Randomised clinical trial: a phase 1, dose-ranging study of the anti-matrix metalloproteinase-9 monoclonal antibody GS-5745 versus placebo for ulcerative colitis.

BACKGROUND: Matrix metalloproteinase-9 is a proteolytic enzyme whose expression is increased in ulcerative colitis. AIM: To evaluate the safety and efficacy of GS-5745, a fully humanised anti-matrix metalloproteinase-9 monoclonal antibody, in moderately-to-severely active ulcerative colitis. METHODS: We randomised 74 patients with ulcerative colitis to treatment with single or multiple ascending intravenous or subcutaneous doses of GS-5745 or placebo. Multiple-dose cohorts received either IV infusions (0.3, 1.0, 2.5 or 5.0 mg/kg GS-5745 or placebo) every 2 weeks (three total IV infusions) or five weekly SC injections (150 mg GS-5745 or placebo). The primary outcomes were the safety, tolerability and pharmacokinetics of escalating single and multiple doses of GS-5745. Exploratory analyses in the multiple-dose cohorts included clinical response (≥3 points or 30% decrease from baseline in Mayo Clinic score and ≥1 point decrease in the rectal bleeding subscore or a rectal bleeding subscore ≤1) and clinical remission (a complete Mayo Clinic score ≤2 with no subscore >1) at Day 36. Biological effects associated with a clinical response to GS-5745 were explored using histological and molecular approaches. RESULTS: Twenty-three of the 42 patients (55%) receiving multiple doses of GS-5745 had adverse events, compared with 5/8 patients (63%) receiving placebo. GS-5745 showed target-mediated drug disposition, approximately dose-proportional increases in maximum plasma concentration and more than dose-proportional increases in the area under the plasma drug concentration-time curve. Clinical response occurred in 18/42 patients (43%) receiving GS-5745 compared with 1/8 patients (13%) receiving placebo. Clinical remission occurred in 6/42 patients (14%) receiving GS-5745 and 0/8 (0%) receiving placebo. Patients with a clinical response to GS-5745 had reductions in matrix metalloproteinase-9 tissue levels (mean 48.9% decrease from baseline compared with a mean 18.5% increase in nonresponders, P = 0.008) significant improvements in histopathology scores (confirmed with three separate histological disease activity indices), as well as changes in colonic gene expression that were consistent with reduced inflammation. CONCLUSION: This phase 1 trial provides preliminary evidence for the safety and therapeutic potential of GS-5745 in the treatment of ulcerative colitis.

Reduced growth rate accompanied by aberrant epidermal growth factor signaling in drug resistant human breast cancer cells.

We examined transforming growth factor (TGF) alpha, epidermal growth factor (EGF) and EGF receptor (EGFR) expression and signaling in three drug resistant MCF-7 human breast cancer sublines and asked whether these pathways contribute to the drug resistance phenotype. In the resistant sublines, upregulation of both TGFalpha and EGFR mRNA was observed. In an apparent contrast with upregulated growth factor and receptor gene expression, the drug resistant sublines displayed a reduced growth rate. Defects in the EGFR signaling pathway cascade were found in all examined drug resistant sublines, including altered EGF-induced Shc, Raf-1, or mitogen-activated protein kinase phosphorylation. Induction of c-fos mRNA expression by EGF was impaired in the sublines compared to parental MCF-7 cells. In contrast, the induction of the stress-activated protein kinase activity was similar in both parental and drug resistant cells. Evaluating the link between the reduced growth rate and drug resistance, serum starvation experiments were performed. These studies demonstrated that a reduced proliferative activity resulted in a marked reduction in sensitivity to cytotoxic agents in the parental MCF-7 cells. We propose that the altered EGFR levels frequently observed in drug resistant breast cancer cells are associated with perturbations in the signaling pathway that mediate a reduced proliferative rate and thereby contribute to drug resistance.

Multidrug resistance gene family and chemical carcinogens.

The data discussed in this review indicate that the coordinated induction of both the mdr gene family and a subfamily of the cytochrome P-450 supergene family provide a unified response of the organism to prevent lethal accumulation of xenobiotics. Consequently, a distinct physiological role for the mdr multigene family now exists. Furthermore, recent evidence suggests the existence of multiple receptors with overlapping substrate specificity that are involved in the induction of both mdr and P-4501A gene families. The increased expression of mdr gene(s) in the early stages of liver carcinogenesis and presumably in other tissues is associated with the development of xenobiotic resistance that is observed in the preneoplastic cell populations. These observations may have important clinical implications and may provide an explanation for resistance to chemotherapy of tumors in organs such as liver and colon that are frequently exposed to both environmental and dietary xenobiotics.

Do maladaptive attitudes cause depression?

The Dysfunctional Attitude Scale (DAS) is an inventory of beliefs about life. These beliefs attribute happiness to external events and reflect absolute expectations for one's own behavior and that of others. Such beliefs, according to some cognitive theorists, predispose persons to depression. To test this theory, we administered the DAS to private psychiatric outpatients. Thirty-five patients were tested when they were depressed and again when they were asymptomatic. Dysfunctional thinking was found to be more prominent during depression; this finding implies that the dysfunctional thinking of depressed persons is a symptom of their illness rather than a character trait. Next, we compared DAS scores for recovered depressives with scores for other stabilized psychiatric patients and for normal persons. Bipolar patients demonstrated less maladaptive thinking than all other groups. Only the bipolars showed significantly less maladaptive thinking than the major depressives.

Biliary excretion of [3H]aldosterone and its sex dependence in adrenalectomized rats.

The rate of excretion of 3-H-radioactivity via the bile into the intestine following intravenous injection of [3-H]aldosterone, was demonstrated to be rapid and sex-dependent in adrenalectomized rats. Within 1 h, female rats excreted into the intesting via the bile greater than 95% of the injected dose of [3-H]aldosterone, compared to 47% in the male rats. In both the male and female rats, greater than 90% of the total radioactivity excreted into the intestine represented dichloromethane nonextractable polar derivatives of aldosterone (NEPD). Similarly, the quantities of NEPD recovered in the bile following bile duct cannulation of the rats, were also sex-dependent. These findings account for the rapidity and sex-dependence of the rates of clearance of aldosterone and its metabolites from the plasma of adrenalectomized rats. The sex hormones appear to influence not only the extent and the routes of metabolism of aldosterone in the liver, but also the rates of clearance of aldosterone and its metabolites from the plasma into the bile.

Cloning and characterization of a member of the rat multidrug resistance (mdr) gene family.

The rat mdr gene family [genes encoding P-glycoprotein (Pgp)] was characterized and the complete sequence of a rat mdr cDNA was determined based on seven independent cDNA clones that correspond to the same gene. The longest of these clones contains a 4.3-kb insert which represents a full-length rat mdr cDNA. The longest open reading frame of this sequence is 3933 bp; the first ATG is at 103 bp, making the deduced protein 1277 amino acids long (141 kDa). This correlates well with previously identified Pgp. The sequence of this gene has a very high, greater than 90%, degree of identity to the mouse mdr1b gene (also known as the mdr1 gene) therefore, we designate it the rat mdr1b gene. Transcription of this gene begins at a single start point 151 nucleotides upstream from the start codon. We show here that the rat gene family is comprised of three members, which is consistent with previous data on other rodent species.

Multidrug resistance gene expression in rodents and rodent hepatocytes treated with mitoxantrone.

Overexpression of P-glycoprotein in tumor cells can represent a severe drawback for cancer chemotherapy. P-glycoprotein acts as an efflux transporter for a variety of chemotherapeutic agents. It is encoded by multidrug resistance (mdr) genes of the subfamily 1 in humans (MDR1) and rodents (mdr1a and 1b). Because mdr1 gene expression is inducible in cultured rat hepatocytes and in rat liver with chemical carcinogens such as 2-acetylaminofluorene or aflatoxin B1, which form DNA-binding electrophiles during their metabolism, we investigated whether the DNA-damaging chemotherapeutic drug mitoxantrone may induce multidrug resistance in rodents and in hepatocytes in primary culture. In H4IIE rat hepatoma cells stably transfected with a luciferase construct containing the rat mdr1b promoter, mitoxantrone caused a concentration-dependent increase in promoter activity. Mdr1 gene expression in cultured rat hepatocytes was enhanced at mitoxantrone concentrations greater than or equal to 0.1 microM and in mouse hepatocytes at 5 microM. In hepatocytes from both species, a correlation was found between mdr1 induction and the inhibition of protein synthesis. In vivo, mitoxantrone was a very powerful inducer of mdr1 gene expression in rat liver and small intestine. In rat kidney, induction of mRNA was lower, and a marginal effect was seen in lung. In contrast with rats, no significant induction of mdr1 gene expression was obtained in mouse liver. Probably as a consequence of inhibition of protein synthesis, mitoxantrone did not lead to a pronounced elevation of P-glycoprotein levels in rat liver and kidney.

Requirement for metabolic activation of acetylaminofluorene to induce multidrug gene expression.

Previously we have demonstrated that several xenobiotics can induce multidrug (mdr) gene expression in cultures of primary isolated hepatocytes. One of the best of these xenobiotic inducers in rat hepatocytes is 2-acetylaminofluorene (2-AAF), which induces mdr expression by an enhancement of mdr gene transcription. In all species studied to date, AAF is extensively and variously metabolized. In this study we have sought to determine if AAF per se or a metabolite is responsible for mediating the increase in mdr gene transcription and expression. This study demonstrates that AAF per se is not active, but that the effect of AAF we have observed on mdr gene transcription and expression in the rat is due to the formation of a reactive metabolite(s). Our data indicate that this reactive metabolite is probably N-acetoxy-2-aminofluorene or the sulfate ester of N-hydroxy-AAF. The requirement for the formation of one of these metabolites may explain the differences in species response to AAF, in terms of mdr gene expression, that we have observed. We hypothesize that the mechanism by which mdr gene transcription is increased in response to AAF involves a covalent interaction between a reactive metabolite and an mdr gene regulatory protein. Our current work is concerned with the exploration of this hypothesis.

Amniotic fluid lecithin, phosphatidylglycerol, L/S ratio, and foam stability test in predicting respiratory distress in the newborn.

Amniotic fluid phospholipids (lecithin, sphingomyelin, phosphatidylglycerol) were extracted and separated by the method of Gluck and associates. In addition, these lipids were quantified against standards that were concurrently developed in three adjacent thin layer chromatography (TLC) channels. A log-log transformation of the reflectance and concentration values provided rectilinear plots for quantification. A foam stability assay (FS) of 0.48 or greater was associated with high values of L/S ratio and lecithin concentration, and values of 0.44 or less almost always were associated with low values. Lecithin values of 12 micrograms/mL or more were associated with L/ S ratios of 2.0 or greater. Phosphatidylglycerol was detected consistently only when lecithin levels were 40 micrograms/mL or greater and L/S ratios 4.0 or greater. Case reviews indicated that: (1) FS test of 0.48 almost always was associated with pulmonary maturity in the newborn; (2) that a pulmonary maturity index combining the lecithin concentration and L/S ratio was a better predictor of pulmonary maturity in the newborn then either one alone; (3) that phosphatidylglycerol added little to this discrimination; and (4) that these assays showed no significant interpretative differences between diabetic and non-diabetic mothers.

Tracheal constrictor drive above the apneic threshold in anesthetized dogs.

We have previously shown that raising arterial PCO(2) (Pa(CO(2))) by small increments in dogs ventilated below the apneic threshold (AT) results in almost complete tracheal constriction before the return of phrenic activity (Dickstein JA, Greenberg A, Kruger J, Robicsek A, Silverman J, Sommer L, Sommer D, Volgyesi G, Iscoe S, and Fisher JA. J Appl Physiol 81: 1844-1849, 1996). We hypothesized that, if increasing chemical drive above the AT mediates increasing constrictor drive to tracheal smooth muscle, then pulmonary slowly adapting receptor input should elicit more tracheal dilation below the AT than above. In six methohexital sodium-anesthetized, paralyzed, and ventilated dogs, we measured changes in tracheal diameter in response to step increases in tidal volume (VT) or respiratory frequency (f) below and above the AT at constant Pa(CO(2)) ( approximately 40 and 67 Torr, respectively). Increases in VT (400-1,200 ml) caused significantly more (P = 0.005) tracheal dilation below than above AT (7.0 +/- 2.2 vs. 2.8 +/- 1.0 mm, respectively). In contrast, increases in f (14-22 breaths/min) caused similar (P = 0.93) tracheal dilations below and above (1.0 +/- 1.3 and 1.0 +/- 0.8 mm, respectively) AT. The greater effectiveness of dilator stimuli below compared with above the AT is consistent with the hypothesis that drive to tracheal smooth muscle increases even after attainment of maximal constriction. Our results emphasize the importance of controlling PCO(2) with respect to the AT when tracheal smooth muscle tone is experimentally altered.

Dynamic measurement of tracheal diameter in dogs.

We describe and validate a new minimally invasive method for continuous measurement of tracheal diameter in anesthetized dogs. The method is based on measuring displacement of water into and out of a modified endotracheal tube cuff placed in the trachea. The system was calibrated to allow tracheal diameter to be calculated from known cuff volume. The resolution of the method in measuring changes in tracheal diameter is 0.1 mm over a range of approximately 10-25 mm. The apparatus was tested in five dogs by observing the response of the trachea to four stimuli previously shown to alter tracheal tone: stimulation of nasal mucosa, hyperinflation of the lungs, induction of hypocapnea, and infusion of atropine. The observed changes in tracheal diameter were generally consistent with those of previous studies. The direction and extent of changes in tracheal diameter in response to the test conditions were confirmed by fluoroscopy. We conclude that continuous measurement of volume changes in the cuff reflects corresponding changes in tracheal diameter.

PCO2 affects tracheal tone during apnea in anesthetized dogs.

We hypothesized that CO2, like hypoxia and withdrawal of pulmonary slowly adapting receptor input, would cause tracheal constriction during neural apnea (absence of phrenic activity). In seven anesthetized paralyzed dogs ventilated to neural apnea, we increased arterial PCO2 (PaCO2) in steps by adding CO2 to the inspirate while keeping ventilation constant. Increases in PaCO2 caused tracheal constriction during neural apnea in all dogs; 69 +/- 26 (SD)% of the change in tracheal diameter occurred during neural apnea. Average sensitivity of tracheal diameter to CO2 was 0.44 mm/Torr PaCO2. Our data suggest that central chemoreceptor inputs to brain stem neurons controlling smooth muscle of the extrathoracic airway bypass central mechanisms generating inspiration.

Prefrontal cortex lesions attenuate substantia nigra self-stimulation: a reward summation analysis.

A curve-shift paradigm was used to assess the effects of lesions of the prefrontal cortex on self-stimulation from electrode sites in the substantia nigra. Combined lesions of the medial and sulcal cortical regions severely attenuated substantia nigra self-stimulation. These results are discussed in the context of the frontal cortex and the substantia nigra as belonging to a reinforcement system that is largely independent of the medial forebrain bundle system.

Cortical and ventral tegmental systems exert opposing influences on self-stimulation from the prefrontal cortex.

Intracranial self-stimulation (ICSS) was obtained from 3 areas of anteromedial cortex: the prelimbic area (Brodman's area 32), the anterior cingulate area and the posterior cingulate area. Electrical stimulation in the prelimbic and anterior cingulate areas also produces a behavioral inhibition which is most pronounced at anterior sites (i.e. prelimbic) and declines at increasingly more posterior sites. It was found that the acquisition of responding for ICSS and the magnitude of amphetamine's facilitation of ICSS were inversely related to the degree of behavioral inhibition. These data and the ability of amphetamine to reverse prefrontal stimulation-induced inhibition suggest an important interaction between the prefrontal cortex and the mesolimbic dopamine systems in the control of goal-directed behavior. A model involving cortical suppression of mesolimbic dopamine function is discussed.

The development of marked elevation in white blood cell count does not predict inferior outcome in chronic lymphocytic leukemia.

Although elevation of the white blood cell (WBC) count at diagnosis of chronic lymphocytic leukemia (CLL) appears to predict shortened survival, its significance later in the course of the disease remains unclear. We reviewed all cases of CLL seen in our center between 1980 and 1999 to evaluate the frequency and clinical significance of WBC elevation > 100 x 10(9)/L. CLL was confirmed according to standard diagnostic criteria and data was collected from diagnosis, occurrence of WBC > 100 x 10(9)/L, and last follow-up. 235 consecutive patients with CLL were identified; 94 were excluded. 141 included patients had a median age of 61 years and median WBC 19.7 x 10(9)/L at diagnosis. Median follow-up for all patients was 56 months, and median survival was 104 months. 41 patients (29%) had > or = 1 episode of WBC > 100 x 10(9)1/L, occurring at a median of 38 months from diagnosis. Compared to controls matched for modified Rai stage, development of a WBC > 100 x 10(9)/L did not predict inferior survival (median 107 vs. 101 months, p = 0.72). We conclude that the occurrence of a WBC count > 100 x 10(9)/L in patients with CLL does not shorten the survival, and patients require therapy only if other indications for treatment are present.

Intestinal MDR transport proteins and P-450 enzymes as barriers to oral drug delivery.

Cytochrome P-450 3A4 (CYP3A4), the major phase I drug metabolizing enzyme in humans, and the multidrug efflux pump, MDR or P-glycoprotein (P-gp), are present at high levels in the villus tip enterocytes of the small intestine, the primary site of absorption for orally administered drugs. These proteins are induced or inhibited by many of the same compounds and demonstrate a broad overlap in substrate and inhibitor specificities, suggesting that they act as a concerted barrier to drug absorption. A series of studies from our laboratory of cyclosporine and tacrolimus in humans and a novel cysteine protease inhibitor in rats, dosed concomitantly with inhibitors and inducers of CYP3A4 and P-gp, suggest that gut extraction can be modeled using measures of intestinal metabolism and absorption rate, the latter reflecting changes in P-gp. Results evaluating a preliminary model applied to the CYP3A substrate drugs midazolam, indinavir, saquinavir, and rifabutin suggest that the model may be useful for predicting in vivo intestinal metabolism from in vitro data.

Tracking of blood pressure and anthropometric measures in Nigerian children.

Persistence in ranks (tracking) for blood pressure and anthropometric measures over a one year period was examined in 208 Nigerian children (age 6-17 years). Systolic blood pressure tracked better than diastolic blood pressure (r = 0.52 to 0.72) and r = 0.25 to 0.55, respectively). For systolic blood pressure, 56.5%-70.6% of the Nigerian children remained in the top tertile after one year compared with 45.5%-69.2% for diastolic blood pressure. Weight showed the strongest correlation over the one year period (r = 0.88 to 0.97), whereas skinfolds demonstrated the weakest association (r = 0.54 to 0.82). The association between anthropometric measures at baseline and blood pressure one year later revealed for both males and females that height and weight were positively and significantly correlated with blood pressure.

Body image and perfectionism of ballerinas: comparison and contrast with anorexia nervosa.

The authors studied a group of young ballerinas through responses to a questionnaire and intensive interviews. The young women described a life characterized by complete dedication in which academics, social life, and pleasures were sacrificed and a program of intensive exercise and practice became their main activity. They tended to feel overweight in spite of being thin and continued to diet or to employ other means to become even thinner. Two heuristic conclusions were reached: (a) the goal of thinness was in part a flight from conflicts about adult sexuality that arose at puberty; and (b) repetitive practice was engaged in for its own sake, not for career advancement, in an attempt to lose themselves in a transcendental quest for perfection. A comparison was made between this group and girls of the same age with anorexia nervosa. Several similarities but many more differences were found. Findings are based on a very small sample and must be interpreted cautiously, but directions for further studies are implied.

Sex dependence of clearance rates of aldosterone and its metabolites from plasma of intact rats.

Following I.V. injection of 3H-aldosterone, the rates of clearance of plasma 3H-radioactivity was demonstrated to be sex-dependent in intact rats. Even though the percentages of CH2Cl2-extractable plasma radioactivity are greater in female than in male rats, the quantities of CH2Cl2-extractable label are similar until 60 min post-injection. However, the quantities of non-extractable, polar metabolites of aldosterone (NEPD) are markedly greater in the plasma of males and rapidly reach peak levels 10 min post-injection of aldosterone. In females, these polar metabolites (NEPD) are rapidly cleared from the blood. After bile-duct cannulation, the rate of excretion of aldosterone radiometabolites was demonstrated to be rapid and sex-dependent. Within 1 hr., female rats excreted via the bile 82% of the injected dose of 3H-aldosterone, compared to 49% in male rats. In both sexes, greater than 95% of the total radioactivity excreted in the bile are non-extractable polar metabolites of aldosterone (NEPD). The sex hormones appear to influence not only the nature of metabolism of aldosterone in the liver, but also the rates of clearance of aldosterone and its metabolites from the plasma into the bile.

Role of P-glycoprotein and cytochrome P450 3A in limiting oral absorption of peptides and peptidomimetics.

Cytochrome P450 3A4 (CYP3A4), the major phase I drug metabolizing enzyme in humans, and the MDR1 gene product P-glycoprotein (P-gp) are present at high concentrations in villus tip enterocytes of the small intestine and share a significant overlap in substrate specificity. A large body of research both in vitro and in vivo has established metabolism by intestinal CYP3A4 as a major determinant of the systemic bioavailability of orally administered drugs. More recently it has been recognized that drug extrusion by intestinal P-gp can both reduce drug absorption and modulate the effects of inhibitors and inducers of CYP3A-mediated metabolism. There is relatively little data regarding the effects of CYP3A and P-gp on peptide drugs; however, studies with the cyclic peptide immunosuppresant cyclosporine as well as peptidomimetics such as the HIV-protease inhibitor saquinavir (Invirase) and a new cysteine protease inhibitor K02 (Morpholine-Urea-Phe-Hphe-Vinyl sulfone; Axys Pharmaceuticals) provide some insight into the impact of these systems on the oral absorption of peptides.