De-escalating radiotherapy in HPV-positive oropharyngeal squamous cell carcinoma: how much is too little?

Oropharyngeal squamous cell carcinoma (OPSCC) had a rapidly increasing incidence rate in high-income countries, with a significant increase in cases related to human papilloma virus (HPV). HPV-positive (HPV+) OPSCC has shown better survival rates compared with HPV-negative (HPV-) cases, prompting investigations into de-escalation strategies to reduce or change chemoradiotherapy protocols. We present a case of a patient with HPV+ OPSCC who discontinued chemoradiotherapy after 2 weeks, effectively receiving a de-escalated dose of 18 Gy over nine fractions and only one cycle of cisplatin, subsequently undergoing curative surgical resection with no residual disease in the radiotherapy field 14 years later. This case challenges the concept of standard radiotherapy dosing in HPV+ OPSCC and discusses the implications on future de-escalation trials.

Bacterial sensitivity to chlorhexidine and povidone-iodine antiseptics over time: a systematic review and meta-analysis of human-derived data.

Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis, minimising SSIs. There is concern that  resistance to topical biocides may be emergeing, although the potential clinical implications remain unclear. The objective of this systematic review was to determine whether the minimum bactericidal concentration (MBC) of topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. We included studies reporting the MBC of laboratory and clinical isolates of common microbes to CHX and PVI. We excluded studies using non-human samples and antimicrobial solvents or mixtures with other active substances. MBC was pooled in random effects meta-analyses and the change in MBC over time was explored using meta-regression. Seventy-nine studies were included, analysing 6218 microbes over 45 years. Most studies investigated CHX (93%), with insufficient data for meta-analysis of PVI. There was no change in the MBC of CHX to Staphylococci or Streptococci over time. Overall, we find no evidence of reduced susceptibility of common SSI-causing microbes to CHX over time. This provides reassurance and confidence in the worldwide guidance that CHX should remain the first-choice agent for surgical skin antisepsis.

A new standardized electrochemical array for drug metabolic profiling with human cytochromes P450.

Over the past two decades, a wealth of information on the human cytochrome P450 enzymes and their role in drug metabolism both in vitro and in vivo has been gathered. Our understanding of this area has progressed greatly, but our confidence in the development of quantitative projections of drug interactions, made from in vitro data, is somehow still shaky. There are therefore no doubts in the necessity for reliable and fast methodologies for P450 drug metabolism analysis, capable of providing accurate and precise in vitro data. This paper reports on the first integration of a P450-electrode into a microtiter plate format for the rapid determination of the affinity parameters (K(M)) for a set of known drugs. The most relevant human drug metabolizing cytochromes P450, isoforms 3A4, 2D6, and 2C9, have been covalently bound to a gold electrode via a 10-carboxydecanethiol and 8-hydroxyoctanethiol (1:1) self-assembled monolayer at the bottom of an eight-well microtiter plate. The electrochemical response of the P450-electrode and the performance of the platform have been validated using a set of 30 known drugs with K(M) values spanning from less than 1 to more than 100 µM. The K(M) values obtained using this platform show an excellent error, and their ranking is within the range of those present in the literature determined from conventional incubation experiments with cytochrome P450s 3A4, 2D6, and 2C9.

Enzyme-based amperometric platform to determine the polymorphic response in drug metabolism by cytochromes P450.

"Personalized medicine" is a new concept in health care, one aspect of which defines the specificity and dosage of drugs according to effectiveness and safety for each patient. Dosage strongly depends from the rate of metabolism which is primarily regulated by the activity of cytochrome P450. In addition to the need for a genetic characterization of the patients, there is also the necessity to determine the drug-clearance properties of the polymorphic P450 enzyme. To address this issue, human P450 2D6 and 2C9 were engineered and covalently linked to an electrode surface allowing fast, accurate, and reliable measurements of the kinetic parameters of these phase-1 drug metabolizing polymorphic enzymes. In particular, the catalytic activity of P450 2C9 on the electrode surface was found to be improved when expressed from a gene-fusion with flavodoxin from Desulfovibrio vulgaris (2C9/FLD). The results are validated using marker drugs for these enzymes, bufuralol for 2D6, and warfarin for 2C9/FLD. The platform is able to measure the same small differences in K(M), and it allows a fast and reproducible mean to generated the product identified by HPLC from which the k(cat) is calculated.

An electrochemical microfluidic platform for human P450 drug metabolism profiling.

This paper is the first report of a P450-electrode in a microfluidic format. A 30 µL microfluidic cell was made in poly(methyl methacrylate) containing the inlet, outlet, and reaction chamber with two electrode strips, one of which contains the human cytochrome P450 3A4 covalently bound to gold via a 6-hexanethiol and 7-mercaptoheptanoic acid (1:1) self-assembled monolayer. The electrochemical response of the P450-electrode in the microfluidic cell was tested using four drugs that are known substrates of P450 3A4: quinidine, nifedipine, alosetron and ondansetron. Titration experiments allowed the electrochemical measurements of K(M) for the four drugs, with values of 2.9, 29.1, 113.4, and 114.1 mM, respectively. The K(M) values are found to be in good agreement and correctly ranked with respect to the published literature on human liver microsomes and baculosomes: [ondansetron ≈ alosetron > nifedipine > quinidine]. The results presented in this paper represent a step forward for a rapid evaluation of the interaction of P450 and drug, requiring small volumes of new chemical entities to be tested.

Direct electrochemistry of drug metabolizing human flavin-containing monooxygenase: electrochemical turnover of benzydamine and tamoxifen.

This communication reports on the first electrochemical study of the human flavin-containing monooxygenase 3 (hFMO3) either absorbed or covalently linked to different electrode surfaces. Glassy carbon and gold electrodes gave reversible electrochemical signals of an active hFMO3. The midpoint potential measured for the immobilized enzyme on a glassy carbon electrode was -445 +/- 8 mV (versus Ag/AgCl). A monolayer coverage was obtained on gold functionalized with dithio-bismaleimidoethane that covalently linked surface accessible cysteines of hFMO3. A structural model of the enzyme was generated to rationalize electrochemistry results. The turnover of the active enzyme was measured with two specific drugs: tamoxifen and benzydamine. For tamoxifen, 1.7 and 8.0 microM of its N-oxide product were formed by the enzyme immobilized on glassy carbon and gold electrodes, respectively. In the case of benzydamine, a K(M) of 44 +/- 5 microM was measured upon application of a -600 mV bias to the enzyme immobilized on the glassy carbon electrode that is in good agreement with the values published for microsomal hFMO3 where NADPH is the electron donor.

Engineering human cytochrome P450 enzymes into catalytically self-sufficient chimeras using molecular Lego.

The membrane-bound human cytochrome P450s have essential roles in the metabolism of endogenous compounds and drugs. Presented here are the results on the construction and characterization of three fusion proteins containing the N-terminally modified human cytochrome P450s CYP2C9, CY2C19 and CYP3A4 fused to the soluble NADPH-dependent oxidoreductase domain of CYP102A1 from Bacillus megaterium. The constructs, CYP2C9/BMR, CYP2C19/BMR and CYP3A4/BMR are well expressed in Escherichia coli as holo proteins. The chimeras can be purified in the absence of detergent and the purified enzymes are both active and correctly folded in the absence of detergent, as demonstrated by circular dichroism and functional studies. Additionally, in comparison with the parent P450 enzyme, these chimeras have greatly improved solubility properties. The chimeras are catalytically self-sufficient and present turnover rates similar to those reported for the native enzymes in reconstituted systems, unlike previously reported mammalian cytochrome P450 fusion proteins. Furthermore the specific activities of these chimeras are not dependent on the enzyme concentration present in the reaction buffer and they do not require the addition of accessory proteins, detergents or phospholipids to be fully active. The solubility, catalytic self-sufficiency and wild-type like activities of these chimeras would greatly simplify the studies of cytochrome P450 mediated drug metabolism in solution.