Repurposing historical control clinical trial data to provide safety context.

Billions of dollars spent, millions of subject-hours of clinical trial experience and an abundance of archived study-level data, yet why are historical data underutilized? We propose that historical data can be aggregated to provide safety, background incidence rate and context to improve the evaluation of new medicinal products. Here, we describe the development and application of the eControls database, which is derived from the control arms of studies of licensed products, and discuss the challenges and potential solutions to the proper application of historical data to help interpret product safety.

Creation and implementation of a historical controls database from randomized clinical trials.

BACKGROUND: Ethical concerns about randomly assigning patients to suboptimal or placebo arms and the paucity of willing participants for randomization into control and experimental groups have renewed focus on the use of historical controls in clinical trials. Although databases of historical controls have been advocated, no published reports have described the technical and informatics issues involved in their creation. OBJECTIVE: To create a historical controls database by leveraging internal clinical trial data at Pfizer, focusing on patients who received only placebo in randomized controlled trials. METHODS: We transformed disparate clinical data sources by indexing, developing, and integrating clinical data within internal databases and archives. We focused primarily on trials mapped into a consistent standard and trials in the pain therapeutic area as a pilot. RESULTS: Of the more than 20,000 internal Pfizer clinical trials, 2404 completed placebo controlled studies with a parallel design were identified. Due to challenges with informed consent and data standards used in older clinical trials, studies completed before 2000 were excluded, yielding 1134 studies from which placebo subjects and associated clinical data were extracted. CONCLUSIONS: It is technically feasible to pool portions of placebo populations through a stratification and segmentation approach for a historical placebo group database. A sufficiently large placebo controls database would enable previous distribution calculations on representative populations to supplement, not eliminate, the placebo arm of future clinical trials. Creation of an industry-wide placebo controls database, utilizing a universal standard, beyond the borders of Pfizer would add significant efficiencies to the clinical trial and drug development process.

Prolonged NO treatment decreases alpha-adrenoreceptor agonist responsiveness in porcine pulmonary artery due to persistent soluble guanylyl cyclase activation.

A cultured porcine pulmonary artery (PA) model was used to examine the effects of prolonged nitric oxide (NO) treatment on the response of this vessel to acutely applied NO and to the alpha-adrenoreceptor agonist phenylephrine. Two-hour treatment with the NO donor (Z)-1-[N-(2-aminoethyl)-N-(2-ammonioethyl)amino]diazen-1-ium-1,2-diolate (DETA-NO) decreased both NO and phenylephrine responsiveness. Twenty-four-hour treatment with DETA-NO resulted in a further reduction in NO responsiveness but no further reduction in phenylephrine responsiveness. Acute addition of soluble guanylyl cyclase (sGC) inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) had no effect on phenylephrine responsiveness in PA not treated with DETA-NO. ODQ treatment fully restored phenylephrine responsiveness in PA treated with DETA-NO. sGCbeta(1) subunit protein levels in PA tissue homogenate were 48.6 +/- 6.9, 51.6 +/- 3.5, and 41.3 +/- 2.8 ng/mg total protein for freshly prepared and 2-h and 24-h NO-treated PA, respectively. Steady-state tissue cGMP was not significantly different in control versus NO-treated PA. sGC specific activity in the absence of added NO was measured in PA homogenate and was 0.29 +/- 0.02, 1.38 +/- 0.12, and 0.53 +/- 0.08 micromol cGMP.min(-1).mg sGC(-1), in freshly prepared and 2-h and 24-h NO treated PA, respectively. Ten-minute Hb treatment completely normalized sGC basal activity in homogenates prepared from DETA-NO-treated PA, which was 0.23 +/- 0.02, 0.18 +/- 0.03, and 0.25 +/- 0.04 micromol cGMP.min(-1).mg sGC(-1), in freshly prepared and 2-h and 24-h NO-treated PA, respectively. The kinetics of the Hb reversal of NO-mediated sGC persistent activation do not support sGC covalent modification as the activation mechanism. We conclude that prolonged NO exposure results in a persistently increased sGC specific activity, which accounts for the observed alpha-adrenoreceptor agonist hyporesponsiveness.

The influence of hemodynamic forces on biomarkers in the walls of elastase-induced aneurysms in rabbits.

INTRODUCTION: Biological and biophysical factors have been shown to play an important role in the initiation, progression, and rupture of intracranial aneurysms. The purpose of this study was to evaluate the association between hemodynamic forces and markers of vascular remodeling in elastase-induced saccular aneurysms in rabbits. METHODS: Elastase-induced aneurysms were created at the origin of the right common carotid artery in rabbits. Hemodynamic parameters were estimated using computational fluid dynamic simulations based on 3-D-reconstructed models of the vasculature. Expression of matrix metalloproteinases (MMPs), their inhibitors (TIMPs) and markers of vascular remodeling were measured in different spatial regions within the aneurysms. RESULTS: Altered expression of biological markers relative to controls was correlated with the locations of subnormal time-averaged wall shear stress (WSS) but not with the magnitude of pressure. In the aneurysms, WSS was low and expression of biological markers was significantly altered in a time-dependent fashion. At 2 weeks, an upregulation of active-MMP-2, downregulation of TIMP-1 and TIMP-2, and intact endothelium were found in aneurysm cavities. However, by 12 weeks, endothelial cells were absent or scattered, and levels of pro- and active-MMP-2 were not different from those in control arteries, but pro-MMP-9 and both TIMPs were upregulated. CONCLUSION: These results reveal a strong, spatially localized correlation between diminished WSS and differential expression of biological markers of vascular remodeling in elastase-induced saccular aneurysms. The ability of the wall to function and maintain a healthy endothelium in a low shear environment appears to be significantly impaired by chronic exposure to low WSS.

Endovascular treatment of experimental aneurysms by use of fibroblast-coated platinum coils: an angiographic and histopathologic study.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether implanting exogenous fibroblasts on platinum coils could enhance intra-aneurysmal fibrosis. Hypotheses included: (1) fibroblast-coated (FBC) platinum coils can improve angiographic results after embolization; and (2) FBC platinum coils can accelerate histological healing of embolized aneurysms. METHODS: Experimental aneurysms in rabbits were embolized with control platinum coils (n=18) or FBC coils (n=18). Subjects were euthanized at 14 days, 1 month, 3 months and 6 months after implantation. Digital subtraction angiography was used to evaluate stability after embolization. Histological samples were examined with a grading system (range, 0 to 12) based on neck and dome healing. RESULTS: Histology total scores and fibrosis ratio at 14 days were significantly greater in the FBC coil group compared with controls (6.6+/-1.9 versus 2.5+/-1.1, 1.2+/-0.6% versus 0.2+/-0.3%, respectively; P=0.0090). Cavities embolized with FBC coils showed cellular proliferation and thrombus organization, with an endothelialized membrane bridging the neck. There were no differences between groups in the later timepoints. The FBC coil group showed radiographic stability in 11 (61%) cases, coil compaction in 2 (11%) cases, and progressive occlusion in 5 (28%) cases. No progressive occlusion was seen in controls; 3 (17%) of 18 control cases exhibited coil compaction (P=0.0546). CONCLUSIONS: FBC coils can accelerate early histological healing compared with control coils in the rabbit aneurysm model.

Vascular anatomic variation in rabbits.

PURPOSE: To explore the vascular anatomic variation along the aortic arch in New Zealand White rabbits with the goal of highlighting potential anatomic configurations that might be encountered in the performance of preclinical endovascular research in rabbits. MATERIALS AND METHODS: Digital subtraction angiography images of the brachiocephalic artery (BCA) and aortic arch in New Zealand White rabbits were obtained after creation of elastase-induced aneurysms at the origin of the right common carotid artery (RCCA) in 214 animals. The patterns of origin of the RCCA and left common carotid artery (LCCA), right subclavian artery (RSCA) and left subclavian artery (LSCA), and right vertebral artery (RVA) and left vertebral artery (LVA) were analyzed. RESULTS: Five predominant variations of vessel origin were identified. In 200 of 214 cases (93%), the LCCA originated from the bifurcation of the BCA and aorta. In eight cases (4%), the LCCA directly originated from the aorta. In two cases (1%), the LCCA originated from the BCA. Aberrant RSCA anatomy in which the RSCA originated from the aortic arch instead of the BCA was found in three cases (1.5%). In a single case (0.5%), aberrant RSCA anatomy with the RVA originating from the BCA was encountered. CONCLUSIONS: Anatomic variation of the BCA in New Zealand White rabbits is similar to that seen in humans. Understanding of the normal and variant anatomy of the rabbit will aid investigators who use the rabbit model for endovascular research.

Modified technique to create morphologically reproducible elastase-induced aneurysms in rabbits.

INTRODUCTION: The purpose of this study was to create morphologically reproducible elastase-induced model aneurysms in rabbits. METHODS: We created 120 elastase-induced aneurysms in rabbits using two different methods: the standard technique (group 1, n=62) and a modified technique (group 2, n=58). In the standard technique a small cutdown with a focal area of exposure of the mid-right common carotid artery (RCCA) was employed, while in the modified technique the RCCA was completely exposed to its origin. We measured aneurysm sizes (neck diameter, width and height) in the two groups. The aneurysm sizes were compared between the two groups using Student's t test, and the standard deviations of the aneurysm sizes were compared between the groups using the F test. RESULTS: The mean aneurysm neck size, width and height in group 1 were 3.4+/-1.2 mm, 3.8+/-1.0 mm and 8.0+/-1.7 mm, respectively, and in group 2, were 3.2+/-0.9 mm, 3.7+/-0.6 mm and 9.1+/-1.8 mm, respectively. The differences in mean aneurysm neck and width between the two groups were not significant (P>0.05). However, there were significant differences in the standard deviation of these two parameters between the two groups (P<0.05 and P<0.01, respectively). The mean aneurysm height in group 2 was larger than in group 1 (P<0.001), but no significant difference in the standard deviation of this parameter between the two groups was found (P>0.05). CONCLUSION: The results indicate that more consistent aneurysm diameters can be created using the modified technique.

Histopathologic and immunohistochemical comparison of human, rabbit, and swine aneurysms embolized with platinum coils.

BACKGROUND AND PURPOSE: The purpose of this study was to clarify the cellular mechanisms of aneurysmal healing by comparing histologic and immunohistochemical findings in experimental rabbit and swine aneurysms to a human aneurysm embolized with platinum coils. METHODS: Swine sidewall aneurysms (n = 5, harvested at 12 weeks) and elastase-induced rabbit aneurysms (n = 6, harvested at 24 weeks) were created and embolized. A single human aneurysm, embolized 6 years before death, was harvested following autopsy. All specimens were processed by using a modified paraffin embedding technique. Tissue was sectioned and stained with hematoxylin and eosin and Masson trichrome. Immunohistochemistry and immunofluorescence were performed with multiple antibodies, including alpha smooth muscle actin, myosin heavy chain, desmin, vimentin, and CD31. RESULTS: The human aneurysm's dome was filled with loose, hypocellular, amorphous tissue. The aneurysm's neck was completely covered with a thin layer of hypocellular tissue. Collagen and myofibroblasts were sparse in both the dome and neck. Rabbit aneurysms' domes were also filled with a loose, hypocellular tissue, amorphous matrix. In 5 of 6 aneurysms, a thin layer of hypocellular tissue ran along the neck. Collagen and myofibroblasts were sparse in the dome. Swine aneurysms were filled with densely infiltrated tissue, including chronic inflammatory tissue and extensive, attenuated collagen fiber bundles associated with myofibroblasts. Thick layers of myofibroblasts entirely bridged the necks. CONCLUSIONS: Absence of collagen deposition and scant myofibroblastic reaction to platinum coil embolization are seen in the rabbit model but not in swine aneurysms. The elastase-induced aneurysm model in rabbits is more suitable than sidewall swine aneurysms for testing of modified devices aimed at improving intra-aneurysmal fibrosis.

Can neck size in elastase-induced aneurysms be controlled? A prospective study.

BACKGROUND AND PURPOSE: An earlier retrospective study indicated that the neck size of elastase-induced aneurysms could be controlled by adjusting the position of the inflated balloon. We report the current prospective study to confirm our previous work. METHODS: Ninety elastase-induced aneurysms were created in rabbits. Group 1 (n = 62) included cases in which the occlusion balloon resided low, completely within the brachiocephalic/subclavian arteries. Group 2 (n = 28) included cases in which the balloon resided high, within both the common carotid artery and brachiocephalic/subclavian arteries. Follow-up digital subtraction angiography was performed. The aneurysm sizes were measured and compared between groups. The Student t test and the Fisher exact test were used for statistical analysis. RESULTS: The mean aneurysm neck diameter and width for group 1 was significantly larger than that of group 2 (3.4 +/- 1.2 and 2.3 +/- 0.9 mm, P < .001; 3.8 +/- 1.0 and 3.3 +/- 0.9 mm, P < .05, respectively). The proportion of wide-necked aneurysms in group 1 was significantly larger than that in group 2 (29% vs 4%; P < .005). Mean dome-to-neck ratios were 1.2 +/- 0.4 and 1.7 +/- 0.7 for groups 1 and 2 (P < .005). There was no significant difference in aneurysm height between groups 1 and 2 (8.0 +/- 1.7 and 7.5 +/- 2.2 mm; P > .05). CONCLUSION: The neck size of elastase-induced aneurysm models in rabbits can be controlled by adjusting the position of the inflated balloon.

Modified histologic technique for processing metallic coil-bearing tissue.

We developed a modified paraffin-embedding histologic technique for processing metallic coil-bearing aneurysm tissues. This modified technique was successfully employed for processing platinum coil-bearing tissue for 30 rabbit aneurysms and 6 swine aneurysms. This technique for sectioning coil-bearing aneurysms resulted in little or no tissue distortion and permitted good preservation of morphology and application of multiple advanced staining techniques. This technique is considered beneficial for studying the molecular mechanisms of aneurysm healing after coiling.

Intra-venous digital subtraction angiography: an alternative method to intra-arterial digital subtraction angiography for experimental aneurysm imaging.

Conventional intra-arterial digital subtraction angiography (IADSA), which necessitates surgical exposure and ligation of the femoral artery, is an invasive and expensive method of evaluation for experimental elastase-induced aneurysms in rabbits. The purpose of this study was to examine and validate intra-venous digital subtraction angiography (IVDSA) as an alternative to IADSA by comparing their diagnostic accuracies. We performed both IVDSA and IADSA for 24 elastase-induced saccular aneurysms in a rabbit model, 1 month following creation. Aneurysm sizes (neck, width and height) from both the IVDSA and IADSA procedures were evaluated and measured. Comparison of the aneurysm sizes between IVDSA and IADSA were performed with the Wilcoxon paired signed-rank test. All the aneurysms were seen clearly in both the IVDSA and IADSA techniques. Mean sizes of the IVDSA aneurysm neck, width and height were 3.41 +/- 0.80 mm, 3.61 +/- 0.93 mm and 8.07 +/- 2.11 mm, respectively. Mean sizes of the IADSA aneurysm neck, width and height were 3.43 +/- 0.80 mm, 3.66 +/- 0.92 mm and 8.16 +/- 2.25 mm, respectively. No significant difference was found in the sizes of the aneurysm neck, width and height between the two groups (P = 0.311, P = 0.086 and P = 0.258, respectively). IVDSA appears to be an alternative method for evaluating elastase-induced aneurysms in rabbits.