Imaging atlas for eligibility and on-study safety of potential knee adverse events in anti-NGF studies (Part 1).

Monoclonal antibodies that bind and inhibit nerve growth factor (NGF) have demonstrated both, good analgesic efficacy and improvement in function in patients with osteoarthritis (OA). Despite initial promising data, trials in OA had been suspended by the Federal Food and Drug Administration (FDA) due to concerns over accelerated rates of OA progression. Imaging will play a crucial role in future clinical trials to define eligibility of potential participants and to monitor safety during the course of these studies. This will require baseline and frequent follow-up radiographs of both, the index joints and other large weight bearing joints to identify subjects at risk prior inclusion and on study so treatment can be discontinued. This imaging overview in the form of an atlas describes and illustrates potential exclusionary joint imaging findings at eligibility and potential adverse joint events on radiography and magnetic resonance imaging (MRI) in studies investigating a-NGF compounds. The overarching goal of this atlas is to facilitate trial design and to promote a common language and understanding between potential expert readers. This first section of the atlas will focus on knee joint specific findings that are relevant to a-NGF studies.

Imaging atlas for eligibility and on-study safety of potential hip adverse events in anti-NGF studies (Part 2).

Recently, nerve growth factor (NGF) inhibitors have been introduced for treatment of osteoarthritis (OA) symptoms, and have shown good analgesic efficacy and improvement in function in patients with OA. However, anti- (a-)NGF trials in OA had been suspended by the U.S. Food and Drug Administration (FDA) due to concerns over accelerated rates of OA progression and osteonecrosis. Since a-NGF therapies offer potential as the first new class of analgesics for many years, future studies assessing a-NGF compounds will have to follow stringent eligibility criteria and will require a rigorous safety monitoring. Imaging is paramount to identify potential negative outcomes as early as possible. These imaging findings include atrophic OA, osteonecrosis and others at eligibility and especially rapid progressive OA (RPOA) during the course of treatment. This second part of the a-NGF imaging atlas will present specific hip joint imaging findings that are relevant for eligibility and safety and represent potential adverse joint events on radiography and magnetic resonance imaging (MRI) in studies investigating a-NGF compounds. Researchers and clinicians should become familiar with several of these entities, and especially osteonecrosis of the hip and insufficiency fractures are relatively common findings in such a patient population. As several of these diagnoses may only be detected at late stages using radiographic methods, MRI plays an important role in identifying such pathologies early and at potentially still reversible stages before irreversible joint destruction has occurred.

Imaging atlas for eligibility and on-study safety of potential shoulder adverse events in anti-NGF studies (Part 3).

Despite promising results, the U.S. Food and Drug Administration (FDA) put on hold trials assessing anti-nerve growth factor (a-NGF) compounds due to concerns over accelerated rates of OA progression. The mechanism of these events is unclear but joint adverse events were observed particularly in patients using a-NGFs in combination with non-steroidal anti-inflammatory drugs (NSAIDs), suggesting that the significantly greater analgesic effect of these separate classes of drugs prompted patients to permit increased joint load without experiencing the usual pain that would limit joint stress. Development of a-NGF drugs is continuing with stringent safety criteria included in future trials as a-NGF therapies offer potential as the first new class of analgesics in many years. Potential imaging joint safety findings and exclusionary criteria for eligibility for the large weight bearing joints were presented in parts I and II of this atlas. The shoulder as a non-weight bearing joint is likely to be less affected by increased loading due to efficacious pain reduction. However, it remains prone to degeneration especially due to concomitant rotator cuff pathology and previous trauma and inflammatory disorders. This third part of the atlas illustrates imaging findings relevant for eligibility and potential joint safety findings such as osteonecrosis, incidental findings such as large cystic lesions, inflammatory disorders, bone marrow disorders and metastases.

OARSI Clinical Trials Recommendations: Hip imaging in clinical trials in osteoarthritis.

Imaging of hip in osteoarthritis (OA) has seen considerable progress in the past decade, with the introduction of new techniques that may be more sensitive to structural disease changes. The purpose of this expert opinion, consensus driven recommendation is to provide detail on how to apply hip imaging in disease modifying clinical trials. It includes information on acquisition methods/techniques (including guidance on positioning for radiography, sequence/protocol recommendations/hardware for magnetic resonance imaging (MRI)); commonly encountered problems (including positioning, hardware and coil failures, artifacts associated with various MRI sequences); quality assurance/control procedures; measurement methods; measurement performance (reliability, responsiveness, and validity); recommendations for trials; and research recommendations.

OARSI Clinical Trials Recommendations: Knee imaging in clinical trials in osteoarthritis.

Significant advances have occurred in our understanding of the pathogenesis of knee osteoarthritis (OA) and some recent trials have demonstrated the potential for modification of the disease course. The purpose of this expert opinion, consensus driven exercise is to provide detail on how one might use and apply knee imaging in knee OA trials. It includes information on acquisition methods/techniques (including guidance on positioning for radiography, sequence/protocol recommendations/hardware for magnetic resonance imaging (MRI)); commonly encountered problems (including positioning, hardware and coil failures, sequences artifacts); quality assurance (QA)/control procedures; measurement methods; measurement performance (reliability, responsiveness, validity); recommendations for trials; and research recommendations.

OARSI Clinical Trials Recommendations: Hand imaging in clinical trials in osteoarthritis.

Tremendous advances have occurred in our understanding of the pathogenesis of hand osteoarthritis (OA) and these are beginning to be applied to trials targeted at modification of the disease course. The purpose of this expert opinion, consensus driven exercise is to provide detail on how one might use and apply hand imaging assessments in disease modifying clinical trials. It includes information on acquisition methods/techniques (including guidance on positioning for radiography, sequence/protocol recommendations/hardware for MRI); commonly encountered problems (including positioning, hardware and coil failures, sequences artifacts); quality assurance/control procedures; measurement methods; measurement performance (reliability, responsiveness, validity); recommendations for trials; and research recommendations.

A double-blind, randomized, Phase III, multicenter study in 358 pediatric subjects receiving isotretinoin therapy demonstrates no effect on pediatric bone mineral density.

UNLABELLED: This study compared the effects of pediatric acne treatment with two isotretinoin formulations on bone mineral density. We demonstrated no difference in the effect of the two formulations. No effect on pediatric bone mineral density was identified for either formulation. INTRODUCTION: Isotretinoin (13-cis-retinoic acid) is a treatment for recalcitrant nodular acne with a purported effect on bone mineral density (BMD). The side effects of isotretinoin on vertebral bone were evaluated to assess the safety of a new FDA-approved isotretinoin formulation: Lidose-isotretinoin (Cip-Iso). METHODS: This double-blind, randomized, phase III, active control, parallel-group, multicenter study compared the safety, efficacy, and non-inferiority of CIP-Iso to a marketed reference product, Accutane®, in severe recalcitrant nodular acne subjects. Three hundred fifty-eight pediatric male and female subjects aged between 12 and 17 years underwent 20 weeks of treatment with PA lumbar spine dual X-ray absorptiometry (DXA) measurements obtained for bone mineral density (BMD) and Z-scores, 5.5 months apart on visits 1 and 8. One hundred sixty-eight of 358 subjects had height adjusted Z-scores (HAZ) calculated. RESULTS: There was no difference in the least squares (LS) mean Z-score or HAZ of the two drugs at visit 1 or 8. The mean and LS mean Z-score and HAZ were greater than zero at visits 1 and 8 for both drugs. The change in the LS mean spine Z-score, but not HAZ, between visits, was statistically significant for both drugs. There was a mean increase in BMD (g/cm(2)) for both products between visits. CONCLUSIONS: There is no difference in the effect of two formulations of isotretinoin on spine bone density after 6 months of treatment. BMD increased and the small change in spine Z-score over treatment disappeared after height adjustment. Mean positive Z-scores and HAZ in the study were likely due to the exclusion of low and inclusion of high Z-score subjects.

Imaging of cartilage and bone: promises and pitfalls in clinical trials of osteoarthritis.

Imaging in clinical trials is used to evaluate subject eligibility, and/or efficacy of intervention, supporting decision making in drug development by ascertaining treatment effects on joint structure. This review focusses on imaging of bone and cartilage in clinical trials of (knee) osteoarthritis. We narratively review the full-text literature on imaging of bone and cartilage, adding primary experience in the implementation of imaging methods in clinical trials. Aims and constraints of applying imaging in clinical trials are outlined. The specific uses of semi-quantitative and quantitative imaging biomarkers of bone and cartilage in osteoarthritis trials are summarized, focusing on radiography and magnetic resonance imaging (MRI). Studies having compared both imaging methodologies directly and those having established a relationship between imaging biomarkers and clinical outcomes are highlighted. To make this review of practical use, recommendations are provided as to which imaging protocols are ideal for capturing specific aspects of bone and cartilage tissue, and pitfalls in their usage are highlighted. Further, the longitudinal sensitivity to change, of different imaging methods is reported for various patient strata. From these power calculations can be accomplished, provided the strength of the treatment effect is known. In conclusion, current imaging methodologies provide powerful tools for scoring and measuring morphological and compositional aspects of most articular tissues, capturing longitudinal change with reasonable to excellent sensitivity. When employed properly, imaging has tremendous potential for ascertaining treatment effects on various joint structures, potentially over shorter time scales than required for demonstrating effects on clinical outcomes.

Conversion of S-phenylsulfonylcysteine residues to mixed disulfides at pH 4.0: utility in protein thiol blocking and in protein-S-nitrosothiol detection.

A three step protocol for protein S-nitrosothiol conversion to fluorescent mixed disulfides with purified proteins, referred to as the thiosulfonate switch, is explored which involves: (1) thiol blocking at pH 4.0 using S-phenylsulfonylcysteine (SPSC); (2) trapping of protein S-nitrosothiols as their S-phenylsulfonylcysteines employing sodium benzenesulfinate; and (3) tagging the protein thiosulfonate with a fluorescent rhodamine based probe bearing a reactive thiol (Rhod-SH), which forms a mixed disulfide between the probe and the formerly S-nitrosated cysteine residue. S-Nitrosated bovine serum albumin and the S-nitrosated C-terminally truncated form of AdhR-SH (alcohol dehydrogenase regulator) designated as AdhR*-SNO were selectively labelled by the thiosulfonate switch both individually and in protein mixtures containing free thiols. This protocol features the facile reaction of thiols with S-phenylsulfonylcysteines forming mixed disulfides at mild acidic pH (pH = 4.0) in both the initial blocking step as well as in the conversion of protein-S-sulfonylcysteines to form stable fluorescent disulfides. Labelling was monitored by TOF-MS and gel electrophoresis. Proteolysis and peptide analysis of the resulting digest identified the cysteine residues containing mixed disulfides bearing the fluorescent probe, Rhod-SH.

Hormone-sensitive lipase: sequence, expression, and chromosomal localization to 19 cent-q13.3.

Hormone-sensitive lipase, a key enzyme in fatty acid mobilization, overall energy homeostasis, and possibly steroidogenesis, is acutely controlled through reversible phosphorylation by catecholamines and insulin. The 757-amino acid sequence predicted from a cloned rat adipocyte complementary DNA showed no homology with any other known lipase or protein. The activity-controlling phosphorylation site was localized to Ser563 in a markedly hydrophilic domain, and a lipid-binding consensus site was tentatively identified. One or several messenger RNA species (3.3, 3.5, or 3.9 kilobases) were expressed in adipose and steroidogenic tissues and heart and skeletal muscle. The human hormone-sensitive lipase gene mapped to chromosome 19 cent-q13.3.

Vinorelbine tartrate and paclitaxel combinations: enhanced activity against in vivo P388 murine leukemia cells.

BACKGROUND: Many critical cellular functions such as mitosis, cell movement, and maintenance of cell structure are performed by microtubules. Antimicrotubule agents (which disrupt or block the formation of microtubules) are among the most widely used anticancer drugs and have contributed to the curative therapy of many neoplasms. Recently, two new antimicrotubule agents, vinorelbine tartrate (Navelbine) and paclitaxel (Taxol) have demonstrated clinical activity against ovarian, breast, and non-small-cell lung carcinomas. These agents target microtubules at different sites, and they both interfere with mitotic spindle function. Since vinorelbine tartrate and paclitaxel have shown a similar antitumor profile in clinical trials thus far, it is reasonable to expect that they may be used interchangeably in some combination therapies or perhaps with each other in the same treatment regimen. PURPOSE: On the basis of their similar activity profile in clinical trials, we decided to investigate the therapeutic outcome of a vinorelbine tartrate and paclitaxel binary drug combination, even though they appeared to have overlapping toxic effects. We wanted to ascertain the effect of this binary drug combination, in an in vivo setting, as it related to host toxicity and antitumor activity. METHODS: CDF-1 female mice that were implanted intraperitoneally with one million P388 murine leukemia cells were treated intraperitoneally with vinorelbine tartrate, paclitaxel, or a combination of the two drugs on a day-1, -5, and -9 dosing schedule. Experimental groups had between five and eight mice per group. Vinorelbine tartrate was administered at either 8, 12, 16, 20, or 24 mg/kg and paclitaxel at either 4.5, 18, or 36 mg/kg. RESULTS: As single agents, neither vinorelbine tartrate nor paclitaxel generated meaningful numbers of 60-day cures (i.e., tumor free at day 60). In contrast, optimal combination regimens produced 60-day cures in more than 80% of the mice. The LD10 (dose lethal to 10% of the mice) of vinorelbine tartrate increased approximately 2.5-fold in the presence of paclitaxel and allowed otherwise lethal vinorelbine tartrate doses to be administered safely, which may have contributed to the antitumor efficacy of the combinations. The effect of the time delay between vinorelbine tartrate and paclitaxel administration on toxicity and cures appeared to be contingent on the vinorelbine tartrate dose. CONCLUSIONS: Results suggest that the overlapping toxic effects of vinorelbine tartrate and paclitaxel might not be a deterrent to their use in combination drug therapy. When used appropriately, rather than having enhanced toxic effects, otherwise toxic doses were better tolerated and survival improved over single-agent therapy.

Role of the immune response during neuro-attenuated herpes simplex virus-mediated tumor destruction in a murine intracranial melanoma model.

Neuro-attenuated herpes simplex virus-1 (HSV-1) gamma34.5 mutants can slow progression of preformed tumors and lead to complete regression of some tumors. However, the role of the immune response in this process is poorly understood. Syngenic DBA/2 tumor-bearing mice treated with HSV-1 1716 fourteen days after tumor implantation had significant prolongation in survival when compared with mice treated with viral growth sera (mock; 38.9 +/- 2.3 versus 24.9 +/- 0.6, respectively; P < 0.0001). Additionally, 60% of the animals treated on day 7 had complete regression of the tumors. However, no difference was observed in the mean survival rates of viral- or mock-treated tumor-bearing SCID mice (15 +/- 1.7 versus 14.8 +/- 2.2, respectively). When DBA/2 mice syngenic for the tumor were depleted of leukocytes by cyclophosphamide administration (before and during viral administration), there was again no significant difference observed in the survival times (19.0 +/- 1.9 versus 19.5 +/- 2.7, respectively). These data demonstrate that the immune response contributes to the viral-mediated tumor destruction and the increase in survival. Immune cell infiltration was up-regulated, specifically CD4+ T cells and macrophages (which are found early after viral administration). Prior immunity to HSV-1 increased survival times of treated mice over those of naive mice, an important consideration because 50-95% of the adult human population is sero-positive for HSV-1. Our results imply that the timing of viral administration and the immune status of the animals will be an important consideration in determining the effectiveness of viral therapies.

Processing of the N termini of nascent polypeptide chains requires deformylation prior to methionine removal.

N-formyl-methionine termini are formed in the initiation reaction of bacterial protein synthesis and processed during elongation of the nascent polypeptide chain. We report that the formyl group must be removed before the methionine residue can be cleaved by methionine aminopeptidase. This has long been implicitly assumed, but that assumption was based on inconclusive data and was in apparent conflict with more recently published data. We demonstrate that the Salmonella typhimurium methionine aminopeptidase is totally inactive on an N-formyl-methionyl peptide in vitro, and present a detailed characterization of the substrate specificity of this key enzyme by use of a very sensitive and quantitative assay. Finally, a reporter protein expressed in a strain lacking peptide deformylase was shown to retain the formyl group confirming the physiological role of the deformylase.

Two chemotactic factors, C5a and MIP-1alpha, dramatically alter the mortality from zymosan-induced multiple organ dysfunction syndrome (MODS): C5a contributes to MODS while MIP-1alpha has a protective role.

Multiple organ dysfunction syndrome (MODS) is a major cause of morbidity and mortality in surgical intensive care units. It is characterized by progressive failure of two or more organs remote from the origin of injury. Since MODS results from a severe generalized inflammatory response, both chemokines and complement have had a proposed role in its pathophysiology. The availability of macrophage inflammatory protein 1 alpha (MIP-1alpha) knockout mice and congenic C5-deficient and C5-sufficient mice allowed us to investigate the individual contribution of these immune modulators in MODS. It has been demonstrated in this assay that MIP-1alpha has a protective role against MODS mortality, while C5a contributes to MODS mortality. Using a zymosan-induced MODS murine model, the absence of MIP-1alpha increased mortality four-fold, whereas the absence of C5 decreased mortality four-fold. Therefore, MIP-1alpha-dependent mediators are essential in the prevention of MODS related deaths, while C5-dependent mediators of inflammation can be considered to be contributing to the development of MODS related deaths.

Catalytic and noncatalytic nucleotide binding sites of chloroplast F1 ATPase. Photoaffinity labeling and peptide sequencing.

Exposure of chloroplast F1 ATPase to 2-azido-ATP results in the noncovalent tight binding of 2-azido-ATP or 2-azido-ADP to noncatalytic or to catalytic sites. Subsequent photolysis results in covalent labeling of adjacent tryptic peptides of the beta-subunit. Binding at noncatalytic sites results in labeling of tyrosine 385 by an ATP or an ADP moiety. Binding at catalytic sites results in labeling of tyrosine 362 by only an ADP moiety. Similar labeling patterns are observed for the heat-activated or the membrane-bound enzymes.

Acute skin injury releases neutrophil chemoattractants.

BACKGROUND: Progressive or ongoing skin necrosis after traumatic injury is well known. Experimental evidence has associated these events with neutrophil activation and secondary oxidant injury. To determine the mechanism by which neutrophils migrate to a site of injury, cytokine release from injured skin was measured. METHODS: Twenty-five skin biopsy specimens of acute partial thickness skin injuries were compared with uninjured skin of the same patient. Conditioned medium from explanted skin was assayed for tumor necrosis factor (TNF), interleukin-6 (IL-6), and IL-8. RESULTS: Acute skin injury resulted in a significant release of IL-8 but not IL-6 or TNF. In eight patients gradient cytokine release was found; IL-8 levels for partial thickness burn were 26.4 ng/ml, for unburned skin adjacent to the burn were 2.1 ng/ml, and for distal normal skin were 0.2 ng/ml. CONCLUSIONS: IL-8 is released from acutely injured skin; IL-6 and TNF are not. This selective release suggests a mechanism whereby neutrophils are recruited into injured tissue. These neutrophils might then induce further injury, increasing the extent of posttraumatic tissue loss.

Transpetrosal approach: surgical anatomy and technique.

Transpetrosal operations have been shown to offer distinct advantages over traditional operations in approaching lesions of the petroclival area. Confusion about these approaches exists due to the variety of names given to these procedures and the lack of detailed descriptions needed to perform them. After extensive review of the literature, we have determined that all transpetrosal techniques fall into one of two categories: anterior petrosectomy or posterior petrosectomy. Combining one of these procedures with existing conventional procedures accurately describes all existing transpetrosal operations and eliminates confusion over nomenclature. In addition, through a series of cadaveric dissections and operative experience, we have detailed each of these procedures as a series of steps that will enable the surgeon to understand the unfamiliar anatomy of the temporal bone and to perform these transpetrosal techniques.

The far lateral/combined supra- and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem.

A far lateral approach to the ventral brain stem, lower clivus, and anterior foramen magnum is described. Methods for further exposure of the superior petroclival region by incorporating a subtemporal craniotomy and posterior petrosectomy are also demonstrated. Eight sequentially illustrated steps depict this technique. The far lateral/combined supra- and infratentorial exposure is a comprehensive surgical approach that provides direct access to the entire anterior and lateral brain stem and craniovertebral junction. It minimizes brain-stem retraction and maximizes visualization of the neurovascular structures.