FASN inhibition targets multiple drivers of NASH by reducing steatosis, inflammation and fibrosis in preclinical models.

Fatty acid synthase (FASN) is an attractive therapeutic target in non-alcoholic steatohepatitis (NASH) because it drives de novo lipogenesis and mediates pro-inflammatory and fibrogenic signaling. We therefore tested pharmacological inhibition of FASN in human cell culture and in three diet induced mouse models of NASH. Three related FASN inhibitors were used; TVB-3664, TVB-3166 and clinical stage TVB-2640 (denifanstat). In human primary liver microtissues, FASN inhibiton (FASNi) decreased triglyceride (TG) content, consistent with direct anti-steatotic activity. In human hepatic stellate cells, FASNi reduced markers of fibrosis including collagen1α (COL1α1) and α-smooth muscle actin (αSMA). In CD4+ T cells exposed to NASH-related cytokines, FASNi decreased production of Th17 cells, and reduced IL-1ß release in LPS-stimulated PBMCs. In mice with diet induced NASH l, FASNi prevented development of hepatic steatosis and fibrosis, and reduced circulating IL-1ß. In mice with established diet-induced NASH, FASNi reduced NAFLD activity score, fibrosis score, ALT and TG levels. In the CCl4-induced FAT-NASH mouse model, FASN inhibition decreased hepatic fibrosis and fibrosis markers, and development of hepatocellular carcinoma (HCC) tumors by 85%. These results demonstrate that FASN inhibition attenuates inflammatory and fibrotic drivers of NASH by direct inhibition of immune and stellate cells, beyond decreasing fat accumulation in hepatocytes. FASN inhibition therefore provides an opportunity to target three key hallmarks of NASH.

Management of Cutaneously Exposed Carotid Stents in Recurrent and Unresectable Head and Neck Cancer.

Objective Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication of head and neck cancer (HNC) treatment. Patients with CBS are managed with covered stents, limited published information exists regarding the management of delayed complications, specifically cutaneous exposure of stents. Here, we present our experience managing cutaneously exposed carotid artery stents (CAS) in patients with recurrent and unresectable HNC. Methods A single-institution retrospective analysis was performed to identify recurrent HNC patients who underwent CAS placement for CBS and complicated with cutaneous exposure of the stent between 2014 and 2016. Medical records were reviewed with attention to treatment history, pre-, intra-, and postoperative courses, anticoagulation needs, and durability of the reconstruction. Results We identified three patients who presented with a right CAS fully exposed in a large, ulcerative wound. All patients underwent a right pectoralis major myocutaneous flap (PMMF) to cover the exposed stent within 30 days of presentation to our institution. Two of three patients attained adequate coverage of the stent for more than 30 days, while one experienced partial flap dehiscence within 12 days. Two patients developed postoperative chest hematomas, which were managed conservatively. Two of three patients were able to undergo further palliative adjuvant treatments within 60 days of the initial surgical procedure. Conclusion In this small series, durable coverage of an exposed carotid artery with PMMF was successful in two of three patients with extensive disease burden and complex prior treatment history. No mortalities occurred within 30 days postoperatively.

Eptifibatide use following emergent carotid stenting in acute anterior circulation ischemic stroke with tandem occlusion.

BACKGROUND: Early revascularization of the extracranial internal carotid artery in acute anterior circulation ischemic stroke (ACIS) is feasible and may improve clinical outcome. When a stent is deployed, antithrombotic agents should be administered peri-procedurally to ensure stent patency. Our institution implemented a protocol for the use of eptifibatide as a means of maintaining stent patency in the treatment of ACIS associated with cervical internal carotid artery occlusion. METHODS: Our internal database was queried for patients who received emergent endovascular therapy (ET) for ACIS with stent placement and eptifibatide administration between July 2016 and 2019. RESULTS: Twenty nine patients met the study criteria. The etiology was large artery atherosclerosis in 26 cases. Two patients had a dissection (7%), and one had a carotid occlusion related to a recent carotid endarterectomy. Mean NIHSS was 14. Sixteen patients received IVrtPA. Extracranial-intracranial tandem occlusion (TO) was present in 21 of cases. All patients received an eptifibatide bolus followed by an infusion for approximately 24 hours post stent deployment. Head CT was obtained prior to initiation of oral dual antiplatelet therapy with aspirin and clopidogrel. Successful recanalization was achieved in all patients with no evidence of downstream embolization. Symptomatic intracerebral hemorrhage occurred in one patient. Stent occlusion occurred in two patients, only one of which was symptomatic. Favorable clinical outcome with mRS ≤ 2 at 3 months was achieved in seventeen patients. CONCLUSIONS: The use of eptifibatide post procedure was associated with low risk of symptomatic intracranial hemorrhage, including in patients treated with rtPA.

Outcome following total knee replacement in patients with a previous patellectomy.

Although patellectomy is a rarely performed surgical procedure, patients may still progress to develop osteoarthritis of the tibiofemoral compartments leading to total knee replacement surgery. Due to the mechanical disadvantage of a previous patellectomy, it has previously been suggested that a prosthesis with more constraint should be used, however, there are conflicting reports in the literature. We aimed to assess the effects of stability following total knee replacement in patellectomised knee with revision as a primary endpoint. We reviewed the outcome of 25 total knee replacements in our institution in patients with a previous patellectomy. Ten were posterior stabilised and 15 minimally stabilised (including those with a 'deep dish'). Five of the patients in the minimally stabilised group underwent revision surgery, and 3 of these were early revision due to instability. None of the patients in the posterior stabilised group underwent revision. We conclude that when a total knee replacement is performed in a patient with a previous patellectomy a posterior stabilised implant should be used.

Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion.

INTRODUCTION: Cavernous carotid aneurysms can cause significant symptomatology through mass effect and may rupture, resulting in carotid-cavernous fistula or epistaxis. Traditional treatment options included endovascular or surgical parent vessel occlusion, or embolization; in the last decade, the development of flow-diverting stents has changed the management paradigm for these lesions. Areas covered: In this review, we summarize the natural history, clinical presentation, and evolution of treatment options for cavernous carotid aneurysms and discuss developments likely to influence treatment strategies in the future. We performed a Medline search for relevant review articles and original reports and additional searches based on review of referenced articles, abstracts, and conference presentations. Expert commentary: Long-term data are still required to fully assess the efficacy of endoluminal reconstruction using flow diversion, but this approach appears to offer an attractive therapy for many cavernous carotid aneurysms requiring intervention.

Technology developments in endovascular treatment of intracranial aneurysms.

Advances in the management and endovascular treatment of intracranial aneurysms are progressing at a tremendous rate. Developments in novel imaging technology may improve diagnosis, risk stratification, treatment planning, intraprocedural assessment, and follow-up evaluation. Evolution of devices, including microwires, microcatheters, balloons, stents, and novel scaffolding devices, has greatly expanded the potential to treat difficult aneurysms. Although developments in technology have greatly improved the efficiency and efficacy of treatment of neurovascular disorders, novel devices do not always improve outcomes and may be associated with unique complications. As such, it is paramount to have an in-depth understanding of new devices and the implications of their introduction into clinical practice. This review provides an update on developments in endovascular treatment of intracranial aneurysms.

Endovascular techniques and devices for the treatment of intracranial aneurysms: a review of neurointerventional outcomes.

Endovascular technology for the treatment of intracranial aneurysms continues to evolve at a rapid pace. In addition to coil embolization, balloon and stent-assisted coiling have been employed for the endovascular treatment of wide-necked or otherwise morphologically challenging intracranial aneurysms, and each technique confers unique advantages. Flow-diverting stents may also be used as a primary treatment modality for complex aneurysms and have a number of benefits and limitations. This article provides a review of the evidence supporting the use of newer coiling techniques and materials, as well as adjunctive technologies such as balloon-assisted and stent-assisted coiling, for the treatment of unruptured and ruptured intracranial aneurysms.

Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization.

BACKGROUND: Endovascular treatment of wide-necked aneurysms is challenging. Stent-assisted coiling (SAC) is associated with increased complications and requires dual antiplatelet therapy. OBJECTIVE: To compare treatment of unruptured, wide-necked aneurysms with a dual-microcatheter technique (DMT) versus SAC. METHODS: Between 2006 and 2011, 100 patients with unruptured wide-necked intracranial aneurysms were treated with DMT and 160 with SAC. Over time there was a significant decrease in the use of SAC and a corresponding increase in DMT. The investigators matched 60 patients treated with DMT blinded to outcome in a 1:2 fashion based on maximal aneurysm dome diameter with 120 patients treated with SAC. Outcomes were determined with conditional (matched) multivariate analysis. RESULTS: There were no significant differences in patient or aneurysm characteristics between cohorts, including aneurysm diameter, neck width, or volume. Overall packing density and coil volume achieved was not significantly different between cohorts. There were higher rates of overall complications in those receiving SAC (19.2%) compared with DMT (5.0%; p=0.012), but no significant difference in major complications (8.3% vs 1.7%, respectively; p=0.103). At a mean follow-up of 27.0 ± 18.9 months, rates of retreatment did not differ between DMT (15.1%) and SAC (17.7%). Delayed in-stent stenosis occurred in five patients and in-stent thrombosis in four patients treated with SAC. There was no difference in favorable functional outcome (modified Rankin score 0-2) between those treated with DMT (90.6%) compared with SAC (91.2%). CONCLUSIONS: DMT and SAC are effective endovascular approaches for unruptured, wide-necked aneurysms; however, DMT may result in less morbidity. Further long-term studies are necessary to determine the optimal indications for these treatment options.

An innovative approach for the characterization of the isoforms of a monoclonal antibody product.

Protein biopharmaceuticals, such as monoclonal antibodies (mAbs) are widely used for the prevention and treatment of various diseases. The complex and lengthy upstream and downstream production methods of the antibodies make them susceptible to physical and chemical modifications. Several IgG1 immunoglobulins are used as medical agents for the treatment of colon, breast, and head and neck cancers, and at least four to eight isoforms exist in the products. The regulatory agencies understand the complex nature of the antibody molecules and allow the manufactures to set their own specifications for lot release, provided the safety and efficacy of the products are established in animal models prior to clinical trials. During the manufacture of a mAb product, we observed lot-to-lot variability in the isoform content and, although the variability is within the set specifications for lot release, made attempts to gain mechanistic insight by isolating and characterizing the individual isoforms. Matrix-assisted laser desorption/ionization (MALDI) and liquid chromatography (LC)/mass spectrometry (MS)/MS analyses of the isolated isoforms indicate that this variability is caused by sialic acid content, as well as truncation of C-terminal lysine of the individual isoforms. Sialidase and carboxypeptidase treatment of the product confirm the observations made by MALDI and LC/MS/MS.

Measurement of water-soluble B vitamins in infant formula by liquid chromatography/tandem mass spectrometry.

A method has been developed for the simultaneous measurement of multiple B vitamins (i.e., B1, B2, B3, B5, and B6) in infant formulas by LC-MSIMS. The vitamins were extracted with acidic solvent, followed by protein precipitation at a pH range of 4.5 to 5.5, and filtered. This simplified procedure eliminates many of the potential sources of laboratory error and facilitates rapid and efficient analysis. As is common in most cases, isotope internal standards were added to account for variations in sample preparation, as well as changes in MS measurement. In this method, isotope-labeled internal standards of B1, B3, B5, and B6 were used. The factors affecting analytical performance were investigated and optimized. In addition, the stability of these vitamins in the extraction solution was investigated. An acidic condition (5 mM HCl) was applied to successfully stabilize B1, which had shown a decrease in signal when other solvents were used. The quantitative extraction and good stability allowed isotope standards to be added to the filtered sample solution, instead of to the extraction solvent. The addition of the isotope to the small portion of the filtered sample solution significantly reduces cost. A comprehensive evaluation of the analysis of the standard reference material and good spike recovery of the vitamins (100 +/- 6%) demonstrates the accuracy of the method. The results for commercially available infant formula samples were also compared with those obtained using the current microbiological method.

Structural characterization of N-linked oligosaccharides on monoclonal antibody cetuximab by the combination of orthogonal matrix-assisted laser desorption/ionization hybrid quadrupole-quadrupole time-of-flight tandem mass spectrometry and sequential enzymatic digestion.

Cetuximab is a novel therapeutic monoclonal antibody with two N-glycosylation sites: a conserved site in the CH2 domain and a second site within the framework 3 of the variable portion of the heavy chain. The detailed structures of these oligosaccharides were successfully characterized using orthogonal matrix-assisted laser desorption/ionization hybrid quadrupole-quadrupole time-of-flight mass spectrometry (oMALDI Qq-TOF MS) and tandem mass spectrometry (MS/MS) in combination with exoglycosidase digestion. The N-linked oligosaccharides were released by treatment with N-glycanase F, reductively aminated with anthranilic acid, and fractionated by normal phase high-performance liquid chromatography (NP-HPLC). The fluorescent-labeled oligosaccharide pool and fractions were analyzed by oMALDI Qq-TOF MS and MS/MS in negative ion mode. Each fraction was further digested with an array of exoglycosidase mixtures, and subsequent MALDI TOF MS analysis of the resulting products yielded information about structural features of the oligosaccharide. The combined data revealed the presence of 21 distinct oligosaccharide structures in cetuximab. These oligosaccharides differ mainly in degree of sialylation with N-glycolyl neuraminic acid and extent of galactosylation (zero-, mono-, di-, and alpha(1-3)-galactosidase). The individual oligosaccharides were further assigned to the specific sites in the Fab and Fc regions of the antibody. This study represents a unique approach in that MS/MS data were used to identify and confirm the oligosaccharide structures of a protein.

Human herpesvirus 6A accelerates AIDS progression in macaques.

Although HIV is the necessary and sufficient causative agent of AIDS, genetic and environmental factors markedly influence the pace of disease progression. Clinical and experimental evidence suggests that human herpesvirus 6A (HHV-6A), a cytopathic T-lymphotropic DNA virus, fosters the progression to AIDS in synergy with HIV-1. In this study, we investigated the effect of coinfection with HHV-6A on the progression of simian immunodeficiency virus (SIV) disease in pig-tailed macaques (Macaca nemestrina). Inoculation of HHV-6A resulted in a rapid appearance of plasma viremia associated with transient clinical manifestations and followed by antibody seroconversion, indicating that this primate species is susceptible to HHV-6A infection. Whereas animals infected with HHV-6A alone did not show any long-term clinical and immunological sequelae, a progressive loss of CD4(+) T cells was observed in all of the macaques inoculated with SIV. However, progression to full-blown AIDS was dramatically accelerated by coinfection with HHV-6A. Rapid disease development in dually infected animals was heralded by an early depletion of both CD4(+) and CD8(+) T cells. These results provide in vivo evidence that HHV-6A may act as a promoting factor in AIDS progression.

Deep hypothermic circulatory arrest and bivalirudin use in a patient with heparin-induced thrombocytopenia and antiphospholipid syndrome.

BACKGROUND: Patients with heparin-induced thrombocytopenia II (HIT II) need an alternative nonheparin-based method of anticoagulation for cardiopulmonary bypass (CPB) to prevent thrombosis and thrombosis related complications. METHODS: Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained. RESULTS: Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful. CONCLUSIONS: Anticoagulation was successfully managed with bivalirudin, a new short-acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA.

The impact of cGMP compliance on consumer confidence in dietary supplement products.

The FDA estimates that US citizens spend more than $ 8.5 billion a year on dietary supplements and world wide the market is estimated at more than $ 60 billion. However, although a majority of consumers express confidence in the safety of these products, 74% believe the government should be more involved in ensuring that these products are safe and efficacious. Recent regulatory initiatives such as the imminent adoption of cGMPs for dietary supplements in the US, implementation of cGMPs in Canada and the recent EU dietary supplement initiative represent legislative and industry response to public clamor for more comprehensive oversight of dietary supplements. Regardless of mandated practices, the majority of dietary supplement manufacturers have done an excellent job of protecting the safety and quality of their products. The promulgation of these cGMPs will help ensure consumers that equal standards are followed throughout the industry. For some companies with established processes based on existing food or pharmaceutical cGMP regulations, the transition will be relatively painless while, for many, it will represent a significant increase in the level of documentation and testing. However, consumers deserve and demand that products meet standards for safety and quality and the implementation of cGMPs for these products are an important first step. Although the cGMPs are designed to ensure products are safe from a standpoint of identity, purity, quality, strength and composition, they do not address preclinical or clinical testing of ingredients for safety or efficacy. This would involve ingredients meeting the requirements of Generally Recognized as Safe (GRAS) status or going through the New Dietary Ingredient (NDI) process.

Development and validation of analytical methods for dietary supplements.

The expanding use of innovative botanical ingredients in dietary supplements and foods has resulted in a flurry of research aimed at the development and validation of analytical methods for accurate measurement of active ingredients. The pressing need for these methods is being met through an expansive collaborative initiative involving industry, government, and analytical organizations. This effort has resulted in the validation of several important assays as well as important advances in the method engineering procedures which have improved the efficiency of the process. The initiative has also allowed researchers to hurdle many of the barricades that have hindered accurate analysis such as the lack of reference standards and comparative data. As the availability for nutraceutical products continues to increase these methods will provide consumers and regulators with the scientific information needed to assure safety and dependable labeling.

Aprotinin decreases ischemic damage during coronary revascularization.

BACKGROUND AND AIM: This study sought to determine whether the favorable anti-inflammatory effects of aprotinin might limit ischemic damage during the revascularization of ischemic myocardium. METHODS: Twenty pigs underwent 90 minutes of coronary occlusion followed by 45 minutes of blood cardioplegic arrest and 180 minutes of reperfusion. Ten animals received a loading dose of aprotinin (40,000 kallikrein inhibiting units/kg) during the start of coronary occlusion followed by an infusion of 20,000 kallikrein inhibiting units/kg/hour. Ten other animals received no aprotinin. Summary statistics are expressed as the mean +/- standard error. RESULTS: The aprotinin-treated animals required less cardioversions for ventricular arrhythmias (1.0 +/- 0.7 vs. 3.6 +/- 0.6; p < 0.001), accumulated less lung water (1.0 +/- 0.2% change vs. 6.2 +/- 0.9% change; p = 0.038), had more complete coronary relaxation to bradykinin (34.1 +/- 5.9% change vs. 9.2 +/- 3.5% change; p = 0.01), and had reduced infarct size (area necrosis/area risk = 20 +/- 1.1% vs. 39 +/- 1.2%; p = 0.003). CONCLUSIONS: Aprotinin limits ischemic injury during acute coronary revascularization by decreasing ventricular arrhythmias and lung edema, preserving endothelial function, and minimizing myocardial necrosis.

Cardiopulmonary bypass: it's not the size, it's how you use it! Review of a comprehensive blood-conservation strategy.

Several of the manufacturers of cardiopulmonary bypass equipment have recently introduced new miniature cardiopulmonary bypass systems. New advancements in cardiopulmonary bypass technology are almost always of interest to the perfusion community. However, the question arises, what advantages do these systems offer over our present technology? The manufacturers claim that these new systems will add to our perfusion armamentarium by offering us an opportunity to further reduce priming volume and the surface area to which the blood is exposed. Our group, in the Department of Cardiac Surgery at Boston Medical Center has been involved in the development of a comprehensive blood conservation strategy since 1994. Our published data clearly demonstrates improved clinical outcomes using coated circuit technology as part of a comprehensive blood conservation strategy. In an effort to clearly evaluate this new technology, in this article we review our current technique at Boston Medical Center.

Determination of ephedra alkaloids by liquid chromatography/tandem mass spectrometry.

In conjunction with an AOAC Task Group on dietary supplements, a liquid chromatography/tandem mass spectrometry (LC-MS/MS) method was validated for measurement of 6 major alkaloids in raw ephedra sinica herb, ephedra extracts, ephedra tablets, complex dietary supplements containing ephedra, and a high-protein drink mix containing ephedra. The amount of ephedrine-type alkaloids present was determined by LC with mass selective detection. Six replicates of each matrix were analyzed on 3 separate occasions. The presence of 6 ephedrine-type alkaloids was detected at a level > 0.5 microg/g based on a 0.5 g sample. The standard curve range for this assay is from 0.02 to 1.0 microg/mL. Appropriate dilutions covered a wide range of specific alkaloid concentrations. The calibration curves for all 6 analytes had correlation coefficients > 0.995.

Isolated limb perfusion: a literature review.

Through patient education, biological research, and technological advances, the rate of many cancers in the United States of America is declining. However, the incidence of melanoma is rising steadily, as are the efforts and resources allocated to its treatment. Isolated limb perfusion, ILP, is a standard of care for treating recurrent malignant melanoma confined to a limb. Although an extracorporeal procedure, only a small percentage of perfusionists are experienced regarding ILP's indications and performance techniques. Use of ILP may increase as the incidence of melanoma increases. This two-part review is designed to familiarize the perfusionist with the procedure and the disease it treats. Part I reviews the history of isolated limb perfusion, the diagnosis and classification of malignant melanoma, and the applicability of ILP in its treatment. Part II details a procedural overview and technical considerations of the therapy from the perfusionist perspective. The review concludes with patient selection, outcomes, and the future of ILP as well as other applications for the hyperthermic regional delivery of chemotherapy using extracorporeal technology.