cell (NKT) 1.1+ subsets of both the host and donors that have been shown to modulate acute GVHD.63 Host NKT cells have been shown to suppress acute GVHD in an IL-4 dependent manner.64 A recent clinical trial of total lymphoid irradiation used as conditioning significantly reduced GVHD and enhanced host NKT cell function.65 By contrast, donor NKT cells can reduce GVHD and enhance perforin mediated GVL in an experimental model.66

Activation of immune cells results in rapid intracellular biochemical cascades that induce transcription of genes for many proteins including cytokines and their receptors. Th1 cytokines (IFN-γ, IL-2 and TNF-α) are produced in large amounts during acute GVHD. IL-2 production by donor T cells remains the principal target of many current clinical therapeutic and prophylactic approaches to GVHD, such as cyclosporine, tacrolimus and monoclonal antibodies (mAbs) directed against IL-2 and its receptor.9 But emerging data indicate an important role for IL-2 in the generation and maintenance of CD4+ CD25+ T regs, suggesting that prolonged interference with IL-2 may have an unintended consequence of preventing the development of long term tolerance after allogeneic HCT.67 IFN-γ has multiple functions and can either amplify or reduce GVHD.68,69 IFN-γ may amplify GVHD by increasing the expression of molecules such as chemokines receptors, MHC proteins, and adhesion molecules; it also increases the sensitivity of monocytes and macrophages to stimuli such as LPS and accelerates intracellular cascades in response to these stimuli.70Early polarization of donor T cells so that they secrete less IFN-γ and more IL-4 can also attenuate experimental acute GVHD.71 IFN-γ may amplify GVHD by directly damaging epithelium in the GI tract and skin and inducing immnosuppression through the induction of nitric oxide.72 By contrast, IFN-γ may suppress GVHD by hastening the apoptosis of activated donor T cells.69, 73. This complexity means the manipulation of IFN-γ may have diverse effects in vivo, making it a challenging target with respect to therapeutic intervention. IL-10 plays a key role in suppression of immune responses, and clinical data suggest it may regulate acute GVHD.17 TGF-β, another suppressive cytokine can suppress acute GVHD but exacerbate chronic GVHD.74 Thus the timing and duration of the secretion of any given cytokine may determine the specific effects of that cytokine on GVHD severity.

Phase III: Cellular and Inflammatory Effector Phase

The effector phase of this process is a complex cascade of both cellular mediators such as cytotoxic T lymphocytes(CTLs) and NK cells and soluble inflammatory mediators such as TNF-α, IFN-γ, IL-1 and nitric oxide.2, 29 These soluble and cellular mediators synergize to amplify local tissue injury and further promote inflammation and target tissue destruction.

Cellular Effectors

The cellular effectors of acute GVHD are primarily CTLs and NK cells.49 CTLs that preferentially use the Fas/FasL pathway of target lysis and appear to predominate in GVHD liver damage (hepatocytes express large amounts of Fas) whereas GVHD CTLs that use the perforin /granzyme pathways are more important in the GI tract and skin.2, 75 Chemokines direct the migration of donor T cells from lymphoid tissues to the target organs where they cause damage. Macrophage inflammatory protein-1alpha (MIP-1α) and other chemokines such as CCL2-5, CXCL2, CXCL9-11, CCL17 and CCL27 are over-expressed and enhance the homing of cellular effectors to target organs during experimental GVHD.76Expression of integrins, such as α4β7 and its ligand MadCAM-1, are also important for homing of donor T cells to Peyer’s patches during intestinal GVHD.52, 77, 78

Prevention of GVHD

Based on the evidence from animal models regarding the central role of T cells in initiating GVHD, numerous clinical studies evaluating T cell depletion (TCD) as prophylaxis for GVHD were performed in the 1980’s and 1990’s. There were three principal TCD strategies: (1) negative selection of T cells ex vivo, (2) positive selection of CD34+ stem cells ex vivo; and (3) anti-T cell antibodies in vivo.83Most strategies showed a significant limitation in both acute and chronic GVHD.84–88 Unfortunately, the lower incidence of severe GVHD was offset by high rates of graft failure, relapse of malignancy, infections, and Epstein-Barr virus-associated lymphoproliferative disorders. Negative selection purging strategies using various anti-T cell antibodies achieved similar long-term results regardless of the breadth of antibody specificity.89–93 One large registry study demonstrated that purging strategies using antibodies with broad specificities produced inferior leukemia-free survival than standard immunosuppression in patients receiving unrelated donor transplants.94 Several studies have investigated partial T cell depletion, either by eliminating specific T cell subsets (e.g., CD8+) or by titrating the dose of T cells present in the inoculum.95–97 None of these approaches, however, has convincingly demonstrated an optimal strategy that improves long-term survival.

Alemtuzumab is a monoclonal antibody that binds CD52, a protein expressed on a broad spectrum of leukocytes including lymphocytes, monocytes, and dendritic cells. Its use in GVHD prophylaxis in a Phase II trial decreased the incidence of acute and chronic GVHD following reduced intensity transplant.98 In two prospective studies, patients who received alemtuzumab rather than methotrexate showed significantly lower rates of acute and chronic GVHD,99 but experienced more infectious complications and higher rates of relapse, so that there was no overall survival benefit. Alemtuzumab may also contribute to graft failure when used with minimal intensity conditioning regimens.100

An alternative strategy to TCD attempted to induce anergy in donor T cells by ex vivo antibody blockade of co-stimulatory pathways prior to transplantation. A small study using this approach in haploidentical HCT recipients was quite encouraging, but has not yet been replicated.101 Thus the focus of most prevention strategies remains pharmacological manipulation of T cells after transplant.

Administration of anti-T cell antibodies in vivo as GVHD prophylaxis has also been extensively tested. The best studied drugs are anti-thymocyte globulin (ATG) or antilymphocyte globulin (ALG) preparations. These sera, which have high titers of polyclonal antibodies, are made by immunizing animals (horses or rabbits) to thymocytes or lymphocytes, respectively. A complicating factor in determining the role of these polyclonal sera in transplantation is the observation that even different brands of the same class of sera exert different biologic effects.102 However, the side effects of ATG/ALG infusions are common across different preparations and include fever, chills, headache, thrombocytopenia (from cross-reactivity to platelets), and, infrequently, anaphylaxis. In retrospective studies, rabbit ATG reduced the incidence of GVHD in related donor HSCT recipients without appearing to improve survival.103, 104 In recipients of unrelated donor HSCT, addition of ALG to standard GVHD prophylaxis effectively prevented severe GVHD, but did not result in improved survival because of increased infections.105 In a long term follow-up study, however, pretransplant ATG provided significant protection against extensive chronic GVHD and chronic lung dysfunction.106

The primary pharmacologic strategy to prevent GVHD is the inhibition of the cytoplasmic enzyme, calcineurin, that is critical for in the activation of T cells. The calcineurin inhibitors, cyclosporine and tacrolimus, have similar mechanisms of action, clinical effectiveness and toxicity profiles, including hypomagnesemia, hyperkalemia, hypertension, and nephrotoxicity.9, 107 Serious side effects include transplant-associated thrombotic microangiopathy (TAM) and neurotoxicity that can lead to premature discontinuation. Although clinically similar to thrombotic thrombocytopenic purpura, TAM does not reliably respond to therapeutic plasmapheresis, carries a high mortality rate, and removal of the offending agent does not always result in improvement.108 Posterior reversible encephalopathy syndrome includes mental status changes, seizures, neurological deficits and characteristic magnetic resonance imaging findings; this syndrome has been seen in 1-2% of HCT recipients receiving and calcineurin inhibitors.109 Side effects of these drugs decrease as the dose is tapered, usually two to four months after HCT.

Calcineurin inhibitors are often administered in combination with other immunosuppressants, such as methotrexate, which is given at low doses in the early post-transplant period.9, 107 The toxicities of methotrexate (neutropenia and mucositis) have led some investigators to replace it with mycophenolate mofetil (MMF). In one prospective randomized trial, patients who received MMF as part of GVHD prophylaxis experienced significantly less severe mucositis and more rapid neutrophil engraftment than those who received methotrexate.110 The incidence and severity of acute GVHD was similar between the two groups, but the study closed early due to superiority of the MMF arm with respect to reduced mucositis and the speed of hematopoietic engraftment. A desire for faster neutrophil engraftment has led to the use of MMF in UCB blood transplants where graft failure is a major concern.111 MMF is also often used after RIC regimens for similar reasons.112, 113

Sirolimus is an immunosuppressant that is structurally similar to tacrolimus but does not inhibit calcineurin. In a small Phase II trial, it showed excellent efficacy in combination with tacrolimus;114 the drug damages endothelial cells, however, and it may enhance TAM that is associated with calcineurin inhibitors.115 The combination of tacrolimus and sirolimus is currently being compared in a large randomized multi-center trial.

RIC regimens attempt to suppress the host immune system sufficiently so that donor T cells can engraft and then ablate the lympho-hematopoietic compartment of the recipient. The term “non-myeloablative” is therefore somewhat misleading. RIC regimens produce less tissue damage and lower levels of the inflammatory cytokines that are important in the initiation of GVHD pathophysiology; this effect may explain the reduced incidence of severe GVHD following RIC compared to the full intensity conditioning used in historical controls.98, 116 The onset of acute GVHD may be delayed after RIC until after day 100, however, and it may present simultaneously with elements of chronic GVHD (“overlap syndrome”).116–120

Treatment of Acute GVHD

GVHD generally first develops in the second month after HCT, during continued treatment with calcineurin-based prophylaxis.23, 121 Steroids, with their potent antilymphocyte and anti-inflammatory activity, are the gold standard for treatment of GVHD. Many centers treat mild GVHD of the skin (Grade I) with topical steroids alone, but for more severe skin GVHD and any degree of visceral GVHD involvement, high-dose systemic steroids are usually initiated. Steroid therapy results in complete remission in less than half of the patients,122 and more severe GVHD is less likely to respond to treatment.123, 124 In a prospective randomized study, the addition of ATG to steroids as primary therapy did not increase the response rate.124 In a retrospective study, the use of ATG in patients who showed early signs of steroid-resistance was beneficial,122 but not all studies show such benefit and ATG is not standardly used because of increased infection risks.106, 125, 126.

An increasingly common treatment for GVHD is extracorporeal photopheresis (ECP). During ECP, the patient’s white blood cells are collected by apheresis, incubated with the DNA-intercalating agent, 8-methoxypsoralen, exposed to ultraviolet light (UVA), and returned to the patient. ECP is known to induce cellular apoptosis, which has strong anti-inflammatory effects in a number of systems, including prevention of rejection of solid organ grafts.127 Animal studies show that ECP reverses acute GVHD by increasing the number of regulatory T cells.128 A Phase II clinical study of steroid-dependent or steroid refractory GVHD showed resolution of GVHD in a large majority of patients, with 50% long-term survival in this very high risk group.129 Randomized multi-center studies of this approach are needed to determine its place in the management of acute GVHD.

Another interesting strategy to treat GVHD is the blockade of the inflammatory cytokine TNF-α. TNF-α can activate APCs, recruit effector cells and cause direct tissue damage.130 In animal models, TNF-α plays a central role in GVHD of the GI tract, which is central to the “cytokine storm” and plasma levels of TNFR I (a surrogate marker for TNF-α) rise in patients before the clinical manifestations of GVHD appear. 51 A recent Phase II trial of etanercept, a solubilized TNFR II, showed significant efficacy when added to systemic steroids as primary therapy for acute GVHD. Seventy percent of patients had complete resolution of all GVHD symptoms within one month, with 80% complete responses in the GI tract and the skin. The authors also showed that plasma levels of TNFR I were a significant biomarker for clinical GVHD.131

Treatment of Chronic GVHD

In contrast to acute GVHD, the pathophysiology of chronic GVHD remains poorly understood, and it is treated with a variety of immunosuppressive agents. The response of chronic GVHD to treatment is unpredictable, and mixed responses in different organs can occur in the same patient. Confounding variables such as infection and co-morbidities also make responses hard to measure. The use of corticosteroids (with or without a calcineurin inhibitor) is the standard of care, but a randomized trial of more than 300 patients with chronic GVHD found no difference between cyclosporine plus prednisone versus prednisone alone.132 Chronic immunosuppressants, especially those containing steroids, are highly toxic and result in infectious deaths. Many second line therapies have been studied, but none has achieved widespread acceptance. As mentioned above, ECP shows some promise, with significant response rates in high-risk patients. The best responses were observed in skin, liver, oral mucosa, eye, and lung.133 This observation is particularly relevant because lung GVHD has the potential to be a particularly devastating complication necessitating lung transplant as the only therapeutic option.134, 135

Essential Supportive Care in GVHD Patients

Meticulous supportive care is critical for patients with both acute and chronic GVHD because of the extended duration of immunosuppressive treatments and because the multiple medications required may have synergistic toxicities. Such care includes extensive infectious prophylaxis, early interventions in cases of suspected infections, and prophylaxis against non-infectious side effects of medications (See Table 3). These complications often require rapid responses to prevent serious or irreversible damage, and are best handled in close collaboration between the primary physician and the transplant specialist.

Table 3

Recommendations for Supportive Care

All patients should receive at least fluconazole as prophylaxis against fungal infections. Invasive molds, especially aspergillus, are common in patients with prolonged steroid use.136 Prophylaxis with voriconazole or posaconazole should be considered for these patients. Usual sites of infection are the lungs, sinuses, brain, skin,137 and serial galactomannan assays may aid in the early detection.138 Candida can cause lesions in the lung and spleen, which may need screening with ultrasonography. Pneumocystis is another opportunistic infection that should receive cotrimoxazol (bactrim) prophylaxis.139

Viral infections are frequent in these patients with GVHD. Cytomegalovirus causes interstitial pneumonia and gastritis. Patients who are at risk should have their blood monitored several times monthly. Techniques that directly detect virus should be performed, such as CMV PCR or pp65 antigen, and evidence of increased viral load should prompt preemptive treatment with ganciclovir or foscarnet prior to clinical manifestations of disease. Shingles is not uncommon and acyclovir prophylaxis may be beneficial.140 Patients and caregivers should receive vaccinations against influenza, and treatment with neuraminidase inhibitors is recommended in the event of influenza infection.141, 142

Patients with GVHD often have IgG2 and IgG4 subclass deficiencies despite normal lgG levels, making them susceptible to infections with encapsulated organisms. Treatment of severe hypogammaglobulinemia with intravenous immunoglobulin is standard in many centers,143 but the level that triggers replacement varies considerably among transplant specialists. There is little supporting evidence for the routine use of intravenous immunoglobulin as prophylaxis144 but patients should receive routine prophylaxis (penicillin or its equivalent) due to the increased risk of streptococcal sepsis.145 Pneumococcal conjugate and hemophilus influenza vaccine may provide additional protection and are also recommended for all patients, including those with chronic GVHD.139, 146, 147 The sites of any indwelling catheters should be assessed regularly and early treatment of a suspected infection initiated. Early signs or symptoms of septic shock such as shaking chills or low blood pressure requires prompt evaluation with chest X-ray and/or CT scan, blood culture and broad spectrum antibiotics because shock may progress rapidly in these patients.

9.3.5 Aspergillus Complicating Allogeneic Transplantation

Aspergillus infections in allogeneic stem cell transplant recipients: have we made any progress?

E Jantunen, V-J Anttila and T Ruutu
BMT 2002; 30(12):925-929
http://www.nature.com/bmt/journal/v30/n12/full/1703738a.html
http://dx.doi.org:/10.1038/sj.bmt.1703738

Invasive aspergillosis (IA) is common in allogeneic SCT recipients, with an incidence of 4-10%. The majority of these infections are diagnosed several months after SCT and they are frequently associated with GVHD. The diagnosis is difficult and often delayed. Established IA is notoriously difficult to treat with a death rate of 80-90%. This review summarises recent data on this problem to assess whether there has been any progress. Effective prophylactic measures are still lacking. Severe immunosuppression is the main obstacle to the success of therapy. Recent and ongoing developments in diagnostic measures and new antifungal agents may improve treatment results to some extent, but Aspergillus infections still remain a formidable problem in allogeneic transplantation. Further studies in this field will focus on the role of various cytokines and combinations of antifungal agents.

Summary

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Manipulate Signaling Pathways [7.6]

Posted in Academic Publishing, Biochemical pathways, Biological Networks, Cancer and Current Therapeutics, CANCER BIOLOGY & Innovations in Cancer Therapy, Cancer Screening, Cell Biology, Signaling & Cell Circuits, Curation, Developmental biology, Disease Biology, Disease Biology, Small Molecules in Development of Therapeutic Drugs, Fatty acids, Gene Regulation, Innovations, Lipid metabolism, Lipids, Liver & Digestive Diseases Research, Metabolism, Metabolomics, Methods, Pharmaceutical Drug Discovery, Proteins, Proteomics, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, RNA Biology, Cancer and Therapeutics, tagged AMPK, anabolic, Apoptosis, C-Jun N-terminal kinases, Cancer - General, catabolic, cell signaling, ER stress, ERK, JNK, KIAA1363, MAPK, mass spectrometry, mitochondrial outer membrane, MKKs, NFkB, p38, Ras/MAPK, tumorigenesis, Unfolded Protein Response (UPR) on April 8, 2015| Leave a Comment »

Manipulate Signaling Pathways

Writer and Curator: Larry H Bernstein, MD, FCAP 

 

7.6  Manipulate Signaling Pathways

7.6.1 The Dynamics of Signaling as a Pharmacological Target

7.6.2 A Protein-Tagging System for Signal Amplification in Gene Expression and Fluorescence Imaging

7.6.3 IQGAPs choreograph cellular signaling from the membrane to the nucleus

7.6.4 Signaling cell death from the endoplasmic reticulum stress response

7.6.5 An Enzyme that Regulates Ether Lipid Signaling Pathways in Cancer Annotated by Multidimensional Profiling

7.6.6 Peroxisomes – A Nexus for Lipid Metabolism and Cellular Signaling

7.6.7 A nexus for cellular homeostasis- the interplay between metabolic and signal transduction pathways

7.6.8 Mechanisms-of-intercellular-signaling

7.6.9 Cathepsin B promotes colorectal tumorigenesis, cell invasion, and metastasis

 

 

7.6.1 The Dynamics of Signaling as a Pharmacological Target

Marcelo Behar, Derren Barken, Shannon L. Werner, Alexander Hoffmann
Cell  10 Oct 2013; 155(2):448–461
http://dx.doi.org/10.1016/j.cell.2013.09.018

Highlights

  • Drugs targeting signaling hubs may block specific dynamic features of the signal
  • Specific inhibition of dynamic features may introduce pathway selectivity
  • Phase space analysis reveals principles for drug targeting signaling dynamics
  • Based on these principles, NFκB dynamics can be manipulated with specificity

Summary

Highly networked signaling hubs are often associated with disease, but targeting them pharmacologically has largely been unsuccessful in the clinic because of their functional pleiotropy. Motivated by the hypothesis that a dynamic signaling code confers functional specificity, we investigated whether dynamic features may be targeted pharmacologically to achieve therapeutic specificity. With a virtual screen, we identified combinations of signaling hub topologies and dynamic signal profiles that are amenable to selective inhibition. Mathematical analysis revealed principles that may guide stimulus-specific inhibition of signaling hubs, even in the absence of detailed mathematical models. Using the NFκB signaling module as a test bed, we identified perturbations that selectively affect the response to cytokines or pathogen components. Together, our results demonstrate that the dynamics of signaling may serve as a pharmacological target, and we reveal principles that delineate the opportunities and constraints of developing stimulus-specific therapeutic agents aimed at pleiotropic signaling hubs.

http://www.cell.com/cms/attachment/2021777732/2041663648/fx1.jpg

Intracellular signals link the cell’s genome to the environment. Misregulation of such signals often cause or exacerbate disease (Lin and Karin, 2007 and Weinberg, 2007) (so-called “signaling diseases”), and their rectification has been a major focus of biomedical and pharmaceutical research (Cohen, 2002, Frelin et al., 2005 and Ghoreschi et al., 2009). For the identification of therapeutic targets, the concept of discrete signaling pathways that transmit intracellular signals to connect cellular sensor/receptors with cellular core machineries has been influential. In this framework, molecular specificity of therapeutic agents correlates well with their functional or phenotypic specificity. However, in practice, clinical outcomes for many drugs with high molecular specificity has been disappointing (e.g., inhibitors of IKK, MAPK, and JNK; Berger and Iyengar, 2011, DiDonato et al., 2012, Röring and Brummer, 2012 and Seki et al., 2012).

Many prominent signaling mediators are functionally pleiotropic, playing roles in multiple physiological functions (Chavali et al., 2010 and Gandhi et al., 2006). Indeed, signals triggered by different stimuli often travel through shared network segments that operate as hubs before reaching the effectors of the cellular response (Bitterman and Polunovsky, 2012 and Gao and Chen, 2010). Hubs’ inherent pleiotropy means that their inhibition may have broad and likely undesired effects (Karin, 2008, Berger and Iyengar, 2011,Force et al., 2007, Oda and Kitano, 2006 and Zhang et al., 2008); this is a major obstacle for the efficacy of drugs targeting prominent signaling hubs such as p53, MAPK, or IKK.

Recent studies have begun to address how signaling networks generate stimulus-specific responses (Bardwell, 2006, Haney et al., 2010, Hao et al., 2008 and Zalatan et al., 2012). For example, the activity of some pleiotropic kinases may be steered to particular targets by scaffold proteins (Park et al., 2003,Schröfelbauer et al., 2012 and Zalatan et al., 2012). Alternatively, or in addition, some signaling hubs may rely on stimulus-specific signal dynamics to activate selective downstream branches in a stimulus-specific manner in a process known as temporal or dynamic coding or multiplexing (Behar and Hoffmann, 2010,Chalmers et al., 2007, Hoffmann et al., 2002, Kubota et al., 2012, Marshall, 1995 and Purvis et al., 2012;Purvis and Lahav, 2013, Schneider et al., 2012 and Werner et al., 2005).

Although the importance of signaling scaffolds and their pharmacological promise is widely appreciated (Klussmann et al., 2008 and Zalatan et al., 2012) and isolated studies have altered the stimulus-responsive signal dynamics (Purvis et al., 2012, Park et al., 2003, Sung et al., 2008 and Sung and Simon, 2004), the capacity for modulating signal dynamics for pharmacological gain has not been addressed in a systematic manner. In this work, we demonstrate by theoretical means that, when signal dynamics are targeted, pharmacological perturbations can produce stimulus-selective results. Specifically, we identify combinations of signaling hub topology and input-signal dynamics that allow for pharmacological perturbations with dynamic feature-specific or input-specific effects. Then, we investigate stimulus-specific drug targeting in the IKK-NFκB signaling hub both in silico and in vivo. Together, our work begins to define the opportunities for pharmacological targeting of signaling dynamics to achieve therapeutic specificity.

Dynamic Signaling Hubs May Be Manipulated to Mute Specific Signals

Previous work has shown how stimulus-specific signal dynamics may allow a signaling hub to selectively route effector functions to different downstream branches (Behar et al., 2007). Here, we investigated the capacity of simple perturbations to kinetic parameters (caused for example by drug treatments) to produce stimulus-specific effects. For this, we examined a simple model of an idealized signaling hub (Figure 1A), reminiscent of the NFκB p53 or of MAPK signaling modules. The hub X∗ reacts with strong but transient activity to stimulus S1 and sustained, slowly rising activity to stimulus S2. These stimulus-specific signaling dynamics are decoded by two effector modules, regulating transcription factors TF1 and TF2. TF1, regulated by a strongly adaptive negative feedback, is sensitive only to fast-changing signals, whereas TF2, regulated by a slowly activating two-state switch, requires sustained signals for activation (Figure 1B). We found it useful to characterize the X∗, TF1, and TF2 responses in terms of two dynamic features, namely the maximum early amplitude (“E,” time < 15′) and the average late amplitude (“L,” 15′ < t < 6 hr). These features, calculated using a mathematical model of the network (see Experimental Procedures) show good fidelity and specificity (Komarova et al., 2005) (Figure 1C), as S1 causes strong activation of TF1 with minimal crosstalk to TF2, and vice versa for S2.

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Figure 1. Pharmacologic Perturbations with Stimulus-Specific Effects

(A) A negative-feedback module transduces input signals S1 and S2, producing outputs that are decoded by downstream effectors circuits that may distinguish between different dynamics.

(B) Unperturbed dynamics of X∗, TF1∗, and TF2∗ in response to S1 (red) and S2 (blue). Definition of early (E) and late (L) parts of the signal is indicated.

(C) Specificity and fidelity of E and L for TF1∗ and TF2∗, as defined in Komarova et al., 2005).

(D) Partial inhibition of X∗ activation (A) abolishes the response to S1, but not S2, whereas a perturbation targeting the feedback regulator (FBR) suppresses the response to S2, but not S1.

(E) Perturbation phenotypes defined as difference between unperturbed and perturbed values of the indicated quantities (arbitrary scales for X∗, TF1∗, and TF2∗). Perturbation A inhibits E and TF1∗, but not TF2∗; perturbation FBR inhibits L and TF2∗, but not TF1∗.

(F) Virtual screening pipeline showing the experimental design and the two analysis branches for characterizing feature- and input-specific effects.

See also in Experimental Procedures and Table S1.

Seeking simple (affecting a single reaction) perturbations that selectively inhibit signaling by S1 or S2, we found that perturbation A, partially inhibiting the activation of X, was capable of suppressing hub activity in response to a range of S1 amplitudes while still allowing for activity in response to S2 (Figure 1D). Consequently, this perturbation significantly reduced TF1 activity in response to S1 but had little effect on TF2 activity elicited by S2. We also found that the most effective way to inhibit S2 signaling was by targeting the deactivation of negative feedback regulator Y (FBR). This perturbation caused almost complete abrogation of late X activity yet allows for significant levels of early activity. As a result, TF2 was nearly completely abrogated in response to S2, but stimulus S1 still produced a solid TF1 response. The early (E) and late (L) amplitudes could be used to quantify the input-signal-specific effects of these perturbations (Figure 1E).

This numerical experiment showed that it is possible to selectively suppress transient or sustained dynamic signals transduced through a common negative-feedback-containing signaling hub. Moreover, the dynamic features E and L could be independently inhibited. To study how prevalent such opportunities for selective inhibition are, we established a computational pipeline for screening reaction perturbations within multiple network topologies and in response to multiple dynamic input signals; the simulation results were analyzed to identify cases of either “input-signal-specific” inhibition or “dynamic feature-specific” inhibition (Figure 1F).

A Computational Screen to Identify Opportunities for Input-Signal-Specific Inhibition

The computational screen involved small libraries of one- and two-component regulatory modules and temporal profiles of input signals (Figure 2A), both commonly found in intracellular signaling networks. All modules (M1–M7, column on left) contained a species X that, upon stimulation by an input signal, is converted into an active form X∗ (the output) that propagates the signal to downstream effectors. One-component modules included a reversible two-state switch (M1) and a three-state cycle with a refractory state (M2). Two-component modules contained a species Y that, upon activation via a feedback (M3 and M5) or feedforward (M4 and M6) loop, either deactivates X (M3 and M4) or inhibits (M5 and M6) its activation. We also included the afore-described topology that mimics the IκB-NFκB or the Mdm2-p53 modules (M7). Mathematical descriptions may be found in the Experimental Procedures. Although many biological signaling networks may conform to one of these simple topologies, others may be abstracted to one that recapitulates the physiologically relevant emergent properties

Figure 2. A Virtual Screen for Stimulus Specificity in Pharmacologic Perturbations

(A) Signaling modules (left) and input library (top) used in the screen. Dotted lines indicate enzymatic reactions (perturbation names indicated in letter code). Time courses of hub activity for each module/input combination for the unperturbed (black) and perturbed cases (blue indicates a decrease, red an increase in parameter value).

(B) Relative sensitivity of the stimulus response to the indicated perturbation (defined as the perturbation’s effect on the area under the curve), normalized per row.

See also Experimental Procedures, Figure S1, and Tables S2 and S3.

The library of stimuli (S1–S10; Figure 2A, top row) comprises ten input functions with different combinations of “fast” and “slow” initiation and decay phases (see Experimental Procedures). The virtual screen was performed by varying the kinetic parameter for each reaction over a range of values, thereby modeling simple perturbations of different strengths and recording the temporal profile of X∗ abundance. To quantify stimulus-specific inhibition, we measured the area under the normalized dose-response curves (time average of X∗ versus perturbation dose) for each module-input combination (Experimental Procedures, Figure 2B, and Figure S1 available online).

Phase Space Analysis Reveals Underlying Regulatory Principles

To understand the origin of dynamic feature-specific inhibition, we investigated the perturbation effects analytically on each module’s phase space, i.e., the space defined by X∗ and Y∗ quasi-equilibrium surfaces (Figures 4 and S4). These surfaces (“q.e. surfaces”) represent the dose response of X∗ as a function of Y∗ and a stationary input signal S (“X surface”) and the dose response of Y∗ as a function of X∗ and S (“Y surface”) (Figure 4A). The points at which the surfaces intersect correspond to the concentrations of X∗ and Y∗ in equilibrium for a given value of S. In the basal state, when S is low, the system is resting at an equilibrium point close to the origin of coordinates. When S increases, the concentrations of X∗ and Y∗ adjust until the signal settles at some stationary value (Figure 4A). Gradually, changing input signals cause the concentrations to follow trajectories close to the q.e. surfaces (quasi-equilibrium dynamics), following the line defined by the intersection of the surfaces (“q.e. line”) in the extreme of infinitely slow inputs. Fast-changing stimuli drive the system out of equilibrium, causing the trajectories to deviate markedly from the q.e. surfaces.

Two main principles emerged: (1) perturbations that primarily affect the shape of a q.e. surface tend to affect steady-state levels or responses that evolve close to quasi-equilibrium, and (2) perturbations that primarily affect the balance of timescales (X∗, Y∗ activation, and S) tend to affect transient out-of-equilibrium parts of the response. These principles reflect the fact that out-of-equilibrium parts of a signal are largely insensitive to the precise shape of the underlying dose-response surfaces (they may still be bounded by them) but depend on the balance between the timescales of the biochemical processes involved. Perturbation of these balances affects how a system approaches steady state (thus affecting out-of-equilibrium and quasi-equilibrium dynamics), but not steady-state levels. To illustrate these principles, we present selected results for modules M3 and M4 and discuss additional cases in the supplement (Figure S3).

Detailed Analysis of Modules M3 and M4, Related to Figure 4

Time courses and projections of the phase space for modules M3 and M4. Color coding similar to Figure 4.

In the feedback-based modules (M3 and M5), the early peak of activity in response to rapidly changing signals is an out-of-equilibrium feature that occurs when the timescale of Y activation is significantly slower than that of X. Under these conditions, the concentration of X∗ increases rapidly (out of equilibrium) before decaying along the X∗ surface (in quasi-equilibrium) as more Y gets activated (Figure 4A, parameters modified to better illustrate the effects being discussed; see Table S2). For input signals that settle at some stationary level of S, Y activation eventually catches up and the concentration of X∗ settles at the equilibrium point where the X∗ and Y∗ curves intersect. Gradually changing signals allow X∗ and Y∗activation to continuously adapt, and the system evolves closer to the q.e. line.

In such modules, perturbation A (X∗ activation) changes both the shape of the q.e. surface for X∗ and the kinetics of activation. When in the unperturbed system Y∗ saturates, perturbation A primarily reduces X∗steady-state level (Figures 4B and 4C, left and center). When Y∗ does not saturate in the unperturbed system, the primary effect is the reduced activation kinetics. Thus the perturbation affects the out-of-equilibrium peak (Figures 4B and 4C, center and right), with only minor reduction of steady-state levels (especially when Y∗’s dose response respect to X∗ is steep). The transition from saturated to not-saturated feedback (as well as the perturbation strength) underlies the dose-dependent switch from L to E observed in the screen. In both saturated and unsaturated regimes, the shift in the shape of the surfaces does change the q.e. line and thus affects responses occurring in quasi-equilibrium. In contrast, perturbation of the feedback recovery (FBR) shifts the Y∗ surface vertically (Figure 4D), specifically affecting the steady-state levels and late signaling; the effect on Y∗ kinetics is limited because the reaction is relatively slow. Perturbation FBA also shifts the Y∗ surface, but the net effect is less specific because the associated increase in the rate of Y∗ activation tends to equalize X∗ and Y∗ kinetics affecting also the out-of-equilibrium peak.

In resting cells, NFκB is held inactive through its association with inhibitors IκBα, β, and ε. Upon stimulation, these proteins are phosphorylated by the kinase IKK triggering their degradation. Free nuclear NFκB activates the expression of target genes, including IκB-encoding genes, which thereby provide negative feedback (Figure 5A). The IκB-NFκB-signaling module is a complex dynamic system; however, by abstracting the control mechanism to its essentials, we show below that the above-described principles can be applied profitably.

IκB-NFκB signaling module

IκB-NFκB signaling module

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Figure 5. Modulating NFκB Signaling Dynamics

(A) The IκB-NFκB signaling module.

(B) Equilibrium dose-response relationship for NFκB versus IKK.

(C) Three IKK curves representative of three stimulation regimes; TNFc (red), TNFp (green), and LPS (blue) function as inputs into the model, which computes the corresponding NFκB activity dynamics (bottom). The quasi-equilibrium line (black) was obtained by transforming the IKK temporal profiles by the dose response in (B). Deviation from the quasi-equilibrium line for the TNF response indicates out-of-equilibrium dynamics.

(D) Coarse-grained model of the IκB-NFκB module and predicted effects of perturbations.

(E) Selected perturbations with specific effects on out-of-equilibrium (top three) or steady state (bottom two). (Left to right) Feature maps in the E-L space (E: t < 60 ′, L: 120′ < t < 300′), tangent angle at the unperturbed point (θ > 0 indicates L is more suppressed than E and vice versa), and time courses (green, TNF chronic; red, TNF pulse; blue, LPS). Only inhibitory perturbations are shown. Additional perturbations are shown in Figure S4.

See also Experimental Procedures and Table S7.

Here, we delineate the potential of achieving stimulus-specific inhibition when targeting molecular reactions within pleiotropic signaling hubs. We found that it is theoretically possible to design perturbations that (1) selectively attenuate signaling in response to one stimulus but not another, (2) selectively attenuate undesirable features of dynamic signals or enhance desirable ones, or (3) remodulate output signals to fit a dynamic profile normally associated with a different stimulus.

These opportunities—not all of them possible for every signaling module topology or biological scenario—are governed by two general principles based on timescale and dose-response relationships between upstream signal dynamics and intramodule reaction kinetics (Figure 4 and Table S4). In short, a steady-state or quasi-equilibrium part of a response may be selectively affected by perturbations that introduce changes in the relevant dose-response surfaces. Out-of-equilibrium responses that are not sensitive to the precise shape of a dose-response curve may be selectively attenuated by perturbations that modify the relative timescales. Dose responses and timescales cannot, in general, be modified independently by simple perturbations (combination treatments are required), but as we show, in some cases, one effect dominates resulting in feature or stimulus specificity.

The degree to which specific dynamic features of a signaling profile or the dynamic responses to specific stimuli can be selectively inhibited depends on how distinctly they rely on quasi-equilibrium and out-of-equilibrium control. Signals that contain both features may be partially inhibited by both types of perturbation, limiting the specific inhibition achievable by simple perturbations. In practice, this limited the degree to which NFκB signaling could be inhibited in a stimulus-specific manner (Figure 5) and the associated therapeutic dose window (Figure 6). The most selective stimulus-specific effects can be introduced when a signal is heavily dependent on a particular dynamic feature; for example, suppression of out-of-equilibrium transients will abrogate the response to stimuli that produce such transients. For a selected group of target genes, this specificity at the signal level translated directly to expression patterns (Figure 6B, middle). More generally, selective inhibition of early or late phases of a signal may allow for specific control of early and late response genes (Figure 6C), a concept that remains to be studied at genomic scales. Though the principles are general, how they apply to specific signaling pathways depends not only on the regulatory topology, but also on the dynamic regime determined by the parameters. As demonstrated with the IκB-NFκB module, analysis of a coarse-grained topology in terms of the principles may allow the prediction of perturbations with a desired specificity.

 

7.6.2 A Protein-Tagging System for Signal Amplification in Gene Expression and Fluorescence Imaging

Marvin E. Tanenbaum, Luke A. Gilbert, Lei S. Qi, Jonathan S. Weissman, Ronald D. Vale
Cell 23 Oct 2014; 159(3): 635–646
http://dx.doi.org/10.1016/j.cell.2014.09.039

Highlights

  • SunTag allows controlled protein multimerization on a protein scaffold
  • SunTag enables long-term single-molecule imaging in living cells
  • SunTag greatly improves CRISPR-based activation of gene expression

Summary

Signals in many biological processes can be amplified by recruiting multiple copies of regulatory proteins to a site of action. Harnessing this principle, we have developed a protein scaffold, a repeating peptide array termed SunTag, which can recruit multiple copies of an antibody-fusion protein. We show that the SunTag can recruit up to 24 copies of GFP, thereby enabling long-term imaging of single protein molecules in living cells. We also use the SunTag to create a potent synthetic transcription factor by recruiting multiple copies of a transcriptional activation domain to a nuclease-deficient CRISPR/Cas9 protein and demonstrate strong activation of endogenous gene expression and re-engineered cell behavior with this system. Thus, the SunTag provides a versatile platform for multimerizing proteins on a target protein scaffold and is likely to have many applications in imaging and controlling biological outputs.

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SunTag, which can recruit multiple copies of an antibody-fusion protein
Development of the SunTag, a System for Recruiting Multiple Protein Copies to a Polypeptide Scaffold Protein multimerization on a single RNA or DNA template is made possible by identifying protein domains that bind with high affinity to a relatively short nucleic acid motif. We therefore sought a protein-based system with similar properties, specifically a protein that can bind tightly to a short peptide sequence (Figures 1A and1B).Antibodies arecapable ofbindingto short,unstructured peptide sequences with high affinity and specificity, and, importantly, peptide epitopes can be designed that differ from naturally occurring sequences in the genome. Furthermore, whereas antibodies generally do not fold properly in the cytoplasm, single-chain variable fragment (scFv) antibodies, in which the epitope-binding regions of the light and heavy chains of the antibody are fused to forma single polypeptide, have been successfully expressed in soluble form in cells (Colby et al., 2004; Lecerf et al., 2001; Wo ¨rn et al., 2000).
We expressed three previously developed single-chain antibodies (Colby et al., 2004; Lecerf et al., 2001; Wo ¨rn et al., 2000) fused to EGFP in U2OS cells and coexpressed their cognate peptides (multimerized in four tandem copies) fused to the cytoplasmic side of the mitochondrial protein mitoNEET (Colca et al., 2004) (referred to here as Mito, Figure S1A). We then assayed whether the antibody-GFP fusion proteins would be recruited to the mitochondria by fluorescence microscopy, which would indicate binding between antibody and peptide (Figure 1B). Of the three antibody-peptide pairs tested, only the GCN4 antibody-peptide pair showed robust and specific binding while not disrupting normal mitochondrial morphology (Figures 1C and S1B). Thus, we focused our further efforts on the GCN4 antibody-peptide pair. The GCN4 antibody was optimized to allow intracellular expression in yeast (Wo ¨rn et al., 2000). In human cells, however, we still observed some protein aggregates of scFv-GCN4-GFP at high expression levels (Figure S2A). To improve scFv-GCN4 stability, we added a variety of N- and C-terminal fusion proteins known to enhance protein solubility and found that fusion of superfolder-GFP (sfGFP) alone
(Pe’delacq et al., 2006) or along with the small solubility tag GB1 (Gronenborn et al., 1991) to the C terminus of the GCN4 antibody almost completely eliminated protein aggregation, even at high expression levels (Figure S2A). Thus, we performed all further experiments with scFv-GCN4-sfGFP-GB1 (hereafter referred to as scFvGCN4-GFP). Very tight binding of the antibody-peptide pair in vivo is critical fortheformation ofmultimersonaproteinscaffoldbackbone.To determine the dissociation rate of the GCN4 antibody-peptide interaction, we performed fluorescence recovery after photobleaching (FRAP) experiments on scFv-GCN4-GFP bound to the mitochondrial-localized mito-mCherry-4xGCN4pep. After photobleaching, very slow GFP recovery was observed (halflife of 5–10 min [Figures 2A and 2B]), indicating that the antibody bound very tightly to the peptide. It is also important to optimize the spacing of the scFv-GCN4 binding sites within the protein scaffold so that they could be saturated by scFvGCN4 because steric hindrance of neighboring peptide binding sites is a concern. We varied the spacing between neighboring GCN4 peptides and quantified the antibody occupancy on the peptide array.

Figure 1. Identification of an Antibody-Peptide Pair that Binds Tightly In Vivo (A) Schematic of the antibody-peptide labeling strategy. (B) Schematic of the experiment described in (C) in which the mitochondrial targeting domain of mitoNEET (yellow box, mito) fused to mCherry and four tandem copies of a peptide recruits a GFP-tagged intracellular antibody to mitochondria. (C) ScFv-GCN4-GFP was coexpressed with either mito-mCherry-4xGCN4peptide (bottom) or mito-mCherry-FKBP as a control (top) in U2OS cells, and cells were imaged using spinning-disk confocal microscopy. Scale bars, 10 mm. See also Figure S1.

Figure 2. Characterization of the Off Rate and Stoichiometry of the Binding Interaction between the scFv-GCN4 Antibody and the GCN4 Peptide Array In Vivo (A) Mito-mCherry-24xGCN4pep was cotransfected with scFv-GCN4-GFP in HEK293 cells, and their colocalization on mitochondria in a single cell is shown (10 s). At 0 s, the mitochondria-localized GFP signal was photobleached in a single z plane using a 472 nm laser, and fluorescence recovery was followed by time-lapse microscopy. Scale bar, 5 mm. (B) The FRAP was quantified for 20 cells. (C–E) Indicated constructs were transfected in HEK293 cells, and images were acquired 24 hr after transfection with identical image acquisition settings. Representative images are shown in (C). Note that the GFP signal intensity in the mito-mCherry-24xGCN4pep + scFv-GCN4-GFP is highly saturated when the same scaling is used as in the other panels. Bottom row shows a zoom of a region of interest: dynamic scaling was different for the GFP and mCherry signals, so that both could be observed. Scale bars, 10 mm. (D and E) Quantifications of the GFP:mCherry fluorescence intensity ratio on mitochondria after normalization. Eachdot represents a single cell, and dashed lines indicates the average value. See also Figure S2.

Figure 3. The SunTag Allows Long-Term Single-Molecule Fluorescence Imaging in the Cytoplasm (A–H) U2OS cells were transfected with indicated SunTag24x constructs together with the scFv-GCN4-GFP-NLS and were imaged by spinning-disk confocal microscopy 24 hr after transfection. (A) A representative image of SunTag24x-CAAX-GFP is shown (left), as well as the fluorescence intensities quantification of the foci (right, blue bars). As a control, U2OS were transfected with sfGFP-CAAX and fluorescence intensities of single sfGFP-CAAX molecules were also quantified (red bars). The average fluorescence intensity of the single sfGFP-CAAX was set to 1. Dotted line marks the outline of the cell (left). Scale bar, 10 mm. (B) Cells expressing K560-SunTag24x-GFP were imaged by spinning disk confocal microscopy (image acquisition every 200 ms). Movement is revealed by a maximum intensity projection of 50 time points (left) and a kymograph (right). Scale bar, 10 mm. (C and D) Cells expressing both EB3-tdTomato and K560-SunTag24x-GFP were imaged, and moving particles were tracked manually. Red and blue tracks (bottom) indicate movement toward the cell interior and periphery, respectively (C). The duration of the movie was 20 s. Scale bar, 5 mm. Dots in (D) represent individual cells with between 5 and 20 moving particles scored per cell. The mean and SD are indicated. (E and F) Cells expressing Kif18b-SunTag24x-GFP were imaged with a 250 ms time interval. Images in (E) show a maximum intensity projection (50 time- points, left) and a kymograph (right). Speeds of moving molecules were quantified from ten different cells (F). Scale bar, 10 mm. (G and H) Cells expressing both mCherry-a-tubulin and K560rig-SunTag24x-GFP were imaged with a 600 ms time interval.The entire cell is shown in (G), whereas H shows zoomed-instills of atime series from the same cell. Open circlestrack two foci on the same microtubule,which is indicated bythe dashed line. Asterisks indicate stationary foci. Scale bars, 10 and 2 mm (G and H), respectively. See also Figure S3 and Movies S1, S2, S3, S4, S5, and S6.
The GCN4 peptide contains many hydrophobic residues (Figure 4B) and is largely unstructured in solution (Berger et al., 1999); thus, the poor expression of the peptide array could be due to its unstructured and hydrophobic nature. To test this idea, we designed several modified peptide sequence that were predicted to increase a-helical propensity and reduce hydrophobicity. One of these optimized peptides (v4, Figure 4B) was expressed moderately well as a 243 peptide array, and even higher expression was achieved with a 103 peptide array (Figure 4C). Importantly, fluorescence imaging revealed that thescFv-GCN4antibody robustlyboundto theGCN4v4peptide array in vivo and FRAP analysis suggests that the scFv-GCN4 antibody dissociates with a similar slow off rate from the GCN4
v4 peptide array as the original peptide (Figures 4D and 4E). Furthermore, K560 motility could be observed when it was tagged with the optimized v4 243 peptide array, indicating that the optimized v4 peptide array did not interfere with protein function (Movie S7). Together, these results identify a second version of the peptide array that can be used for applications requiring higher expression.
Activation of Gene Transcription Using Cas9-SunTag Because the SunTag system could be used for amplification of a fluorescence signal, we tested whether it also could be used to amplify regulatory signals involved in gene expression. Transcription of a gene is strongly enhanced by recruiting multiple copies of transcriptional activators to endogenous or artificial gene promoters (Anderson and Freytag, 1991; Chen et al., 1992; Pettersson and Schaffner, 1990). Thus, we thought that robust, artificial activation of gene transcription might also be achieved by recruiting multiple copies of a synthetic transcriptional activator to a gene using the SunTag.

Figure 4. An Optimized Peptide Array for High Expression (A) Indicated constructs were transfected in HEK293 cells and imaged 24 hr after transfection using wide-field microscopy. All images were acquired using identical acquisition parameters. Representative images are shown (left), and fluorescence intensities were quantified (n = 3) (right). (B) Sequence of the first and second generation GCN4 peptide (modified or added residues are colored blue, hydrophobic residues are red, and linker residues are yellow). (C–E) Indicated constructs were transfected in HEK293 cells and imaged 24 hr after transfection using wide-field (C) or spinning-disk confocal (D and E) microscopy. (C) Representative images are shown (left), and fluorescence intensities were quantified (n = 3) (right). (D and E) GFP signal on mitochondria was photobleached, and fluorescence recovery was determined over time. The graph (E) represents an average of six cells per condition. (E) shows an image of a representative cell before photobleaching. Scale bars in (A) and (C), 50 mm; scale bars in (D) and (E), 10 mm. Error bars in (A) and (C) represent SDs. See also Movie S7.

Figure 5. dCas9-SunTag Allows Genetic Rewiring of Cells through Activation of Endogenous Genes (A) Schematic of gene activation by dCas9-VP64 and dCas9-SunTag-VP64. dCas9 binds to a gene promoter through its sequence-specific sgRNA (red line). Direct fusion of VP64 to dCas9 (top) results in a single VP64 domain at the promoter, which poorly activates transcription of the downstream gene. In contrast, recruitment of many VP64 domains using the SunTag potently activates transcription of the gene (bottom). (B–D) K562 cells stably expressing dCas9-VP64 or dCas9-SunTag-VP64 were infected with lentiviral particles encoding indicated sgRNAs, as well as BFP and a puromycin resistance gene and selected with 0.7 mg/ml puromycin for 3 days to kill uninfected cells. (B and C) Cells were stained for CXCR4 using adirectlylabeleda-CXCR4 antibody, and fluorescence was analyzed by FACS. (D) Trans-well migration assays (see Experimental Procedures) were performed with indicated sgRNAs. Results are displayed as the fold change in directional migrating cells over control cell migration. (E) dCas9-VP64 or dCas9-SunTag-VP64 induced transcription of CDKN1B with several sgRNAs. mRNA levels were quantified by qPCR. (F) Doubling timeofcontrolcells orcells expressing indicated sgRNAs was determined (see Experimental Procedures section). Graphs in (C), (D), and (F) are averages of three independent experiments. Graph in (E) is average of two biological replicates, each with two or three technical replicates. All error bars indicate SEM. See also Figure S4

 

7.6.3 IQGAPs choreograph cellular signaling from the membrane to the nucleus

Jessica M. Smith, Andrew C. Hedman, David B. Sacks
Trends Cell Biol Mar 2015; 25(3): 171–184
http://dx.doi.org/10.1016/j.tcb.2014.12.005

Highlights

  • IQGAP proteins scaffold diverse signaling molecules.
  • IQGAPs mediate crosstalk between signaling pathways.
  • IQGAP1 regulates nuclear processes, including transcription.

Since its discovery in 1994, recognized cellular functions for the scaffold protein IQGAP1 have expanded immensely. Over 100 unique IQGAP1-interacting proteins have been identified, implicating IQGAP1 as a critical integrator of cellular signaling pathways. Initial research established functions for IQGAP1 in cell–cell adhesion, cell migration, and cell signaling. Recent studies have revealed additional IQGAP1 binding partners, expanding the biological roles of IQGAP1. These include crosstalk between signaling cascades, regulation of nuclear function, and Wnt pathway potentiation. Investigation of the IQGAP2 and IQGAP3 homologs demonstrates unique functions, some of which differ from those of IQGAP1. Summarized here are recent observations that enhance our understanding of IQGAP proteins in the integration of diverse signaling pathways.

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7.6.4 Signaling cell death from the endoplasmic reticulum stress response

Shore GC1, Papa FR, Oakes SA
Curr Opin Cell Biol. 2011 Apr; 23(2):143-9
http://dx.doi.org/10.1016%2Fj.ceb.2010.11.003

Inability to meet protein folding demands within the endoplasmic reticulum (ER) activates the unfolded protein response (UPR), a signaling pathway with both adaptive and apoptotic outputs. While some secretory cell types have a remarkable ability to increase protein folding capacity, their upper limits can be reached when pathological conditions overwhelm the fidelity and/or output of the secretory pathway.

The lumen of the ER is a unique cellular environment optimized to carry out the three primary tasks of this organelle:

  1. calcium storage and release,
  2. protein folding and secretion, and
  3. lipid biogenesis [1].

A range of cellular disturbances lead to accumulation of misfolded proteins in the ER, including

  • point mutations in secreted proteins that disrupt their proper folding,
  • sustained secretory demands on endocrine cells,
  • viral infection with ER overload of virus-encoding protein, and
  • loss of calcium homeostasis with detrimental effects on ER-resident calcium-dependent chaperones [2–4].

 

The tripartite UPR consists of three ER transmembrane proteins (IRE1α, PERK, ATF6) that

  • alert the cell to the presence of misfolded proteins in the ER and
  • attempt to restore homeostasis in this organelle through increasing ER biogenesis,
  1. decreasing the influx of new proteins into the ER,
  2. promoting the transport of damaged proteins from the ER to the cytosol for degradation, and
  3. upregulating protein folding chaperones [5].

The adaptive responses of the UPR can markedly expand the protein folding capacity of the cell and restore ER homeostasis [6]. However, if these adaptive outputs fail to compensate because ER stress is excessive or prolonged, the UPR induces cell death.

The cell death pathways collectively triggered by the UPR include both caspase-dependent apoptosis and caspase-independent necrosis. While many details remain unknown, we are beginning to understand how cells determine when ER stress is beyond repair and communicate this information to the cell death machinery. For the purposes of this review, we focus on the apoptotic outputs triggered by the UPR under irremediable ER stress.

Connections from the UPR to the Mitochondrial Apoptotic Pathway

Connections from the UPR to the Mitochondrial Apoptotic Pathway

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078187/bin/nihms256554f1.jpg

Figure 1 Connections from the UPR to the Mitochondrial Apoptotic Pathway

Under excessive ER stress, the ER transmembrane sensors IRE1α and PERK send signals through the BCL-2 family of proteins to activate the mitochondrial apoptotic pathway. In response to unfolded proteins, IRE1α oligomerizes and induces endonucleolytic decay of hundreds of ER-localized mRNAs, depleting ER protein folding components and leading to worsening ER stress. Phosphorylated IRE1α also recruits TNF receptor-associated factor 2 (TRAF2) and activates apoptosis signaling kinase 1 (ASK1) and its downstream target c-Jun NH2-terminal kinase (JNK). JNK then activates pro-apoptotic BIM and inhibits anti-apoptotic BCL-2. These conditions result in dimerization of PERK and activation of its kinase domain to phosphorylate eukaryotic translation initiation factor 2α (eIF2α), which causes selective translation of activating transcription factor-4 (ATF4). ATF4 upregulates expression of the CHOP/GADD153 transcription factor, which inhibits the gene encoding anti-apoptotic BCL-2 while inducing expression of pro-apoptotic BIM. ER stress also promotes p53-dependent transcriptional upregulation of Noxa and Puma, two additional pro-apoptotic BH3-only proteins. Furthermore, high levels of UPR signaling induce initiator caspase-2 to proteolytically cleave and activate pro-apoptotic BID upstream of the mitochondrion. In addition to antagonizing pro-survival BCL-2 members, cleaved BID, BIM and PUMA activate Bax and/or Bak. Hence, in response to excessive UPR signaling, the balance of BCL-2 family proteins shifts in the direction of apoptosis and leads to the oligomerization of BAX and BAK, two multi-domain pro-apoptotic BCL-2 family proteins that then drive the permeabilization of the outer mitochondrial membrane, apoptosome formation and activation of executioner caspases such as Caspase-3. Figure adapted with permission from the Journal of Cell Science [58].

The proximal unfolded protein response sensors

UPR signaling is initiated by three ER transmembrane proteins:

  1. IRE1α,
  2. PERK, and

The most ancient ER stress sensor, IRE1α, contains

  1. an ER lumenal domain,
  2. a cytosolic kinase domain and
  3. a cytosolic RNase domain [9,10].

In the presence of unfolded proteins, IRE1α’s ER lumenal domains homo-oligomerize, leading

  • first to kinase trans-autophosphorylation and
  • subsequent RNase activation.

Dissociation of the ER chaperone BiP from IRE1α’s lumenal domain in order to engage unfolded proteins may facilitate IRE1α oligomerization [11]; alternatively, the lumenal domain may bind unfolded proteins directly [12]. PERK’s ER lumenal domain is thought to be activated similarly [13,14]. The ATF6 activation mechanism is less clear. Under ER stress, ATF6 translocates to the Golgi and is cleaved by Site-1 and Site-2 proteases to generate the ATF6(N) transcription factor [15].

All three UPR sensors have outputs that attempt to tilt protein folding demand and capacity back into homeostasis. PERK contains a cytosolic kinase that phosphorylates eukaryotic translation initiation factor 2α (eIF2α), which impedes translation initiation to reduce the protein load on the ER [16]. IRE1α splices XBP1mRNA, to produce the homeostatic transcription factor XBP1s [17,18]. Together with ATF6(N), XBP1s increases transcription of genes that augment ER size and function[19]. When eIF2α is phosphorylated, the translation of the activating transcription factor-4 (ATF4) is actively promoted and leads to the transcription of many pro-survival genes [20]. Together, these transcriptional events act as homeostatic feedback loops to reduce ER stress. If successful in reducing the amount of unfolded proteins, the UPR attenuates.

However, when these adaptive responses prove insufficient, the UPR switches into an alternate mode that promotes apoptosis. Under irremediable ER stress, PERK signaling can induce ATF-4-dependent upregulation of the CHOP/GADD153 transcription factor, which inhibits expression of the gene encoding anti-apoptotic BCL-2 while upregulating the expression of oxidase ERO1α to induce damaging ER oxidation [21,22]. Sustained IRE1α oligomerization leads to activation of apoptosis signal-regulating kinase 1 (ASK1) and its downstream target c-Jun NH2-terminal kinase (JNK) [23,24]. Phosphorylation by JNK has been reported to both activate pro-apoptotic BIM and inhibit anti-apoptotic BCL-2 (see below). Small molecule modulators of ASK1 have been shown to protect cultured cells against ER stress-induced apoptosis, emphasizing the importance of the IRE1α-ASK1-JNK output as a death signal in this pathway [25]. In response to sustained oligomerization, the IRE1α RNase also causes endonucleolytic decay of hundreds of ER-localized mRNAs [26]. By depleting ER cargo and protein folding components, IRE1α-mediated mRNA decay may worsen ER stress, and could be a key aspect of IRE1α’s pro-apoptotic program [27]. Recently, inhibitors of IRE1α’s kinase pocket have been shown to conformationally activate its adjacent RNase domain in a manner that enforces homeostatic XBP1s without causing destructive mRNA decay [27], a potentially exciting strategy for preventing ER stress-induced cell loss.

The BCL-2 family and the Mitochondrial Apoptotic Pathway

A wealth of genetic and biochemical data argues that the intrinsic (mitochondrial) apoptotic pathway is the major cell death pathway induced by the UPR, at least in most cell types. This apoptotic pathway is set in motion when several toxic proteins (e.g., cytochrome c, Smac/Diablo) are released from mitochondria into the cytosol where they lead to activation of downstream effector caspases (e.g., Caspase-3) [30]. The BCL-2 family, a large class of both pro- and anti- survival proteins, tightly regulates the intrinsic apoptotic pathway by controlling the integrity of the outer mitochondrial membrane [31]. This pathway is set in motion when cell injury leads to the transcriptional and/or post-translational activation of one or more BH3-only proteins that share sequence similarity in a short alpha helix (~9–12 a.a.) known as the Bcl-2 homology 3 (BH3) domain [32]. Once activated, BH3-only proteins lead to loss of mitochondrial integrity by disabling mitochondrial protecting proteins that drive the permeabilization of the outer mitochondrial membrane.

ER stress has been reported to activate at least four distinct BH3-only proteins (BID, BIM, NOXA, PUMA) that then signal the mitochondrial apoptotic machinery (i.e., BAX/BAK) [33–35]. Each of these BH3-only proteins is activated by ER stress in a unique way. Cells individually deficient in any of these BH3-only proteins are modestly protected against ER stress-inducing agents, but not nearly as resistant as cells null for their common downstream targets BAX and BAK [36]—the essential gatekeepers to the mitochondrial apoptotic pathway. Moreover, cells genetically deficient in both Bim andPuma are more protected against ER stress-induced apoptosis than Bim or Puma single knockout cells [37].

The ER stress sensor that signals these BH3-only proteins is known in a few cases (i.e., BIM is downstream of PERK); however, we do not yet understand how the UPR communicates with most of the BH3-only proteins. Moreover, it is not known if all of the above BH3-only proteins are simultaneously set in motion by all forms of ER stress or if a subset is activated under specific pathological stimuli that injure this organelle. Understanding the molecular details of how ER damage is communicated to the mitochondrial apoptotic machinery is critical if we want to target disease specific apoptotic signals sent from the ER.

Initiator and Executor Caspases

Caspases, or cysteine-dependent aspartate-directed proteases, play essential roles in both initiating apoptotic signaling (initiator caspases- 2, 4, 8, 12) and executing the final stages of cell demise (executioner caspases- 3, 7, 9) [38]. It is not surprising that the executioner caspases (casp-3,7,9) are critical for cell death resulting from damage to this organelle. Caspase 12 was the first caspase reported to localize to the ER downstream of BAX/BAK-dependent mitochondrial permeabilization becomes activated by UPR signaling in murine cells [39],but humans fail to express a functional Caspase 12 [41. Genetic knockdown or pharmacological inhibition of caspase-2 confers resistance to ER stress-induced apoptosis [42]. How the UPR activates caspase-2 and whether other initiator caspasesare also involved remains to be determined.

Calcium and Cell Death

Although an extreme depletion of ER luminal Ca2+ concentrations is a well-documented initiator of the UPR and ER stress-induced apoptosis or necrosis, it represents a relatively non-physiological stimulus. Ca2+ signaling from the ER is likely coupled to most pathways leading to apoptosis. UPR-induced activation of ERO1-α via CHOP in macrophages results in stimulation of inositol 1,4,5-triphosphate receptor (IP3R) [43]. All three sub-groups of the Bcl-2 family at the ER regulate IP3R activity. A significant fraction of IP3R is a constituent of highly specialized tethers that physically attach ER cisternae to mitochondria (mitochondrial-associated membrane) and regulate local Ca2+ dynamics at the ER-mitochondrion interface [45–46]. This results in propagation of privileged IP3R-mediated Ca2+ oscillations into mitochondria. In an extreme scenario, massive transmission of Ca2+ into mitochondria results in Ca2+ overload and cell death by caspase-dependent and –independent means [46,47]. More refined transmission regulated by the Bcl-2 axis at the ER can influence cristae junctions and the availability of cytochrome c for its release across the outer mitochondrial membrane [48]. Finally, such regulated Ca2+transmission to mitochondria is a key determinant of mitochondrial bioenergetics [49].

ER Stress-Induced Cell Loss and Disease

Mounting evidence suggests that ER stress-induced apoptosis contributes to a range of human diseases of cell loss, including diabetes, neurodegeneration, stroke, and heart disease, to name a few (reviewed in REF [50]). The cause of ER stress in these distinct diseases varies depending on the cell type affected and the intracellular and/or extracellular conditions that disrupt proteostasis. Both mutant SOD1 and mutant huntingtin proteins aggregate, exhaust proteasome activity, and result in secondary accumulations of misfolded proteins in the ER [51–52].

In the case of IRE1α, it may be possible to use kinase inhibitors to activate its cytoprotective signaling and shut down its apoptotic outputs [27]. Whether similar strategies will work for PERK and/or ATF6 remains to be seen. Alternatively, blocking the specific apoptotic signals that emerge from the UPR is perhaps a more straightforward strategy to prevent ER stress-induced cell loss. To this end, small molecular inhibitors of ASK and JNK are currently being tested in a variety preclinical models of ER stress [52–53,56–57]. This is just the beginning, and much work needs to be done to validate the best drugs targets in the ER stress pathway.

Conclusions

The UPR is a highly complex signaling pathway activated by ER stress that sends out both adaptive and apoptotic signals. All three transmembrane ER stress sensors (IRE1α, PERK, AFT6) have outputs that initially decrease the load and increase capacity of the ER secretory pathway in an effort to restore ER homeostasis. However, under extreme ER stress, continuous engagement of IRE1α and PERK results in events that simultaneously exacerbate protein misfolding and signal death, the latter involving caspase-dependent apoptosis and caspase-independent necrosis. Advances in our molecular understanding of how these stress sensors switch from life to death signaling will hopefully lead to new strategies to prevent diseases caused by ER stress-induced cell loss.

​

7.6.5 An Enzyme that Regulates Ether Lipid Signaling Pathways in Cancer Annotated by Multidimensional Profiling

Chiang KP, Niessen S, Saghatelian A, Cravatt BF.
Chem Biol. 2006 Oct; 13(10):1041-50.
http://dx.doi.org/10.1016/j.chembiol.2006.08.008

Hundreds, if not thousands, of uncharacterized enzymes currently populate the human proteome. Assembly of these proteins into the metabolic and signaling pathways that govern cell physiology and pathology constitutes a grand experimental challenge. Here, we address this problem by using a multidimensional profiling strategy that combines activity-based proteomics and metabolomics. This approach determined that KIAA1363, an uncharacterized enzyme highly elevated in aggressive cancer cells, serves as a central node in an ether lipid signaling network that bridges platelet-activating factor and lysophosphatidic acid. Biochemical studies confirmed that KIAA1363 regulates this pathway by hydrolyzing the metabolic intermediate 2-acetyl monoalkylglycerol. Inactivation of KIAA1363 disrupted ether lipid metabolism in cancer cells and impaired cell migration and tumor growth in vivo. The integrated molecular profiling method described herein should facilitate the functional annotation of metabolic enzymes in any living system.

Elucidation of the metabolic and signaling networks that regulate health and disease stands as a principal goal of postgenomic research. The remarkable complexity of these molecular pathways has inspired the advancement of “systems biology” methods for their characterization [1]. Toward this end, global profiling technologies, such as DNA microarrays 2 and 3 and mass spectrometry (MS)-based proteomics 4 and 5, have succeeded in generating gene and protein signatures that depict key features of many human diseases. However, extricating from these associative relationships the roles that specific biomolecules play in cell physiology and pathology remains problematic, especially for proteins of unknown biochemical or cellular function.

The functions of certain proteins, such as adaptor or scaffolding proteins, can be gleaned from large-scale protein-interaction maps generated by technologies like yeast two-hybrid 6 and 7, protein microarrays [8], and MS analysis of immunoprecipitated protein complexes 9 and 10. In contrast, enzymes contribute to biological processes principally through catalysis. Thus, elucidation of the activities of the many thousands of enzymes encoded by eukaryotic and prokaryotic genomes requires knowledge of their endogenous substrates and products. The functional annotation of enzymes in prokaryotic systems has been facilitated by the clever analysis of gene clusters or operons 11 and 12, which correspond to sets of genes adjacently located in the genome that encode for enzymes participating in the same metabolic cascade. The assembly of eukaryotic enzymes into metabolic pathways is more problematic, however, as their corresponding genes are not, in general, physically organized into operons, but rather are scattered randomly throughout the genome.

We hypothesized that the determination of endogenous catalytic activities for uncharacterized enzymes could be accomplished directly in living systems by the integrated application of global profiling technologies that survey both the enzymatic proteome and its primary biochemical output (i.e., the metabolome). Here, we have tested this premise by utilizing multidimensional profiling to characterize an integral membrane enzyme of unknown function that is highly elevated in human cancer.

Development of a Selective Inhibitor for the Uncharacterized Enzyme KIAA1363

Previous studies using the chemical proteomic technology activity-based protein profiling (ABPP) 15, 16 and 17 have identified enzyme activity signatures that distinguish human cancer cells based on their biological properties, including tumor of origin and state of invasiveness [18]. A primary component of these signatures was the protein KIAA1363, an uncharacterized integral membrane hydrolase found to be upregulated in aggressive cancer cells from multiple tissues of origin. To investigate the role that KIAA1363 plays in cancer cell metabolism and signaling, a selective inhibitor of this enzyme was generated by competitive ABPP 20 and 21.

Previous competitive ABPP screens that target the serine hydrolase superfamily identified a set of trifluoromethyl ketone (TFMK) inhibitors that showed activity in mouse brain extracts [20]. These TFMK inhibitors showed only limited activity in living human cells (data not shown). We postulated that the activity of KIAA1363 inhibitors could be enhanced by replacing the TFMK group with a carbamate, which inactivates serine hydrolases via a covalent mechanism (Figure S1; see the Supplemental Data available with this article online). Carbamate AS115 (Figure 1A) was synthesized and tested for its effects on the invasive ovarian cancer cell line SKOV-3 by competitive ABPP (Figure 1B). AS115 was found to potently and selectively inactivate KIAA1363, displaying an IC50 value of 150 nM, while other serine hydrolase activities were not affected by this agent (IC50 values > 10 μM) (Figures 1B and 1C). AS115 also selectively inhibited KIAA1363 in other aggressive cancer cell lines that possess high levels of this enzyme, including the melanoma lines C8161 and MUM-2B (Figure S2B).

Figure 1. Characterization of AS115, a Selective Inhibitor of the Cancer-Related Enzyme KIAA1363

Profiling the Metabolic Effects of KIAA1363 Inactivation in Cancer Cells

We next compared the global metabolite profiles of SKOV-3 cells treated with AS115 to identify endogenous small molecules regulated by KIAA1363, using a recently described, untargeted liquid chromatography-mass spectrometry (LC-MS) platform for comparative metabolomics [22]. AS115 (10 μM, 4 hr) was found to cause a dramatic reduction in the levels of a specific set of lipophilic metabolites (m/z 317, 343, and 345) in SKOV-3 cells ( Figure 2A). These metabolites did not correspond to any of the typical lipid species found in cells, none of which were significantly altered by AS115 treatment ( Table S1). High-resolution MS of the m/z 317 metabolite provided a molecular formula of C19H40O3 ( Figure 2B), which suggests that this compound might represent a monoalkylglycerol ether bearing a C16:0 alkyl chain (C16:0 MAGE).  This structure assignment was corroborated by tandem MS and LC analysis, in which the endogenous m/z 317 product and synthetic C16:0 MAGE displayed equivalent fragmentation and migration patterns, respectively ( Figure S3). By extension, the m/z 343 and 345 metabolites were interpreted to represent the C18:1 and C18:0 MAGEs, respectively. A control carbamate inhibitor, URB597, which targets other hydrolytic enzymes [23], but not KIAA1363, did not affect MAGE levels in cancer cells ( Figure S4).

Pharmacological Inhibition of KIAA1363 Reduces Monoalkylglycerol Ether, MAGE, Levels in Human Cancer Cells

Pharmacological Inhibition of KIAA1363 Reduces Monoalkylglycerol Ether, MAGE, Levels in Human Cancer Cells

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Figure 2. Pharmacological Inhibition of KIAA1363 Reduces Monoalkylglycerol Ether, MAGE, Levels in Human Cancer Cells

(A) Global metabolite profiling of AS115-treated SKOV-3 cells (10 μM AS115, 4 hr) with untargeted LC-MS methods [22]revealed a specific reduction in a set of structurally related metabolites with m/z values of 317, 343, and 345 (p < 0.001 for AS115- versus DMSO-treated SKOV-3 cells). Results represent the average fold change for three independent experiments. See Table S1for a more complete list of metabolite levels.

(B) High-resolution MS analysis of the sodium adduct of the purified m/z 317 metabolite provided a molecular formula of C19H40O3, which, in combination with tandem MS and LC analysis ( Figure S3), led to the determination of the structure of this small molecule as C16:0 monoalkylglycerol ether (C16:0 MAGE).

Biochemical Characterization of KIAA1363 as a 2-Acetyl MAGE Hydrolase

The correlation between KIAA1363 inactivation and reduced MAGE levels suggests that these lipids are products of a KIAA1363-catalyzed reaction. A primary route for the biosynthesis of MAGEs has been proposed to occur via the enzymatic hydrolysis of their 2-acetyl precursors 24 and 25. This 2-acetyl MAGE hydrolysis activity was first detected in cancer cell extracts over a decade ago [25], but, to date, it has eluded molecular characterization. To test whether KIAA1363 functions as a 2-acetyl MAGE hydrolase, this enzyme was transiently transfected into COS7 cells. KIAA1363-transfected cells possessed significantly higher 2-acetyl MAGE hydrolase activity compared to mock-transfected cells, and this elevated activity was blocked by treatment with AS115 (Figure 3A). In contrast, KIAA1363- and mock-transfected cells showed no differences in their respective hydrolytic activity for 2-oleoyl MAGE, monoacylglycerols, or phospholipids (e.g., platelet-activating factor [PAF], phosphatidylcholine) (Figure S5A). These data indicate that KIAA1363 selectively catalyzes the hydrolysis of 2-acetyl MAGEs to MAGEs.

KIAA1363 Regulates an Ether Lipid Signaling Network that Bridges Platelet-Activating Factor and the Lysophospholipids

Examination of the Kyoto Encyclopedia of Genes and Genomes (KEGG) database [26] suggests that the KIAA1363-MAGE pathway might serve as a unique metabolic node linking the PAF [27] and lysophospholipid [28] signaling systems in cancer cells (Figure 4A). Consistent with a direct pathway leading from MAGEs to these lysophospholipids, addition of 13C-MAGE to SKOV-3 cells resulted in the formation of 13C-labeled alkyl-LPC and alkyl-LPA (Figure 4C).
Conversely, the levels of 2-acetyl MAGE in SKOV-3 cells, as judged by metabolic labeling experiments, were significantly stabilized by treatment with AS115, which, in turn, led to an accumulation of PAF (Figure 4D).  A comparison of the metabolite profiles of SKOV-3 and OVCAR-3 cells revealed significantly higher levels of MAGE, alkyl-LPC, and alkyl-LPA in the former line (Figure 4E). These data indicate that the lysophospholipid branch of the MAGE network is elevated in aggressive cancer cells, and that this metabolic shift is regulated by KIAA1363.

Figure 4. KIAA1363 Serves as a Key Enzymatic Node in a Metabolic Network that Connects the PAF and Lysophospholipid Families of Signaling Lipids

Stable Knockdown of KIAA1363 Impairs Tumor Growth In Vivo

Figure 6. KIAA1363 Contributes to Ovarian Tumor Growth and Cancer Cell Migration

The decrease in tumorigenic potential of shKIAA1363 cells was not associated with a change in proliferation potential in vitro (Figure S8). shKIAA1363 cells were, however, impaired in their in vitro migration capacity compared to control cells (Figure 6B). Neither MAGE nor alkyl-LPC impacted cancer cell migration at concentrations up to 1 μM (Figure 6B). In contrast, alkyl-LPA (10 nM) completely rescued the reduced migratory activity of shKIAA1363 cells. Collectively, these results indicate that KIAA1363 contributes to the pathogenic properties of cancer cells in vitro and in vivo, possibly through regulating the levels of the bioactive lipid LPA.

We have determined by integrated enzyme and small-molecule profiling that KIAA1363, a protein of previously unknown function, is a 2-acetyl MAGE hydrolase that serves as a key regulator of a lipid signaling network that contributes to cancer pathogenesis. Although we cannot yet conclude which of the specific metabolites regulated by KIAA1363 supports tumor growth in vivo, the rescue of the reduced migratory phenotype of shKIAA1363 cancer cells by LPA is consistent with previous reports showing that this lipid signals through a family of G protein-coupled receptors to promote cancer cell migration and invasion 28, 29 and 30. LPA is also an established biomarker in ovarian cancer, and the levels of this metabolite are elevated nearly 10-fold in ascites fluid and plasma of patients with ovarian cancer [31]. Our results suggest that additional components in the KIAA1363-ether lipid network, including MAGE, alkyl LPC, and KIAA1363 itself, might also merit consideration as potential diagnostic markers for ovarian cancer. Consistent with this premise, our preliminary analyses have revealed highly elevated levels of KIAA1363 in primary human ovarian tumors compared to normal ovarian tissues (data not shown). The heightened expression of KIAA1363 in several other cancers, including breast 18 and 32, melanoma [18], and pancreatic cancer [33], indicates that alterations in the KIAA1363-ether lipid network may be a conserved feature of tumorigenesis. Considering further that reductions in KIAA1363 activity were found to impair tumor growth of both ovarian and breast cancer cells, it is possible that inhibitors of this enzyme may prove to be of value for the treatment of multiple types of cancer.

 

7.6.6 Peroxisomes – A Nexus for Lipid Metabolism and Cellular Signaling

Lodhi IJ, Semenkovich CF
Cell Metab. 2014 Mar 4; 19(3):380-92
http://dx.doi.org/10.1016%2Fj.cmet.2014.01.002

Peroxisomes are often dismissed as the cellular hoi polloi, relegated to cleaning up reactive oxygen chemical debris discarded by other organelles. However, their functions extend far beyond hydrogen peroxide metabolism. Peroxisomes are intimately associated with lipid droplets and mitochondria, and their ability to carry out fatty acid oxidation and lipid synthesis, especially the production of ether lipids, may be critical for generating cellular signals required for normal physiology. Here we review the biology of peroxisomes and their potential relevance to human disorders including cancer, obesity-related diabetes, and degenerative neurologic disease.

Peroxisomes are multifunctional organelles present in virtually all eukaryotic cells. In addition to being ubiquitous, they are also highly plastic, responding rapidly to cellular or environmental cues by modifying their size, number, morphology, and function (Schrader et al., 2013). Early ultrastructural studies of kidney and liver cells revealed cytoplasmic particles enclosed by a single membrane containing granular matrix and a crystalline core (Rhodin, 1958). These particles were linked with the term “peroxisome” by Christian de Duve, who first identified the organelle in mammalian cells when enzymes such as oxidases and catalases involved in hydrogen peroxide metabolism co-sedimented in equilibrium density gradients (De Duve and Baudhuin, 1966). Based on these studies, it was originally thought that the primary function of these organelles was the metabolism of hydrogen peroxide. Novikoff and colleagues observed a large number of peroxisomes in tissues active in lipid metabolism such as liver, brain, intestinal mucosa, and adipose tissue (Novikoff and Novikoff, 1982;Novikoff et al., 1980). Peroxisomes in different tissues vary greatly in shape and size, ranging from 0.1-0.5 μM in diameter. In adipocytes, peroxisomes tend to be small in size and localized in the vicinity of lipid droplets. Notably, a striking increase in the number of peroxisomes was observed during differentiation of adipogenic cells in culture (Novikoff and Novikoff, 1982). These findings suggest that peroxisomes may be involved in lipid metabolism.

Lazarow and de Duve hypothesized that peroxisomes in animal cells were capable of carrying out fatty acid oxidation. This was confirmed when they showed that purified rat liver peroxisomes contained fatty acid oxidation activity that was robustly increased by treatment of animals with clofibrate (Lazarow and De Duve, 1976). In a series of experiments, Hajra and colleagues discovered that peroxisomes were also capable of lipid synthesis (Hajra and Das, 1996). Over the past three decades, multiple lines of evidence have solidified the concept that peroxisomes play fundamentally important roles in lipid metabolism. In addition to removal of reactive oxygen species, metabolic functions of peroxisomes in mammalian cells include β-oxidation of very long chain fatty acids, α-oxidation of branched chain fatty acids, and synthesis of ether-linked phospholipids as well as bile acids (Figure 1). β-oxidation also occurs in mitochondria, but peroxisomal β-oxidation involves distinctive substrates and complements mitochondrial function; the processes of α-oxidation and ether lipid synthesis are unique to peroxisomes and important for metabolic homeostasis.

Structure and functions of peroxisomes

Structure and functions of peroxisomes

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951609/bin/nihms-555068-f0001.jpg

Figure 1 Structure and functions of peroxisomes

The peroxisome is a single membrane-enclosed organelle that plays an important role in metabolism. The main metabolic functions of peroxisomes in mammalian cells include β-oxidation of very long chain fatty acids, α-oxidation of branched chain fatty acids, synthesis of bile acids and ether-linked phospholipids and removal of reactive oxygen species. Peroxisomes in many, but not all, cell types contain a dense crystalline core of oxidative enzymes.

Here we highlight the established role of peroxisomes in lipid metabolism and their emerging role in cellular signaling relevant to metabolism. We describe the origin of peroxisomes and factors involved in their assembly, division, and function. We address the interaction of peroxisomes with lipid droplets and implications of this interaction for lipid metabolism. We consider fatty acid oxidation and lipid synthesis in peroxisomes and their importance in brown and white adipose tissue (sites relevant to lipid oxidation and synthesis) and disease pathogenesis.

peroxisomal biogenesis and protein import

peroxisomal biogenesis and protein import

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951609/bin/nihms-555068-f0002.jpg

Potential pathways to peroxisomal biogenesis. Peroxisomes are generated autonomously through division of pre-existing organelles (top) or through a de novo process involving budding from the ER followed by import of matrix proteins (bottom). B. Peroxisomal membrane protein import. Peroxisomal membrane proteins (PMPs) are imported post-translationally to the peroxisomal membrane. Pex19 is a soluble chaperone that binds to PMPs and transports them to the peroxisomal membrane, where it docks with a complex containing Pex16 and Pex3. Following insertion of the PMP, Pex19 is recycled back to the cytosol.

Regardless of their origin, peroxisomes require a group of proteins called peroxins for their assembly, division, and inheritance. Over 30 peroxins, encoded by Pex genes, have been identified in yeast (Dimitrov et al., 2013). At least a dozen of these proteins are conserved in mammals, where they regulate various aspects of peroxisomal biogenesis, including factors that control assembly of the peroxisomal membrane, factors that interact with peroxisomal targeting sequences allowing proteins to be shuttled to peroxisomes, and factors that act as docking receptors for peroxisomal proteins.

At least three peroxins (Pex3, Pex16 and Pex19) appear to be critical for assembly of the peroxisomal membrane and import of peroxisomal membrane proteins (PMPs) (Figure 2B). Pex19 is a soluble chaperone and import receptor for newly synthesized PMPs (Jones et al., 2004). Pex3 buds from the ER in a pre-peroxisomal vesicle and functions as a docking receptor for Pex19 (Fang et al., 2004). Pex16 acts as a docking site on the peroxisomal membrane for recruitment of Pex3 (Matsuzaki and Fujiki, 2008). Peroxisomal matrix proteins are translated on free ribosomes in the cytoplasm prior to their import. These proteins have specific peroxisomal targeting sequences (PTS) located either at the carboxyl (PTS1) or amino (PTS2) terminus (Gould et al., 1987; Swinkels et al., 1991).

 

7.6.7 A nexus for cellular homeostasis- the interplay between metabolic and signal transduction pathways

Ana P Gomes, John Blenis
Current Opinion in Biotechnology Aug 2015; 34:110–117
http://dx.doi.org/10.1016/j.copbio.2014.12.007

Highlights

  • Signaling networks sense intracellular and extracellular cues to maintain homeostasis.
  • PI3K/AKT and Ras/ERK signaling induces anabolic reprogramming.
  • mTORC1 is a master node of signaling integration that promotes anabolism.
  • AMPK and SIRT1 fine tune signaling networks in response to energetic status.

In multicellular organisms, individual cells have evolved to sense external and internal cues in order to maintain cellular homeostasis and survive under different environmental conditions. Cells efficiently adjust their metabolism to reflect the abundance of nutrients, energy and growth factors. The ability to rewire cellular metabolism between anabolic and catabolic processes is crucial for cells to thrive. Thus, cells have developed, through evolution, metabolic networks that are highly plastic and tightly regulated to meet the requirements necessary to maintain cellular homeostasis. The plasticity of these cellular systems is tightly regulated by complex signaling networks that integrate the intracellular and extracellular information. The coordination of signal transduction and metabolic pathways is essential in maintaining a healthy and rapidly responsive cellular state.

AMPK and SIRT1 fine tune signaling networks in response to energetic status

AMPK and SIRT1 fine tune signaling networks in response to energetic status

 

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AMPK and SIRT1 fine tune signaling networks in response to energetic status

 

http://ars.els-cdn.com/content/image/1-s2.0-S0958166914002225-gr1.sml

mTORC1 is a master node of signaling integration that promotes anabolism.

 

http://ars.els-cdn.com/content/image/1-s2.0-S0958166914002225-gr2.sml

Fine-tuning signaling networks

 PI3K/Akt signaling-induced anabolic reprogramming

Growth factors and other ligands activate PI3K signaling upon binding and consequent activation of their cell surface receptors, such as receptor tyrosine kinases (RTKs) and G protein-coupled
receptors (GPCRs). This leads to the phosphorylation of membrane phosphatidylinositiol lipids and the recruitment and activation of several protein kinases, which perpetuate the extracellular
signals to modulate intracellular processes [3,4]. One of the most crucial signal propagators regulated by PI3K signaling is protein kinase B/Akt [3,4]. Indeed, Akt rewires metabolism in response
to environmental cues by three distinct means;
(i) by the direct phosphorylation and regulation of metabolic enzymes,
(ii) by activating/inactivating metabolism altering transcriptional factors, and
(iii) by modulating other kinases that themselves regulate metabolism [5].
Akt regulates glucose metabolism, inducing both glucose uptake and glycolytic flux by increasing the expression of the glucose transporter genes and regulating the activity of glycolytic enzymes,
respectively [6–8]. Moreover, the ability of Akt to induce glycolysis is also mediated by the regulation of Hexokinase (HK). HK performs the first step of glycolysis.

Figure 1 Anabolic rewiring induced by PI3K/Akt, Ras/ERK and mTORC1 signaling.
Extracellular signals activate two major signaling cascades controlled by the activation of PI3K and Ras. PI3K and Ras regulate Akt and ERK, which in turn induce changes in intermediate metabolism
to promote anabolic processes. In addition, they also induce the activation of  mTORC1, thus further supporting the rewiring of cellular metabolism towards anabolic processes. Through various mechanisms
Akt, ERK and mTORC1 stimulate mRNA translation, aerobic glycolysis, glutamine anaplerosis, lipid synthesis, the pentose phosphate and pyrimidine synthesis, thus producing the major components
necessary for cell growth and proliferation.

Figure 2. Regulation of intermediate metabolism by nutrient and energy sensors.
Nutrient and energy-responsive pathways fine-tune the output of signaling cascades, allowing for the correct balance between the availability of nutrients and the cellular capacity to use them effectively.
AMPK and SIRT1 respond to the energy status of the cells through sensing of AMP and NAD+ levels respectively. When energy is scarce, these sensors are activated inducing a rewiring of intermediate
metabolism to catabolic processes in order to produce energy and restore homeostasis. When nutrients (such as glucose and amino acids) and energy are available, AMPK, SIRT1, SIRT3 and SIRT6 are
repressed and mTORC1 is active, thus promoting a shift towards anabolic processes and energy production. These networks of signaling cascades, their interconnection and regulation allow the cells
to maintain energetic balance and allow for the physiological adaptation to the ever-changing environment.

 

7.6.8 Mechanisms-of-intercellular-signaling

7.6.8.1 Activation and signaling of the p38 MAP kinase pathway

Tyler Zarubin1 and Jiahuai Han
Cell Research (2005) 15, 11–18
http://dx.doi.org:/10.1038/sj.cr.7290257

The family members of the mitogen-activated protein (MAP) kinases mediate a wide variety of cellular behaviors in response to extracellular stimuli. One of the four main sub-groups, the p38 group of MAP kinases, serve as a nexus for signal transduction and play a vital role in numerous biological processes. In this review, we highlight the known characteristics and components of the p38 pathway along with the mechanism and consequences of p38 activation. We focus on the role of p38 as a signal transduction mediator and examine the evidence linking p38 to inflammation, cell cycle, cell death, development, cell differentiation, senescence and tumorigenesis in specific cell types. Upstream and downstream components of p38 are described and questions remaining to be answered are posed. Finally, we propose several directions for future research on p38.

Cellular behavior in response to extracellular stimuli is mediated through intracellular signaling pathways such as the mitogen-activated protein (MAP) kinase pathways 1. MAP kinases are members of discrete signaling cascades and serve as focal points in response to a variety of extracellular stimuli. Four distinct subgroups within the MAP kinase family have been described:

  • extracellular signal-regulated kinases (ERKs),
  • c-jun N-terminal or stress-activated protein kinases (JNK/SAPK),
  • ERK/big MAP kinase 1 (BMK1), and
  • the p38 group of protein kinases.

The focus of this review will be to highlight the characteristics of

  • the p38 kinases,
  • components of this kinase cascade,
  • activation of this pathway, and
  • the biological consequences of its activation.

p38 (p38) was first isolated as a 38-kDa protein rapidly tyrosine phosphorylated in response to LPS stimulation 2, 3. p38 cDNA was also cloned as a molecule that binds puridinyl imidazole derivatives which are known to inhibit biosynthesis of inflammatory cytokines such as interleukin-1 (IL-1) and tumor-necrosis factor (TNF) in LPS stimulated monocytes 4. To date, four splice variants of the p38 family have been identified: p38, p38 5, p38 (ERK6, SAPK3) 6, 7, and p38(SAPK4) 8, 9. Of these, p38 and p38 are ubiquitously expressed while p38 and p38 are differentially expressed depending on tissue type. All p38 kinases can be categorized by a Thr-Gly-Tyr (TGY) dual phosphorylation motif 10. Sequence comparisons have revealed that each p38 isoform shares 60% identity within the p38 group but only 40–45% to the other three MAP kinase family members.

Mammalian p38s activation has been shown to occur in response to extracellular stimuli such as UV light, heat, osmotic shock, inflammatory cytokines (TNF- & IL-1), and growth factors (CSF-1) 1, 3, 15, 16, 17,18, 19, 20, 21. This plethora of activators conveys the complexity of the p38 pathway and this matter is further complicated by the observation that activation of p38 is not only dependent on stimulus, but on cell type as well. For example, insulin can stimulate p38 in 3T3-L1 adipocytes 22, but downregulates p38 activity in chick forebrain neuron cells 23. The activation of p38 isoforms can be specifically controlled through different regulators and coactivated by various combinations of upstream regulators 24, 26.

Like all MAP kinases, p38 kinases are activated by dual kinases termed the MAP kinase kinases (MKKs). However, despite conserved dual phosphorylation sites among p38 isoforms, selective activation by distinct MKKs has been observed. There are two main MAPKKs that are known to activate p38, MKK3 and MKK6. It is proposed that upstream kinases can differentially regulate p38 isoforms as evidenced by the inability of MKK3 to effectively activate p38 while MKK6 is a potent activator despite 80% homology between these two MKKs 27. Also, it has been shown that MKK4, an upstream kinase of JNK, can aid in the activation of p38 and p38 in specific cell types 8. This data suggests then, that activation of p38 isoforms can be specifically controlled through different regulators and coactivated by various combinations of upstream regulators. Furthermore, substrate selectivity may be a reason why each MKK has a distinct function. In addition to the activation by upstream kinases, there is a MAPKK-independent mechanism of p38 MAPK activation involving TAB1 (transforming growth factor–activated protein kinase 1 (TAK1)-binding protein) 28. The activation of p38 in this pathway is achieved by the autophosphorylation of p38 after interaction with TAB1.

The activation of p38 in response to the wide range of extracellular stimuli can be seen in part by the diverse range of MKK kinases (MAP3K) that participate in p38 activation. These include TAK1 33, ASK1/MAPKKK5 34, DLK/MUK/ZPK 35, 36, and MEKK4 35, 37, 38. Overexpression of these MAP3Ks leads to activation of both p38 and JNK pathways which is possibly one reason why these two pathways are often co-activated. Also contributing to p38 activation upstream of MAPK kinases are low molecular weight GTP-binding proteins in the Rho family such as Rac1 and Cdc42 40, 41. Rac1 can bind to MEKK1 or MLK1 while Cdc42 can only bind to MLK1 and both result in activation of p38 via MAP3Ks 35, 42.

Dephosphorylation, would seem to play a major role in the downregulation of MAP kinase activity. Many dual-specificity phosphatases have been identified that act upon various members of the MAP kinase pathway and are grouped as the MAP kinase phosphatase (MKP) family 45. Several members can efficiently dephosphorylate p38 and p38 46, 47; however, p38 and p38 are resistant to all known MKP family members.

The first p38 substrate identified was the MAP kinase-activated protein kinase 2 (MAPKAPK2 or MK2) 1, 15, 52. This substrate, along with its closely related family member MK3 (3pk), were both shown to activate various substrates including small heat shock protein 27 (HSP27) 53, lymphocyte-specific protein 1 (LSP1) 54, cAMP response element-binding protein (CREB) 55, transcription factor ATF1 55, SRF 56, and tyrosine hydroxylase 57. p38 regulated/activated kinase (PRAK) is a p38 and/or p38activated kinase that shares 20-30% sequence identity to MK2 and is thought to regulate heat shock protein 27 (HSP27) 61. Mitogen- and stress-activated protein kinase-1 (MSK1) can be directly activated by p38 and ERK, and may mediate activation of CREB 62, 63, 64.

Another group of substrates that are activated by p38 comprise transcription factors. Many transcription factors encompassing a broad range of action have been shown to be phosphorylated and subsequently activated by p38. Examples include activating transcription factor 1, 2 & 6 (ATF-1/2/6), SRF accessory protein (Sap1), CHOP (growth arrest and DNA damage inducible gene 153, or GADD153), p53, C/EBP, myocyte enhance factor 2C (MEF2C), MEF2A, MITF1, DDIT3, ELK1, NFAT, and high mobility group-box protein 1 (HBP1) 17, 55, 66, 67, 68, 69, 70, 71, 72,73, 74, 75, 76. An important cis-element, AP-1 appears to be influenced by p38 through several different mechanisms.  Taken together, all the data suggest that the p38 pathway has a wide variety of functions.

Abundant evidence for p38 involvement in apoptosis exists to date and is based on concomitant activation of p38 and apoptosis induced by a variety of agents such as NGF withdrawal and Fas ligation 95, 96, 97. Cysteine proteases (caspases) are central to the apoptotic pathway and are expressed as inactive zymogens 98,99. Caspase inhibitors then can block p38 activation through Fas cross-linking, suggesting p38 functions downstream of caspase activation 97, 100. However, overexpression of dominant active MKK6b can also induce caspase activity and cell death thus implying that p38 may function both upstream and downstream of caspases in apoptosis 101, 102. It must be mentioned that the role of p38 in apoptosis is cell type and stimulus dependent. While p38 signaling has been shown to promote cell death in some cell lines, in different cell lines p38 has been shown to enhance survival, cell growth, and differentiation.

p38 now seems to have a role in tumorigenesis and sensescence. There have been reports that activation of MKK6 and MKK3 led to a senescent phenotype dependent upon p38 MAPK activity. Also, p38 MAPK activity was shown responsible for senescence in response to telomere shortening, H2O2 exposure, and chronic RAS oncogene signaling 117, 118, 119. A common feature of tumor cells is a loss of senescence and p38 may be linked to tumorigenesis in certain cells. It has been reported that p38 activation may be reduced in tumors and that loss of components of the p38 pathway such as MKK3 and MKK6 resulted in increased proliferation and likelihood of tumorigenic conversion regardless of the cell line or the tumor induction agent used in these studies 29.

Although all research done on the p38 pathway cannot be reviewed here, certain conclusions can still be made regarding the operation of p38 as a signal transduction mediator. The p38 family (,,,) is activated by both stress and mitogenic stimuli in a cell dependent manner and certain isoforms can either directly or indirectly target proteins to control pre/post transcription. p38 MAPKs also have the ability to activate other kinases and consequently regulate numerous cellular responses. Because p38 signaling has been implicated in cellular responses including inflammation, cell cycle, cell death, development, cell differentiation, senescence, and tumorigenesis, emphasis must be placed on p38 function with respect to specific cell types.

Regulation of the p38 pathway is not an isolated cascade and many different upstream signals can lead to p38 activation. These signals may be p38 specific (MKK3/6), general MAPKKs (MKK4), or MAPKK independent signals (TAB1). Downstream signaling pathways of p38 are quite divergent and each component may interact with other cellular components, both upstream and downstream, to coordinate cellular processes such as feedback mechanisms. Furthermore, in vivo p38 is not an isolated event and exists in the presence of other MAP kinases and a plethora of other signaling pathways. The subcellular location of p38 activation may also play a critical role determining the resulting effect and may add yet another order of complexity to the investigation of p38 function.

 

7.6.8.2 Mitogen-Activated Protein Kinase Pathways Mediated by ERK, JNK, and p38 Protein Kinases

Gary L. Johnson and Razvan Lapadat
Science 6 Dec 2002; 298: 1911-1912.

Multicellular organisms have three well-characterized subfamilies of mitogen activated protein kinases (MAPKs) that control a vast array of physiological processes. These enzymes are regulated by a characteristic phosphorelay system in which a series of three protein kinases phosphorylate and activate one another. The extracellular signal–regulated kinases (ERKs) function in the control of cell division, and inhibitors of these enzymes are being explored as anticancer agents. The c-Jun amino-terminal kinases ( JNKs) are critical regulators of transcription, and JNK inhibitors may be effective in control of rheumatoid arthritis. The p38 MAPKs are activated by inflammatory cytokines and environmental stresses.

Protein kinases are enzymes that covalently attach phosphate to the side chain of either serine, threonine, or tyrosine of specific proteins inside cells. Such phosphorylation of proteins can control their enzymatic activity, their interaction with other proteins and molecules, their location in the cell, and their propensity for degradation by proteases. Mitogen-activated protein kinases (MAPKs) compose a family of protein kinases whose function and regulation have been conserved during evolution from unicellular organisms such as brewers’ yeast to complex organisms including humans (1). MAPKs phosphorylate specific serines and threonines of target protein substrates and regulate cellular activities ranging from gene expression, mitosis, movement, metabolism, and programmed death. Because of the many important cellular functions controlled by MAPKs, they have been studied extensively to define their roles in physiology and human disease. MAPK-catalyzed phosphorylation of substrate proteins functions as a switch to turn on or off the activity of the substrate protein.

MAPKs are part of a phosphorelay system composed of three sequentially activated kinases, and, like their substrates, MAPKs are regulated by phosphorylation (Fig. 1) (2). MKK-catalyzed phosphorylation activates the MAPK and increases its activity in catalyzing the phosphorylation of its own substrates. MAPK phosphatases reverse the phosphorylation and return the MAPK to an inactive state. MKKs are highly selective in phosphorylating specific MAPKs. MAPK kinase kinases (MKKKs) are the third component of the phosphorelay system. MKKKs phosphorylate and activate specific MKKs. MKKKs have distinct motifs in their sequences that selectively confer their activation in response to different stimuli.

Fig. 1. MAPK phosphorelay systems.

The modules shown are representative of pathway connections for the respective MAPK phosphorelay systems.There are multiple component MKKKs, MKKs, and MAPKs for each system.For example, there are three Raf proteins (c-Raf1, B-Raf, A-Raf), two MKKs (MKK1 and MKK2), and two ERKs (ERK1 and ERK2) that can compose MAPK phosphorelay systems responsive to growth factors.The ERK, JNK, and p39 pathways in the STKE Connections Map demonstrate the potential complexity of these systems.

ERKs 1 and 2 are both components of a three-kinase phosphorelay module that includes the MKKK c-Raf1, B-Raf, or A-Raf, which can be activated by the proto-oncogene Ras. Mutations that convert Ras to an activated oncogene are common oncogenic mutations in many human tumors. Oncogenic Ras persistently activates the ERK1 and ERK2 pathways, which contributes to the increased proliferative rate of tumor cells. For this reason, inhibitors of the ERK pathways are entering clinical trials as potential anticancer agents.

Regulation of the JNK pathway is extremely complex and is influenced by many MKKKs. As depicted in the STKE JNK Pathway Connections Map, there are 13 MKKKs that regulate the JNKs. This diversity of MKKKs allows a wide range of stimuli to activate this MAPK pathway. JNKs are important in controlling programmed cell death or apoptosis (9). The inhibition of JNKs enhances chemotherapy-induced inhibition of tumor cell growth, suggesting that JNKs may provide a molecular target for the treatment of cancer. The pharmaceutical industry is bringing JNK inhibitors into clinical trials.

Recently, a major paradigm shift for MAPK regulation was developed for p38. The p38 enzyme is activated by the protein TAB1 (12), but TAB1 is not a MKK. Rather, TAB1 appears to be an adaptor or scaffolding protein and has no known catalytic activity. This is the first demonstration that another mechanism exists for the regulation of MAPKs in addition to the MKKK-MKKMAPK regulatory module.

The importance of MAPKs in controlling cellular responses to the environment and in regulating gene expression, cell growth, and apoptosis has made them a priority for research related to many human diseases. The ERK, JNK, and p38 pathways are all molecular targets for drug development, and inhibitors of MAPKs will undoubtedly be one of the next group of drugs developed for the treatment of human disease (13).

7.6.9 Cathepsin B promotes colorectal tumorigenesis, cell invasion, and metastasis

B Bian, S Mongrain, S Cagnol, Marie-Josée Langlois, J Boulanger, et al.
Molec Carcinogen 25 Mar 2015; 54(5). http://dx.doi.org:/10.1002/mc.22312

Cathepsin B is a cysteine proteinase that primarily functions as an endopeptidase within endolysosomal compartments in normal cells. However, during tumoral expansion, the regulation of cathepsin B can be altered at multiple levels, thereby resulting in its overexpression and export outside of the cell. This may suggest a possible role of cathepsin B in alterations leading to cancer progression. The aim of this study was to determine the contribution of intracellular and extracellular cathepsin B in growth, tumorigenesis, and invasion of colorectal cancer (CRC) cells. Results show that mRNA and activated levels of cathepsin B were both increased in human adenomas and in CRCs of all stages. Treatment of CRC cells with the highly selective and non-permeant cathepsin B inhibitor Ca074 revealed that extracellular cathepsin B actively contributed to the invasiveness of human CRC cells while not essential for their growth in soft agar. Cathepsin B silencing by RNAi in human CRC cells inhibited their growth in soft agar, as well as their invasion capacity, tumoral expansion, and metastatic spread in immunodeficient mice. Higher levels of the cell cycle inhibitor p27Kip1 were observed in cathepsin B-deficient tumors as well as an increase in cyclin B1. Finally, cathepsin B colocalized with p27Kip1 within the lysosomes and efficiently degraded the inhibitor. In conclusion, the present data demonstrate that cathepsin B is a significant factor in colorectal tumor development, invasion, and metastatic spreading and may, therefore, represent a potential pharmacological target for colorectal tumor therapy

Colorectal cancer (CRC),a major malignancy worldwide and the second leading cause of cancer death in North America, develops through multiple steps. The ability of cancers to invade and metastasize depends on the action of proteases actively taking center stage in extracellular proteolysis [2]. Of all the proteases, the cysteine protease cathepsin B is of significant importance [3]. Cathepsin B primarily functions as an endopeptidase within endolysosomal compartments in normal cells. However, during malignant transformation cathepsin B can be upregulated [3, 4]. Cathepsin B in tumors can either be secreted, bound to the cell membrane or released by shedding vesicles [4]. Expression and redistribution of active cathepsin B to the basal plasma membrane occurs in late colon adenomas [5, 6] coincident with the activation of KRAS [1]. In line with these results, Cavallo-Medved et al. [7] have demonstrated that trafficking of cathepsin B to caveolae and its secretion are regulated by active KRAS in CRC cells in culture. Accordingly, secretion of cathepsin B, increased in the extracellular environment of CRC [8, 9], is suspected to play an essential role in disrupting extracellular matrix barriers, facilitating invasion and metastasis [10-12]. These data are consistent with the link between cathepsin B protein expression in colorectal carcinomas and shortened patient survival [6].

In a recent prospective cohort study of 558 men and women with colonic tumors [13] 82% of patients had tumors that expressed cathepsin B, irrespective of stage, while the remaining 18% had tumors that did not express cathepsin B. Other studies have suggested that cathepsin B expression or activity may actually peak during early stage cancer and subsequently decline with advanced disease [14, 15]. This points to a possible role of cathepsin B in both early and late alterations leading to colonic cancer.

This study used two strategies to specifically counteract the action of cathepsin B. The first involved the use of RNA interference (RNAi) to inhibit the expression of cathepsin B protein into CRC cells while the second approach employed the highly selective cathepsin inhibitor Ca074 to block extracellular cathepsin B activity. Results suggest that extracellular cathepsin B is involved in cell invasion whereas intracellular cathepsin B controls malignant properties of CRC cells. Further, biochemical analysis suggests that intracellular cathepsin B regulates tumorigenesis by degrading the p27Kip1 cell cycle inhibitor.

mRNA and Activated Levels of Cathepsin B Are Increased in Adenomas and in Colorectal Tumors of All Stages

Cathepsin B expression was analyzed at both the mRNA and protein levels in a series of human paired specimens at various tumor stages. As shown in Figure 1A, increased transcript levels of cathepsin B were observed in colorectal tumors, regardless of tumor stage, including in adenomas. Of note, increased cathepsin B expression was more prominent in tumors exhibiting APC mutations. By contrast, there did not appear to be a significant difference relative to KRAS mutations (Figure 1B). To establish whether these increased mRNA levels could be correlated with increased cathepsin B protein levels and more importantly with increased activity, expression of the active processed forms of the protease (25 and 30 kDa) was analyzed by Western blot. Both pro-cathepsin B and active cathepsin B were also increased in colorectal tumors compared to normal tissues (Figure 1C and D). These data hence suggest that increased transcription contributes to a greater expression of active cathepsin B in CRC.

Extracellular Cathepsin B Contributes to Invasiveness of Human CRC Cells but is Dispensable for Their Growth in Soft Agar

Cathepsin B protein levels were next examined in lysates obtained from various human CRC cell lines. As shown in Figure 2A, the proactive and catalytically active processed forms of cathepsin B were detected at various levels in CRC cell lines. Selected cathepsin B presence was also confirmed in conditioned culture medium of CRC cells, again at various levels (Figure 2A, lower panel). However, while the pro-form of cathepsin B was readily observed in conditioned culture medium of all CRC cells, the catalytically-active processed forms of cathepsin B were not detected in Western blot analyses. Additionally, using a fluorescence-based enzymatic assay, no cathepsin B enzyme activity was detected in conditioned medium. Since the pro-protease form might be activated under acidic pH conditions (peri- or extracellular) and by extracellular components of the extracellular matrix, the impact of extracellular inhibition of cathepsin B activation on CRC cell invasion was verified using Biocoat Matrigel chambers. HT-29, DLD1, and SW480 CRC cell lines secreting different levels of pro-cathepsin B (Figure 2A) were tested. Experiments were performed using the highly selective and non-permeant inhibitor Ca074 to reduce extracellular cathepsin B activity. At 10 μM, Ca074 produced a >99% inhibition of recombinant cathepsin B levels while barely reducing intracellular cathepsin B, that is, 5–8%, even upon 12 h exposure to the inhibitor (data not shown). Of note, treatment with 10 μM Ca074 significantly inhibited Matrigel invasion by approximately 45–60% in HT29, DLD1, and SW480 CRC cell lines (Figure 2B). By contrast, treatment with Ca074 had no significant effect on their capacity to form colonies in soft agarose (Figure 2C).

Cathepsin B Silencing in Human CRC Cells Inhibits Tumorigenicity and Metastasis in Immunodeficient Mice

Suppression of cathepsin B expression was found to significantly attenuate the metastatic potential of CRC cells in vivo in experimental metastasis assays. Indeed, immunodeficient mice injected with control CRC cells into the tail vein showed extensive lung metastasis within 28 d, whereas cells expressing shRNA against cathepsin B exhibited reduced lung colonization (Figure 4A). Cathepsin B silencing also altered the capacity of CRC cells to form tumors in mice as assessed by subcutaneous xenograft assays. HT29 cells induced palpable tumors with a short latency period of 9 d after their injection while downregulation of cathepsin B expression in these cells severely impaired their capacity to grow as tumors (Figure 4B).

Cathepsin B Silencing in Human CRC Cells Inhibits Growth in Soft Agar and Invasion Capacity

Recombinant lentiviruses encoding anti-cathepsin B short hairpin RNA (shRNA) were developed in order to stably suppress cathepsin B expression in CRC cells. As shown in Figure 3A, intracellular cathepsin B mRNA and protein levels were decreased in HT29 and DLD1 cells in comparison to a control shRNA which had no effect. Reduction of cathepsin B expression modestly slowed the proliferation rate of HT29 and DLD1 populations in 2D cell culture (Figure 3B). Conversely, cathepsin B silencing significantly reduced the ability of HT29 and DLD1 cells to form colonies in soft agarose (Figure 3C). This indicates that intracellular cathepsin B controls anchorage-independent growth of CRC cells given the absence of Ca074 effect (Figure 2C). Moreover, cathepsin B silencing also reduced the number of invading HT29 and DLD1 cells to a similar extent as Ca074 treatment (Figure 3D vs. Figure 2B).

Cathepsin B Silencing in Human CRC Cells Inhibits Tumorigenicity and Metastasis in Immunodeficient Mice

Suppression of cathepsin B expression was found to significantly attenuate the metastatic potential of CRC cells in vivo in experimental metastasis assays. Indeed, immunodeficient mice injected with control CRC cells into the tail vein showed extensive lung metastasis within 28 d, whereas cells expressing shRNA against cathepsin B exhibited reduced lung colonization (Figure 4A). Cathepsin B silencing also altered the capacity of CRC cells to form tumors in mice as assessed by subcutaneous xenograft assays. HT29 cells induced palpable tumors with a short latency period of 9 d after their injection while downregulation of cathepsin B expression in these cells severely impaired their capacity to grow as tumors (Figure 4B).

Cathepsin B Cleaves the Cell Cycle Inhibitor p27Kip1

In order to verify whether p27Kip1 is in fact a substrate for cathepsin B, both proteins were first overexpressed in 293 T cells and cells subsequently lysed 2 d later for Western blot analysis of their respective expression. As shown in Figure 5A, forced expression of cathepsin B in 293 T cells dose-dependently reduced p27Kip1 protein levels. Next, to determine whether p27Kip1 could be degraded by cathepsin B in vitro, lysates from 293 T cells overexpressing HA-tagged p27Kip1 were incubated with purified cathepsin B and analyzed by Western blot. Figure 5B and C shows that cathepsin B degraded p27Kip1 in a time-dependent manner as visualized by the accumulation of three lower molecular mass species (26, 20, and 12 kDa) in addition to the full-length p27Kip1 protein (see arrows versus arrowhead).

Cathepsin B is capable of endopeptidase, peptidyl-dipeptidase, and carboxydipeptidase activities [18-20]. Cathepsin B also possesses a basic amino acid in the catalytic subsite in position S2 enabling the protease to preferentially split its substrates after Arg–Arg or Lys–Arg or Arg–Lys sequences. At least five of these sequences can be found within the human p27Kip1 sequence (Figure 5D). Therefore, the first amino acid of these doublets was mutated into alanine to test whether it would affect the degradation by cathepsin B. Mutation of arginine 58 (Figure 5E) and lysine 189 (Figure 5F) did not alter the cleavage profile of p27Kip1 by cathepsin B. Mutation of lysine 165 and arginine 194 also had no altering effect (not shown). On the other hand, mutation of arginine 152 into alanine markedly reduced the detection of the 20-kDa fragment (Figure 5E).

The protein stability of wild-type p27Kip1 was then compared to that of the p27Kip1 R152A/Δ189–198 mutant, which is more resistant to cathepsin B cleavage. 293T cells were transiently transfected with either wild-type p27Kip1 or p27Kip1 mutant and subsequently treated with cycloheximide to inhibit protein neosynthesis. Thereafter, cells were lysed at different time intervals in order to analyze protein expression levels of p27Kip1 forms. As shown in Figure 6A, following cycloheximide treatment, protein levels of the p27Kip1 mutant decreased much more slowly than that of wild-type protein. Specifically, 10 h after cycloheximide addition, expression of p27Kip1 protein was clearly decreased while expression of the p27Kip1 mutant remained at control (time 0) levels. Of note, forced expression of cathepsin B in 293 T cells dose-dependently reduced the wild-type form of p27Kip1 protein levels while expression of p27Kip1 R152A/Δ189–198 mutant was only very slightly affected (Figure 6B).

Colocalization of Endogenous p27Kip1 With Cathepsin B Into Lysosomes

As shown in Figure 7A, the anti-cathepsin B antibody confirmed the colocalization of cathepsin B (in green) with the lysosomal acidotropic probe LysoTracker (in red). As expected, most of p27Kip1 staining (in green) was observed in the cell nucleus (Figure 7B). However, certain areas of colocalization were observed between endogenous p27Kip1 (in green) and cathepsin B (in red) (Figure 7B, asterisks). Moreover, Western blot analyses revealed the presence of p27Kip1 protein in lysosome-enriched fractions obtained from differential centrifugation of Caco-2/15 and SW480 cell lysates (Figure 7C and D). These lysosomal fractions were enriched in lysosome-associated membrane protein 1 (LAMP1) and exhibited very low or undetectable levels of the nuclear lamin B protein.

The most extensive literature to date regarding cathepsin B highlights a key role of this protease in the invasiveness and metastasis of various carcinoma cells [3, 8, 10-12]. The present findings demonstrate that cathepsin B has not only a role in facilitating CRC invasion and metastasis, but also in mediating early premalignant processes. Results herein show that cathepsin B promotes anchorage-independent CRC cell growth, which translates in vivo to enhanced tumor growth. In addition, cathepsin B was identified as a new protease capable of proteolytic cleavage of the cell cycle inhibitor p27Kip1. This is especially relevant since the loss of p27Kip1 expression has been strongly associated with aggressive tumor behavior and poor clinical outcome in CRC [22, 23].

These data are reminiscent of the immunohistochemistry data reported by Chan et al. [13] showing that cathepsin B protein was expressed in the vast majority of colon cancers analyzed (558 tumors), which was also independent of tumor stage. The present data also revealed that increased transcription of cathepsin B was associated with the presence of mutations in APC but not in KRAS, thus emphasizing the fact that cathepsin B gene expression is already deregulated in early stages of colorectal carcinoma. Indeed, most CRCs acquire loss-of-function mutations in both copies of the APC gene, resulting in inefficient breakdown of intracellular β-catenin and enhanced nuclear signaling [27]. Given the importance of the Wnt/APC/β-catenin pathway in human tumorigenesis initiation, the present data showing an association between cathepsin B expression and APC mutations are particularly noteworthy.

 

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Acute Lung Injury

Posted in Biological Networks, Ca2+ triggered activation, Calcium Signaling, Calmodulin Kinase and Contraction, Cell Biology, Signaling & Cell Circuits, Chemical Biology and its relations to Metabolic Disease, Clinical Diagnostics, Curation, Cytoskeleton, Disease Biology, Disease Biology, Small Molecules in Development of Therapeutic Drugs, Drug Toxicity, Gene Regulation, Hematology, Human Immune System in Health and in Disease, Lipid metabolism, Metabolism, Metabolomics, Microbiology, Nitric Oxide in Health and Disease, Nutrition and Phytochemistry, Pharmaceutical Analytics, Pharmaceutical Drug Discovery, Pharmacologic toxicities, Plant extract, Proteins, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, tagged Acute lung injury, cell supernatant, immunomodulation, lipopolysaccharide (LPS), plasma products, platelets, PPARs, Sepsis, transfusion reaction on February 26, 2015| Leave a Comment »

Acute Lung Injury

Writer and Curator: Larry H. Bernstein, MD, FCAP 

 

 

Introduction

Acute lung injury is a serious phenomenon only recognized as having significant relevance to allogeneic blood transfusion in the last 15 years.  It is not limited to transfusion events, and is also related to SIRS and sepsis.  It is simulated in experimental models by lipoprotein, such as endotoxin.  It occurs in the pretransfused surgical patient, or in the medical patient as well.  Why it was not recognized earlier is a matter of conjecture.  The significant reduction in immune modulated blood type incompatibility reactions in Western countries is a factor.  The other factor is that the lipoprotein antigenic fractions involved are associated with component transfusions other than stored red cells. The following discussion will elaborate on what is increasingly recognized as a relevant issue in medicine today.
Transfusion Related Reaction

In medicine, transfusion related acute lung injury (TRALI) is a serious blood transfusion complication characterized by the acute onset of non-cardiogenic pulmonary edema following transfusion of blood products.[1]

Although the incidence of TRALI has decreased with modified transfusion practices, it is still the leading cause of transfusion-related fatalities in the United States from fiscal year 2008 through fiscal year 2012.

Transfusion Related Acute Lung Injury

TRALI-Hyaline_membranes_-_very_high_mag

TRALI-Hyaline_membranes_-_very_high_mag

Micrograph of diffuse alveolar damage, the histologic correlate of TRALI. H&E stain. Very high magnification micrograph of hyaline membranes, as seen in diffuse alveolar damage (DAD), the histologic correlate of acute respiratory distress syndrome (ARDS), transfusion related acute lung injury (TRALI), acute interstitial pneumonia (AIP).
http://upload.wikimedia.org/wikipedia/commons/thumb/c/c8/Hyaline_membranes_-_very_high_mag.jpg/1024px-Hyaline_membranes_-_very_high_mag.jpg

TRALI is defined as an acute lung injury that is temporally related to a blood transfusion; specifically, it occurs within the first six hours following a transfusion.[3]

It is typically associated with plasma components such as platelets and Fresh Frozen Plasma, though cases have been reported with packed red blood cells since there is some residual plasma in the packed cells. The blood component transfused is not part of the case definition. Transfusion-related acute lung injury (TRALI) is an uncommon syndrome that is due to the presence of leukocyte antibodies in transfused plasma. TRALI is believed to occur in approximately one in every 5000 transfusions. Leukoagglutination and pooling of granulocytes in the recipient’s lungs may occur, with release of the contents of leukocyte granules, and resulting injury to cellular membranes, endothelial surfaces, and potentially to lung parenchyma. In most cases leukoagglutination results in mild dyspnea and pulmonary infiltrates within about 6 hours of transfusion, and spontaneously resolves;

Occasionally more severe lung injury occurs as a result of this phenomenon and Acute Respiratory Distress Syndrome (ARDS) results. Leukocyte filters may prevent TRALI for those patients whose lung injury is due to leukoagglutination of the donor white blood cells, but because most TRALI is due to donor antibodies to leukocytes, filters are not helpful in TRALI prevention. Transfused plasma (from any component source) may also contain antibodies that cross-react with platelets in the recipient, producing usually mild forms of posttransfusion purpura or platelet aggregation after transfusion.

Another nonspecific form of immunologic transfusion complication is mild to moderate immunosuppression consequent to transfusion. This effect of transfusion is not completely understood, but appears to be more common with cellular transfusion and may result in both desirable and undesirable effects. Mild immunosuppression may benefit organ transplant recipients and patients with autoimmune diseases; however, neonates and other already immunosuppressed hosts may be more vulnerable to infection, and cancer patients may possibly have worse outcomes postoperatively.

http://en.wikipedia.org/wiki/Transfusion-related_acute_lung_injury

 

 

Perioperative transfusion-related acute lung injury: The Canadian Blood Services experience

Asim Alam, Mary Huang, Qi-Long Yi, Yulia Lin, Barbara Hannach
Transfusion and Apheresis Science 50 (2014) 392–398
http://dx.doi.org/10.1016/j.transci.2014.04.008

Purpose: Transfusion-related acute lung injury (TRALI) is a devastating transfusion-associated adverse event. There is a paucity of data on the incidence and characteristics of TRALI cases that occur perioperatively. We classified suspected perioperative TRALI cases reported to Canadian Blood Services between 2001 and 2012, and compared them to non-perioperative cases to elucidate factors that may be associated with an increased risk of developing TRALI in the perioperative setting. Methods: All suspected TRALI cases reported to Canadian Blood Services (CBS) since 2001 were reviewed by two experts or, from 2006 to 2012, the CBS TRALI Medical Review Group (TMRG). These cases were classified based on the Canadian Consensus Conference (CCC) definitions and detailed in a database. Two additional reviewers further categorized them as occurring within 72 h from the onset of surgery (perioperative) or not in that period (non-perioperative). Various demographic and characteristic variables of each case were collected and compared between groups. Results: Between 2001 and 2012, a total of 469 suspected TRALI cases were reported to Canadian Blood Services; 303 were determined to be within the TRALI diagnosis spectrum. Of those, 112 (38%) were identified as occurring during the perioperative period. Patients who underwent cardiac surgery requiring cardiopulmonary bypass (25.0%), general surgery (18.0%) and orthopedics patients (12.5%) represented the three largest surgical groups. Perioperative TRALI cases comprised more men (53.6% vs. 41.4%, p = 0.04) than non-perioperative patients. Perioperative TRALI patients more often required supplemental O2 (14.3% vs. 3.1%, p = 0.0003), mechanical ventilation (18.8% vs. 3.1%), or were in the ICU (14.3% vs. 3.7%, p = 0.0043) prior to the onset of TRALI compared to non-perioperative TRALI patients. The surgical patients were transfused on average more components than non-perioperative patients (6.0 [SD = 8.3] vs. 3.6 [5.2] products per patient, p = 0.0002). Perioperative TRALI patients were transfused more plasma (152 vs. 105, p = 0.013) and cryoprecipitate (51 vs. 23, p < 0.01) than non-perioperative TRALI patients. There was no difference between donor antibody test results between the groups. Conclusion: CBS data has provided insight into the nature of TRALI cases that occur perioperatively; this  group represents a large proportion of TRALI cases.

 

Transfusion-related acute lung injury: a clinical review

Alexander P J Vlaar, Nicole P Juffermans
Lancet 2013; 382: 984–94
http://dx.doi.org/10.1016/S0140-6736(12)62197-7

Three decades ago, transfusion-related acute lung injury (TRALI) was considered a rare complication of transfusion medicine. Nowadays, the US Food and Drug Administration acknowledge the syndrome as the leading cause of transfusion-related mortality. Understanding of the pathogenesis of TRALI has resulted in the design of preventive strategies from a blood-bank perspective. A major breakthrough in efforts to reduce the incidence of TRALI has been to exclude female donors of products with high plasma volume, resulting in a decrease of roughly two-thirds in incidence. However, this strategy has not completely eradicated the complication. In the past few years, research has identified patient-related risk factors for the onset of TRALI, which have empowered physicians to take an individualized approach to patients who need transfusion.

Development of an international consensus definition has aided TRALI research, yielding a higher incidence in specific patient populations than previously acknowledged Patients suffering from a clinical disorder such as sepsis are increasingly recognized as being at risk for development of TRALI. Thereby, from a diagnosis by exclusion, TRALI has become the leading cause of transfusion-related mortality. However, the syndrome is still under diagnosed and under-reported in some countries.

Although blood transfusion can be life-saving, it can also be a life-threatening intervention. Physicians use blood transfusion on a daily basis. Increased awareness of the risks of this procedure is needed, because management of patient-tailored transfusion could reduce the risk of TRALI. Such an individualized approach is now possible as insight into TRALI risk factors evolves. Furthermore, proper reporting of TRALI could prevent recurrence.

Absence of an international definition for TRALI previously contributed to underdiagnosis. As such, a consensus panel, and the US National Heart, Lung and Blood Institute Working Group in 2004, formulated a case definition of TRALI based on clinical and radiological parameters. The definition is derived from the widely used definition of acute lung injury (panel 1). Suspected TRALI is defined as fulfilment of the definition of acute lung injury within 6 h of transfusion in the absence of another risk factor (panel 1).

Although this definition seems to be straightforward, the characteristics of TRALI are indistinguishable from acute lung injury due to other causes, such as sepsis or lung contusion. Therefore, this definition would rule out the possibility of diagnosing TRALI in a patient with an underlying risk factor for acute lung injury who has also received a transfusion. To identify such cases, the term possible TRALI was developed.

Although the TRALI definition is an international consensus definition, surveillance systems in some countries, including the USA, France and the Netherlands, use an alternative in which imputability is scored. Imputability aims to identify the likelihood that transfusion is the causal factor. Imputability scores mostly imply that other causes of acute lung injury can be ruled out, so that diagnosis of TRALI is by exclusion. However, observational and animal studies suggest that risk factors for TRALI include other disorders, such as sepsis. Therefore, an imputability definition would result in underdiagnosis of TRALI. The consensus definition accommodates the uncertainty of the association of acute lung injury to the transfusion in possible TRALI. The conventional definition of TRALI uses a timeframe of 6 h in which acute lung injury needs to develop after a blood transfusion. In critically ill patients, transfusion increases the risk (odds ratio 2·13, 95% CI 1·75–2·52) for development of acute lung injury 6–72 h after transfusion.  However, whether the pathogenesis of delayed TRALI is similar to that of TRALI is unclear.

A two-hit hypothesis has been proposed for TRALI. The first hit is underlying patient factors, resulting in adherence of primed neutrophils to the pulmonary endothelium. The second hit is caused by mediators in the blood transfusion that activate the endothelial cells and pulmonary neutrophils, resulting in capillary leakage and subsequent pulmonary edema. The second hit can be antibody-mediated or non-antibody-mediated.

Panel 1: Definition of transfusion-related acute lung injury (TRALI)

Suspected TRALI

  • Acute onset within 6 h of blood transfusion
    • PaO2/FIO2<300 mm Hg, or worsening of P to F ratio
    • Bilateral infi ltrative changes on chest radiograph
    • No sign of hydrostatic pulmonary oedema (pulmonary arterial occlusion
    pressure ≤18 mm Hg or central venous pressure ≤15 mm Hg)
    • No other risk factor for acute lung injury

Possible TRALI
Same as for suspected TRALI, but another risk factor present for acute lung injury

Delayed TRALI
Same as for (possible) TRALI and onset within 6–72 h of blood transfusion

Pathophysiology of two-hit mediated transfusion-related acute lung injury (TRALI).  The pre-phase of the syndrome consists of a fi rst hit, which is mainly systemic. This first hit is the underlying disorder of the patient (eg, sepsis or pneumonia) causing neutrophil attraction to the capillary of the lung. Neutrophils are attracted to the lung by release of cytokines and chemokines from upregulated lung endothelium. Loose binding by L-selectin takes place. Firm adhesion is mediated by E-selectin and platelet-derived P-selectin and intracellular adhesion molecules (ICAM-1). In the acute phase of the syndrome, a second hit caused by mediators in the blood transfusion takes place. This hit results in activation of inflammation and coagulation in the pulmonary compartment. Neutrophils adhere to the injured capillary endothelium and marginate through the interstitium into the air space, which is filled with protein-rich edema fluid. In the air space, cytokines interleukin-1, -6, and -8, (IL-1, IL-6, and IL-8, respectively) are secreted, which act locally to stimulate chemotaxis and activate neutrophils resulting in formation of the elastase-α1-antitrypsin (EA) complex. Neutrophils can release oxidants, proteases, and other proinflammatory molecules, such as platelet-activating factor (PAF), and form neutrophil extracellular traps (NETs). Furthermore, activation of the coagulation system happens, shown by an increase in thrombin-antithrombin complexes (TATc), as does a decrease in activity of the fibrinolysis system, shown by a reduction in plasminogen activator activity. The influx of protein-rich edema fluid into the alveolus leads to the inactivation of surfactant, which contributes to the clinical picture of acute respiratory distress in the onset of TRALI. PAI-1 = plasminogen activator inhibitor-1.

Antibody-mediated TRALI is caused by passive transfusion of HLA or human neutrophil antigen (HNA) and corresponding antibodies from the donor directed against antigens of the recipient. Neutrophil activation occurs directly by binding of the antibody to the neutrophil surface (HNA antibodies) or indirectly, mainly by binding to the endothelial cells with activation of the neutrophil (HLA class I antibodies) or to monocytes with subsequent activation of the neutrophil (HLA class II antibodies). The antibody titer and the volume of antibody containing plasma both increase the risk for onset of TRALI. Although the role of donor HLA and HNA antibodies from transfused blood is widely accepted, not all TRALI cases are antibody mediated. In many patients, antibodies cannot be detected. Furthermore, many blood products containing antibodies do not lead to TRALI. This finding has led to development of an alternative hypothesis for the onset of TRALI, termed non-antibody-mediated TRALI.

Non-antibody-mediated TRALI is caused by accumulation of proinflammatory mediators during storage of blood products, and possibly by ageing of the erythrocytes and platelets themselves. Although most preclinical studies have noted a positive correlation between storage time of cell-containing blood products and TRALI, the mechanism is controversial. Two mechanisms have been suggested, including either plasma or the aged cells. In a small-case study and animal experiments, accumulation of bioactive lipids and soluble CD40 ligand (sCD40L) in the plasma layer of cell-containing blood products has been associated with TRALI. Bioactive lipids are thought to cause neutrophil activation through the G-protein coupled receptor on the neutrophil.

The two-hit model suggests that patients in a poor clinical state are at risk for development of TRALI. However, cases have been described of antibody-mediated TRALI developing in fairly healthy recipients. To explain this discrepancy, a threshold model has been suggested in which a threshold must be overcome to induce a TRALI reaction. The threshold is dependent both on the predisposition of the patient (first hit) and the quantity of antibodies in the transfusion (second hit). A large quantity of antibody that matches the recipient’s antigen can cause severe TRALI in a recipient with no predisposition.

Threshold model of antibody-mediated transfusion-related acute lung injury (TRALI). A specific threshold must be overcome to induce a TRALI reaction. To overcome a threshold, several factors act together: the activation status of the pulmonary neutrophils at the time of transfusion, the strength of the neutrophil-priming activity of transfused mediators (A), and the clinical status of the patient (B).

Panel 2: Clinical characteristics of transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO)

TRALI
• Dyspnea
• Fever
• Usually hypotension
• Hypoxia
• Leukopenia
• Thrombocytopenia
• Pulmonary edema on chest x-ray
• Normal left ventricular function*
• Normal pulmonary artery occlusion pressure

TACO
• Dyspnea
• Usually hypertension
• Hypoxia
• Pulmonary edema on chest radiographs
• Normal or decreased left ventricular function
• Increased pulmonary artery occlusion pressure
• Raised brain natriuretic peptide

Restrictive transfusion policy

The most effective prevention is a restrictive transfusion strategy. In a randomised clinical trial in critically ill patients, a restrictive transfusion policy for red blood cells was associated with a decrease in incidence of acute lung injury compared with a liberal strategy (7·7% vs 11·4%), suggesting that some of these patients might have had TRALI. The restrictive threshold was well tolerated and has greatly helped in guidance of red blood cell transfusion in the intensive-care unit.

Patient-tailored transfusion policy

Transfusion cannot be avoided altogether. A multivariate analysis in patients in intensive care showed that patient related risk factors contributed more to the onset of TRALI than did transfusion-related risk factors, suggesting that development of a TRALI reaction is dependent more on host factors then on factors in the blood product. Therefore, a patient-tailored approach aimed at reducing TRALI risk factors could be effective to alleviate the risk of TRALI.

Despite limitations of diagnostic tests, TRALI incidence seems to be high in at-risk patient populations. Therefore, TRALI is an underestimated health-care problem. Preventive measures, such as mainly male donor strategies, have been successful in reducing risk of TRALI. Identification of risk factors further improves the risk–benefit assessment of a blood transfusion. Efforts to further decrease the risk of TRALI needs increased awareness of this syndrome among physicians.

 

Transfusion-related acute lung injury: Current understanding and preventive strategies

A.P.J. Vlaar
Transfusion Clinique et Biologique 19 (2012) 117–124
http://dx.doi.org/10.1016/j.tracli.2012.03.001

Transfusion-related acute lung injury (TRALI) is the most serious complication of transfusion medicine. TRALI is defined as the onset of acute hypoxia within 6 hours of a blood transfusion in the absence of hydrostatic pulmonary edema. The past decades have resulted in a better understanding of the pathogenesis of this potentially life-threating syndrome. The present notion is that the onset of TRALI follows a threshold model in which both patient and transfusion factors are essential. The transfusion factors can be divided into immune and non-immune mediated TRALI. Immune-mediated TRALI is caused by the passive transfer of human neutrophil antibodies (HNA) or human leukocyte antibodies (HLA) present in the blood product reacting with a matching antigen in the recipient. Non-immune mediated TRALI is caused by the transfusion of stored cell-containing blood products. Although the mechanisms behind immune-mediated TRALI are reasonably well understood, this is not the case for non-immune mediated TRALI. The increased understanding of pathways involved in the onset of immune-mediated TRALI has led to the design of preventive strategies. Preventive strategies are aimed at reducing the risk to exposure of HLA and HNA to the recipient of the transfusion. These strategies include exclusion of “at risk” donors and pooling of high plasma volume products and have shown to reduce the TRALI incidence effectively.

Studies show that, in at risk patient populations, up to 8% of transfused patients may develop TRALI. Since the syndrome TRALI has been recognized, evidence on the pathogenesis of TRALI has been accumulating. The present notion is that the onset of TRALI follows a threshold model in which both patient and transfusion factors are essential in the development of TRALI. The transfusion factors can be divided into immune and non-immune mediated TRALI. Immune-mediated TRALI is caused by the passive transfer of human neutrophil antibodies (HNA) or human leukocyte antibodies (HLA) present in the blood product, reacting with a matching antigen in the recipient. Non-immune mediated TRALI is caused by the transfusion of stored cell-containing blood products. In recent years, many countries have successfully implemented preventive strategies resulting in a decrease of the incidence of TRALI.

Definition of transfusion-related acute lung injury (TRALI).

  • Acute onset within 6 hours after a blood transfusion
  • PaO2/FiO2 < 300 mmHg
  • Bilateral infiltrative changes on the chest X-ray
  • No sign of hydrostatic pulmonary edema (PAOP < 18 mmHg or CVP < 15 mmHg)
  • No other risk factor for acute lung injury present

Possible TRALI

  • Other risk factor for acute lung injury present

PAOP: pulmonary arterial occlusion pressure; CVP: central venous pressure

The first landmark report creating the basis for the understanding of the pathogenesis of TRALI was published by Popovsky et al. in 1983. They provided evidence on the association between the presence of leucocyte antibodies in the donor serum and onset of acute lung injury in the recipient of the transfusion. It was also recognized that multiparous blood donors whose plasma contained these antibodies represented a potential transfusion hazard. It was this research group that was the first to identify TRALI as a distinct clinical entity. Subsequently, many other authors reported on the association between the presence of HLA or HNA antibodies in donor blood and the onset of TRALI in the recipient.

Although the role of transfused blood donor HLA and HNA antibodies was widely accepted to be involved in the onset of TRALI, not all cases could be explained by this theory. A significant part of reported TRALI cases have no detectable antibodies. Also, many antibody-containing blood products fail to produce TRALI.

The alternative hypothesis proposed by the group of Silliman posed that TRALI is a “two hit” event. The “first hit” is the underlying condition of the patient, resulting in priming of the pulmonary neutrophil. The “second hit” is the transfusion of a blood product causing activation of the neutrophils in the pulmonary compartment, causing pulmonary edema finally resulting in TRALI. The transfusion factors causing the “second hit” are divided in two groups; immune and non-immune mediated TRALI.

The “second hit” is the transfusion itself and is either immune or non-immune mediated TRALI. The mechanisms behind immune-mediated TRALI are widely accepted and proven in both pre-clinical and clinical studies.  The mechanisms involved in non-immune mediated TRALI are less clear.

The role of stored cell-containing blood products in the onset of non-immune TRALI has extensively been studied in preclinical and clinical studies. Although most of the pre-clinical studies find a positive correlation between the transfusion of stored cell-containing blood products in the presence of a “first hit” and the onset of TRALI, the mechanism behind the onset is controversial.

TRALI management consists mainly of preventing future adverse reactions and providing proper incidence estimates. All suspected TRALI cases should be reported to the blood bank for immunologic work-up as it is impossible to distinguish immune-mediated TRALI from non-immune mediated TRALI at bedside. Immunologic work-up includes testing of incompatibility by cross-matching donor plasma against recipient’s leucocytes. A donor with antibodies which are incompatible with the patient is excluded from further donation of blood for transfusion products. Furthermore, it is important to stress that the absence of a positive serologic work-up does not exclude the diagnosis of TRALI. TRALI is a clinical diagnosis and the immunologic work-up can be supportive but is not part of the diagnosis of TRALI. the two-event hypothesis and threshold hypothesis do not exclude the role of antibodies in the occurrence of TRALI in the presence of an inflammatory condition. Thus any patient fulfilling the TRALI definition (including possible TRALI) should be reported to the blood bank for an immunologic work-up of the recipient and the implicated donors on the presence of HLA and HNA antibodies.

Prevention of immune-mediated TRALI is achieved by exclusion of donors proven to have HLA or HNA antibodies in their plasma present or donors “at risk” to have these antibodies present.

  1. Exclusion of HLA or HNA positive donors
  2. Exclusion of donors “at risk” of being HLA or HNA positive
    Female donors – more specifically, multiparous donors
  3. Testing donors for HLA or HNA antibodies
  4. Multiple plasma pooling
    solvent/detergent plasma is produced from multiple donations, leading to an at least 500-fold dilution of a single plasma unit;
    neither HNA nor HLA antibodies are detectable in solvent/detergent fresh frozen plasma.
  5. To prevent non-immune mediated TRALI, the use of fresh blood only has been suggested

Strategies to prevent the onset of TRALI include the exclusion of female plasma donors and the pooling of plasma products. These strategies have already been implemented in some countries resulting in a reduction of the incidence of TRALI.
Transfusion-related immunomodulation (TRIM): An update

Eleftherios C. Vamvakas, Morris A. Blajchman
Blood Reviews (2007) 21, 327–348
http://dx.doi.org:/10.1016/j.blre.2007.07.003

Allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) encompasses the laboratory immune aberrations that occur after ABT and their established or purported clinical effects. TRIM is a real biologic phenomenon resulting in at least one established beneficial clinical effect in humans, but the existence of deleterious clinical TRIM effects has not yet been confirmed. Initially, TRIM encompassed effects attributable to ABT by immunomodulatory mechanisms (e.g., cancer recurrence, postoperative infection, or virus activation). More recently, TRIM has also included effects attributable to ABT by pro-inflammatory mechanisms (e.g., multiple-organ failure or mortality). TRIM effects may be mediated by: (1) allogeneic mononuclear cells; (2) white-blood-cell (WBC)-derived soluble mediators; and/or (3) soluble HLA peptides circulating in allogeneic plasma. This review categorizes the available randomized controlled trials based on the inference(s) that they permit about possible mediator(s) of TRIM, and examines the strength of the evidence available for relying on WBC reduction or autologous transfusion to prevent TRIM effects.

Allogeneic blood transfusion (ABT) may either cause alloimmunization or induce tolerance in recipients. ABTs introduce a multitude of foreign antigens into the recipient, including HLA-DR antigens found on the donor’s dendritic antigen presenting cells (APCs). The presence or absence of recipient HLA-DR antigens on the donor’s white blood cells (WBCs) plays a decisive role as to whether alloimmunization or immune suppression will ensue following ABT. In general, allogeneic transfusions sharing at least one HLA-DR antigen with the recipient induce tolerance, while fully HLA-DR-mismatched transfusions lead to alloimmunization.

In addition to the degree of HLA-DR compatibility between donor and recipient, the immunogenicity of cellular or soluble HLA antigens associated with transfused blood components depends on the viability of the donor dendritic APCs and the presence of co-stimulatory signals for the presentation of the donor antigens to the recipient’s T cells. Nonviable APCs and/or the absence of the requisite co-stimulatory signals result in T-cell unreponsiveness.  Thus, when a multitude of antigens is introduced into the host by an ABT, the host response to some of these antigens is often decreased, and immune tolerance ensues. ABT has been shown to cause decreased helper T-cell count, decreased helper/suppressor T-lymphocyte ratio, decreased lymphocyte response to mitogens, decreased natural killer (NK) cell function, reduction in delayed-type hypersensitivity, defective antigen presentation, suppression of lymphocyte blastogenesis, decreased cytokine (IL-2, interferon-c) production, decreased monocyte/macrophage phagocytic function, and increased production of antiidiotypic and anticlonotypic antibodies.

All these laboratory immune aberrations that indicate immune suppression and occur in transfused patients could potentially be associated with clinically-manifest ABT effects. Thus a variety of beneficial or deleterious clinical effects, potentially attributable to ABT-related immunosuppression, have been described over the last 30 years. The constellation of all such ABT-associated laboratory and clinical findings is known as ABT-related immunomodulation (TRIM). Initially, TRIM encompassed effects attributable to ABT by means of immunologic mechanisms only; however more recently, the term has been used more broadly, to encompass additional effects that could be related to ABT by means of ‘‘proinflammatory’’ rather than ‘‘immunomodulatory’’ mechanisms.

Over 30 years ago, it was reported that pre-transplant ABTs could improve renal-allograft survival in patients who had undergone renal transplantation.  This beneficial immunosuppressive effect of ABT has been confirmed by animal data, observational clinical studies, and clinical experience worldwide, although it has not been proven in randomized controlled trials (RCTs). Before the advent of the AIDS pandemic, it had become standard policy in many renal units to deliberately expose patients on transplant waiting lists to one or more red blood cell (RBC) transfusions.

All the available data considered together indicate that TRIM is most likely a real biologic phenomenon, which results in at least one established beneficial clinical effect in humans, although the available evidence has not yet confirmed  the existence and/or magnitude of the deleterious clinical TRIM effects. In fact, the debate over the existence of such deleterious clinical TRIM effects has been long and sometimes acrimonious.

Many studies tended to indicate that patients receiving perioperative transfusion (compared with those not needing transfusion) almost always had a higher risk of developing postoperative bacterial infection. The studies also indicated that patients receiving ABT differed from those not receiving a transfusion in several prognostic factors that predisposed to adverse clinical outcomes.

The specific constituent(s) of allogeneic blood that mediate(s) either or both the immunomodulatory and the pro-inflammatory effect(s) of ABT remain
(s) unknown, and the published literature suggests that these TRIM effects
may be mediated by: (1) allogeneic mononuclear cells; (2) soluble biologic response modifiers released in a time dependent manner from WBC granules or membranes into the supernatant fluid of RBC or platelet concentrates
during storage; and/or  (3) soluble HLA class I peptides that circulate in allogeneic plasma. If each of these mediators do cause TRIM effects, ABT effects mediated by allogeneic mononuclear cells would be expected to be preventable by WBC reduction (performed either before or after storage of cellular blood components), as well as by autologous transfusion. The ABT effects mediated by soluble HLA peptides circulating in allogeneic plasma would be expected to be preventable only by autologous transfusion.

BENEFICIAL TRIM EFFECTS

  1. Enhanced survival of renal allografts
  2. Reduced recurrence rate of Crohn’s disease

DELETERIOUS

  1. Increased recurrence rate of resected malignancies
  2. Increased incidence of postoperative bacterial infections
  3. Activation of endogenous CMV or HIV infection
  4. Increased short-term (up to 3-month) mortality

Possible mechanisms and mediators of TRIM effects

Although the mechanisms of TRIM have been debated extensively, the exact mechanism(s) of this phenomenon has yet to be elucidated. A number of putative mechanisms have been postulated. The three major mechanisms accounting for much of the experimental data include:

  • clonal deletion,
  • induction of anergy, and
  • immune suppression.

Conceptually, clonal deletion refers to the inactivation and removal of alloreactive lymphocytes that would, for example, cause the rejection of an allograft; anergy implies immunologic nonresponsiveness; and immune suppression suggests that the responding cell is being inhibited of doing so by a cellular mechanism or by a cytokine. Antiidiotypic antibodies, which are predominantly of the VH6 gene family, have also been demonstrated in the sera of ABT recipients and in patients with long-term functioning renal allografts.

To date, no RCT has enrolled patients with sarcomas—tumors whose growth is stimulated by TGF-β—or patients with tumors for which the immune response plays a major role. (These would include skin tumors—such as melanomas, keratoacanthomas, squamous and basal-cell carcinomas—and certain virus-induced tumors—notably Kaposi’s sarcoma and certain lymphomas.) Instead, the 3 available RCTs of ABT and cancer recurrence enrolled patients with colorectal cancer—a tumor that is not sufficiently antigenic to render an impairment of host immunity capable of facilitating tumor growth, and a tumor whose cells have not been shown to be stimulated by TGF-β.

Fig not shown. Randomized controlled trials (RCTs) investigating the association of WBC-containing allogeneic blood transfusion (ABT) with cancer recurrence. For each RCT, the figure shows the odds ratio (OR) of cancer recurrence in recipients of non-WBC-reduced allogeneic versus autologous or WBC-reduced allogeneic RBCs, as calculated from an intention-to-treat analysis. A deleterious effect of ABT (and thus a benefit from autologous transfusion or WBC reduction) exists when the OR is greater than 1 as well as statistically significant. (In the figure, each OR is surrounded by its 95% confidence interval [CI]; if the 95% CI of the OR includes the null value of 1, the TRIM effect is not statistically significant [p > 0.05]).

Fig not shown. Randomized controlled trials (RCTs) investigating the association of WBC-containing allogeneic blood transfusions with postoperative infection (n = 17). For each RCT, the figure shows the odds ratio (OR) of postoperative infection in recipients of non-WBC reduced allogeneic versus autologous or WBC-reduced allogeneic RBCs, as calculated from an intention-to-treat analysis. A deleterious effect of ABT (and thus a benefit from autologous transfusion or WBC reduction) exists when the OR is greater than 1 as well as statistically significant. (In the figure, each OR is surrounded by its 95% confidence interval [CI]; if the 95% CI of the OR includes the null value of 1, the TRIM effect is not statistically significant [p > 0.05]).

The totality of the evidence from RCTs does not demonstrate a TRIM effect manifest across all clinical settings and transfused RBC products. Instead, WBC-containing ABT is associated with an increased risk of short-term (up to 3-month post transfusion) mortality from all causes combined specifically in cardiac surgery. The additional deleterious TRIM effect detected by the latest meta-analysis (i.e., the effect on postoperative infection prevented by poststorage filtration) contradicts current theories about the pathogenesis of TRIM, because it is not accompanied by a similar or larger effect prevented by prestorage filtration.

Thus, only in cardiac surgery (Fig. 5 – not shown) are the findings of RCTs pertaining to a deleterious TRIM effect consistent. Even in this setting, however, the reasons for the excess deaths attributed to WBC containing ABT remain elusive. The initial hypothesis suggested that WBC-containing ABT may predispose to MOF which, in turn, may predispose to mortality. However, hitherto, no cardiac-surgery RCT has demonstrated an association between WBC-containing ABT and MOF, and no other cause of death specifically attributed to WBC-containing ABT has been proposed.

The TRIM effect seen in cardiac surgery deserves further study to pinpoint the cause(s) of the excess deaths, but-now that the majority of transfusions in Western Europe and North America are WBC reduced- the undertaking of further RCTs comparing recipients of non-WBC-reduced versus WBC reduced allogeneic RBCs in cardiac surgery is unlikely. For countries that have not yet converted to universal WBC reduction, whether to opt for WBC reduction of all cellular blood components transfused in cardiac surgery-in the absence of information on the specific cause(s) of death ascribed to WBC-containing ABT-is a policy decision that will have to be made based on the hitherto available data.

 

Regulation of alveolar fluid clearance and ENaC expression in lung by exogenous angiotensin II

Jia Denga, Dao-xin Wanga, Wang Deng, Chang-yi Li, Jin Tong, Hilary Ma
Respiratory Physiology & Neurobiology 181 (2012) 53– 61
http://dx.doi.org:/10.1016/j.resp.2011.11.009

Angiotensin II (Ang II) has been demonstrated as a pro-inflammatory effect in acute lung injury, but studies of the effect of Ang II on the formation of pulmonary edema and alveolar filling remains unclear. Therefore, in this study the regulation of alveolar fluid clearance (AFC) and the expression of epithelial sodium channel (ENaC) by exogenous Ang II was verified. SD rats were anesthetized and were given Ang II with increasing doses (1, 10 and 100 [1]g/kg per min) via osmotic minipumps, whereas control rats received only saline vehicle. AT1 receptor antagonist ZD7155 (10 mg/kg) and inhibitor of cAMP degeneration rolipram (1 mg/kg) were injected intraperitoneally 30 min before administration of Ang II. The lungs were isolated for measurement of alveolar fluid clearance. The mRNA and protein expression of ENaC were detected by RT-PCR and Western blot. Exposure to higher doses of Ang II reduced AFC in a dose-dependent manner and resulted in a non-coordinate regulation of α-ENaC vs the regulation of β- and ϒ-ENaC, however Ang II type 1 (AT1) receptor antagonist ZD7155 prevented the Ang II-induced inhibition of fluid clearance and dysregulation of ENaC expression. In addition, exposure to inhibitor of cAMP degradation rolipram blunted the Ang II-induced inhibition of fluid clearance. These results indicate that through activation of AT1 receptor, exogenous Ang II promotes pulmonary edema and alveolar filling by inhibition of alveolar fluid clearance via downregulation of cAMP level and dysregulation of ENaC expression.

Effects of angiotensin II (Ang II) receptor antagonists and rolipram  on AFC

Effects of angiotensin II (Ang II) receptor antagonists and rolipram on AFC

Effects of angiotensin II (Ang II) receptor antagonists and rolipram on rat alveolar fluid clearance (AFC). Then AFC was measured 1 h after fluid instillation (4 mL/kg). Amiloride (100 [1]M), Ang II (10−7 M), ZD7155 (10−6 M), and rolipram (10−5 M) were added to the instillate as indicated (n = 10 per group). Mean values ± SEM. p < 0.01 vs control. p < 0.01 vs Ang II + ZD7155.
p < 0.05 vs amiloride. p < 0.05 vs Ang II.

Effects of angiotensin II (Ang II) on cyclic adenosine monophosphate (cAMP)

Effects of angiotensin II (Ang II) on cyclic adenosine monophosphate (cAMP)

Effects of angiotensin II (Ang II) on cyclic adenosine monophosphate (cAMP) concentration in lung. Rats were given saline or Ang II (1, 10 and 100 µg/kg per min) for 6 h, and cAMP in lung was determined by RIA (n = 30 per group). Mean values ± SEM. p < 0.01 vs control. p < 0.05 vs 10 µg/kg Ang II.

Histological examination of lung

Histological examination of lung

Histological examination of lung. Rats were given saline or Ang II (10 µg/kg per min) by osmotic minipump for 6 h. ZD7155 (10 mg/kg) was injected intraperitoneally 30 min before administration of Ang II. Shown are representative lung specimens obtained from the control (A), Ang II (B) and Ang II + ZD7155 (C) groups. All photographs are at 100× magnification. Interstitial edema and inflammatory cell infiltration were seen in Ang II group, but reduced in Ang II + ZD7155 group.
The present results demonstrate that Ang II infusion is associated with pulmonary edema and alveolar filling. Three important findings were observed:

(1) high doses of Ang II led to reduction of alveolar fluid clearance, and this effect was blunted by an AT1 receptor antagonist.
(2) Ang II infusion increased the abundance of α-ENaC, whereas decreased the abundance ofβ and ϒ-ENaC, and these effects were reversed in response to an AT1 receptor antagonist.
(3) Ang II infusion decreased cAMP concentration in lung tissue, and an inhibitor of cAMP degradation prevented inhibition of alveolar fluid clearance by Ang II, but had no effect on the dysregulation of ENaC.

Our data indicate that Ang II results in pulmonary edema by inhibition of alveolar fluid clearance via down-regulation of cellular cAMP level and dysregulation of the abundance of ENaC, whereas these effects are prevented by an AT1 receptor antagonist.

The renin-angiotensin system is a major regulator of body fluid and sodium balance, predominantly through the actions of its main effector Ang II. Several previous experimental studies demonstrated that plasma Ang II levels vary in both physiological and pathological conditions. In the kidney, Ang II added to the peritubular perfusion has a biphasic action with stimulation of sodium reabsorption at low doses (10−12–10−10M) and inhibition at high doses (10−7–10−6M) (Harris and Young, 1977). In vitro, Ang II also exerts a dose-dependent dual action on intestinal absorption (Levens, 1985). The evidence shows that the effect of Ang II on sodium and water absorption is dose-dependent. Our results showed that low intravenous doses of Ang II (<1 µg/kg per min) had no effect on alveolar fluid clearance which represents the sodium and water reabsorption in alveoli. However, with high intravenous doses, Ang II decreased alveolar fluid clearance. This finding suggests that the effect of Ang II on fluid absorption in lung is also dose-dependent.

 

Rat models of acute lung injury: Exhaled nitric oxide as a sensitive,noninvasive real-time biomarker of prognosis and efficacy of intervention

Fangfang Liu, Wenli Lib, Jürgen Pauluhn, Hubert Trübel, Chen Wang
Toxicology 310 (2013) 104– 114
http://dx.doi.org/10.1016/j.tox.2013.05.016

Exhaled nitric oxide (eNO) has received increased attention in clinical settings because this technique is easy to use with instant readout. However, despite the simplicity of eNO in humans, this endpoint has not frequently been used in experimental rat models of septic (endotoxemia) or irritant acute lung injury (ALI). The focus of this study is to adapt this method to rats for studying ALI-related lung disease and whether it can serve as instant, non-invasive biomarker of ALI to study lung toxicity and pharmacological efficacy. Measurements were made in a dynamic flow of sheath air containing the exhaled breath from spontaneously breathing, conscious rats placed into a head-out volume plethysmograph. The quantity of eNO in exhaled breath was adjusted (normalized) to the physiological variables (breathing frequency, concentration of exhaled carbon dioxide) mirroring pulmonary perfusion and ventilation. eNO was examined on the instillation/inhalation exposure day and first post-exposure day in Wistar rats intratracheally instilled with lipopolysaccharide (LPS) or single inhalation exposure to chlorine or phosgene gas. eNO was also examined in a Brown Norway rat asthma model using the asthmagen toluene diisocyanate (TDI). The diagnostic sensitivity of adjusted eNO was superior to the measurements not accounting forthe normalization of physiological variables. In all bioassays – whether septic, airway or alveolar irritant or allergic, the adjusted eNO was significantly increased when compared to the concurrent control. The maximum increase of the adjusted eNO occurred following exposure to the airway irritant chlorine. The specificity of adjustment was experimentally verified by decreased eNO following inhalation dosing ofthe non-selective nitric oxide synthase inhibitor amoni-guanidine. In summary, the diagnostic sensitivity of eNO can readily be applied to spontaneously breathing, conscious rats without any intervention or anesthesia. Measurements are definitely improved by accounting for the disease-related changes inexhaled CO2and breathing frequency. Accordingly, adjusted eNO appears to be a promising methodological improvement for utilizing eNO in inhalation toxicology and pharmacological disease models
with fewer animals.

 

Role of p38 MAP Kinase in the Development of Acute Lung Injury

J Arcaroli, Ho-Kee Yum, J Kupfner, JS Park, Kuang-Yao Yang, and E Abraham
Clinical Immunology 2001; 101(2):211–219
http://dx.doi.org:/10.1006/clim.2001.5108

Acute lung injury (ALI) is characterized by an intense pulmonary inflammatory response, in which neutrophils play a central role. The p38 mitogen-activated protein kinase pathway is involved in the regulation of stress-induced cellular functions and appears to be important in modulating neutrophil activation, particularly in response to endotoxin. Although p38 has potent effects on neutrophil functions under in vitro conditions, there is relatively little information concerning the role of p38 in affecting neutrophil driven inflammatory responses in vivo. To examine this issue, we treated mice with the p38 inhibitor SB203580 and then examined parameters of neutrophil activation and acute lung injury after hemorrhage or endotoxemia. Although p38 was activated in lung neutrophils after hemorrhage or endotoxemia, inhibition of p38 did not decrease neutrophil accumulation in the lungs or the development of lung edema under these conditions. Similarly, the increased production of proinflammatory cytokines and activation of NF-kB in lung neutrophils induced by hemorrhage or endotoxemia was not diminished by p38 inhibition. These results indicate that p38 does not have a central role
in the development of ALI after either hemorrhage or endotoxemia.

 

The coagulation system and pulmonary endothelial function in acute lung injury

James H. Finigan
Microvascular Research 77 (2009) 35–38
http://dx.doi.org:/10.1016/j.mvr.2008.09.002

Acute lung injury (ALI) is a disease marked by diffuse endothelial injury and increased capillary permeability. The coagulation system is a major participant in ALI and activation of coagulation is both a consequence and contributor to ongoing lung injury. Increased coagulation and depressed fibrinolysis result in diffuse alveolar fibrin deposition which serves to amplify pulmonary inflammation. In addition, existing evidence demonstrates a direct role for different components of coagulation on vascular endothelial barrier function. In particular, the pro-coagulant protein thrombin disrupts the endothelial actin cytoskeleton resulting in increased endothelial leak. In contrast, the anti-coagulant activated protein C (APC) confers a barrier protective actin configuration and enhances the vascular barrier in vitro and in vivo. However, recent studies suggest a complex landscape with receptor cross-talk, temporal heterogeneity and pro-coagulant/anticoagulant protein interactions. In this article, the major signaling pathways governing endothelial permeability in lung injury are reviewed with a particular focus on the role that endothelial proteins, such as thrombin and APC, which play on the vascular barrier function.

Acute lung injury (ALI) is a devastating illness with an annual incidence of approximately 200,000 and a mortality of 40%. Most commonly seen in the setting of sepsis, ALI is a complex inflammatory syndrome marked by increased vascular permeability resulting in tissue edema and organ dysfunction. The vascular endothelium is a key target and critical participant in the pathogenesis of sepsis-induced organ dysfunction and disruption of the endothelial barrier is central to the pathophysiology of both sepsis and ALI. Sepsis and acute lung injury (ALI) are syndromes marked by diffuse inflammation with a key feature being endothelial cell barrier disruption and increased vascular permeability resulting in widespread organ dysfunction. The endothelial cytoskeleton has been identified as a critical regulator of vascular barrier integrity with a current model of endothelial barrier regulation suggesting a balance between barrier-disrupting cellular contractile forces and barrier-protective cell–cell and cell–matrix forces. These competing forces exert their opposing effects via manipulation of the actin-based endothelial cytoskeleton and associated endothelial regulatory proteins. Endothelial cells generate tension via an actomyosin motor, and focally distributed changes in tension/relaxation can be accomplished by spatially-defined regulation of the phosphorylation of the regulatory 20 kDa myosin light chain (MLC) catalyzed by the Ca2+/calmodulin (CaM)-dependent enzyme myosin light chain kinase (MLCK).

Thrombin is the proto-typical coagulation protein with direct effects on the endothelial barrier via alterations in the cytoskeleton. In the coagulation cascade, thrombin converts fibrinogen to fibrin in the final step of thrombus formation and also activated platelets. In addition, this multifunctional protease is present at sites of vascular inflammation and induces barrier dysfunction. Through its receptor, protease-activated receptor-1 (PAR1), thrombin initiates a series of events which includes MLC phosphorylation, dramatic cytoskeletal reorganization and stress fiber formation, increased cellular contractility, paracellular gap formation, and enhanced fluid and protein transport. Similarly, thrombin exposure results in increased pulmonary edema in vivo, a finding which is also seen after treatment with a PAR1 activating peptide and attenuated in PAR1 knockout mice.

Disruptions in the coagulation system have long been recognized to be an integral part of inflammation, sepsis and ALI. In 1969, Saldeen demonstrated that thrombin infusion produced canine respiratory insufficiency which was linked pathologically to emboli in the pulmonary microcirculation, a condition he labeled the “Microembolism Syndrome” (Saldeen, 1979). Elemental to the pathophysiology of sepsis and ALI is a shift towards a pro-coagulant state. Bronchoalveolar (BAL) fluid from patients with ALI reflects this increase in procoagulant activity with elevated levels of fibrinopeptide A, factor VII and d-dimer. Concomitantly, there is a decrease in fibrinolytic activity, as shown by depressed BAL levels of urokinase and increased levels of the fibrinolysis inhibitors plasminogen activator inhibitor (PAI) and α2-antiplasmin.

Given that APC is a vascular endothelial protein which interacts with other coagulation proteins such as thrombin, it seems logical that it might have an effect on endothelial integrity. In cultured human pulmonary endothelial cells, while thrombin results in decreased electrical resistance, a reflection of increased permeability, pre- or post-exposure to physiologic concentrations of APC significantly attenuates this thrombin-induced drop in resistance. These APC-mediated alterations in barrier function are associated with MLC phosphorylation as well as activation of the endothelial protein Rac, and cytoskeletal re-arrangement in a barrier protective configuration all findings very reminiscent of the barrier protective signaling induced by the bioactive lipid, S1P. Interestingly, APC appears to activate sphingosine kinase and mediate its barrier protective effects through PI3 kinase and AKT-dependent ligation of the S1P receptor, S1P1. Moreover, the endothelial barrier-protective effects of APC have been observed in other tissues including brain and kidney. The barrier protection in these beds appears independent of any anti-coagulant effect of APC and is associated with decreased endothelial apoptosis.

Recently, the endothelial protein C receptor (EPCR) has been identified as a crucial participant in the protein C pathway. Structurally similar to the major histocompatibility class I/CD1 family of molecules, EPCR binds protein C, presenting it to the thrombin/TM complex, thereby increasing the activation of protein C by ∼20 fold. Importantly, APC can also bind EPCR, and while the bound form of APC loses its extra-cellular anti-coagulant activity, increasing evidence indicates that much, if not all, of APC intra-cellular signaling requires EPCR. APC-mediated increases in endothelial phosphor-MLC and activated Rac are all EPCR-dependent and APC-induced endothelial barrier protection requires ligation of EPCR.

Sepsis and ALI are significant causes of morbidity and mortality in the intensive care unit and are marked by zealous activation of the coagulation system. While this could conceivably confer certain benefits, such as enclosing and spatially controlling an infection, it is clear that this pro-coagulant environment participates in the pathophysiology of ALI, particularly via exacerbating endothelial damage and augmenting endothelial permeability. However, the biology of coagulation in ALI is incompletely understood and trials of new therapies specifically targeting coagulation in patients with ALI have been disappointing. Despite this, recent advances in the knowledge of the dynamic interplay between inflammation and coagulation in ALI as well as endothelial receptor-ligand binding and receptor cross talk have stimulated promising research and identified novel therapeutic targets for patients with ALI.

 

Phosphatidylserine-expressing cell by-products in transfusion: A pro-inflammatory or an anti-inflammatory effect?

  1. Saas, F. Angelot, L. Bardiaux, E. Seilles, F. Garnache-Ottou, S. Perruche
    Transfusion Clinique et Biologique 19 (2012) 90–97
    http://dx.doi.org/10.1016/j.tracli.2012.02.002

Labile blood products contain phosphatidylserine-expressing cell dusts, including apoptotic cells and microparticles. These cell by-products are produced during blood product process or storage and derived from the cells of interest that exert a therapeutic effect (red blood cells or platelets). Alternatively, phosphatidylserine-expressing cell dusts may also derived from contaminating cells, such as leukocytes, or may be already present in plasma, such as platelet-derived microparticles. These cell by-products present in labile blood products can be responsible for transfusion induced immunomodulation leading to either transfusion-related acute lung injury (TRALI) or increased occurrence of post-transfusion infections or cancer relapse. In this review, we report data from the literature and our laboratory dealing with interactions between antigen-presenting cells and phosphatidylserine-expressing cell dusts, including apoptotic leukocytes and blood cell-derived microparticles. Then, we discuss how these phosphatidylserine-expressing cell by-products may influence transfusion.

Potential consequences of phosphatidylserine-expressing cell by-products in transfusion

Potential consequences of phosphatidylserine-expressing cell by-products in transfusion

Potential consequences of phosphatidylserine-expressing cell by-products in transfusion. Interactions of phosphatidylserine-expressing cell dusts (apoptotic cells or microparticles) may lead to antigen-presenting cell activation or inhibition. Antigen-presenting cell activation may trigger inflammation and be involved in transfusion-related acute lung injury (TRALI), while antigen-presenting cell inhibition may exert transient immunosuppression or tolerance. Blood product process or storage may influence the generation of phosphatidylserine-expressing cell dusts. PtdSer: phosphatidylserine; APC: antigen-presenting cell.

Several publications report the presence of phosphatidylserine-expressing cell by-products in blood products. These cell by-products may be generated during the blood product process, such as filtration, or during storage (either cold storage for red blood cells or between 20–24 ◦C for platelets). Alternatively, they may be limited by filtration. Phosphatidylserine-expressing cell by-products can be apoptotic cells. Apoptotic cells have been found in different blood products: red blood cell units and platelet concentrates. These apoptotic cells correspond to dying cells of interest: red blood cells or platelets, both enucleated cells that can undergo apoptosis.

Immunomodulatory effects of apoptotic leukocytes

Immunomodulatory effects of apoptotic leukocytes

Immunomodulatory effects of apoptotic leukocytes. Early during the apoptotic program, phosphatidylserine-exposure occurs leading to apoptotic cell removal by macrophages or conventional dendritic cells. This uptake by antigen-presenting cells induces the production of anti-inflammatory factors and concomitantly inhibits the synthesis of inflammatory cytokines. These antigen-presenting cells are refractory to TLR activation. This leads to a transient immunosuppressive microenvironment. If antigen-presenting cells from this microenvironment migrate to secondary lymphoid organs, naive T cells are converted into inducible regulatory T cells. This leads to tolerance against apoptotic cell-derived antigens. M[1]: macrophage; cDC: conventional dendritic cells; PtdSer: phosphatidylserine; Treg: regulatory T cells; Th1: helper T cells; HGF: hepatocyte growth factor; IL-: interleukin; NO: nitrite oxide; PGE-2: prostaglandin-E2; TGF: transforming growth factor; TNF: tumor necrosis factor; TLR: Toll-like receptor.

Implication of phosphatidylserine in the inhibition of both inflammation and specific immune responses has been further demonstrated using  phosphatidylserine-expressing liposomes and is sustained by the following observations:

  • phosphatidylserine-dependent ingestion of apoptotic cells induces TGF-β secretion and resolution of lung inflammation;
  • inhibition of phosphatidylserine recognition through annexin-V enhances the immunogenicity of irradiated tumor cells in vivo;
  • masking of phosphatidylserine inhibits apoptotic cell engulfment and induces autoantibody production in mice.

Based on data from our group and Peter Henson’s group, some authors have speculated that apoptotic leukocytes present in blood products may be responsible for transfusion-related immunosuppression.

The first consequences of phosphatidylserine-expressing apoptotic cells in blood products may be a transient immunosuppression−responsible for an increase in infection rate and of cancer relapse−or tolerance induction− as observed after donor-specific transfusion − when Treg have been generated. However, apoptotic leukocytes become secondarily necrotic in the absence of phagocytes. This may certainly occur in blood product bags. Necrotic cells, through the release of damage-associated molecular patterns, may become immunogenic. The same process may occur for platelets. Necrotic platelets may represent the procoagulant form of platelets. Thus, hemostatic activation of platelets or their by-products may link thrombosis and inflammation to amplify lung microvascular damage during nonimmune TRALI.

What are the next steps to answer the question on the role of phosphatidylserine-expressing cell dusts in the modulation of immune responses after transfusion?

The next steps are to characterize or identify factors involved in the triggering of inflammation or its inhibition and produced during blood product storage or process. Several factors influence the immune responses against dying cells. We can speculate on some factors, including:

  • the number of phosphatidylserine-expressing cell byproducts contained per blood product, as the immunogenicity of apoptotic cells may be proportional to their number;
  • the occurrence of secondary necrosis and so the passive release of intracellular damage-associated molecular patterns that overpasses the inhibitory signals delivered by phosphatidylserine. One of these damage associated molecular patterns can be the heme released from stored red blood cells which signals via TLR4;
  • the size of cell by-products and especially microparticles, since these latter exert different functions according to their size. Moreover, antigen-presenting cells, such as plasmacytoid dendritic cells, respond only to lower size synthetic particles. This may explain the different responses observed between “amateur” phagocytes (plasmacytoid dendritic cells) versus professional phagocytes (conventional dendritic cells/macrophages) after incubation with microparticles. The size of cell by-products diminishes during plasma filtration, as assessed by dynamic light scattering from 101 to 464 nm in unfiltered fresh-frozen plasma versus 21 to 182 nm after 0.2 µm filtration process;
  • expression of the recently described phosphatidylserine receptors on different antigen-presenting cell subsets may also explain the different responses between plasmacytoid dendritic cells versus conventional dendritic cells/macrophages and may impact on the overall immune response.

 

Peroxisome proliferator-activated receptors and inflammation

Leonardo A. Moraes, Laura Piqueras, David Bishop-Bailey
Pharmacology & Therapeutics 110 (2006) 371 – 385
http://dx.doi.org:/10.1016/j.pharmthera.2005.08.007

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptors family. PPARs are a family of 3 ligand-activated transcription factors: PPARa (NR1C1), PPARh/y (NUC1; NR1C2), and PPARg (NR1C3). PPARα, -h/y, and -ϒ are encoded by different genes but show substantial amino acid similarity, especially within the DNA and ligand binding domains. All PPARs act as heterodimers with the 9-cis-retinoic acid receptors (retinoid X receptor; RXRs) and play important roles in the regulation of metabolic pathways, including those of lipid of biosynthesis and glucose metabolism, as well as in a variety of cell differentiation, proliferation, and apoptosis pathways. Recently, there has been a great deal of interest in the involvement of PPARs in inflammatory processes. PPAR ligands, in particular those of PPARα and PPARϒ, inhibit the activation of inflammatory gene expression and can negatively interfere with proinflammatory transcription factor signaling pathways in vascular and inflammatory cells. Furthermore, PPAR levels are differentially regulated in a variety of inflammatory disorders in man, where ligands appear to be promising new therapies.

Fig. not shown.  Structure and transcriptional activation of PPARs. (A) Generic schematic of the structure of the PPAR family of nuclear receptors. Indicated are the N–C terminal regions subdivided in to 4 domains: the A/B, N terminal domain [also called the activation function (AF)-1 domain]; C, the DNA binding domain; D, the F hinge_region; and E, the ligand binding domain (AF-2). (B) Generic scheme for the activation of a PPAR receptor as a transcription factor. PPAR activation leads to heterodimerization with RXR and an accumulation in the nucleus. Ligand activation of PPAR results in a change from a repressed binding protein complex which may contain histone deacetylases (HDAC), the nuclear receptor corepressor (NCo-R), and the silencing mediator of retinoid and thyroid signaling (SMRT) to an activation complex that may contain the histone acetylases, steroid receptor co-activator-1 (SRC-1), the PPAR binding protein (PBP), cAMP response element binding protein (CBP/p300), TATA box binding proteins, and RNA polymerase (RNA pol) III. The activated PPAR–RXR heterodimer complex binds to DNA sequences called PPAR response elements (PPRE) in target genes initiation their transcription.

Although the nature of true endogenous PPAR ligands are still not known (Bishop-Bailey & Wray, 2003), PPARs can be activated by a wide variety of F endogenous or pharmacological ligands. PPARα activators include a variety of endogenously present fatty acids, LTB4 and hydroxyeicosatetraenoic acids (HETEs), and clinically used drugs, such as the fibrates, a class of first-line drugs in the treatment of dyslipidemia. Similarly, PPARg can be activated by a number of ligands, including docosahexaenoic acid, linoleic acid, the anti-diabetic glitazones, used as insulin sensitizers, and a number of lipids, including oxidized LDL, azoyle-PAF, and eicosanoids, such as 5,8,11,14-eicosatetraynoic acid and the prostanoids PGA1, PGA2, PGD2, and its dehydration products of the PGJ series of cyclopentanones (e.g., 15 deoxy-D12,14-PGJ2). Dyslipidemia and insulin-dependent diabetes are commonly found existing together as part of the metabolic X syndrome.

Because PPARa and PPARg ligands independently are useful clinical drugs in the treatment of these respective disorders, synthetic dual PPARα/ϒ ligands have recently been developed and show a combined clinical efficacy. PPAR h/y activators include fatty acids and prostacyclin and synthetic compounds L-165,041, GW501516, compound F and L-783,483. Unlike PPARα or-ϒ, there are no PPAR h/y drugs in the clinic, although ligands are in phase II clinical trials for dyslipidemia (http://www.science.gsk.com/pipeline). Indeed, part of the challenge in determining the function of PPARh/y has been the identification and availability of new ligands with more potency and selectivity for use as pharmacological tools.

Fig. not shown. Mechanisms of the anti-inflammatory effects of PPARα. PPARα ligands inhibit the activities of NF-nB, AP-1, and T-bet within cells. In sites of local inflammation, tissue and endothelial cell activity is inhibited, and expressions of adhesion molecules (ICAM-1 and VCAM-1), pro-inflammatory cytokines (IL-1, -6, -8, -12, and TNFα), vasoactive mediators (inducible cyclo-oxygenase, inducible nitric oxide synthase, and endothelin-1; COX-2, iNOS, and ET-1), and proteases (MMP-9) are decreased. The inflammatory responses in leukocytes are also diminished. Monocyte/macrophage activity is decreased, and lipid metabolizing pathways increased, T- and B-lymphocyte proliferation and differentiation are inhibited, and T-lymphocyte and eosinophil chemotaxis reduced. Bold italic text indicates positive regulation by the PPAR, all other text indicates a negative regulation.

Fig. not shown. Mechanisms of the anti-inflammatory effects of PPAR h/y. PPAR h/y ligands inhibit the activities of NF-nB and release the suppressor BCL-6 from PPAR h/y. In sites of local inflammation, endothelial cell adhesion molecule (VCAM-1) and chemokine (MCP-1) are reduced. PPAR h/y and its endogenous ligand(s) are induced during the inflammatory response in keratinocytes, which then promotes cell survival (integrin-linked kinase—Akt pathway) and wound healing. The inflammatory responses in monocyte/ macrophages are modulated. In the absence of ligand, PPAR h/y sequesters BCL-6 and induces MCP-1, MCP-3, and IL-1h. When PPAR h/y ligand is given, BCL-6 is released and MCP-1, -3, and IL-1h levels are reduced. Bold italic text indicates positive regulation by the PPAR, all other text indicates a negative regulation.

Fig. not shown. Mechanisms of the anti-inflammatory effects of PPARg. PPARg ligands can inhibit the activities of NF-nB, AP-1, STAT-1, N-FAT, Erg-1, Jun, and GATA-3 within cells. In sites of local inflammation, tissue and endothelial cell activity is inhibited, and expression of adhesion molecules (ICAM-1), proinflammatory cytokines (IL-8, -12, and TNFα), chemokines (MCP-1, MCP-3, IP-10, Mig, and I-TAC), vasoactive mediators (inducible nitric oxide synthase and endothelin-1; iNOS and ET-1), and proteases (MMP-9) are decreased. The inflammatory responses in leukocytes are also diminished. Monocyte/ macrophage activity is decreased, T- and B-lymphocyte proliferation and differentiation are inhibited, and T-lymphocyte and eosinophil chemotaxis reduced. Platelet activity is inhibited and dendritic cell production of IL-12, and expression of CCL3, CCL5, and CD80 is reduced, so pro-inflammatory TH1 lymphocytes maturation is inhibited. Bold italic text indicates positive regulation by the PPAR, all other text indicates a negative regulation.

The PPARs are one of the most intensely studied members of the nuclear receptor gene family, and since their initial discovery just over decade ago, the PPARs have attracted an increasing amount of experimental and clinical research by investigators from different scientific areas. PPARs through their central roles in regulating energy homeostasis regulate physiological function in many cell types, tissues, and organ systems. Many disease states from carcinogenesis to inflammation have been linked to abnormalities in the function of PPAR-regulated transcription factors. PPARs are expressed or regulate pathophysiology of diverse human disorders including atherosclerosis, inflammation, obesity, diabetes, and the immune response. PPARs have beneficial effects in many inflammatory conditions, where they regulate cytokine production, adhesion molecule expression, fibrinolysis cell proliferation, apoptosis, and differentiation. Further studies and development of novel PPAR ligands and their selective modulators may lead to novel therapeutic agents in the many conditions associated with inflammatory processes.

 

Regulators of endothelial and epithelial barrier integrity and function in acute lung injury

Rudolf Lucas, Alexander D. Verin, Stephen M. Black, John D. Catravas
Biochemical Pharmacology 77 (2009) 1763–1772
http://dx.doi.org:/10.1016/j.bcp.2009.01.014

Pulmonary permeability edema is a major complication of acute lung injury (ALI), severe pneumonia and ARDS. This pathology can be accompanied by

(1) a reduction of alveolar liquid clearance capacity, caused by an inhibition of the expression of crucial sodium transporters, such as the epithelial sodium channel (ENaC) and the Na+-K+-ATPase,
(2) an epithelial and endothelial hyperpermeability and
(3) a disruption of the epithelial and endothelial barriers, caused by increased apoptosis or necrosis.

Since, apart from ventilation strategies, no standard treatment exists for permeability edema, the following chapters will review a selection of novel approaches aiming to improve these parameters in the capillary endothelium and the alveolar epithelium.

Apoptosis is an essential physiological process for the selective elimination of cells. However, the dysregulation of apoptotic pathways is thought to play an important role in the pathogenesis of ALI. Both delayed neutrophil apoptosis and enhanced endothelial/epithelial cell apoptosis have been identified in ALI/ARDS. In the case of neutrophils, which contribute significantly to ALI/ ARDS, studies in both animals and ARDS patients suggest that apoptosis is inhibited during the early stages (<2 h) of inflammation.

Peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors belonging to the nuclear hormone receptor superfamily, that includes receptors for steroid hormones, thyroid hormones, retinoic acid, and fat-soluble vitamins. Since their discovery in 1990, increasing data has been published on the role of PPARs in diverse processes, including lipid and glucose metabolism, diabetes and obesity, atherosclerosis, cellular proliferation and differentiation, neurological diseases, inflammation and immunity. PPARs have both gene-dependent and gene-independent effects. Gene-dependent functions involve the formation of heterodimers with the retinoid X-receptor. Activation by PPAR ligands results in the binding of the heterodimer to peroxisome proliferator response elements, located in the promoter regions of PPAR-regulated genes. Gene independent effects involve the direct binding of PPARs to transcription factors, such as NF-kB, which then alters their binding to DNA promoter elements. PPARs can also bind and sequester various cofactors for transcription factors, and thus further alter gene expression. Importantly, the precise effects of PPARs vary greatly between cell types. To date, three subtypes of PPAR have been identified: α, β, and ϒ. There is increasing data suggesting that PPAR signaling may play an important role in the pathobiology of systemic vascular disease. However, there is less data implicating PPAR signaling in diseases of the lung.

A role for PPARs in the control of inflammation was first evidenced for PPARα, where mice deficient in PPARα exhibited an increased duration of ear-swelling in response to the proinflammatory mediator, LTB4. More recently, a number of studies in mice and in humans have shown that PPAR agonists exhibit anti-inflammatory effects under a wide range of conditions. There are two main mechanisms by which PPARs exert their anti-inflammatory effect. The first involves complex formation, and the inhibition of transcription factors that positively regulate the transcription of pro-inflammatory genes. These include nuclear factor-kB (NF-kB), signal transducers and activators of transcription (STATs), nuclear factor of activated T cells (NF-AT), CAAT/enhancer binding protein (C/EBP) and activator protein 1 (AP-1). These transcription factors are the main mediators of the major proinflammatory cytokines, chemokines, and adhesion molecules involved in inflammation. The second PPAR-mediated anti-inflammatory pathway is mediated by the sequestration of rate limiting, but essential, co-activators or co-repressors.

Recent studies have shown that PPAR signaling can attenuate the airway inflammation induced by LPS in the mouse. It was shown that mice treated with the PPARα agonist, fenofibrate, had decreases in both inflammatory cell infiltration and inflammatory mediators. Conversely, PPARα -/- mice have been shown to have a greater number of neutrophils and macrophages, and increased levels of inflammatory mediators in bronchoalveolar lavage fluids (BALF). Other PPAR agonists, such as rosiglitazone or SB 21994 have also been shown to reduce LPS-mediated ALI in the mouse lung. PPARϒ signaling has also been shown to be protective in regulating pulmonary inflammation associated with fluorescein isothiocyanate (FITC)-induced lung injury, with the PPARϒ ligand pioglitazone decreasing neutrophil infiltration. Collectively, these data suggest that therapeutic agents that activate either or both PPARα and PPARϒ could be beneficial for the treatment of ALI.

Permeability edema is characterized by a reduced alveolar liquid clearance capacity, combined with an endothelial hyperpermeability. Various signaling pathways, such as those involving reactive oxygen species (ROS), Rho GTPases and tyrosine phosphorylation of junctional proteins, converge to regulate junctional permeability, either by affecting the stability of junctional proteins or by modulating their interactions. The regulation of junctional permeability is mainly mediated by dynamic interactions between the proteins of the adherens junctions and the actin cytoskeleton. Actin-mediated endothelial cell contraction is the result of myosin light chain (MLC) phosphorylation by MLC kinase (MLCK) in a Ca2+/calmodulin-dependent manner. RhoA additionally potentiates MLC phosphorylation, by inhibiting MLC phosphatase activity through its downstream effector Rho kinase (ROCK). As such, actin/myosin-driven contraction will generate a contractile force that pulls VE-cadherin inward. This contraction will force VE-cadherin to dissociate from its adjacent partner, as such producing interendothelial gaps.

Vascular endothelial cells can be regulated by nucleotides released from platelets. During vascular injury, broken cells are also the source of the extracellular nucleotides. Furthermore, endothelium may provide a local source of ATP within vascular beds. Primary cultures of human endothelial cells derived from multiple blood vessels release ATP constitutively and exclusively across the apical membrane under basal conditions. Hypotonic challenge or the calcium agonists (ionomycin and thapsigargin) stimulate ATP release in a reversible and regulated manner. Enhanced release of pharmacologically relevant amounts of ATP was observed in endothelial cells under such stimuli as shear stress, lipopolysaccharide (LPS), and ATP itself. Pearson and Gordon demonstrated that incubation of aortic endothelial and smooth muscle cells with thrombin resulted in the specific release of ATP, which was converted to ADP by vascular hydrolases. Yang et al. showed that endothelial cells isolated from guinea pig heart release nucleotides in response to bradykinin, acetylcholine, serotonin and ADP. Nucleotide action is mediated by cell surface purinoreceptors. Once released from endothelial cells, ATP may act in the blood vessel lumen at P2 receptors on nearby endothelium downstream from the site of release. ATP is also degraded rapidly and its metabolites have also been recognized as signaling molecules, which can initiate additional receptor-mediated functions. These include ADP and the final hydrolysis product adenosine.

Signal transduction pathways implicated in ATP-mediated endothelial barrier enhancement

Signal transduction pathways implicated in ATP-mediated endothelial barrier enhancement

Signal transduction pathways implicated in ATP-mediated endothelial barrier enhancement

During the course of ALI, the alveolar space, as well as the interstitium, are sites of intense inflammation, leading to the local production of pro-inflammatory cytokines, such as IL-1β, TGF-β and TNF. The latter pleiotropic cytokine is a 51 kDa homotrimeric protein, binding to two types of receptors, i.e. TNF-R1 and TNF-R2 and which is mainly produced by activated macrophages and T cells. Soluble TNF, as well as the soluble TNF receptors 1 and 2, are generated upon cleavage of membrane TNF or of the membrane associated receptors, respectively, by the enzyme TNF-α convertase (TACE). TNF-R1, but not TNF-R2, contains a death domain, which signals apoptosis upon the formation of the Death Inducing Signaling Complex (DISC). In spite of its lack of a death domain, TNF-R2 can nevertheless be implicated in apoptosis induction, since its activation causes degradation of TNF Receptor Associated Factor 2 (TRAF2), an inhibitor of the TNF-R1-induced DISC formation. Moreover, apoptosis induction of lung microvascular endothelial cells by TNF was shown to require activation of both TNF receptors. TNF-R2 was also shown to be important for ICAM-1 upregulation in endothelial cells in vitro and in vivo, an activity important in the sequestration of leukocytes in the microvessels. Moreover, lung microvascular endothelial cells isolated from ARDS patients express significantly higher levels of TNF-R2 and of ICAM-1 than cells isolated from patients who had undergone a lobectomy for lung carcinoma, used as controls. These findings therefore suggest that ICAM-1 and TNF-R2 may have a particular involvement in the pathogenesis of acute lung injury.

Dichotomous activity of TNF in alveolar liquid clearance and barrier protection

Dichotomous activity of TNF in alveolar liquid clearance and barrier protection

Dichotomous activity of TNF in alveolar liquid clearance and barrier protection during ALI. TNF, which is induced during ALI, causes a downregulation of ENaC expression in type II alveolar epithelial cells, upon activating TNF-R1. Moreover, TNF increases permeability, by means of interfering with tight junctions (TJ) in both alveolar epithelial (AEC) and capillary endothelial cells (MVEC). ROS, the generation of which is frequently increased during ALI, were also shown to downregulate ENaC and Na+-K+-ATPase expression and moreover also lead to decreased endothelial barrier integrity. The TIP peptide, mimicking the lectin-like domain of TNF, is able to increase sodium uptake in alveolar epithelial cells and to restore endothelial barrier integrity, as such providing a significant protection against the development of permeability edema (red lines: inhibition, green arrows: activation).

Proposed mechanism of action for the anti-inflammatory and barrier-protective actions of hsp90 inhibitors.

Proposed mechanism of action for the anti-inflammatory and barrier-protective actions of hsp90 inhibitors.

Proposed mechanism of action for the anti-inflammatory and barrier-protective actions of hsp90 inhibitors.

Permeability edema represents a life-threatening complication of acute lung injury, severe pneumonia and ARDS, characterized by a combined dysregulation of pulmonary epithelial and endothelial apoptosis, endothelial barrier integrity and alveolar liquid clearance capacity. As such, it is likely that several of these parameters have to be targeted in order to obtain a successful therapy. This review focuses on a selection of recently discovered substances and mechanisms that might improve ALI therapy. As such, we have discussed the inhibition of apoptosis and necrosis occurring during ALI, by means of the restoration of Zn2+ homeostasis. PPARα and ϒ agonists can represent therapeutically  promising molecules, since they inhibit transcription factors as well as essential co-activators involved in the activation of pro-inflammatory cytokines, chemokines and adhesion molecules, all of which are implicated in ALI. Apart from inducing a potent inhibition of inflammation upon interfering with NF-kB activation, hsp90 inhibitors were shown to prevent and restore endothelial barrier integrity. These agents are able to significantly improve survival and lung function during LPS-induced ALI. A restoration of endothelial barrier integrity during ALI can also be obtained upon increasing extracellular levels of ATP or adenosine, which activate the purinoreceptors P2Y and P1A2, respectively, leading to a decrease in myosin light chain phosphorylation and an increase in MLC phosphatase 1 activity. The pro-inflammatory cytokine TNF is involved in endothelial apoptosis and hyperpermeability, as well as in the reduction of alveolar liquid clearance, upon activating its receptors. However, apart from its receptor binding sites, TNF harbors a lectin-like domain, which can be mimicked by the TIP peptide. This peptide has been shown to increase alveolar liquid clearance and moreover induces endothelial barrier protection. As such, TNF can be considered as a moonlighting cytokine, combining both positive and negative activities for permeability edema generation within one molecule.

 

The protective effect of CDDO-Me on lipopolysaccharide-induced acute lung injury in mice

Tong Chen, Yi Moua, Jiani Tan, LinlinWei, Yixue Qiao, Tingting Wei, et al.
International Immunopharmacology 25 (2015) 55–64
http://dx.doi.org/10.1016/j.intimp.2015.01.011

ALI is a clinical syndrome characterized by a disruption of epithelial integrity, neutrophil accumulation, noncardiogenic pulmonary edema, severe hypoxemia and an intense pulmonary inflammatory response with a wide array of increasing severity of lung parenchymal injury. Previous studies have shown that lots of pathogenesis contribute to ALI, such as oxidant/antioxidant dysfunction, dysregulation of inflammatory/anti-inflammatory pathway, upregulation of chemokine production and adhesion molecules. However, to date there is no effective medicine to control ALI. Lipopolysaccharide (LPS) is a main component of the outer membrane of Gram negative bacteria. It has been reported to activate toll like receptors 4 (TLR4) and to stimulate the release of inflammatory mediators inducing ALI-like symptoms. Intratracheal administration of LPS has been used to construct animal models of ALI.

The biological importance of naturally occurring triterpenoids has long been recognized. Oleanolic acid, exhibiting modest biological activities, has been marketed in China as an oral drug for the treatment of liver disorders in humans. Among its derivatives, bardoxolonemethyl (2-cyano-3,12-dioxooleana-1,9(11)-dien-28-oic acid methylester) CDDO-Me, had completed a successful phase I clinical trial for the treatment of cancer and started a phase II trial for the treatment of patients with pulmonary arterial hypertension. For its broad spectrum antiproliferative and anti-tumorigenic activities, CDDO-Me has also been reported to possess a number of pharmacological activities such as antioxidant, anti-tumor and anti-inflammatory effects. However, the mechanisms by which CDDO-Me exerted its anti-inflammatory effects on macrophage were insufficiently elucidated. More importantly, there is no available report to evaluate its therapeutic effect on acute lung injury.

CDDO-Me, initiated in a phase II clinical trial, is a potential useful therapeutic agent for cancer and inflammatory dysfunctions, whereas the therapeutic efficacy of CDDO-Me on LPS-induced acute lung injury (ALI) has not been reported as yet. The purpose of the present study was to explore the protective effect of CDDO-Me on LPS-induced ALI in mice and to investigate its possible mechanism. BalB/c mice received CDDO-Me (0.5 mg/kg, 2 mg/kg) or dexamethasone (5 mg/kg) intraperitoneally 1 h before LPS stimulation and were sacrificed 6 h later. W/D ratio, lung MPO activity, number of total cells and neutrophils, pulmonary histopathology, IL-6, IL-1β, and TNF-α in the BALF were assessed. Furthermore, we estimated iNOS, IL-6, IL-1β, and TNF-α mRNA expression and NO production as well as the activation of the three main MAPKs, AkT, IκB-α and p65. Pretreatment with CDDO-Me significantly ameliorated W/D ratio, lung MPO activity, inflammatory cell infiltration, and inflammatory cytokine production in BALF from the in vivo study. Additionally, CDDO-Me had beneficial effects on the intervention for pathogenesis process at molecular, protein and transcriptional levels in vitro. These analytical results provided evidence that CDDO-Me could be a potential therapeutic candidate for treating LPS-induced ALI.

Effects of CDDO-Me on LPS-mediated lung changes

Effects of CDDO-Me on LPS-mediated lung histopathologic changes in lung tissues. (A) The lung section from the control mice; (B) the lung section from the mice administered with LPS (8 mg/kg); (C) the lung section from the mice administered with dexamethasone (5 mg/kg) and LPS (8 mg/kg); (D) the lung section from the mice administered with CDDO-Me (0.5mg/kg) and LPS (8mg/kg); (E) the lung section from the mice administered with CDDO-Me (2mg/kg) and LPS (8mg/kg); (hematoxylin and eosin staining, magnification 200×). Control group: the green arrow indicated alveolar wall, no hyperemia. All the other groups: The black arrow indicated the inflammatory cell infiltration; the green arrow indicated alveolar wall hyperemia.

 

The impact of cardiac dysfunction on acute respiratory distress syndrome and mortality in mechanically ventilated patients with severe sepsis and septic shock: An observational study

Brian M. Fuller, Nicholas M. Mohr, Thomas J. Graetz, et al.
Journal of Critical Care 30 (2015) 65–70
http://dx.doi.org/10.1016/j.jcrc.2014.07.027

Purpose: Acute respiratory distress syndrome (ARDS) is associated with significant mortality and morbidity in survivors. Treatment is only supportive, therefore elucidating modifiable factors that could prevent ARDS could have a profound impact on outcome. The impact that sepsis-associated cardiac dysfunction has on ARDS is not known. Materials and Methods: In this retrospective observational cohort study of mechanically ventilated patients with severe sepsis and septic shock, 122 patients were assessed for the impact of sepsis-associated cardiac dysfunction on incidence of ARDS (primary outcome) and mortality. Results: Sepsis-associated cardiac dysfunction occurred in 44 patients (36.1%). There was no association of sepsis-associated cardiac dysfunction with ARDS incidence (p= 0.59) or mortality, and no association with outcomes in patients that did progress to ARDS after admission. Multivariable logistic regression demonstrated that higher BMI was associated with progression to ARDS (adjusted OR 11.84, 95% CI 1.24 to 113.0, p= 0.02). Conclusions: Cardiac dysfunction in mechanically ventilated patients with sepsis did not impact ARDS incidence, clinical outcome in ARDS patients, or mortality. This contrasts against previous investigations demonstrating an influence of nonpulmonary organ dysfunction on outcome in ARDS. Given the frequency of ARDS as a sequela of sepsis, the impact of cardiac dysfunction on outcome should be further studied.

 

Suppression of NF-κβ pathway by crocetin contributes to attenuation of lipopolysaccharide-induced acute lung injury in mice

Ruhui Yang, Lina Yang, Xiangchun Shen, Wenyuan Cheng, et al.
European Journal of Pharmacology 674 (2012) 391–396
http://dx.doi.org:/10.1016/j.ejphar.2011.08.029

Crocetin, a carotenoid compound, has been shown to reduce expression of inflammation and inhibit the production of reactive oxygen species. In the present study, the effect of crocetin on acute lung injury induced by lipopolysaccharide (LPS) was investigated in vivo. In the mouse model, pretreatment with crocetin at dosages of 50 and 100 mg/kg reduced the LPS-induced lung edema and histological changes, increased LPS-impaired superoxide dismutase (SOD) activity, and decreased lung myeloperoxidase (MPO) activity. Furthermore, treatment with crocetin significantly attenuated LPS-induced mRNA and the protein expressions of interleukin-6 (IL-6), macrophage chemoattractant protein-1 (MCP-1), and tumour necrosis factor-α (TNF-α) in lung tissue. In addition, crocetin at different dosages reduced phospho-IκB expression and NF-κB activity in LPS-induced lung tissue alteration. These results indicate that crocetin can provide protection against LPS-induced acute lung injury in mice.

 

Sauchinone, a lignan from Saururus chinensis, attenuates neutrophil pro-inflammatory activity and acute lung injury

Hui-Jing Han, Mei Li, Jong-Keun Son, Chang-Seob Seo, et al.
International Immunopharmacology 17 (2013) 471–477
http://dx.doi.org/10.1016/j.intimp.2013.07.011

Previous studies have shown that sauchinone modulates the expression of inflammatory mediators through mitogen-activated protein kinase (MAPK) pathways in various cell types. However, little information exists about the effect of sauchinone on neutrophils, which play a crucial role in inflammatory process such as acute lung injury (ALI). We found that sauchinone decreased the phosphorylation of p38 MAPK in lipopolysaccharide (LPS)-stimulated murine bone marrow neutrophils, but not ERK1/2 and JNK. Exposure of LPS-stimulated neutrophils to sauchinone or SB203580, a p38 inhibitor, diminished production of tumor necrosis factor (TNF)-α and macrophage inflammatory protein (MIP)-2 compared to neutrophils cultured with LPS. Treatment with sauchinone decreased the level of phosphorylated ribosomal protein S6 (rpS6) in LPS-stimulated neutrophils. Systemic administration of sauchinone to mice led to reduced levels of phosphorylation of p38 and rpS6 in mice lungs given LPS, decreased TNF-α and MIP-2 production in bronchoalveolar lavage fluid, and also diminished the severity of LPS-induced lung injury, as determined by reduced neutrophil accumulation in the lungs, wet/dry weight ratio, and histological analysis. These results suggest that sauchinone diminishes LPS-induced neutrophil activation and ALI.

In the present study, the systemic administration of sauchinone decreased the phosphorylation of p38 MAPK and rpS6 in mice lungs subjected to LPS and diminished the severity of LPS-induced ALI. Neutrophils play an important role in acute inflammatory processes, such as ALI, which was demonstrated by various experimental models. Previous reports suggested that p38 MAPK inhibition of murine neutrophils could lead to the loss of chemotaxis toward MIP-2, as well as the loss of TNF-αandMIP-2 production in response to LPS, and also attenuated neutrophil accumulation in LPS-induced ALI models. Therefore, the beneficial effects of sauchinone on LPS-induced ALI are likely associated with decreases in the production of pro-inflammatory mediators by neutrophils, consistent with our in vitro experiments. However, we cannot exclude that the effects of sauchinone on reducing the release of TNF-α and MIP-2 in mice lungs subjected to LPS, with the resultant prevention of ALI, could be affected by various pulmonary cell populations, such as alveolar macrophages. Also, the inhibitory effects of sauchinone on NF-κB activation through various pulmonary cell populations (Supplemental Fig. S2), in addition to p38MAPK activity in mouse lungs given LPS, might enhance the anti-inflammatory action of sauchinone in mouse lungs subjected to LPS. In conclusion, we found that sauchinone significantly diminished the release of inflammatory mediators in isolated neutrophils and lungs subjected to LPS. The anti-inflammatory action of sauchinone was associated with the prevention of p38 MAPK and rpS6 activation. These findings suggest that sauchinone may be an appropriate pharmacological candidate for the treatment of ALI as well as other neutrophil driven acute inflammatory diseases.
Supplementary data to this article can be found online at
http://dx.doi.org/10.1016/j.intimp.2013.07.011

 

Protective effect of dexmedetomidine in a rat model of α-naphthylthiourea- induced acute lung injury

Volkan Hancı, Gamze Yurdakan, Serhan Yurtlu, et al.
J Surg Res 178 (2012):424-430
http://dx.doi.org:/10.1016/j.jss.2012.02.027

Background: We assessed the effects of dexmedetomidine in a rat model of a-naphthylthiourea (ANTU)einduced acute lung injury.  Methods: Forty Wistar Albino male rats weighing 200e240 g were divided into 5 groups (n = 8 each), including a control group. Thus, there were one ANTU group and three dexmedetomidine groups (10-, 50-, and 100-mg/kg treatment groups), plus a control group. The control group provided the normal base values. The rats in the ANTU group were given 10 mg/kg of ANTU intraperitoneally and the three treatment groups received 10, 50, or 100 mg/kg of dexmedetomidine intraperitoneally 30 min before ANTU application. The rat body weight (BW), pleural effusion (PE), and lung weight (LW) of each group were measured 4 h after ANTU administration. The histopathologic changes were evaluated using hematoxylin-eosin staining. Results: The mean PE, LW, LW/BW, and PE/BW measurements in the ANTU group were significantly greater than in the control groups and all dexmedeto-midine treatment groups (P < 0.05). There were also significant decreases in the mean PE, LW, LW/BW and PE/BW values in the dexmedetomidine 50-mg/kg group compared with those in the ANTU group (P < 0.01). The inflammation, hemorrhage, and edema scores in the ANTU group were significantly greater than those in the control or dexmedetomidine 50-mg/kg group (P < 0.01). Conclusion: Dexmedetomidine treatment has demonstrated  a potential benefit by preventing ANTU-induced acute lung injury in an experimental rat model. Dexmedetomidine could have a potential protective effect on acute lung injury in intensive care patients.

 

Protective effects of Isofraxidin against lipopolysaccharide-induced acute lung injury in mice

Xiaofeng Niu, YuWang, Weifeng Li, Qingli Mu, et al.
International Immunopharmacology 24 (2015) 432–439
http://dx.doi.org/10.1016/j.intimp.2014.12.041

Acute lung injury (ALI) is a life-threatening disease characterized by serious lung inflammation and increased capillary permeability, which presents a high mortality worldwide. Isofraxidin (IF), a Coumarin compound isolated from the natural medicinal plants such as Sarcandra glabra and Acanthopanax senticosus, has been reported to have definite anti-bacterial, anti-oxidant, and anti-inflammatory activities. However, the effects of IF against lipopoly-saccharide-induced ALI have not been clarified. The aim of the present study is to explore the protective effects and potential mechanism of IF against LPS-induced ALI in mice. In this study, We found that pretreatment with IF significantly lowered LPS-induced mortality and lung wet-to-dry weight (W/D) ratio and reduced the levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and prostaglandin E2 (PGE2) in serum and bronchoalveolar lavage fluid (BALF). We also found that total cells, neutrophils and macrophages in BALF,MPO activity in lung tissues were markedly decreased. Besides, IF obviously inhibited lung histopathological changes and cyclooxygenase-2 (COX-2) protein expression. These results suggest that IF has a protective effect against LPS induced ALI, and the protective effect of IF seems to result from the inhibition of COX-2 protein expression in the lung, which regulates the production of PGE2.

Ingestion of LPS stimulates vascular permeability, promotes inflammatory cytokines such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) from blood into lung tissues and activates numerous inflammatory cells such as neutrophils and macrophages. In macrophages, LPS challenge induces the transcription of gene encoding pro-inflammatory protein, which leads to cytokine release and synthesis of enzymes, such as cyclo-oxygenase-2 (COX-2). COX-2 usually can’t be found in normal tissues, but widely induced by pro-inflammatory stimuli, such as cytokines, endotoxins, and growth factors. COX-2 plays a vital role in the regulation of inflammatory process by modulating the production of prostaglandin E2 (PGE2). PGE2, induced by cytokines and other initiator, is an inflammatory mediator which is produced in the regulation of COX-2. Previous researches demonstrated that inhibition of COX-2 produced a dramatically anti-inflammatory effect with little gastrointestinal toxicity. Therefore, inhibition of COX-2 protein expression has far-reaching significance in the treatment of ALI.

effects of IF on LPS-induced mortality in ALI mice

effects of IF on LPS-induced mortality in ALI mice

The effects of IF on LPS-induced mortality in ALI mice (n = 12/group). IF (5, 10, 15 mg/kg, i.p.) or DEX (5 mg/kg, i.p.) were given to mice 1 h prior to LPS challenge. The mortalities were observed at 0, 12, 24, 36, 48, 60, and 72 h. ###P = 0.001 when compared with the control group; *P = 0.05, **P = 0.01, and ***P = 0.001 when compared with the LPS group.

 

Protective effects of intranasal curcumin on paraquot induced acute lung injury (ALI) in mice

Namitosh Tyagi, Asha Kumaria, D. Dash, Rashmi Singh
Environment  Toxicol  & Pharmacol  38 (2014) 913–921
http://dx.doi.org/10.1016/j.etap.2014.10.003

Paraquot (PQ) is widely and commonly used as herbicide and has been reported to be hazardous as it causes lung injury. However, molecular mechanism underlying lung toxicity caused by PQ has not been elucidated. Curcumin, a known anti-inflammatory molecule derived from rhizomes of Curcuma longa has variety of pharmacological activities including free-radical scavenging properties but the protective effects of curcumin on PQ-induced acute lung injury (ALI) have not been studied. In this study, we aimed to study the effects of curcumin on ALI caused by PQ in male parke’s strain mice which were challenged acutely byPQ (50 mg/kg, i.p.) with or without curcumin an hour before (5 mg/kg, i.n.) PQ intoxication. Lung specimens and the bronchoalveolar lavage fluid (BALF) were isolated for pathological and biochemical analysis after 48 h of PQ exposure. Curcumin administration has significantly enhanced superoxide dismutase (SOD) and catalase activities. Lung wet/dry weight ratio, malondialdehyde (MDA) and lactate dehydrogenase (LDH) content, total cell number and myeloperoxidase (MPO) levels in BALF as well as neutrophil infiltration were attenuated by curcumin. Pathological studies also revealed that intranasal curcumin alleviate PQ-induced pulmonary damage and pro-inflammatory cytokine levels like tumor necrosis factor-α (TNF-α) and nitric oxide (NO). These results suggest that intranasal curcumin may directly target lungs and curcumin inhalers may prove to be effective in PQ-induced ALI treatment in near future.

 

Phillyrin attenuates LPS-induced pulmonary inflammation via suppression of MAPK and NF-κB activation in acute lung injury mice

Wei-ting Zhong, Yi-chun Wu, Xian-xing Xie, Xuan Zhou, et al.
Fitoterapia 90 (2013) 132–139
http://dx.doi.org/10.1016/j.fitote.2013.06.003

Phillyrin (Phil) is one of the main chemical constituents of Forsythia suspensa (Thunb.), which has shown to be an important traditional Chinese medicine. We tested the hypothesis that Phil modulates pulmonary inflammation in an ALI model induced by LPS. Male BALB/c mice were pretreated with or without Phil before respiratory administration with LPS, and pretreated with dexamethasone as a control. Cytokine release (TNF-α, IL-1β, and IL-6) and amounts of inflammatory cell in bronchoalveolar lavage fluid (BALF) were detected by ELISA and cell counting separately. Pathologic changes, including neutrophil infiltration, interstitial edema, hemorrhage, hyaline membrane formation, necrosis, and congestion during acute lung injury in mice were evaluated via pathological section with HE staining. To further investigate the mechanism of Phil anti-inflammatory effects, activation of MAPK and NF-κB pathways was tested by western blot assay. Phil pretreatment significantly attenuated LPS-induced pulmonary histopathologic changes, alveolar hemorrhage, and neutrophil infiltration. The lung wet-to-dry weight ratios, as the index of pulmonary edema, were markedly decreased by Phil retreatment. In addition, Phil decreased the production of the proinflammatory cytokines including (TNF-α, IL-1β, and IL-6) and the concentration of myeloperoxidase (MPO) in lung tissues. Phil pretreatment also significantly suppressed LPS-induced activation of MAPK and NF-κB pathways in lung tissues. Taken together, the results suggest that Phil may have a protective effect on LPS-induced ALI, and it potentially contributes to the suppression of the activation of MAPK and NF-κB pathways. Phil may be a new preventive agent of ALI in the clinical setting.

A mass of studies have been reported basically on alleviating LPS-induced acute lung injury in models. Phillyrin (Fig. 1), a lignin, is one of the main chemical constituents of Forsythia suspensa (Thunb.), which is an important traditional Chinese medicine (“Lianqiao” in Chinese), and has long been used for gonorrhea, erysipelas, inflammation, pyrexia and ulcer. Previous studies indicated that Phil significantly inhibited NO production in LPS-activated macrophage cells. But there is not much evidence showing the anti-inflammatory properties of phillyrin. In the present study, we sought to investigate the effects of phillyrin on LPS-induced pulmonary inflammation in mice.

Fig. not shown. A: Effects of Phil on histopathological changes in lung tissues in LPS-induced ALI mice. Mice were given an intragastric administration of Phil (10 and 20 mg/kg) or Dex (5 mg/kg) 1 h prior to an intranasal administration of LPS. Then mice were anesthetized and lung tissue samples were collected at 6 h after LPS challenge for histological evaluation. These representative histological changes of the lung were obtained from mice of different groups (hematoxylin and eosin staining, original magnification 200×, Scale bar: 50 μm). B: Effects of Phil on LPS-induced lung morphology. The slides were histopathologically evaluated using a semi-quantitative scoring method. Lung injury was graded from 0 (normal) to 4 (severe) in four categories: congestion, edema, interstitial inflammation and inflammatory cell infiltration. The total lung injury score was calculated by adding up the individual scores of each category. The values presented are the means ± S.E.M. (n = 4–6 in each group). ##P b 0.01 vs. the control group, **P b 0.01 vs. the LPS group. Cont: control group; LPS: LPS group; Phil + LPS: Phil + LPS group; Dex + LPS: Dex + LPS group.

In summary, the present study indicated that Phil has a protective effect on LPS-induced acute lung injury. Phil significantly attenuated histopathological changes initiated by LPS via reducing over inflammatory responses. We also demonstrated that MAPK and NF-κB signaling pathways are the important targets of Phil to perform its actions. Phil acts by preventing NF-κB translocation to the nucleus or inhibiting the activation of MAPKs directly or indirectly, which is to be investigated in further studies. All these results suggest that Phil may be a new therapeutic agent for the prevention of inflammation during acute lung injury.

 

 

 

 

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Oracle Industry Connect Presents Their 2015 Life Sciences and Healthcare Program

Posted in HealthCare IT, Personal Health Applications: Tech Innovations serves HealhCare, Personalized and Precision Medicine & Genomic Research, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Scientific & Biotech Conferences: Press Coverage, Venture Capital, tagged Aviva Lev-Ari, Big data, Bioinformatics, Clinical trial, cloud, Conditions and Diseases, curated database, Curation methodology, Data management, genomics, Health informatics, Health Information Technology, healthcare IT, innovation in health, innovation in healthcare, medicine, oracle healthcare, Personalized medicine, research, science, Venture capital on February 19, 2015| Leave a Comment »

  • Oracle Industry Connect Presents Their 2015 Life Sciences and Healthcare Program

 

Reporter: Stephen J. Williams, Ph.D. and Aviva Lev-Ari, Ph.D., R.N.

oraclehealthcare

Copyright photo Oracle Inc. (TM)

 

Transforming Clinical Research and Clinical Care with Data-Driven Intelligence

March 25-26 Washington, DC

For more information click on the following LINK:

https://www.oracle.com/oracleindustryconnect/life-sciences-healthcare.html

oracle-healthcare-solutions-br-1526409

https://www.oracle.com/industries/health-sciences/index.html  

Oracle Health Sciences: Life Sciences & HealthCare — the Solutions for Big Data

Healthcare and life sciences organizations are facing unprecedented challenges to improve drug development and efficacy while driving toward more targeted and personalized drugs, devices, therapies, and care. Organizations are facing an urgent need to meet the unique demands of patients, regulators, and payers, necessitating a move toward a more patient-centric, value-driven, and personalized healthcare ecosystem.

Meeting these challenges requires redesigning clinical R&D processes, drug therapies, and care delivery through innovative software solutions, IT systems, data analysis, and bench-to-bedside knowledge. The core mission is to improve the health, well-being, and lives of people globally by:

  • Optimizing clinical research and development, speeding time to market, reducing costs, and mitigating risk
  • Accelerating efficiency by using business analytics, costing, and performance management technologies

 

  • Establishing a global infrastructure for collaborative clinical discovery and care delivery models
  • Scaling innovations with world-class, transformative technology solutions
  • Harnessing the power of big data to improve patient experience and outcomes

The Oracle Industry Connect health sciences program features 15 sessions showcasing innovation and transformation of clinical R&D, value-based healthcare, and personalized medicine.

The health sciences program is an invitation-only event for senior-level life sciences and healthcare business and IT executives.

Complete your registration and book your hotel reservation prior to February 27, 2015 in order to secure the Oracle discounted hotel rate.

Learn more about Oracle Healthcare.

General Welcome and Joint Program Agenda

Wednesday, March 25

10:30 a.m.–12:00 p.m.

Oracle Industry Connect Opening Keynote

Mark Hurd, Chief Executive Officer, Oracle

Bob Weiler, Executive Vice President, Global Business Units, Oracle

Warren Berger, Author of “A More Beautiful Question: The Power of Inquiry to Spark Breakthrough Ideas.”

12:00 p.m.–1:45 p.m.

Networking Lunch

1:45 p.m.–2:45 p.m.

Oracle Industry Connect Keynote

Bob Weiler, Executive Vice President, Global Business Units, Oracle

2:45 p.m.–3:45 p.m.

Networking Break

3:45 p.m.–5:45 p.m.

Life Sciences and Healthcare General Session

Robert Robbins, President, Chief Executive Officer, Texas Medical Center

Steve Rosenberg, Senior Vice President and General Manager Health Sciences Global Business Unit, Oracle

7:00 p.m.–10:00 p.m.

Life Sciences and Healthcare Networking Reception

National Museum of American History
14th Street and Constitution Avenue, NW
Washington DC 20001

Life Sciences Agenda

Thursday, March 26

7:00 a.m.–8:00 a.m.

Networking Breakfast

8:00 a.m.–9:15 a.m.

Digital Trials and Research Models of the Future 

Markus Christen, Senior Vice President and Head of Global Development, Proteus

Praveen Raja, Senior Director of Medical Affairs, Proteus Digital Health

Michael Stapleton, Vice President and Chief Information Officer, R&D IT, Merck

9:15 a.m.–10:30 a.m.

Driving Patient Engagement and the Internet of Things 

Howard Golub, Vice President of Clinical Research, Walgreens

Jean-Remy Behaeghel, Senior Director, Client Account Management, Product Development Solutions, Vertex Pharmaceuticals

10:30 a.m.–10:45 a.m.

Break

10:45 a.m.–12:00 p.m.

Leveraging Data and Advanced Analytics to Enable True Pharmacovigilance and Risk Management 

Leonard Reyno, Senior Vice President, Chief Medical Officer, Agensys

 

Accelerating Therapeutic Development Through New Technologies 

Andrew Rut, Chief Executive Officer, Co-Founder and Director, MyMeds&Me

12:45 a.m.–1:45 p.m.

Networking Lunch

1:45 p.m.–2:30 p.m.

Oracle Industry Connect Keynote

2:30 p.m.–2:45 p.m.

Break

2:45 p.m.–3:15 p.m.

Harnessing Big Data to Increase R&D Innovation, Efficiency, and Collaboration 

Sandy Tremps, Executive Director, Global Clinical Development IT, Merck

3:15 p.m.–3:30 p.m.

Break

3:30 p.m.–4:45 p.m.

Transforming Clinical Research from Planning to Postmarketing 

Kenneth Getz, Director of Sponsored Research Programs and Research Associate Professor, Tufts University

Jason Raines, Head, Global Data Operations, Alcon Laboratories

4:45 p.m.–6:00 p.m.

Increasing Efficiency and Pipeline Performance Through Sponsor/CRO Data Transparency and Cloud Collaboration 

Thomas Grundstrom, Vice President, ICONIK, Cross Functional IT Strategies and Innovation, ICON

Margaret Keegan, Senior Vice President, Global Head Data Sciences and Strategy, Quintiles

6:00 p.m.–9:00 p.m.

Oracle Customer Networking Event

Healthcare Agenda

Thursday, March 26

7:00 a.m.–8:15 a.m.

Networking Breakfast

8:30 a.m.–9:15 a.m.

Population Health: A Core Competency for Providers in a Post Fee-for-Service Model 

Margaret Anderson, Executive Director, FasterCures

Balaji Apparsamy, Director, Business Intellegence, Baycare

Leslie Kelly Hall, Senior Vice President, Policy, Healthwise

Peter Pronovost, Senior Vice President, Patient Safety & Quality, Johns Hopkins

Sanjay Udoshi, Healthcare Product Strategy, Oracle

9:15 a.m.–9:30 a.m.

Break

9:30 a.m.–10:15 a.m.

Population Health: A Core Competency for Providers in a Post Fee-for-Service Model (Continued)

10:15 a.m.–10:45 a.m.

Networking Break

10:45 a.m.–11:30 a.m.

Managing Cost of Care in the Era of Healthcare Reform 

Chris Bruerton, Director, Budgeting, Intermountain Healthcare

Tony Byram, Vice President Business Integration, Ascension

Kerri-Lynn Morris, Executive Director, Finance Operations and Strategic Projects, Kaiser Permanente

Kavita Patel, Managing Director, Clinical Transformation, Brookings Institute

Christine Santos, Chief of Strategic Business Analytics, Providence Health & Services

Prashanth Kini, Senior Director, Healthcare Product Strategy, Oracle

11:30 a.m.–11:45 a.m.

Break

11:45 a.m.–12:45 p.m.

Managing Cost of Care in the Era of Healthcare Reform (Continued)

12:45 p.m.–1:45 p.m.

Networking Lunch

1:45 p.m.–2:30 p.m.

Oracle Industry Connect Keynote

2:30 p.m.–2:45 p.m.

Break

2:45 p.m.–3:30 p.m.

Precision Medicine 

Annerose Berndt, Vice President, Analytics and Information, UPMC

James Buntrock, Vice Chair, Information Management and Analytics, Mayo Clinic

Dan Ford, Vice Dean for Clinical Investigation, Johns Hopkins Medicine

Jan Hazelzet, Chief Medical Information Officer, Erasmus MC

Stan Huff, Chief Medical Information Officer, Intermountain Healthcare

Vineesh Khanna, Director, Biomedical Informatics, SIDRA

Brian Wells, Vice President, Health Technology, Penn Medicine

Wanmei Ou, Senior Product Strategist, Healthcare, Oracle

3:30 p.m.–3:45 p.m.

Networking Break

3:45 p.m.–4:30 p.m.

Precision Medicine (Continued)

4:30 p.m.–4:45 p.m.

Break

6:00 p.m.–9:00 p.m.

Oracle Customer Networking Event

Additional Links to Oracle Pharma, Life Sciences and HealthCare

 
Life Sciences | Industry | Oracle <http://www.oracle.com/us/industries/life-sciences/overview/>

http://www.oracle.com/us/industries/life-sciences/overview/

 
Oracle Corporation

 
Oracle Applications for Life Sciences deliver a powerful combination of technology and preintegrated applications.

  • Clinical

<http://www.oracle.com/us/industries/life-sciences/clinical/overview/index.html>

  • Medical Devices

<http://www.oracle.com/us/industries/life-sciences/medical/overview/index.html>

  • Pharmaceuticals

<http://www.oracle.com/us/industries/life-sciences/pharmaceuticals/overview/index.html>

 
Life Sciences Solutions | Pharmaceuticals and … – Oracle <http://www.oracle.com/us/industries/life-sciences/solutions/index.html>

http://www.oracle.com  Industries  Life Sciences

 
Oracle Corporation

 
Life Sciences Pharmaceuticals and Biotechnology.

 
Oracle Life Sciences Data Hub – Overview | Oracle <http://www.oracle.com/us/products/applications/health-sciences/e-clinical/data-hub/index.html>

http://www.oracle.com  …  E-Clinical Solutions

 
Oracle Corporation

 
Oracle Life Sciences Data Hub. Better Insights, More Informed Decision-Making. Provides an integrated environment for clinical data, improving regulatory …

 
Pharmaceuticals and Biotechnology | Oracle Life Sciences <http://www.oracle.com/us/industries/life-sciences/pharmaceuticals/overview/index.html>

http://www.oracle.com/us/…/life-sciences/…/index.html

 
Oracle Corporation

 
Oracle Applications for Pharmaceuticals and Biotechnology deliver a powerful combination of technology and preintegrated applications.

 
Oracle Health Sciences – Healthcare and Life Sciences … <https://www.oracle.com/industries/health-sciences/>

https://www.oracle.com/industries/health-sciences/

 
Oracle Corporation

 
Oracle Health Sciences leverages industry-shaping technologies that optimize clinical R&D, mitigate risk, advance healthcare, and improve patient outcomes.

 
Clinical | Oracle Life Sciences | Oracle <http://www.oracle.com/us/industries/life-sciences/clinical/overview/index.html>

http://www.oracle.com  Industries  Life Sciences  Clinical

 
Oracle Corporation

 
Oracle for Clinical Applications provides an integrated remote data collection facility for site-based entry.

 
Oracle Life Sciences | Knowledge Zone | Oracle … <http://www.oracle.com/partners/en/products/industries/life-sciences/get-started/index.html>

http://www.oracle.com/partners/…/life-sciences/…/index.ht&#8230;

 
Oracle Corporation

 
This Knowledge Zone was specifically developed for partners interested in reselling or specializing in Oracle Life Sciences solutions. To become a specialized …

 
[PDF]Brochure: Oracle Health Sciences Suite of Life Sciences … <http://www.oracle.com/us/industries/life-sciences/oracle-life-sciences-solutions-br-414127.pdf>

http://www.oracle.com/…/life-sciences/oracle-life-sciences-s&#8230;

 
Oracle Corporation

 
Oracle Health Sciences Suite of. Life Sciences Solutions. Integrated Solutions for Global Clinical Trials. Oracle Health Sciences provides the world’s broadest set …

 

 

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The Union of Biomarkers and Drug Development

Posted in Academic Publishing, Bio Instrumentation in Experimental Life Sciences Research, Biochemical pathways, Biological Networks, Biomarkers & Medical Diagnostics, Biomedical Measurement Science, Cancer and Current Therapeutics, Cancer Screening, Cardiovascular Pharmacogenomics, Cell Biology, Cerebrovascular and Neurodegenerative Diseases, Chemical Biology and its relations to Metabolic Disease, Clinical Diagnostics, Curation, Disease Biology, Drug Toxicity, Epigenetics and Cardiovascular Risks, FDA Regulatory Affairs, Frontiers in Cardiology and Cardiovascular Disorders, Gene Regulation, Genetics & Pharmaceutical, Genomic Testing: Methodology for Diagnosis, Genomics Pharmacy, Global Partnering & Biotech Investment, HealthCare IT, Hematology, Historical relevance, Human Immune System in Health and in Disease, Infectious Disease & New Antibiotic Targets, Infectious Disease Immunodiagnostics, Innovations, Investment in Technological Breakthrough, Lipid metabolism, Liver & Digestive Diseases Research, Mass automation of plasma proteins, Metabolism, Metabolomics, Molecular Genetics & Pharmaceutical, Mutant Gene Expression, Nephrology, Neurological Diseases, Nitric Oxide in Health and Disease, Personalized and Precision Medicine & Genomic Research, Pharmaceutical Analytics, Pharmaceutical Discovery, Pharmaceutical Industry Competitive Intelligence, Pharmaceutical R&D Investment, Pharmacodynamics and Pharmacokinetics, Pharmacogenomics, Pharmacologic toxicities, Pharmacotherapy of Cardiovascular Disease, Population Health Management, Proteomics, Rapid automation of plasma protein pools, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, RNA Biology, Signaling & Cell Circuits, Small Molecules in Development of Therapeutic Drugs, Technology Advance Assessment of, tagged biomarker testing, clinical reference laboratories, companion diagnostics, Health Care Delivery, high throughput separation chromatography, mass spectrometry, Medical Industry innovation, Personalized medicine, pharmaceutical development, Pharmaceuticals, Proteomics, Raman spectroscopy, therapeutic drug monitoring on December 24, 2014| Leave a Comment »

The Union of Biomarkers and Drug Development

Author and Curator: Larry H. Bernstein, MD, FCAP

There has been consolidation going on for over a decade in both thr pharmaceutical and in the diagnostics industry, and at the same time the page is being rewritten for health care delivery.  I shall try to work through a clear picture of these not coincidental events.

Key notables:

  1. A growing segment of the US population is reaching Medicare age
  2. There is also a large underserved population in both metropolitan and nonurban areas and a fragmentation of the middle class after a growth slowdown in the economy since the 2008 deep recession.
  3. The deep recession affecting worldwide economies was only buffered by availability of oil or natural gas.
  4. In addition, there was a self-destructive strategy to cut spending on national scales that withdrew the support that would bolster support for infrastrucrue renewl.
  5. There has been a dramatic success in the clinical diagnostics industry, with a long history of being viewed as a loss leader, and this has been recently followed by the pharmaceutical industry faced with inability to introduce new products, leading to more competition in off-patent medications.
  6. The introduction of the Accountable Care Act has opened the opportunities for improved care, despite political opposition, and has probably sustained opportunity in the healthcare market.

Let’s take a look at this three headed serpent. – Pharma, Diagnostics, New Entity
?  The patient  ?
?  Insurance    ?
?  Physician    ?

Part I.   The Concept

When Illumina Buys Roche: The Dawning Of The Era Of Diagnostics Dominance

Robert J. Easton, Alain J. Gilbert, Olivier Lesueur, Rachel Laing, and Mark Ratner
http://PharmaMedtechBI.com    | IN VIVO: The Business & Medicine Report Jul/Aug 2014; 32(7).

  • With current technology and resources, a well-funded IVD company can create and pursue a strategy of information gathering and informatics application to create medical knowledge, enabling it to assume the risk and manage certain segments of patients
  • We see the first step in the process as the emergence of new specialty therapy companies coming from an IVD legacy, most likely focused in cancer, infection, or critical care

When Illumina Inc. acquired the regulatory consulting firm Myraqa, a specialist in in vitro diagnostics (IVD), in July, the press release announcement characterized the deal as one that would bolster illumina’s in-house capabilities for clinical readiness and help prepare for its next growth phase in regulated markets. That’s not surprising given the US Food and Drug Administration’s (FDA) approval a year and a half ago of its MiSeq next-generation sequencer for clinical use. But the deal could also suggest illumina is beginning to move along the path toward taking on clinical risk – that is, eventually

  • advising physicians and patients, which would mean facing regulators directly

Such a move – by illumina, another life sciences tools firm, or an information specialist from the high-tech universe – is inevitable given

  • the emerging power of diagnostics and traditional health care players’ reluctance to themselves take on such risk.

Alternatively, we believe that a well-funded diagnostics company could establish this position. either way, such a champion would establish dominion over and earn higher valuation than less-aggressive players who

  • only supply compartmentalized drug and device solutions.

Diagnostics companies have long been dogged by a fundamental issue:

  1. they are viewed and valued more along the lines of a commodity business than as firms that deliver a unique product or service
  2. diagnostics companies are in position to do just that today because they are now advantaged by having access to more data points.
  3. if they were to cobble together the right capabilities, diagnostics companies would have the ability to turn information into true medical knowledge

Example: PathGEN PathChip

nucleic-acid-based platform detects 296 viruses, bacteria, fungi & parasites

http://ow.ly/d/2GvQhttp://ow.ly/DSORV

This puts the diagnostics player in an unfamiliar realm where it can ask the question of what value they offer compared with a therapeutic. The key is that diagnostics can now offer unique information and potentially unique tools to capture that information. In order to do so, it has to create information from the data it generates, and then to supply that knowledge to users who will value and act on that knowledge. Complex genomic tests, as much as physical examination, may be the first meaningful touch point for physicians’ classification of disease.

Even if lab tests are more expensive, it is a cheaper means for deciding what to do first for a patient than the trial and error of prescribing medication without adequate information. Information is gaining in value as the amount of treatment data available on genomically characterizable subpopulations increases. In such a circumstance
it is the ability to perform that advisory function that will add tremendous value above what any test provides, the leverage of being able to apply a proprietary diagnostics platform – and importantly, the data it generates. It is the ability to perform that advisory function that will add tremendous value above what any test provides.

Integrated Diagnostics Inc. and Biodesix Inc. with mass spectrometry has the tools for unraveling disease processes, and numerous players are quite visibly in or are getting into the business of providing medical knowledge and clinical decision support in pursuit of a huge payout for those who actually solve important disease mysteries. Of course one has to ask whether MS/MS is sufficient for the assigned task, and also whether the technology is ready for the kind of workload experienced in a clinical service compared to a research vehicle.  My impression (as a reviewer) is that it is not now the time to take this seriously.

Roche has not realized its intent with Ventana: failing to deliver on the promise of boosting Roche’s pipeline, which was a significant factor in the high price Roche paid. The combined company was to be “uniquely positioned to further expand Ventana’s business globally and together develop more cost-efficient, differentiated, and targeted medicines.  On the other hand,  Biodesix decided to use Veristrat to look back and analyze important trial data to try to ascertain which patients would benefit from ficlatuzumab (subset). The predictive effect for the otherwise unimpressive trial results was observed in both progression-free survival and overall survival endpoints, and encouraged the companies to conduct a proof-of-concept study of ficlatuzumab in combination with Tarceva in advanced Non Small Cell Lung Cancer Patients (NSCLC) selected using the Veristrat test.

A second phase of IVD evolution will be far more challenging to pharma, when the most accomplished companies begin to assemble and integrate much broader data
sets, thereby gaining knowledge sufficient to actually manage patients and dictate therapy, including drug selection. No individual physician has or will have access to all of this information on thousands of patients, combined with the informatics to tease out from trillions of data points the optimal personalized medical approach. When the IVD-origin knowledge integrator amasses enough data and understanding to guide therapy decisions in large categories, particularly drug choices, it will become more valuable than any of the drug suppliers.

This is an apparent reversal of fortune. The pharmaceutical industry has been considered the valued provider, while the IVD manufacturer has been the low valued cousin. Now, it is by an ability to make kore accurate the drug administration that the IVD company can control the drug bill, to the detriment of drug developers, by finding algorithms that generate equal-to-innovative-drug outcomes using generics for most of the patients, thereby limiting the margins of drug suppliers and the upsides for new drug discovery/development.

It is here that there appears to be a misunderstanding of the whole picture of the development of the healthcare industry.  The pharmaceutical industry had a high value added only insofar it could replace market leaders for treatment before or at the time of patent expiration, which largely depended either introducing a new class of drug, or by relieving the current drug in its class of undesired toxicities or “side effects”.  Otherwise, the drug armamentarium was time limited to the expiration date. In other words, the value was dependent on a window of no competition.  In addition, as the regulation of healthcare costs were tightening under managed care, the introduction of new products that were deemed to be only marginally better, could be substitued by “off-patent” drug products.

The other misunderstanding is related to the IVD sector.  Laboratory tests in the 1950’s were manual, and they could be done by “technicians” who might not have completed a specialized training in clinical laboratory sciences.  The first sign of progress was the introduction of continuous flow chemistry, with a sampling probe, tubing to bring the reacting reagents into a photocell, and the timing of the reaction controlled by a coiled glass tubing before introducing the colored product into a uv-visible photometer.  In perhaps a decade, the Technicon SMA 12 and 6 instruments were introduced that could do up to 18 tests from a single sample.

Part 2. Emergence of an IVD Clinical Automated Diagnostics Industry

Why tests are ordered

  1. Screening
  2. Diagnosis
  3. Monitoring

Historical Perspective

Case in Point 1:  Outstanding Contributions in Clinical Chemistry. 1991. Arthur Karmen.

Dr. Karmen was born in New York City in 1930. He graduated from the Bronx High School of Science in 1946 and earned an A.B. and M.D. in 1950 and 1954, respectively, from New York University. In 1952, while a medical student working on a summer project at Memorial-Sloan Kettering, he used paper chromatography of amino acids to demonstrate the presence of glutamic-oxaloacetic and glutaniic-pyruvic ransaminases (aspartate and alanine aminotransferases) in serum and blood. In 1954, he devised the spectrophotometric method for measuring aspartate aminotransferase in serum, which, with minor modifications, is still used for diagnostic testing today. When developing this assay, he studied the reaction of NADH with serum and demonstrated the presence of lactate and malate dehydrogenases, both of which were also later used in diagnosis. Using the spectrophotometric method, he found that aspartate aminotransferase increased in the period immediately after an acute myocardial infarction and did the pilot studies that showed its diagnostic utility in heart and liver diseases.  This became as important as the EKG. It was replaced in cardiology usage by the MB isoenzyme of creatine kinase, which was driven by Burton Sobel’s work on infarct size, and later by the troponins.

Case in point 2: Arterial Blood Gases.  Van Slyke. National Academy of Sciences.

The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflect gas exchange across the alveolar-capillary membrane.

DONALD DEXTER VAN SLYKE died on May 4, 1971, after a long and productive career that spanned three generations of biochemists and physicians. He left behind not only a bibliography of 317 journal publications and 5 books, but also more than 100 persons who had worked with him and distinguished themselves in biochemistry and academic medicine. His doctoral thesis, with Gomberg at University of Michigan was published in the Journal of the American Chemical Society in 1907.  Van Slyke received an invitation from Dr. Simon Flexner, Director of the Rockefeller Institute, to come to New York for an interview. In 1911 he spent a year in Berlin with Emil Fischer, who was then the leading chemist of the scientific world. He was particularly impressed by Fischer’s performing all laboratory operations quantitatively —a procedure Van followed throughout his life. Prior to going to Berlin, he published the  classic nitrous acid method for the quantitative determination of primary aliphatic amino groups,  the first of the many gasometric procedures devised by Van Slyke, and made possible the determination of amino acids. It was the primary method used to study amino acid

composition of proteins for years before chromatography. Thus, his first seven postdoctoral years were centered around the development of better methodology for protein composition and amino acid metabolism.

With his colleague G. M. Meyer, he first demonstrated that amino acids, liberated during digestion in the intestine, are absorbed into the bloodstream, that they are removed by the tissues, and that the liver alone possesses the ability to convert the amino acid nitrogen into urea.  From the study of the kinetics of urease action, Van Slyke and Cullen developed equations that depended upon two reactions: (1) the combination of enzyme and substrate in stoichiometric proportions and (2) the reaction of the combination into the end products. Published in 1914, this formulation, involving two velocity constants, was similar to that arrived at contemporaneously by Michaelis and Menten in Germany in 1913.

He transferred to the Rockefeller Institute’s Hospital in 2013, under Dr. Rufus Cole, where “Men who were studying disease clinically had the right to go as deeply into its fundamental nature as their training allowed, and in the Rockefeller Institute’s Hospital every man who was caring for patients should also be engaged in more fundamental study”.  The study of diabetes was already under way by Dr. F. M. Allen, but patients inevitably died of acidosis.  Van Slyke reasoned that if incomplete oxidation of fatty acids in the body led to the accumulation of acetoacetic and beta-hydroxybutyric acids in the blood, then a reaction would result between these acids and the bicarbonate ions that would lead to a lower than-normal bicarbonate concentration in blood plasma. The problem thus became one of devising an analytical method that would permit the quantitative determination of bicarbonate concentration in small amounts of blood plasma.  He ingeniously devised a volumetric glass apparatus that was easy to use and required less than ten minutes for the determination of the total carbon dioxide in one cubic centimeter of plasma.  It also was soon found to be an excellent apparatus by which to determine blood oxygen concentrations, thus leading to measurements of the percentage saturation of blood hemoglobin with oxygen. This found extensive application in the study of respiratory diseases, such as pneumonia and tuberculosis. It also led to the quantitative study of cyanosis and a monograph on the subject by C. Lundsgaard and Van Slyke.

In all, Van Slyke and his colleagues published twenty-one papers under the general title “Studies of Acidosis,” beginning in 1917 and ending in 1934. They included not only chemical manifestations of acidosis, but Van Slyke, in No. 17 of the series (1921), elaborated and expanded the subject to describe in chemical terms the normal and abnormal variations in the acid-base balance of the blood. This was a landmark in understanding acid-base balance pathology.  Within seven years after Van moved to the Hospital, he had published a total of fifty-three papers, thirty-three of them coauthored with clinical colleagues.

In 1920, Van Slyke and his colleagues undertook a comprehensive investigation of gas and electrolyte equilibria in blood. McLean and Henderson at Harvard had made preliminary studies of blood as a physico-chemical system, but realized that Van Slyke and his colleagues at the Rockefeller Hospital had superior techniques and the facilities necessary for such an undertaking. A collaboration thereupon began between the two laboratories, which resulted in rapid progress toward an exact physico-chemical description of the role of hemoglobin in the transport of oxygen and carbon dioxide, of the distribution of diffusible ions and water between erythrocytes and plasma,
and of factors such as degree of oxygenation of hemoglobin and hydrogen ion concentration that modified these distributions. In this Van Slyke revised his volumetric gas analysis apparatus into a manometric method.  The manometric apparatus proved to give results that were from five to ten times more accurate.

A series of papers on the CO2 titration curves of oxy- and deoxyhemoglobin, of oxygenated and reduced whole blood, and of blood subjected to different degrees of oxygenation and on the distribution of diffusible ions in blood resulted.  These developed equations that predicted the change in distribution of water and diffusible ions between blood plasma and blood cells when there was a change in pH of the oxygenated blood. A significant contribution of Van Slyke and his colleagues was the application of the Gibbs-Donnan Law to the blood—regarded as a two-phase system, in which one phase (the erythrocytes) contained a high concentration of nondiffusible negative ions, i.e., those associated with hemoglobin, and cations, which were not freely exchaThe importance of Vanngeable between cells and plasma. By changing the pH through varying the CO2 tension, the concentration of negative hemoglobin charges changed in a predictable amount. This, in turn, changed the distribution of diffusible anions such as Cl” and HCO3″ in order to restore the Gibbs-Donnan equilibrium. Redistribution of water occurred to restore osmotic equilibrium. The experimental results confirmed the predictions of the equations.

As a spin-off from the physico-chemical study of the blood, Van undertook, in 1922, to put the concept of buffer value of weak electrolytes on a mathematically exact basis.
This proved to be useful in determining buffer values of mixed, polyvalent, and amphoteric electrolytes, and put the understanding of buffering on a quantitative basis. A
monograph in Medicine entitled “Observation on the Courses of Different Types of Bright’s Disease, and on the Resultant Changes in Renal Anatomy,” was a landmark that
related the changes occurring at different stages of renal deterioration to the quantitative changes taking place in kidney function. During this period, Van Slyke and R. M. Archibald identified glutamine as the source of urinary ammonia. During World War II, Van and his colleagues documented the effect of shock on renal function and, with R. A. Phillips, developed a simple method, based on specific gravity, suitable for use in the field.

Over 100 of Van’s 300 publications were devoted to methodology. The importance of Van Slyke’s contribution to clinical chemical methodology cannot be overestimated.
These included the blood organic constituents (carbohydrates, fats, proteins, amino acids, urea, nonprotein nitrogen, and phospholipids) and the inorganic constituents (total cations, calcium, chlorides, phosphate, and the gases carbon dioxide, carbon monoxide, and nitrogen). It was said that a Van Slyke manometric apparatus was almost all the special equipment needed to perform most of the clinical chemical analyses customarily performed prior to the introduction of photocolorimeters and spectrophotometers for such determinations.

The progress made in the medical sciences in genetics, immunology, endocrinology, and antibiotics during the second half of the twentieth century obscures at times the progress that was made in basic and necessary biochemical knowledge during the first half. Methods capable of giving accurate quantitative chemical information on biological material had to be painstakingly devised; basic questions on chemical behavior and metabolism had to be answered; and, finally, those factors that adversely modified the normal chemical reactions in the body so that abnormal conditions arise that we characterize as disease states had to be identified.

Viewed in retrospect, he combined in one scientific lifetime (1) basic contributions to the chemistry of body constituents and their chemical behavior in the body, (2) a chemical understanding of physiological functions of certain organ systems (notably the respiratory and renal), and (3) how such information could be exploited in the
understanding and treatment of disease. That outstanding additions to knowledge in all three categories were possible was in large measure due to his sound and broadly based chemical preparation, his ingenuity in devising means of accurate measurements of chemical constituents, and the opportunity given him at the Hospital of the Rockefeller Institute to study disease in company with physicians.

In addition, he found time to work collaboratively with Dr. John P. Peters of Yale on the classic, two-volume Quantitative Clinical Chemistry. In 1922, John P. Peters, who had just gone to Yale from Van Slyke’s laboratory as an Associate Professor of Medicine, was asked by a publisher to write a modest handbook for clinicians describing useful chemical methods and discussing their application to clinical problems. It was originally to be called “Quantitative Chemistry in Clinical Medicine.” He soon found that it was going to be a bigger job than he could handle alone and asked Van Slyke to join him in writing it. Van agreed, and the two men proceeded to draw up an outline and divide up the writing of the first drafts of the chapters between them. They also agreed to exchange each chapter until it met the satisfaction of both.At the time it was published in 1931, it contained practically all that could be stated with confidence about those aspects of disease that could be and had been studied by chemical means. It was widely accepted throughout the medical world as the “Bible” of quantitative clinical chemistry, and to this day some of the chapters have not become outdated.

History of Laboratory Medicine at Yale University.

The roots of the Department of Laboratory Medicine at Yale can be traced back to John Peters, the head of what he called the “Chemical Division” of the Department of Internal Medicine, subsequently known as the Section of Metabolism, who co-authored with Donald Van Slyke the landmark 1931 textbook Quantitative Clinical Chemistry (2.3); and to Pauline Hald, research collaborator of Dr. Peters who subsequently served as Director of Clinical Chemistry at Yale-New Haven Hospital for many years. In 1947, Miss Hald reported the very first flame photometric measurements of sodium and potassium in serum (4). This study helped to lay the foundation for modern studies of metabolism and their application to clinical care.

The Laboratory Medicine program at Yale had its inception in 1958 as a section of Internal Medicine under the leadership of David Seligson. In 1965, Laboratory Medicine achieved autonomous section status and in 1971, became a full-fledged academic department. Dr. Seligson, who served as the first Chair, pioneered modern automation and computerized data processing in the clinical laboratory. In particular, he demonstrated the feasibility of discrete sample handling for automation that is now the basis of virtually all automated chemistry analyzers. In addition, Seligson and Zetner demonstrated the first clinical use of atomic absorption spectrophotometry. He was one of the founding members of the major Laboratory Medicine academic society, the Academy of Clinical Laboratory Physicians and Scientists.

Davenport fig 10.jpg

Case in Point 3.  Nathan Gochman.  Developer of Automated Chemistries.

Nathan Gochman, PhD, has over 40 years of experience in the clinical diagnostics industry. This includes academic teaching and research, and 30 years in the pharmaceutical and in vitro diagnostics industry. He has managed R & D, technical marketing and technical support departments. As a leader in the industry he was President of the American Association for Clinical Chemistry (AACC) and the National Committee for Clinical Laboratory Standards (NCCLS, now CLSI). He is currently a Consultant to investment firms and IVD companies.

Nathan Gochman

Nathan Gochman

The clinical laboratory has become so productive, particularly in chemistry and immunology, and the labor, instrument and reagent costs are well determined, that today a physician’s medical decisions are 80% determined by the clinical laboratory.  Medical information systems have lagged far behind.  Why is that?  Because the decision for a MIS has historical been based on billing capture.  Moreover, the historical use of chemical profiles were quite good at validating healthy dtatus in an outpatient population, but the profiles became restricted under Diagnostic Related Groups.    Thus, it came to be that the diagnostics was considered a “commodity”.  In order to be competitive, a laboratory had to provide “high complexity” tests that were drawn in by a large volume of “moderate complexity”tests.

Part 3. Biomarkers in Medical Practice

Case in Point 1.

A Solid Prognostic Biomarker

HDL-C: Target of Therapy or Fuggedaboutit?

Steven E. Nissen, MD, MACC, Peter Libby, MD

DisclosuresNovember 06, 2014

Steven E. Nissen, MD, MACC: I am Steve Nissen, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic. I am here with Dr Peter Libby, chief of cardiology at the Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. We are going to discuss high-density lipoprotein cholesterol (HDL-C), a topic that has been very controversial recently. Peter, HDL-C has been a pretty good biomarker. The question is whether it is a good target.

Peter Libby, MD: Since the early days in Berkley, when they were doing ultracentrifugation, and when it was reinforced and put on the map by the Framingham Study,[1] we have known that HDL-C is an extremely good biomarker of prospective cardiovascular risk with an inverse relationship with all kinds of cardiovascular events. That is as solid a finding as you can get in observational epidemiology. It is a very reliable prospective marker. It’s natural that the pharmaceutical industry and those of us who are interested in risk reduction would focus on HDL-C as a target. That is where the controversies come in.

Dr Nissen: It has been difficult. My view is that the trials that have attempted to modulate HDL-C or the drugs they used have been flawed. Although the results have not been promising, the jury is yet out. Torcetrapib, the cholesteryl ester transfer protein (CETP) inhibitor developed by Pfizer, had anoff-target toxicity.[2] Niacin is not very effective, and there are a lot of downsides to the drug. That has been an issue, but people are still working on this. We have done some studies. We did our ApoA-1 Milano infusion study[3]about a decade ago, which showed very promising results with respect to shrinking plaques in coronary arteries. I remain open to the possibility that the right drug in the right trial will work.

Dr Libby: What do you do with the genetic data that have come out in the past couple of years? Sekar Kathiresan masterminded and organized an enormous collaboration[4] in which they looked, with contemporary genetics, at whether HDL had the genetic markers of being a causal risk factor. They came up empty-handed.

Dr Nissen: I am cautious about interpreting those data, like I am cautious about interpreting animal studies of atherosclerosis. We have both lived through this problem in which something works extremely well in animals but doesn’t work in humans, or it doesn’t work in animals but it works in humans. The genetic studies don’t seal the fate of HDL. I have an open mind about this. Drugs are complex. They work by complex mechanisms. It is my belief that what we have to do is test these hypotheses in well-designed clinical trials, which are rigorously performed with drugs that are clean—unlike torcetrapib—and don’t have off-target toxicities.

An Unmet Need: High Lp(a) Levels

Dr Nissen: I’m going to push back on that and make a couple of points. The HPS2-THRIVE study was flawed. They studied the wrong people. It was not a good study, and AIM-HIGH[8] was underpowered. I am not putting people on niacin. What do you do with a patient whose Lp(a) is 200 mg/dL?

Dr Libby: I’m waiting for the results of the PCSK9 and anacetrapib studies. You can tell me about evacetrapib.[9]Reducing Lp(a) is an unmet medical need. We both care for kindreds with high Lp(a) levels and premature coronary artery disease. We have no idea what to do with them other than to treat them with statins and lower their LDL-C levels.

Dr Nissen: I have taken a more cautious approach with respect to taking people off of niacin. If I have patients who are doing well and tolerating it (depending on why it was started), I am discontinuing niacin in some people. I am starting very few people on the drug, but I worry about the quality of the trial.

Dr Libby: So you are of the “don’t start don’t stop” school?

Dr Nissen: Yes. It’s difficult when the trial is fatally flawed. There were 11,000 patients from China in this study. I have known for years that if you give niacin to people of Asiatic ethnic descent, they have terrible flushing and they won’t continue the drug. One question is, what was the adherence? The adverse events would have been tolerable had there been efficacy. The concern here is that this study was destined to fail because they studied a low LDL/high HDL population, a group of people for whom niacin just isn’t used.

Triglycerides and HDL: Do We Have It Backwards?

Dr Libby: What about the recent genetic[10] and epidemiologic data that support triglycerides, and apolipoprotein C3 in particular as a causal risk factor? Have we been misled through all of the generations in whom we have been adjusting triglycerides for HDL-C and saying that triglycerides are not a causal risk factor because once we adjust for HDL, the risk goes away? Do you think we got it backwards?

Dr Nissen: The tricky factor here is that because of this intimate inverse relationship between triglycerides and HDL, we may be talking about the same phenomenon. That is one of the reasons that I am not certain we are not going to be able to find a therapy. What if you had a therapy that lowered triglycerides and raised HDL-C? Could that work? Could that combination be favorable? I want answers from rigorous, well-designed clinical trials that ask the right questions in the right populations. I am disappointed, just as I have been disappointed by the fibrate trials.[11,12] There is a class of drugs that raises HDL-C a little and lowers triglycerides a lot.

Dr Nissen: But the gemfibrozil studies (VA-HIT[13] and Helsinki Heart[14]) showed benefit.

The Dyslipidemia Bar Has Been Raised

Dr Libby: Those studies were from the pre-statin era. We both were involved in trials in which patients were on high-dose statins at baseline. Do you think that this is too high a bar?

Dr Nissen: The bar has been raised, and for the pharmaceutical industry, the studies that we need to find out whether lowering triglycerides or raising HDL is beneficial are going to be large. We are doing a study with evacetrapib. It has 12,000 patients. It’s fully enrolled. Evacetrapib is a very clean-looking drug. It doesn’t have such a long biological half-life as anacetrapib, so I am very encouraged that it won’t have that baggage of being around for 2-4 years. We’ve got a couple of shots on goal here. Don’t forget that we have multiple ongoing studies of HDL-C infusion therapies that are still under development. Those have some promise too. The jury is still out.

Dr Libby: We agree on the need to do rigorous, large-scale endpoint trials. Do the biomarker studies, but don’t wait to start the endpoint trial because that’s the proof in the pudding.

Dr Nissen: Exactly. We have had a little controversy about HDL-C. We often agree, but not always, and we may have a different perspective. Thanks for joining me in this interesting discussion of what will continue to be a controversial topic for the next several years until we get the results of the current ongoing trials.

Case in Point 2.

NSTEMI? Honesty in Coding and Communication?

Melissa Walton-Shirley

November 07, 2014

The complaint at ER triage: Weakness, fatigue, near syncope of several days’ duration, vomiting, and decreased sensorium.

The findings: O2sat: 88% on room air. BP: 88 systolic. Telemetry: Sinus tachycardia 120 bpm. Blood sugar: 500 mg/dL. Chest X ray: atelectasis. Urinalysis: pyuria. ECG: T-wave-inversion anterior leads. Echocardiography: normal left ventricular ejection fraction (LVEF) and wall motion. Troponin I: 0.3 ng/mL. CT angiography: negative for pulmonary embolism (PE). White blood cell count: 20K with left shift. Blood cultures: positive for Gram-negative rods.

The treatment: Intravenous fluids and IV levofloxacin—changed to ciprofloxacin.

The communication at discharge: “You had a severe urinary-tract infection and grew bacteria in your bloodstream. Also, you’ve had a slight heart attack. See your cardiologist immediately upon discharge-no more than 5 days from now.”

The diagnoses coded at discharge: Urosepsis and non-ST segment elevation MI (NSTEMI) 410.1.

One year earlier: This moderately obese patient was referred to our practice for a preoperative risk assessment. The surgery planned was a technically simple procedure, but due to the need for precise instrumentation, general endotracheal anesthesia (GETA) was being considered. The patient was diabetic, overweight, and short of air. A stress exam was equivocal for CAD due to poor exercise tolerance and suboptimal imaging. Upon further discussion, symptoms were progressive; therefore, cardiac cath was recommended, revealing angiographically normal coronaries and a predictably elevated left ventricular end diastolic pressure (LVEDP) in the mid-20s range. The patient was given a diagnosis of diastolic dysfunction, a prescription for better hypertension control, and in-depth discussion on exercise and the Mediterranean and DASH diets for weight loss. Symptoms improved with a low dose of diuretic. The surgery was completed without difficulty. Upon follow-up visit, the patient felt well, had lost a few pounds, and blood pressure was well controlled.

Five days after ER workup: While out of town, the patient developed profound weakness and went to the ER as described above. Fast forward to our office visit in the designated time frame of “no longer than 5 days’ postdischarge,” where the patient and family asked me about the “slight heart attack” that literally came on the heels of a normal coronary angiogram.

But the patient really didn’t have a “heart attack,” did they? The cardiologist aptly stated that it was likely nonspecific troponin I leak in his progress notes. Yet the hospitalist framed the diagnosis of NSTEMI as item number 2 in the final diagnoses.

The motivations on behalf of personnel who code charts are largely innocent and likely a direct result of the lack of understanding of the coding system on behalf of us as healthcare providers. I have a feeling, though, that hospitals aren’t anxious to correct this misperception, due to an opportunity for increased reimbursement. I contacted a director of a coding department for a large hospital who prefers to remain anonymous. She explained that NSTEMI ICD9 code 410.1 falls in DRG 282 with a weight of .7562. The diagnosis of “demand ischemia,” code 411.89, a slightly less inappropriate code for a nonspecific troponin I leak, falls in DRG 311 with a weight of .5662. To determine reimbursement, one must multiply the weight by the average hospital Medicare base rate of $5370. Keep in mind that each hospital’s base rate and corresponding payment will vary. The difference in reimbursement for a large hospital bill between these two choices for coding is substantial, at over $1000 difference ($4060 vs $3040).

Although hospitals that are already reeling from shrinking revenues will make more money on the front end by coding the troponin leak incorrectly as an NSTEMI, when multiple unnecessary tests are generated to follow up on a nondiagnostic troponin leak, the amount of available Centers for Medicare & Medicaid Services (CMS) reimbursement pie shrinks in the long run. Furthermore, this inappropriate categorization generates extreme concern on behalf of patients and family members that is often never laid to rest. The emotional toll of a “heart-attack” diagnosis has an impact on work fitness, quality of life, cost of medication, and the cost of future testing. If the patient lived for another 100 years, they will likely still list a “heart attack” in their medical history.

As a cardiologist, I resent the loose utilization of one of “my” heart-attack codes when it wasn’t that at all. At discharge, we need to develop a better way of communicating what exactly did happen. Equally important, we need to communicate what exactly didn’t happen as well.

Case in Point 3.

Blood Markers Predict CKD Heart Failure 

Published: Oct 3, 2014 | Updated: Oct 3, 2014

Elevated levels of high-sensitivity troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) strongly predicted heart failure in patients with chronic kidney disease followed for a median of close to 6 years, researchers reported.

Compared with patients with the lowest blood levels of hsTnT, those with the highest had a nearly five-fold higher risk for developing heart failure and the risk was 10-fold higher in patients with the highest NT-proBNP levels compared with those with the lowest levels of the protein, researcher Nisha Bansal, MD, of the University of Washington in Seattle, and colleagues wrote online in the Journal of the American Society of Nephrology.

A separate study, published online in theJournal of the American Medical Association earlier in the week, also examined the comorbid conditions of heart and kidney disease, finding no benefit to the practice of treating cardiac surgery patients who developed acute kidney injury with infusions of the antihypertensive drug fenoldopam.

The study, reported by researcher Giovanni Landoni, MD, of the IRCCS San Raffaele Scientific Institute, Milan, Italy, and colleagues, was stopped early “for futility,” according to the authors, and the incidence of hypotension during drug infusion was significantly higher in patients infused with fenoldopam than placebo (26% vs. 15%; P=0.001).

Blood Markers Predict CKD Heart Failure

The study in patients with mild to moderate chronic kidney disease (CKD) was conducted to determine if blood markers could help identify patients at high risk for developing heart failure.

Heart failure is the most common cardiovascular complication among people with renal disease, occurring in about a quarter of CKD patients.

The two markers, hsTnT and NT-proBNP, are associated with overworked cardiac myocytes and have been shown to predict heart failure in the general population.

However, Bansal and colleagues noted, the markers have not been widely used in diagnosing heart failure among patients with CKD due to concerns that reduced renal excretion may raise levels of these markers, and therefore do not reflect an actual increase in heart muscle strain.

To better understand the importance of elevated concentrations of hsTnT and NT-proBNP in CKD patients, the researchers examined their association with incident heart failure events in 3,483 participants in the ongoing observational Chronic Renal Insufficiency Cohort (CRIC) study.

All participants were recruited from June 2003 to August 2008, and all were free of heart failure at baseline. The researchers used Cox regression to examine the association of baseline levels of hsTnT and NT-proBNP with incident heart failure after adjustment for demographic influences, traditional cardiovascular risk factors, makers of kidney disease, pertinent medication use, and mineral metabolism markers.

At baseline, hsTnT levels ranged from ≤5.0 to 378.7 pg/mL and NT-proBNP levels ranged from ≤5 to 35,000 pg/mL. Compared with patients who had undetectable hsTnT, those in the highest quartile (>26.5 ng/mL) had a significantly higher rate of heart failure (hazard ratio 4.77; 95% CI 2.49-9.14).

Compared with those in the lowest NT-proBNP quintile (<47.6 ng/mL), patients in the highest quintile (>433.0 ng/mL) experienced an almost 10-fold increase in heart failure risk (HR 9.57; 95% CI 4.40-20.83).

The researchers noted that these associations remained robust after adjustment for potential confounders and for the other biomarker, suggesting that while hsTnT and NT-proBNP are complementary, they may be indicative of distinct biological pathways for heart failure.

Even Modest Increases in NP-proBNP Linked to Heart Failure

The findings are consistent with an earlier analysis that included 8,000 patients with albuminuria in the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) study, which showed that hsTnT was associated with incident cardiovascular events, even after adjustment for eGFR and severity of albuminuria.

“Among participants in the CRIC study, those with the highest quartile of detectable hsTnT had a twofold higher odds of left ventricular hypertrophy compared with those in the lowest quartile,” Bansal and colleagues wrote, adding that the findings were similar after excluding participants with any cardiovascular disease at baseline.

Even modest elevations in NT-proBNP were associated with significantly increased rates of heart failure, including in subgroups stratified by eGFR, proteinuria, and diabetic status.

“NT-proBNP regulates blood pressure and body fluid volume by its natriuretic and diuretic actions, arterial dilation, and inhibition of the renin-aldosterone-angiotensin system and increased levels of this marker likely reflect myocardial stress induced by subclinical changes in volume or pressure, even in persons without clinical disease,” the researchers wrote.

The researchers concluded that further studies are needed to develop and validate risk prediction tools for clinical heart failure in patients with CKD, and to determine the potential role of these two biomarkers in a heart failure risk prediction and prevention strategy.

Fenoldopam ‘Widely Promoted’ in AKI Cardiac Surgery Setting

The JAMA study examined whether the selective dopamine receptor D agonist fenoldopam mesylate can reduce the need for dialysis in cardiac surgery patients who develop acute kidney injury (AKI).

Fenoldopam induces vasodilation of the renal, mesenteric, peripheral, and coronary arteries, and, unlike dopamine, it has no significant affinity for D2 receptors, meaning that it theoretically induces greater vasodilation in the renal medulla than in the cortex, the researchers wrote.

“Because of these hemodynamic effects, fenoldopam has been widely promoted for the prevention and therapy of AKI in the United States and many other countries with apparent favorable results in cardiac surgery and other settings,” Landoni and colleagues wrote.

The drug was approved in 1997 by the FDA for the indication of in-hospital, short-term management of severe hypertension. It has not been approved for renal indications, but is commonly used off-label in cardiac surgery patients who develop AKI.

Although a meta analysis of randomized trials, conducted by the researchers, indicated a reduction in the incidence and progression of AKI associated with the treatment, Landoni and colleagues wrote that the absence of a definitive trial “leaves clinicians uncertain as to whether fenoldopam should be prescribed after cardiac surgery to prevent deterioration in renal function.”

To address this uncertainty, the researchers conducted a prospective, randomized, parallel-group trial in 667 patients treated at 19 hospitals in Italy from March 2008 to April 2013.

All patients had been admitted to ICUs after cardiac surgery with early acute kidney injury (≥50% increase of serum creatinine level from baseline or low output of urine for ≥6 hours). A total of 338 received fenoldopam by continuous intravenous infusion for a total of 96 hours or until ICU discharge, while 329 patients received saline infusions.

The primary end point was the rate of renal replacement therapy, and secondary end points included mortality (intensive care unit and 30-day mortality) and the rate of hypotension during study drug infusion.

Study Showed No Benefit, Was Stopped Early

Yale Lampoon – AA Liebow.   1954

Not As a Doctor
[Fourth Year]

These lyrics, sung by John Cole, Jack Gariepy and Ed Ransenhofer to music borrowed from Gilbert and Sullivan’s The Mikado, lampooned Averill Liebow, M.D., a pathologist noted for his demands on students. (CPC stands for clinical pathology conference.)

If you want to know what this is,
it’s a medical CPC
Where we give the house staff
the biz, for there’s no one so
wise as we!
We pathologists show them how,
Although it is too late now.
Our art is a sacred cow!

American physician, born 1911, Stryj in Galicia, Austria (now in Ukraine); died 1978.

Averill Abraham Liebow, born in Austria, was the “founding father” of pulmonary pathology in the United States. He started his career as a pathologist at Yale, where he remained for many years. In 1968 he moved to the University of California School of Medicine, San Diego, where he taught for 7 years as Professor and Chairman, Department of Pathology.

His studies include many classic studies of lung diseases. Best known of these is his famous classification of interstitial lung disease. He also published papers on sclerosing pneumocytoma, pulmonary alveolar proteinosis, meningothelial-like nodules, pulmonary hypertension, pulmonary veno-occlusive disease, lymphomatoid granulomatosis, pulmonary Langerhans cell histiocytosis, pulmonary epithelioid hemangioendothelioma and pulmonary hyalinizing granuloma .

As a Lieutenant Colonel in the US Army Medical Corps, He was a member of the Atomic Bomb Casualty Commission who studied the effects of the atomic bomb in Hiroshima and Nagasaki.

We thank Sanjay Mukhopadhyay, M.D., for information submitted.

As a resident at UCSD, Dr. Liebow held “Organ Recitals” every morning, including Mother’s day.  The organs had to be presented in specified order… heart, lung, and so forth.  On one occasion, we needed a heart for purification of human lactate dehydrogenase for a medical student project, so I presented the lung out of order.  Dr. Liebow asked where the heart was, and I told the group it was noprmal and I froze it for enzyme purification (smiles).  In the future show it to me first. He was generous to those who showed interest.  As I was also doing research in Nathan Kaplan’s laboratory, he made special arrangements for me to mentor Deborah Peters, the daughter of a pulmonary physician, and granddaughter of the Peters who collaborated with Van Slyke.  I mentored many students with great reward since then.  He could look at a slide and tell you what the x-ray looked like.  I didn’t encounter that again until he sent me to the Armed Forces Institute of Pathology, Washington, DC during the Vietnam War and Watergate, and I worked in Orthopedic Pathology with Lent C. Johnson.  He would not review a case without the x-ray, and he taught the radiologists.

Part 3

My Cancer Genome from Vanderbilt University: Matching Tumor Mutations to Therapies & Clinical Trials

Reporter: Aviva Lev-Ari, PhD, RN

My Cancer Genome from Vanderbilt University: Matching Tumor Mutations to Therapies & Clinical Trials


GenomOncology and Vanderbilt-Ingram Cancer Center (VICC) today announced a partnership for the exclusive commercial development of a decision support tool based on My Cancer Genome™, an online precision cancer medicine knowledge resource for physicians, patients, caregivers and researchers.

Through this collaboration, GenomOncology and VICC will enhance My Cancer Genome through the development of a new genomics content management tool. The MyCancerGenome.org website will remain free and open to the public. In addition, GenomOncology will develop a decision support tool based on My Cancer Genome™ data that will enable automated interpretation of mutations in the genome of a patient’s tumor, providing actionable results in hours versus days.

Vanderbilt-Ingram Cancer Center (VICC) launched My Cancer Genome™ in January 2011 as an integral part of their Personalized Cancer Medicine Initiative that helps physicians and researchers track the latest developments in precision cancer medicine and connect with clinical research trials. This web-based information tool is designed to quickly educate clinicians on the rapidly expanding list of genetic mutations that impact cancers and enable the research of treatment options based on specific mutations. For more information on My Cancer Genome™visit www.mycancergenome.org/about/what-is-my-cancer-genome.

Therapies based on the specific genetic alterations that underlie a patient’s cancer not only result in better outcomes but often have less adverse reactions

Up front fee

Nominal fee covers installation support, configuring the Workbench to your specification, designing and developing custom report(s) and training your team.

Per sample fee

GenomOncology is paid on signed-out clinical reports. This philosophy aligns GenomOncology with your Laboratory as we are incentivized to offer world-class support and solutions to differentiate your clinical NGS program. There is no annual license fee.

Part 4

Clinical Trial Services: Foundation Medicine & EmergingMed to Partner

Reporter: Aviva Lev-Ari, PhD, RN

Clinical Trial Services: Foundation Medicine & EmergingMed to Partner


Foundation Medicine and EmergingMed said today that they will partner to offer clinical trial navigation services for health care providers and their patients who have received one of Foundation Medicine’s tumor genomic profiling tests.

The firms will provide concierge services to help physicians

  • identify appropriate clinical trials for patients
  • based on the results of FoundationOne or FoundationOne Heme.

“By providing clinical trial navigation services, we aim to facilitate

  • timely and accurate clinical trial information and enrollment support services for physicians and patients,
  • enabling greater access to treatment options based on the unique genomic profile of a patient’s cancer

Currently, there are over 800 candidate therapies that target genomic alterations in clinical trials,

  • but “patients and physicians must identify and act on relevant options
  • when the patient’s clinical profile is aligned with the often short enrollment window for each trial.

These investigational therapies are an opportunity to engage patients with cancer whose cancer has progressed or returned following standard treatment in a most favorable second option after relapse.  The new service is unique in notifying when new clinical trials emerge that match a patient’s genomic and clinical profile.

Google signs on to Foundation Medicine cancer Dx by offering tests to employees

By Emily Wasserman

Diagnostics luminary Foundation Medicine ($FMI) is generating some upward momentum, fueled by growing revenues and the success of its clinical tests. Tech giant Google ($GOOG) has taken note and is signing onto the company’s cancer diagnostics by offering them to employees.

Foundation Medicine CEO Michael Pellini said during the company’s Q3 earnings call that Google will start covering its DNA tests for employees and their family members suffering from cancer as part of its health benefits portfolio, Reuters reports.

Both sides stand to benefit from the deal, as Google looks to keep a leg up on Silicon Valley competitors and Foundation Medicine expands its cancer diagnostics platform. Last month, Apple ($AAPL) and Facebook ($FB) announced that they would begin covering the cost of egg freezing for female employees. A diagnostics partnership and attractive health benefits could work wonders for Google’s employee retention rates and bottom line.

In the meantime, Cambridge, MA-based Foundation Medicine is charging full speed ahead with its cancer diagnostics platform after filing for an IPO in September 2013. The company chalked up 6,428 clinical tests during Q3 2014, an eye-popping 149% increase year over year, and brought in total revenue for the quarter of $16.4 million–a 100% leap from last year. Foundation Medicine credits the promising numbers in part to new diagnostic partnerships and extended coverage for its tests.

In January, the company teamed up with Novartis ($NVS) to help the drugmaker evaluate potential candidates for its cancer therapies. In April, Foundation Medicine announced that it would develop a companion diagnostic test for a Clovis Oncology ($CLVS) drug under development to treat patients with ovarian cancer, building on an ongoing collaboration between the two companies.

Foundation Medicine also has its sights set on China’s growing diagnostics market, inking a deal in October with WuXi PharmaTech ($WX) that allows the company to perform lab testing for its FoundationOne assay at WuXi’s Shanghai-based Genome Center.

a nod to the deal with Google during a corporate earnings call on Wednesday, according to a person who listened in. Pellini said Google employees were made aware of this new benefit last week.

Foundation Medicine teams with MD Anderson for new trial of cancer Dx

Second study to see if targeted therapy can change patient outcomes

August 15, 2014 | By Joseph Keenan  FierceDiagnostics

Foundation Medicine ($FMI) is teaming up with the MD Anderson Cancer Center in Texas for a new trial of the the Cambridge, MA-based company’s molecular diagnostic cancer test that targets therapies matched to individual patients.

The study is called IMPACT2 (Initiative for Molecular Profiling and Advanced Cancer Therapy) and is designed to build on results from the the first IMPACT study that found

  • 40% of the 1,144 patients enrolled had an identifiable genomic alteration.

The company said that

  • by matching specific gene alterations to therapies,
  • 27% of patients in the first study responded versus
  • 5% with an unmatched treatment, and
  • “progression-free survival” was longer in the matched group.

The FoundationOne molecular diagnostic test

  • combines genetic sequencing and data gathering
  • to help oncologists choose the best treatment for individual patients.

Costing $5,800 per test, FoundationOne’s technology can uncover a large number of genetic alterations for 200 cancer-related genes,

  • blending genomic sequencing, information and clinical practice.

“Based on the IMPACT1 data, a validated, comprehensive profiling approach has already been adopted by many academic and community-based oncology practices,” Vincent Miller, chief medical officer of Foundation Medicine, said in a release. “This study has the potential to yield sufficient evidence necessary to support broader adoption across most newly diagnosed metastatic tumors.”

The company got a boost last month when the New York State Department of Health approved Foundation Medicine’s two initial cancer tests: the FoundationOne test and FoundationOne Heme, which creates a genetic profile for blood cancers. Typically,

  • diagnostics companies struggle to win insurance approval for their tests
  • even after they gain a regulatory approval, leaving revenue growth relatively flat.

However, Foundation Medicine reported earlier this week its Q2 revenue reached $14.5 million compared to $5.9 million for the same period a year ago. Still,

  1. net losses continue to soar as the company ramps up
  2. its commercial and business development operation,
  • hitting $13.7 million versus a $10.1 million deficit in the second quarter of 2013.

Oncology

There has been a remarkable transformation in our understanding of

  • the molecular genetic basis of cancer and its treatment during the past decade or so.

In depth genetic and genomic analysis of cancers has revealed that

  • each cancer type can be sub-classified into many groups based on the genetic profiles and
  • this information can be used to develop new targeted therapies and treatment options for cancer patients.

This panel will explore the technologies that are facilitating our understanding of cancer, and

  • how this information is being used in novel approaches for clinical development and treatment.
Oncology _ Reprted by Dr. Aviva Lev-Ari, Founder, Leaders in Pharmaceutical Intelligence

Opening Speaker & Moderator:

Lynda Chin, M.D.
Department Chair, Department of Genomic Medicine
MD Anderson Cancer Center

  • Who pays for PM?
  • potential of Big data, analytics, Expert systems, so not each MD needs to see all cases, Profile disease to get same treatment
  • business model: IP, Discovery, sharing, ownership — yet accelerate therapy
  • security of healthcare data
  • segmentation of patient population
  • management of data and tracking innovations
  • platforms to be shared for innovations
  • study to be longitudinal,
  • How do we reconcile course of disease with PM
  • phinotyping the disease vs a Patient in wait for cure/treatment

Panelists:

Roy Herbst, M.D., Ph.D.
Ensign Professor of Medicine and Professor of Pharmacology;
Chief of Medical Oncology, Yale Cancer Center and Smilow Cancer Hospital

Development new drugs to match patient, disease and drug – finding the right patient for the right Clinical Trial

  • match patient to drugs
  • partnerships: out of 100 screened patients, 10 had the gene, 5 were able to attend the trial — without the biomarker — all 100 patients would participate for the WRONG drug for them (except the 5)
  • patients wants to participate in trials next to home NOT to have to travel — now it is in the protocol
  • Annotated Databases – clinical Trial informed consent – adaptive design of Clinical Trial vs protocol
  • even Academic MD can’t read the reports on Genomics
  • patients are treated in the community — more training to MDs
  • Five companies collaborating – comparison og 6 drugs in the same class
  • if drug exist and you have the patient — you must apply PM

Summary and Perspective:

The current changes in Biotechnology have been reviewed with an open question about the relationship of In Vitro Diagnostics to Biopharmaceuticals switching, with the potential, particularly in cancer and infectious diseases, to added value in targeted therapy by matching patients to the best potential treatment for a favorable outcome.

This reviewer does not see the movement of the major diagnostics leaders entering into the domain of direct patient care, even though there are signals in that direction.  The Roche example is perhaps the most interesting because Roche already became the elephant in the room after the introduction of Valium,  subsequently bought out Boehringer Mannheim Diagnostics to gain entry into the IVD market, and established a huge presence in Molecular Diagnostics early.  If it did anything to gain a foothold in the treatment realm, it would more likely forge a relationship with Foundation Medicine.  Abbott Laboratories more than a decade ago was overextended, and it had become the leader in IVD as a result of the specialty tests, but it fell into difficulties with quality control of its products in the high volume testing market, and acceeded to Olympus, Roche, and in the mid volume market to Beckman and Siemens.  Of course, Dupont and Kodak, pioneering companies in IVD, both left the market.

The biggest challenge in the long run is identified by the ability to eliminate many treatments that would be failures for a large number of patients. That has already met the proof of concept.  However, when you look at the size of the subgroups, we are not anywhere near a large scale endeavor.  In addition, there is a lot that has to be worked out that is not related to genomic expression by the “classic” model, but has to take into account the emrging knowledge and greater understanding of regulation of cell metabolism, not only in cancer, but also in chronic inflammatory diseases.

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HDL-C: Target of Therapy – Steven E. Nissen, MD, MACC, Cleveland Clinic vs Peter Libby, MD, BWH

Posted in Atherogenic Processes & Pathology, Frontiers in Cardiology and Cardiovascular Disorders, Origins of Cardiovascular Disease, Population Health Management, Genetics & Pharmaceutical, Regulated Clinical Trials: Design, Methods, Components and IRB related issues on November 7, 2014| Leave a Comment »

HDL-C: Target of Therapy – Steven E. Nissen, MD, MACC, Cleveland Clinic vs Peter Libby, MD, BWH

Reporter: Aviva Lev-Ari, PhD, RN

 

UPDATED on 7/29/2018

HDL-C: Is It Time to Stop Calling It the ‘Good’ Cholesterol? – Medscape – Jul 27, 2018.

What triggers dysfunctional HDL? It has long been known that such conditions as acute coronary syndrome,[15] diabetes, or systemic inflammation can alter HDL from a cardioprotective particle to one that promotes inflammation and LDL oxidation.[16] Budoff and fellow investigators for the MESA study suggest that the transition to menopause should be added to that list. In the main MESA cohort, HDL-C was inversely associated with CAD and carotid intima-media thickness (cIMT).[17] In contrast, in almost 1500 postmenopausal women, HDL-C was positively associated with increased cIMT.[18] NMR analysis suggested that small HDL particles are less susceptible to adverse modification at menopause than larger particles. HDL particles were inversely associated with cIMT for men and women—a relationship that held even after adjustment for atherogenic particles.

What to Measure?

If tests for HDL function are not ready for prime time, could measuring the size of the subfractions be the way to go, because very small cholesterol-depleted HDL particles are the main players in cholesterol efflux?[19] This, too, is overly simplistic for Rosenson, who cautioned that there are many subclasses of HDL and they’re not just differentiated by density. There are more than 60 different proteins associated with HDL, but most particles will only carry a few. Which proteins confer which properties is not fully understood either. The flaw with HDL-C–raising therapies, he noted, is that loading up the particle with cholesterol led to the loss of some surface proteins important in cardioprotection.

Both Budoff and Rosenson like non–HDL-C because it captures all atherogenic particles. But what about patients with very high levels of potentially dysfunctional HDL-C? Budoff explained that when he has a patient of uncertain risk with high LDL-C and very high HDL-C, he will get the HDL particle number; such tests are commercially available. He might also suggest she (he can’t remember seeing a man with HDL-C > 100 mg/dL) get a calcium score. “If the coronaries are clean, the HDL is working,” he said.

SOURCE

https://www.medscape.com/viewarticle/899791?src=WNL_infoc_180729_MSCPEDIT_card&uac=93761AJ&impID=1696486&faf=1#vp_2

 

HDL-C – A Solid Prognostic Biomarker

Steven E. Nissen, MD, MACC: I am Steve Nissen, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic. I am here with Dr Peter Libby, chief of cardiology at the Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. We are going to discuss high-density lipoprotein cholesterol (HDL-C), a topic that has been very controversial recently. Peter, HDL-C has been a pretty good biomarker. The question is whether it is a good target.

Peter Libby, MD: Since the early days in Berkley, when they were doing ultracentrifugation, and when it was reinforced and put on the map by the Framingham Study,[1] we have known that HDL-C is an extremely good biomarker of prospective cardiovascular risk with an inverse relationship with all kinds of cardiovascular events. That is as solid a finding as you can get in observational epidemiology. It is a very reliable prospective marker. It’s natural that the pharmaceutical industry and those of us who are interested in risk reduction would focus on HDL-C as a target. That is where the controversies come in.

VIEW VIDEO

http://www.medscape.com/viewarticle/834197?nlid=69312_1984&src=wnl_edit_medn_card&uac=93761AJ&spon=2

 

 

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Twitter is Becoming a Powerful Tool in Science and Medicine

Posted in Academic Publishing, Clinical Diagnostics, Computational Biology/Systems and Bioinformatics, Conference Coverage with Social Media, Curation, Curation methodology, Digital HealthCare – biotech & internet joint ventures, Drug Toxicity, Evolutionary cognition, FDA, FDA Regulatory Affairs, Global Partnering & Biotech Investment, Health Economics and Outcomes Research, HealthCare IT, Interviews with Scientific Leaders, Investment in Technological Breakthrough, Personal Health Applications: Tech Innovations serves HealhCare, Pharmaceutical Analytics, Pharmaceutical Discovery, Pharmacologic toxicities, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Scientific & Biotech Conferences: Press Coverage, tagged #mobilehealth, #science2_0, @science 2_0, Adverse event, Aviva Lev-Ari, Cancer - General, cancer patient management, Clinical trial, Conditions and Diseases, Conference Coverage with Social Media, Content Curation, Curation methodology, Food and Drug Administration, health, https://twitter.com/#!/pharma_BI, medical devices and digital health, medicine, mobile applications, patient outcomes, patient-interaction, Pharmacovigilance, research, science, Social media, Social network, Twitter on November 6, 2014| Leave a Comment »

Twitter is Becoming a Powerful Tool in Science and Medicine

 Curator: Stephen J. Williams, Ph.D.

Article ID #159: Twitter is Becoming a Powerful Tool in Science and Medicine. Published on 11/6/2014

WordCloud Image Produced by Adam Tubman

Updated 4/2016

Life-cycle of Science 2

twittter-logo-2012-370x229

Twitter.com

A recent Science article (Who are the science stars of Twitter?; Sept. 19, 2014) reported the top 50 scientists followed on Twitter. However, the article tended to focus on the use of Twitter as a means to develop popularity, a sort of “Science Kardashian” as they coined it. So the writers at Science developed a “Kardashian Index (K-Index) to determine scientists following and popularity on Twitter.

Now as much buzz Kim Kardashian or a Perez Hilton get on social media, their purpose is solely for entertainment and publicity purposes, the Science sort of fell flat in that it focused mainly on the use of Twitter as a metric for either promotional or public outreach purposes. A notable scientist was mentioned in the article, using Twitter feed to gauge the receptiveness of his presentation. In addition, relying on Twitter for effective public discourse of science is problematic as:

  • Twitter feeds are rapidly updated and older feeds quickly get buried within the “Twittersphere” = LIMITED EXPOSURE TIMEFRAME
  • Short feeds may not provide the access to appropriate and understandable scientific information (The Science Communication Trap) which is explained in The Art of Communicating Science: traps, tips and tasks for the modern-day scientist. “The challenge of clearly communicating the intended scientific message to the public is not insurmountable but requires an understanding of what works and what does not work.” – from Heidi Roop, G.-Martinez-Mendez and K. Mills

However, as highlighted below, Twitter, and other social media platforms are being used in creative ways to enhance the research, medical, and bio investment collaborative, beyond a simple news-feed.  And the power of Twitter can be attributed to two simple features

  1. Ability to organize – through use of the hashtag (#) and handle (@), Twitter assists in the very important task of organizing, indexing, and ANNOTATING content and conversations. A very great article on Why the Hashtag in Probably the Most Powerful Tool on Twitter by Vanessa Doctor explains how hashtags and # search may be as popular as standard web-based browser search. Thorough annotation is crucial for any curation process, which are usually in the form of database tags or keywords. The use of # and @ allows curators to quickly find, index and relate disparate databases to link annotated information together. The discipline of scientific curation requires annotation to assist in the digital preservation, organization, indexing, and access of data and scientific & medical literature. For a description of scientific curation methodologies please see the following links:

Please read the following articles on CURATION

The Methodology of Curation for Scientific Research Findings

Power of Analogy: Curation in Music, Music Critique as a Curation and Curation of Medical Research Findings – A Comparison

Science and Curation: The New Practice of Web 2.0

  1. Information Analytics –

Multiple analytic software packages have been made available to analyze information surrounding Twitter feeds, including Twitter feeds from #chat channels one can set up to cover a meeting, product launch etc.. Some of these tools include:

Twitter Analytics – measures metrics surrounding Tweets including retweets, impressions, engagement, follow rate, …

Twitter Analytics – Hashtags.org – determine most impactful # for your Tweets For example, meeting coverage of bioinvestment conferences or startup presentations using #startup generates automatic retweeting by Startup tweetbot @StartupTweetSF.

 

  1. Tweet Sentiment Analytics

Examples of Twitter Use

A. Scientific Meeting Coverage

  • The 2013 Society of Teachers of Family Medicine Annual Spring Conference. integrated social media with meeting proceedings to enhance conference engagement

In a paper entitled Twitter Use at a Family Medicine Conference: Analyzing #STFM13 authors Ranit Mishori, MD, Frendan Levy, MD, and Benjamin Donvan analyzed the public tweets from the 2013 Society of Teachers of Family Medicine (STFM) conference bearing the meeting-specific hashtag #STFM13. Thirteen percent of conference attendees (181 users) used the #STFM13 to share their thoughts on the meeting (1,818 total tweets) showing a desire for social media interaction at conferences but suggesting growth potential in this area. As we have also seen, the heaviest volume of conference-tweets originated from a small number of Twitter users however most tweets were related to session content.

However, as the authors note, although it is easy to measure common metrics such as number of tweets and retweets, determining quality of engagement from tweets would be important for gauging the value of Twitter-based social-media coverage of medical conferences.

Thea authors compared their results with similar analytics generated by the HealthCare Hashtag Project, a project and database of medically-related hashtag use, coordinated and maintained by the company Symplur.  Symplur’s database includes medical and scientific conference Twitter coverage but also Twitter usuage related to patient care. In this case the database was used to compare meeting tweets and hashtag use with the 2012 STFM conference.

These are some of the published journal articles that have employed Symplur (www.symplur.com) data in their research of Twitter usage in medical conferences.

  • The impact of social media on a major international emergency medicine conference.
    Neill, A., Cronin, J. J., Brannigan, D., O’Sullivan, R., & Cadogan, M. (2013). The impact of social media on a major international emergency medicine conference. Emergency Medicine Journal, emermed-2012. Chicago
  • Social media in radiology: early trends in Twitter microblogging at radiology’s largest international meeting.
    Hawkins, C. M., Duszak, R., & Rawson, J. V. (2014). Social Media in Radiology: Early Trends in Twitter Microblogging at Radiology’s Largest International Meeting. Journal of the American College of Radiology, 11(4), 387-390.
  • International Urology Journal Club via Twitter: 12-Month Experience.
    Thangasamy, I. A., Leveridge, M., Davies, B. J., Finelli, A., Stork, B., & Woo, H. H. (2014). International Urology Journal Club via Twitter: 12-Month Experience. European urology.
  • Use of social media in urology: data from the American Urological Association (AUA).
    Loeb, S., Bayne, C. E., Frey, C., Davies, B. J., Averch, T. D., Woo, H. H., … & Eggener, S. E. (2014). Use of social media in urology: data from the American Urological Association (AUA). BJU international, 113(6), 993-998. Chicago.
  • Social media: A tool to spread information: A case study analysis of Twitter conversation at the Cardiac Society of Australia & New Zealand 61st Annual Scientific Meeting 2013.
    Ferguson, C., Inglis, S. C., Newton, P. J., Cripps, P. J., Macdonald, P. S., & Davidson, P. M. (2014). Social media: A tool to spread information: A case study analysis of Twitter conversation at the Cardiac Society of Australia & New Zealand 61st Annual Scientific Meeting 2013. Collegian.
  • Here, at Leaders in Pharmaceutical Business Intelligence (LBPI) we have integrated our web site, Twitter handle (@pharma_BI), and meeting specific hashtags, with a unique methodology, to monitor and measure meeting participant engagement for various international meetings (please see our Press Coverage section of our site for more information). These meetings included the 2nd Annual Sachs Associates Cancer BioInvestment & Partnering Forum and the 14th Annual Sachs Associates Global Forum.

B. Twitter Usage for Patient Care and Engagement

Although the desire of patients to use and interact with their physicians over social media is increasing, along with increasing health-related social media platforms and applications, there are certain obstacles to patient-health provider social media interaction, including lack of regulatory framework as well as database and security issues. Some of the successes and issues of social media and healthcare are discussed in the post Can Mobile Health Apps Improve Oral-Chemotherapy Adherence? The Benefit of Gamification.

However there is also a concern if social media truly engages the patient and improves patient education. In a study of Twitter communications by breast cancer patients Tweeting about breast cancer, authors noticed Tweeting was a singular event. The majority of tweets did not promote any specific preventive behavior. The authors concluded “Twitter is being used mostly as a one-way communication tool.” (Using Twitter for breast cancer prevention: an analysis of breast cancer awareness month. Thackeray R1, Burton SH, Giraud-Carrier C, Rollins S, Draper CR. BMC Cancer. 2013;13:508).

In addition a new poll by Harris Interactive and HealthDay shows one third of patients want some mobile interaction with their physicians.

Some papers cited in Symplur’s HealthCare Hashtag Project database on patient use of Twitter include:

  • e-Patients in Twitter Hashtag Communities.
    Harmel M, Young K. e-Patients in twitter hashtag communities . J Participat Med. 2013 Jan 16; 5:e22
  • Nurses and Twitter: The good, the bad, and the reluctant.
    Wilson, R., Ranse, J., Cashin, A., & McNamara, P. (2013). Nurses and Twitter: The good, the bad, and the reluctant. Collegian. Chicago.
  • Using social media for continuous professional development.
    Moorley, C., & Chinn, T. (2014). Using social media for continuous professional development. Journal of advanced nursing.
  • Networking opportunities for learning disability nurses.
    Abdulla, S., Marsden, D., Wilson, S., & Parker, M. (2013). Networking opportunities for learning disability nurses: Samuel Abdulla and colleagues explain why social media offer professionals new opportunities for information sharing, discussion and peer support. Learning Disability Practice, 16(5), 30-32.
  • Using Twitter for professional knowledge.
    Kraft, M. A. (2013). Using Twitter for professional knowledge. Journal of the European Association for Health Information and Libraries, 9(4), 10.
  • A Study on the Influence of Semantics on the Analysis of Micro-blog Tags in the Medical Domain.
    Vicient, C., & Moreno, A. (2013). A Study on the Influence of Semantics on the Analysis of Micro-blog Tags in the Medical Domain. In Availability, Reliability, and Security in Information Systems and HCI (pp. 446-459). Springer Berlin Heidelberg.
  • Twitter for Public Health: An Open-source Data Solution.
    Nghiema, S., Mehtab, P., & Taoc, L. Twitter for Public Health: An Open-source Data Solution. Chicago.

C. Twitter Use in Pharmacovigilance to Monitor Adverse Events

Pharmacovigilance is the systematic detection, reporting, collecting, and monitoring of adverse events pre- and post-market of a therapeutic intervention (drug, device, modality e.g.). In a Cutting Edge Information Study, 56% of pharma companies databases are an adverse event channel and more companies are turning to social media to track adverse events (in Pharmacovigilance Teams Turn to Technology for Adverse Event Reporting Needs). In addition there have been many reports (see Digital Drug Safety Surveillance: Monitoring Pharmaceutical Products in Twitter) that show patients are frequently tweeting about their adverse events.

There have been concerns with using Twitter and social media to monitor for adverse events. For example FDA funded a study where a team of researchers from Harvard Medical School and other academic centers examined more than 60,000 tweets, of which 4,401 were manually categorized as resembling adverse events and compared with the FDA pharmacovigilance databases. Problems associated with such social media strategy were inability to obtain extra, needed information from patients and difficulty in separating the relevant Tweets from irrelevant chatter.  The UK has launched a similar program called WEB-RADR to determine if monitoring #drug_reaction could be useful for monitoring adverse events. Many researchers have found the adverse-event related tweets “noisy” due to varied language but had noticed many people do understand some principles of causation including when adverse event subsides after discontinuing the drug.

However Dr. Clark Freifeld, Ph.D., from Boston University and founder of the startup Epidemico, feels his company has the algorithms that can separate out the true adverse events from the junk. According to their web site, their algorithm has high accuracy when compared to the FDA database. Dr. Freifeld admits that Twitter use for pharmacovigilance purposes is probably a starting point for further follow-up, as each patient needs to fill out the four-page forms required for data entry into the FDA database.

D. Use of Twitter in Big Data Analytics

Published on Aug 28, 2012

http://blogs.ischool.berkeley.edu/i29…

Course: Information 290. Analyzing Big Data with Twitter
School of Information
UC Berkeley

Lecture 1: August 23, 2012

Course description:
How to store, process, analyze and make sense of Big Data is of increasing interest and importance to technology companies, a wide range of industries, and academic institutions. In this course, UC Berkeley professors and Twitter engineers will lecture on the most cutting-edge algorithms and software tools for data analytics as applied to Twitter microblog data. Topics will include applied natural language processing algorithms such as sentiment analysis, large scale anomaly detection, real-time search, information diffusion and outbreak detection, trend detection in social streams, recommendation algorithms, and advanced frameworks for distributed computing. Social science perspectives on analyzing social media will also be covered.

This is a hands-on project course in which students are expected to form teams to complete intensive programming and analytics projects using the real-world example of Twitter data and code bases. Engineers from Twitter will help advise student projects, and students will have the option of presenting their final project presentations to an audience of engineers at the headquarters of Twitter in San Francisco (in addition to on campus). Project topics include building on existing infrastructure tools, building Twitter apps, and analyzing Twitter data. Access to data will be provided.

Other posts on this site on USE OF SOCIAL MEDIA AND TWITTER IN HEALTHCARE and Conference Coverage include:

Methodology for Conference Coverage using Social Media: 2014 MassBio Annual Meeting 4/3 – 4/4 2014, Royal Sonesta Hotel, Cambridge, MA

Strategy for Event Joint Promotion: 14th ANNUAL BIOTECH IN EUROPE FORUM For Global Partnering & Investment 9/30 – 10/1/2014 • Congress Center Basel – SACHS Associates, London

REAL TIME Cancer Conference Coverage: A Novel Methodology for Authentic Reporting on Presentations and Discussions launched via Twitter.com @ The 2nd ANNUAL Sachs Cancer Bio Partnering & Investment Forum in Drug Development, 19th March 2014 • New York Academy of Sciences • USA

PCCI’s 7th Annual Roundtable “Crowdfunding for Life Sciences: A Bridge Over Troubled Waters?” May 12 2014 Embassy Suites Hotel, Chesterbrook PA 6:00-9:30 PM

CRISPR-Cas9 Discovery and Development of Programmable Genome Engineering – Gabbay Award Lectures in Biotechnology and Medicine – Hosted by Rosenstiel Basic Medical Sciences Research Center, 10/27/14 3:30PM Brandeis University, Gerstenzang 121

Tweeting on 14th ANNUAL BIOTECH IN EUROPE FORUM For Global Partnering & Investment 9/30 – 10/1/2014 • Congress Center Basel – SACHS Associates, London

http://pharmaceuticalintelligence.com/press-coverage/

Statistical Analysis of Tweet Feeds from the 14th ANNUAL BIOTECH IN EUROPE FORUM For Global Partnering & Investment 9/30 – 10/1/2014 • Congress Center Basel – SACHS Associates, London

1st Pitch Life Science- Philadelphia- What VCs Really Think of your Pitch

What VCs Think about Your Pitch? Panel Summary of 1st Pitch Life Science Philly

How Social Media, Mobile Are Playing a Bigger Part in Healthcare

Can Mobile Health Apps Improve Oral-Chemotherapy Adherence? The Benefit of Gamification.

Medical Applications and FDA regulation of Sensor-enabled Mobile Devices: Apple and the Digital Health Devices Market

E-Medical Records Get A Mobile, Open-Sourced Overhaul By White House Health Design Challenge Winners

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Biotech Chinese and Israeli Strategic Collaboration: Pontifax and WuXi PharmaTech (Cayman) Inc. (NYSE: WX)

Posted in Cell Biology, Gene Regulation and Evolution, Genetics & Pharmaceutical, Genome Biology, Genomic Testing: Methodology for Diagnosis, Global Partnering & Biotech Investment, Medical Devices R&D Investment, Pharmaceutical Discovery, Pharmaceutical Drug Discovery, Pharmaceutical Industry Competitive Intelligence, Pharmaceutical R&D Investment, Pharmacogenomics, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Small Molecules in Development of Therapeutic Drugs, Technology Transfer: Biotech and Pharmaceutical, Translational Science on November 3, 2014| Leave a Comment »

Biotech Chinese and Israeli Strategic Collaboration: Pontifax and WuXi PharmaTech (Cayman) Inc. (NYSE: WX)

UPDATED on 12/15/2015

China’s WuXi raises a $290M VC fund with eyes on ‘cross-border’ biotech bets

By Damian Garde

 

WuXi PharmaTech, China’s largest CRO, closed an oversubscribed $290 million venture fund, turning its attention to biopharma startups at home and in the U.S.

Wuxi PharmaTech CEO Ge Li

The fund, which the company said exceeded its $200 million target, will bankroll investments in early-stage biotech and healthcare companies. WuXi’s first foray into VC, a $63 million fund debuted in 2011, bought the CRO stakes in 18 companies including U.S. biotechs Juno Therapeutics ($JUNO) and Agios Pharmaceuticals ($AGIO), plus Chinese upstarts Hua Medicine and Adagene.

Now WuXi wants to broaden its venture arm and deepen its presence in the growing biotech VC scene on two continents. The company plans to place its bets through deal-scouting offices in Shanghai and Boston, leaning on its fast-growing U.S. operation and decades of work in its native country.

“China and the United States are the two largest and most dynamic healthcare markets in the world and countries where our firm has deep investment expertise and experience,” WuXi Chief Financial Officer Edward Hu said in a statement. “The cross-border nature of our investment strategy and our appetite for early-stage innovation and entrepreneurship have aligned us well with the macro-trends in both countries.”

The move comes a week after WuXi abandoned its public listing and went private in a $3.3 billion deal led by founder and CEO Ge Li. The CRO, on pace for about $800 million in revenue this year, has been broadening its business model beyond traditional outsourced clinical trials, buying big into genomics and signing risk-sharing R&D deals with its pharma partners. And Li, joined by a syndicate of investors, believes its brightest future lies away from the public markets.

– read the statement

Related Articles:

WuXi Healthcare plots a $250M biotech venture fund for U.S., China

CRO giant WuXi is going private in a $3.3B deal

Biotech notches another $2B VC quarter, but can it last?

SOURCE 

From: Gerard Loiseau <gerard.loiseau@bluewin.ch>

Date: Tuesday, December 15, 2015 at 12:38 PM

To: Aviva Lev-Ari <AvivaLev-Ari@alum.berkeley.edu>

Subject: China !!

UPDATED on 11/5/2015

WuXi pads its revenue on the way to a big buyout decision

By Damian Garde

Wuxi PharmaTech CEO Ge Li

Chinese CRO WuXi PharmaTech ($WX) extended its run of quarterly growth on the eve of a shareholder vote that could take the company private in a multibillion-dollar deal.

In the third quarter, WuXi boosted its revenue 23.1% to $213.6 million, driven by 18% growth in lab services, a 19.6% jump in small-molecule manufacturing services and a 66% leap in biologics services. Profits, however, tumbled by nearly 50% to $16.1 million due largely to charges related to foreign exchange and losses tied to joint ventures with PRA Health Sciences ($PRAH) and AstraZeneca ($AZN), the company said.

WuXi is not providing a forward-looking guidance because it is preparing for the possibility of becoming a private company in the coming months. In April a group led by founder and CEO Ge Li made an offer to take the company off the market in a $3.3 billion deal. A special committee formed by WuXi’s board has voted in favor of the transaction, and the idea will come before a shareholder vote on Nov. 25.

If the deal is approved, WuXi will become part of a newly formed parent company through an all-cash transaction that trades $46 for each of WuXi’s American-traded securities. The total represents a 16.5% premium over WuXi’s closing price before the offer came to light.

Meanwhile, the company has continued to expand its business beyond traditional CRO work and more in line with Li’s long-stated vision of becoming “an open-access capability and technology platform that enables anyone and any company [to] discover and develop therapeutic products to benefit patients.” That has meant embracing genomics through its NextCODE subsidiary, which has signed deals with hospitals around the world to provide patient screening, and expanding its footprint to include capacity for cell therapies and other next-generation therapeutics.

WuXi AppTec Launches Representative Office in Israel, Forms Strategic Collaboration with Pontifax

SHANGHAI, Oct. 30, 2014 /PRNewswire/ — WuXi PharmaTech (Cayman) Inc. (NYSE: WX), a leading open-access R&D capability and technology platform company serving the pharmaceutical, biotechnology, and medical device industries, with operations in China and the United States, today announced the establishment of a representative office in the Tel Aviv area of Israel.

The new office will promote WuXi’s broad platform of integrated R&D services to local customers. It will also collaborate with Pontifax, a leading healthcare-dedicated venture capital firm based in Israel, to invest in promising technologies in Israel, particularly those that can potentially advance WuXi’s capabilities.

“We welcome WuXi’s presence in Israel and believe the new representative office will be mutually beneficial to WuXi and the Israeli biotech industry,” said Tomer Kariv, CEO of Pontifax.

“We are excited to establish a presence in Israel and to contribute to one of the most dynamic healthcare innovation ecosystems in the world,” said Dr. Ge Li, chairman and CEO of WuXi PharmaTech. “We value the expertise that Pontifax has developed in Israel’s biotech industry and look forward to working closely with them to help many of their portfolio companies and other startup companies. This step advances WuXi’s mission of helping entrepreneurs in the global life sciences industry to realize their dreams of developing innovative products to benefit the world’s patients.”

About WuXi PharmaTech

WuXi PharmaTech (NYSE: WX) is a leading open-access R&D capability and technology platform company serving the pharmaceutical, biotechnology, and medical device industries, with operations in China and the United States. As a research-driven and customer-focused company, WuXi PharmaTech provides pharmaceutical, biotechnology, and medical device companies with a broad and integrated portfolio of laboratory and manufacturing services throughout the drug and medical device R&D process. WuXi PharmaTech’s services are designed to help its global partners in shortening the cycle and lowering the cost of drug and medical device R&D. The operating subsidiaries of WuXi PharmaTech are known as WuXi AppTec. Please visit http://www.wuxiapptec.com.

For further information please contact:

Dana Yarden, MD, MBA
Executive Director, Israel Business Development
+972-9-9725617 or +972-54-8085692
dana_yarden@wuxiapptec.com

Ronald Aldridge
Director of Investor Relations
+1-201-585-2048
ron_aldridge@wuxiapptec.com

Aaron Shi
Associate Director of Corporate Communications
+86-21-5046-4362
aaron_shi@wuxiapptec.com

SOURCE WuXi PharmaTech

WuXi PharmaTech

Web Site: http://www.wuxiapptec.com

SOURCE

From: “PR Newswire for Journalists” <push_services@prnewswire.com>
Sent: Thursday, October 30, 2014 5:42 PM

Corporate Profile


Services & Solutions by WuXi AppTec WuXi PharmaTech (pronounced woo-shee pharma-tek) is a leading global contract R&D services provider serving the pharmaceutical, biotech, and medical device industries. The company is headquartered in Shanghai and has operations in both China and the United States. We provide a broad and integrated portfolio of laboratory and manufacturing services throughout the R&D process. Our services are designed to help our global partners shorten the time and lower the cost of R&D. The parent company is known as WuXi PharmaTech, and its operating divisions are known as WuXi AppTec (pronounced woo-shee app-tek)
WuXi PharmaTech is the product of the merger in early 2008 of WuXi PharmaTech Inc., a chemistry-based company founded in China in 2000, and AppTec Laboratory Services Inc., a U.S. company founded in 2001 with expertise in medical-device and biologics testing. WuXi PharmaTech Inc. expanded its services rapidly throughout the decade, offering discovery chemistry services in 2001; process development in 2003; research manufacturing in 2004; bioanalytical chemistry in 2005; discovery biology in 2006; toxicology and formulation in 2007; commercial manufacturing in 2009; genomics, clinical trial management and research reagents in 2011; and biologics discovery, development and manufacturing in 2012.Biopharmaceutical and medical device research and development is complex, high-risk, and expensive for our customers. Improving R&D productivity is vitally important not only for the continued success of life sciences companies but also for the health of our families and each of us. Our competitive advantage rests on these elements:

  • an experienced international management team;
  • a highly educated and trained workforce of about 7,000 employees, including about 6,000 scientists, the majority with advanced degrees;
  • broad technical expertise;
  • operational excellence;
  • world-class facilities in both China and the United States;
  • an intense focus on a diversified, high-quality customer base;
  • a flexible contractual approach; and
  • strong procedures to protect customers’ intellectual property.

The company’s client list includes most of the major pharmaceutical and biotechnology companies. As our customers recognize the value we bring, they give WuXi AppTec larger and more valuable contracts. In recognition of the key contributions we made to their success, WuXi AppTec has received awards from leading pharmaceutical customers, including Pfizer, Merck, AstraZeneca, Novartis, Genentech, Millennium, and other companies.

WuXi is recognized as a strong growth company that has delivered solid financial performance since its inception. Revenues totaled $499.9 million and GAAP net income totaled $86.6 million in 2012. Our management has strategies in place to build on this record and to sustain long-term growth. Key drivers of growth in 2012 are our expanding capabilities and capacity and high-quality services in China-based Laboratory Services; increasing utilization of our integrated drug development services for API manufacturing, IND-enabling toxicology studies and IND filings with the China SFDA and global regulatory authorities; strong growth in testing revenues for both biologics and medical devices in our U.S.-based Laboratory Services; an expanding pipeline in both research manufacturing and commercial manufacturing; and the ramp-up of biologics drug discovery, development, and manufacturing services. Success in these areas is expected to deliver strong customer benefit and drive growth in shareholder value for many years to come. Our goal is to be the outsourcing partner of choice from bench to market.

SOURCE
http://ir.wuxiapptec.com/phoenix.zhtml?c=212698&p=irol-homeProfile&t=&id=&

Services and Solutions – WuXi AppTec – WuXi PharmaTech

  • Genome Center

  • Clinical & Regulatory Services

  • Bioanalytical Services

  • Toxicology Services

  • Chemistry Services

  • Medical Device Services

  • Biologics Services

  • Development Services

  • API Development and Manufacturing (STA)

  • Lab Testing Division (LTD)

  • International Discovery Service Unit (IDSU)

  • Discovery Services

  • Biological Reagents – Abgent

  • Unsurpassed Development Capabilities
  • ELITE™ Custom Antibody Service
  • WuXi Venture Fund

Discovery Services

WuXi AppTec provides pharmaceutical discovery services across the entire spectrum of the drug discovery process. Our pharmaceutical discovery services can be fully integrated to provide a flexible and customized solution for client’s specific project needs.

Lab Testing Division (LTD)

Lab Testing Division (LTD) is comprised of seven business units. LTD’s integrated services and solutions in the fields of Chemistry and Biology span from early screening to preclinical development and into clinical sample analysis. Leveraging other established WuXi businesses in MedChem, synthesis and formulation, LTD is well positioned to enable customers to accelerate their discovery processes and empower them to bring new, innovative medicines to patients.

API Development and Manufacturing (STA)

Shanghai Syn-The-All Pharmaceutical Co. Ltd. (“STA”) is a wholly owned subsidiary of WuXi AppTec which provides an integrated platform with “end-to-end” small molecule APIs/intermediates development and manufacturing capabilities from preclinical to commercial stages. We proudly support over 100 life-science clients worldwide and manufacture over 100 APIs per year.

Development Services

WuXi AppTec provides end-to-end API services from process R&D, to API manufacturing at phase I, II, III and commercial scale. The services also include pre-formulation studies, analytical development, stability evaluation and formulation development, all the way to CMC services. All of these services are integrated to help our clients quickly and seamlessly move NCEs from preclinical stage to patients.

Biologics Services

WuXi AppTec provides a seamless, high-quality, single-source approach for the development, testing and manufacture of biotherapeutics. This single- source strategy can reduce the time-to-clinic and can significantly decrease the cost of our customers’ drug development efforts.

Medical Device Services

WuXi AppTec is uniquely positioned to support product development from concept to commercialization, with industry leading comprehensive testing programs that help ensure regulatory submission success.

Chemistry Services

WuXi AppTec offers a complete spectrum of chemistry services, all led by experts in their respective fields: from synthetic chemistry to chiral separations, from small molecule to peptide/peptidomimetics, from nucleoside to fluorinated building blocks, from milligram synthesis to kilogram GLP scale-up, and from reagent service to compound management.

Toxicology Services

WuXi AppTec’s toxicology services feature a full-range of in-vivo and in-vitro non-clinical safety evaluation programs. As the uniqueness of each product requires a case-by-case approach, we partner with clients to ensure that all study components meet specific program objectives.

Bioanalytical Services

WuXi AppTec offers comprehensive and FDA/OECD/SFDA GLP-compliant bioanalysis services to support preclinical and clinical development for small molecule drugs, biologics, vaccines and PD biomarkers.

Clinical and Regulatory Services

WuXi AppTec has strong experience in clinical trial management and regulatory affairs consultation; our experts are able to provide in-depth support to help clients bring new drugs and devices to the market smarter and faster.

Genome Center

WuXi Genome Center is a leading global genomic sequencing provider. It offers a complete solution to tackle biological and clinical challenges by combining components of genomics, bioinformatics, disease biology and clinical expertise to advance drug discovery, clinical development, and personalized medicine.

Biological Reagents

Abgent, a WuXi AppTec company, is a leading provider of antibodies and related services for biomedical research and drug discovery. Our competencies lie in the development of high quality antibodies and related reagents for the study of neurodegenerative diseases, stem cells, autophagy, and model organisms. Our antibodies are rigorously validated and optimized to ensure accurate and consistent performance.

SOURCE

http://www.wuxiapptec.com/services.html
For further information please contact:

Pontifax: Investor Details

Investments

18 Investments in 13 CompaniesExits

2 IPOs

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.7o6U0khk.dpuf

Founders:

Ran Nussbaum, Tomer Kariv

Headquarters:

Herzliya, Israel

  • Office

    8 Hama 3236 Nofim St.

    Herzliya Pituach

    Herzliya, 46725

    ISRAEL

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.7o6U0khk.dpuf

Description:

Venture capital Firm

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.7o6U0khk.dpuf

Current Team (3)

UPDATE

  • Cb default image 98x98

    Tomer Kariv

    Founder and CEO
  • Cb default image 98x98

    Ran Nussbaum

    Co-Founder, Managing Partner, and Partner
  • Cb default image 98x98

    Michael Sela

    Chairman

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.7o6U0khk.dpuf

Founded: 2004
Type: Venture Capital that does Early Stage Venture, Later Stage Venture, and Private Equity InvestmentsSectors:Biotechnology, Health Care, Pharmaceuticals

Pontifax Ltd. is a venture capital firm specialzing in investments in incubation, seed or startups, early, and mid stage. It seeks to invest in life sciences sector. The firm seeks to invest in companies based in Israel

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.7o6U0khk.dpuf

Categories favored by Pontifax

  • Cb default image

    Biotechnology
    8 companies
  • Cb default image

    Health Care
    4 companies
  • Cb default image

    Medical Devices
    2 companies
  • Cb default image

    Pharmaceuticals
    2 companies
  • Cb default image

    Medical
    1 company

– See more at: http://www.crunchbase.com/organization/pontifax/insights/categories#sthash.EKcOI6Ij.dpuf

Investments
18 Investments in 13 CompaniesExits
2 IPOs &
Founders:Ran Nussbaum, Tomer Kariv
Headquarters:HerzliyaDescription:Venture capital Firm

– See more at: http://www.crunchbase.com/organization/pontifax#sthash.fWmB2WSO.dpuf

All Investments made by Pontifax

COMPANY INVESTMENTS
Arno TherapeuticsArno Therapeutics Private Equity

October 30, 2013
HeadSense MedicalHeadSense Medical Not Disclosed

July 8, 2013
Rewalk RoboticsRewalk Robotics Series D

June 17, 2013
TheraCoatTheraCoat Series A

May 21, 2013
cCAM BiotherapeuticscCAM Biotherapeutics Series A

September 15, 2012
Stimatix GIStimatix GI Not Disclosed

March 7, 2011
Avraham PharmaceuticalsAvraham Pharmaceuticals Series A

July 13, 2010
AposenseAposense Not Disclosed

May 23, 2010
Applied Immune TechnologiesApplied Immune Technologies Not Disclosed

April 26, 2010
ProtAbProtAb Series A

April 23, 2010
AposenseAposense Not Disclosed

August 20, 2008
CollplantCollplant Not Disclosed

April 1, 2008
CollplantCollplant Not Disclosed

April, 2007
CollplantCollplant Not Disclosed

February 13, 2007
CollplantCollplant Not Disclosed

September 4, 2006
CritiSenseCritiSense Not Disclosed

June 21, 2006
CritiSenseCritiSense Not Disclosed

June 8, 2005

Pontifax has co-invested with these investors

  • 02b04e0d61d7876150bee2cc466a9e58

    Docor International Management
    4 companies
  • 6096ae9e5d1e3e104436edb08e96b885

    Clal Biotechnology
    3 companies
  • 87efc57ff3eb26ebc027537da4998129

    Arkin Holdings
    1 company
  • Cb default image

    Bargal R&D Investment
    1 company
  • Cb default image

    Bellco Capital
    1 company
  • D3d9166d63a6d7753542c2e1155ba346

    Bridge Investment Fund
    1 company
  • Cb default image

    Commercial Capital LLC
    1 company
  • Cb default image

    Federman & Sons
    1 company
  • 5feb9500716b62dd07cc1d637dea8a52

    GE Healthcare
    1 company
  • E25bdc53bdc114eb8787f37929a4430d

    GE Ventures
    1 company
  • 6441558051350816ddd43bd5d532e323

    HBL Hadasit Bio Holdings
    1 company
  • 931713698c5e38fd2028106b946a14f6

    Israel Healthcare Ventures
    1 company
  • Cb default image

    Meitav Underwriting
    1 company
  • Cb default image

    Modgal Industries
    1 company
  • B1ce9d2887c930e2d5d82b64a7eebcb9

    OrbiMed Advisors
    1 company
  • Dtnvqetcgpwkkob18g1a

    OurCrowd
    1 company
  • 63acf575568e1a1288d8b5f8ceb3dfec

    Perceptive Advisors
    1 company
  • A3b47ab6cbb85e3ab8926172b9cd18a2

    Phoenix Insurance
    1 company
  • 704ba721dc396d01f5a4344ba79e333e

    Polar Investments
    1 company
  • Cb default image

    Sabby Capital
    1 company
  • Bcce6ed0baba102b263072bdf2049689

    SCP Vitalife Partners
    1 company
  • 6a662c8686252f8a1ffbdeaea9afbe82

    Shanghai Fosun Pharmaceutical
    1 company
  • Cfh1qsicbmkzr9limcuc

    Soros Fund Management
    1 company
  • Cb default image

    Technorov
    1 company
  • 69cf5930576ab39c372bd903593a14f6

    U.S. Venture Partners
    1 company
  • 1abc8818a43c22fb044e9a0b03db8d4e

    Yissum Research Development
    1 company
  • 12e735385fa05514d54620da463f0045

    Ziegler Meditech Equity Partners
    1 company
SOURCE
The Business Graph

410 Townsend Street
San Francisco, CA 94107

– See more at: http://www.crunchbase.com/organization/pontifax/insights/co-investors#sthash.ivYx5BBy.dpuf

– See more at: http://www.crunchbase.com/organization/pontifax/investments#sthash.DB87s0tR.dpuf

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