Leveraging the Value of CDISC SEND Data Sets for Cross-Study Analysis: Incidence of Microscopic Findings in Control Animals.

Implementation of the Clinical Data Interchange Standards Consortium (CDISC)'s Standard for Exchange of Nonclinical Data (SEND) by the United States Food and Drug Administration Center for Drug Evaluation and Research (US FDA CDER) has created large quantities of SEND data sets and a tremendous opportunity to apply large-scale data analytic approaches. To fully realize this opportunity, differences in SEND implementation that impair the ability to conduct cross-study analysis must be addressed. In this manuscript, a prototypical question regarding historical control data (see Table of Contents graphic) was used to identify areas for SEND harmonization and to develop algorithmic strategies for nonclinical cross-study analysis within a variety of databases. FDA CDER's repository of >1800 sponsor-submitted studies in SEND format was queried using the statistical programming language R to gain insight into how the CDISC SEND Implementation Guides are being applied across the industry. For each component needed to answer the question (defined as "query block"), the frequency of data population was determined and ranged from 6 to 99%. For fields populated <90% and/or that did not have Controlled Terminology, data extraction methods such as data transformation and script development were evaluated. Data extraction was successful for fields such as phase of study, negative controls, and histopathology using scripts. Calculations to assess accuracy of data extraction indicated a high confidence in most query block searches. Some fields such as vehicle name, animal supplier name, and test facility name are not amenable to accurate data extraction through script development alone and require additional harmonization to confidently extract data. Harmonization proposals are discussed in this manuscript. Implementation of these proposals will allow stakeholders to capitalize on the opportunity presented by SEND data sets to increase the efficiency and productivity of nonclinical drug development, allowing the most promising drug candidates to proceed through development.

Discordant biological and toxicological species responses to TLR3 activation.

Toll-like receptors (TLRs) are highly conserved type 1 membrane proteins that initiate a multiplicity of transient gene transcriptions, resulting in innate and adaptive immune responses. These essential immune responses are triggered by common TLR pattern recognition receptors of microbial products expressed through the cytoplasmic carboxy-terminal Toll/IL-1 domain. Toll/IL-1 adapter protein cascades are induced by an activated Toll/IL-1 to induce transient transcription responses. All TLRs, with the exception of TLR3, use an MyD88 adapter to Toll/IL-1 to initiate a proinflammatory cascade. TLR3 uses the toll receptor 3/4 induction factor adapter to initiate a different cytosolic adapter cascade with double-stranded RNA agonists. This non-MyD88 pathway induces both NF-κB and type 1 interferon responses. By using a TLR3-restricted double-stranded RNA agonist, rintatolimod, we demonstrate significant unexpected differences in toxic responses between rats and primates. The mechanism of this differential response is consistent with a relative down-regulation of the NF-κB inflammatory cytokine induction pathway in the cynomolgus monkey and humans, but not observed systemically in rat. Our findings suggest evaluation of TLR3 agonists in drug therapy.

Utilization of the Zucker Diabetic Fatty (ZDF) Rat Model for Investigating Hypoglycemia-related Toxicities.

Glucokinase (GK) catalyzes the initial step in glycolysis and is a key regulator of glucose homeostasis. Therefore, glucokinase activators (GKa) have potential benefit in treating type 2 diabetes. Administration of a Bristol-Myers Squibb GKa (BMS-820132) to healthy euglycemic Sprague-Dawley (SD) rats and beagle dogs in 1 mo toxicology studies resulted in marked and extended hypoglycemia with associated clinical signs of toxicity and degenerative histopathological changes in the stomach, sciatic nerve, myocardium, and skeletal muscles at exposures comparable to those expected at therapeutic clinical exposures. To investigate whether these adverse effects were secondary to exaggerated pharmacology (prolonged hypoglycemia), BMS-820132 was administered daily to male Zucker diabetic fatty (ZDF) rats for 1 mo. ZDF rats are markedly hyperglycemic and insulin resistant. BMS-820132 did not induce hypoglycemia, clinical signs of hypoglycemia, or any of the histopathologic adverse effects observed in the 1 mo toxicology studies at exposures that exceeded those observed in SD rats and dogs. This indicates that the toxicity observed in euglycemic animals was secondary to the exaggerated pharmacology of potent GK activation. This study indicates that ZDF rats, with conventional toxicity studies, are a useful disease model for testing antidiabetic agents and determining toxicities that are independent of prolonged hypoglycemia.

Vertebral osteomyelitis: retrospective review of 11 years of experience.

INTRODUCTION: Infectious vertebral osteomyelitis (VO) is a significant source of morbidity that can lead to chronic sequelae. The objectives of this study were to describe the clinical presentations and assess the outcomes of VO. METHODS: A retrospective review of cases of VO admitted to an inpatient service between 1 January 2000 and 31 March 2012 was carried out. Cases had evidence of VO by clinical syndrome, imaging, histopathology, and/or microbiology. Outcomes assessed were implantation of prosthetic material for stabilization, hospital readmission for management of VO, repeat surgical intervention, and additional or prolonged courses of antibiotics. RESULTS: Of 117 VO cases, a causative organism was identified in the majority (88.0%). Staphylococcus aureus was the most common organism isolated, followed by Streptococcus species. The most common infection site was the lumbar spine (55.5%). Surgical intervention was required in 81.2% of cases. Infections involving the lumbar vertebrae were associated with a higher risk of all 4 outcomes. Individuals with methicillin-resistant S. aureus infection were more likely to require a readmission for management of VO (odds ratio (OR) 3.94, 95% confidence interval (CI) 1.25-12.42). Individuals with lumbar infections were more likely to require additional antibiotics (OR 4.08, 95% CI 1.34-12.40) and more likely to require readmission (OR 8.29, 95% CI 1.84-37.33) for management of VO. An early infectious disease consultation was associated with a decreased risk for additional antibiotics (OR 0.30, 95% CI 0.11-0.83). CONCLUSIONS: VO was frequently caused by S. aureus or Streptococcus species. Most cases required surgical intervention. An early infectious disease consult ensured a more appropriate antibiotic course.

Mycobacterium abscessus: a rare cause of vascular graft infection.

Prosthetic vascular graft infection (PVGI) following vascular reconstructive surgery is an uncommon but serious complication and is associated with high morbidity as well as mortality rate. Staphylococcal species are the most common organisms causing PVGI. Mycobacterium abscessus is a very rare cause of PVGI and poses a significant diagnostic and management dilemma. To the best of our knowledge, we report the third documented case of M. abscessus vascular graft infection that was diagnosed with 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scan and treated successfully.

Gastric Perforation Due to Sarcina ventriculi: A Histologically Confirmed Case.

We present a case of a rare cause of gastric perforation and pneumoperitoneum, associated with Sarcina ventriculi. An 88-year-old male presented to the emergency room with significant abdominal pain as his chief complaint. Abdominal radiograph showed extensive free intraperitoneal gas under the diaphragms. Computed tomography (CT) of the abdomen and pelvis showed pneumatosis, portal venous gas, and extensive free intraperitoneal gas with free fluid. Immediate surgical intervention ensued. The gastric biopsies obtained proved valuable for confirming the diagnosis of S. ventriculi. In conjunction with surgery, the patient received a course of antibiotics for a cure.

Self-defense of human sarcoma cells against cytolytic lymphoid cells of their host.

Metastatic human sarcomas temporarily respond to radio-chemotherapy relapse and remain highly resistant to further combination chemotherapy as to a curative effect, including checkpoint control.

Pooled sample strategy in conjunction with high-resolution liquid chromatography-mass spectrometry-based background subtraction to identify toxicological markers in dogs treated with ibipinabant.

Metabolomics with chromatography-mass spectrometry is often challenging and relies on statistical tools to discern changes in a metabolome. A pooled sample strategy was proposed, consisting of (1) identification of potential marker candidates by detecting changes of metabolites in a few pooled samples between treated and control groups and (2) validation of markers of statistically significant changes with a large set of individual samples. This strategy was enabled by applying a thorough background subtraction approach based on high-resolution mass spectrometry. In a proof-of-principle study, plasma samples were generated and pooled in a 6-week investigational study to identify potential toxicological markers for an observed muscle toxicity associated with the treatment of ibipinabant in dogs. With pooled control samples as backgrounds, potential marker candidates were revealed in the background-subtracted profiles of the pooled ibipinabant-treated samples. After further cleaning with the use of mass defect filtering to exclude drug metabolites and the comparison of profiles between pooled treated samples to eliminate inconsistent peaks, the major biomarker candidates in the profiles were identified to be 19 acylcarnitines. A total of 3 of the 19 acylcarnitines were measured on the set of individual samples to allow for statistical analysis. The results confirmed the significance of acylcarnitine elevations in ibipinabant-treated dogs and indicated that the acylcarnitines could be early markers for the dog-specific toxicity. The advantages of the pooled sample strategy and its potential limitations for metabolomics are discussed.

Evidence accumulating in support of cancer vaccines combined with chemotherapy: a pragmatic review of past and present efforts.

In the early 1970s supervised clinical trials were initiated at The University of Texas M.D. Anderson Hospital in Houston, TX, for the combination of viral oncolysate-based vaccines and contemporary chemotherapy for the treatment of patients with metastatic melanoma and sarcomas. This therapeutic approach was then generally considered to be inappropriate based on a widely held belief that the efficacy of cancer vaccines would be negated by the immunosuppressive effects of the chemotherapy. Not NCI grants, but institutional funds supported these clinical trials. These early clinical trials included in vitro tests for anti-tumor cell antibodies and cytotoxic lymphocytes both in autologous and allogeneic settings and showed that these faculties remained active even after chemotherapy. The contemporary reports of unexpectedly favorable clinical results are recited in this article. Despite these most promising results, support from federal granting agencies (the NIH/NCI) was repeatedly denied; these denials were based on the prevailing dogma that the two treatment modalities are expected to be antagonistic and not synergistic or not even additive. However, thirty years later, now in the new era of molecular medicine, a rapidly increasing number of peer-reviewed publications appear and offer convincing evidence that strongly substantiate the therapeutic value of combined cancer chemoimmunotherapy. The important provision is that the sequencing and dosing of the two major treatment modalities, the vaccination and the chemotherapy, are to be pre-tested and then the methodology is to be adhered to in the new clinical trials. New sophisticated experiments carried out in vitro and in vivo and subsequent clinical trials attest to the potential value of this combinatory approach and explain the underlying molecular mechanisms. This pragmatic review recapitulates the empirically administered earliest clinical trials, and lists and interprets, in view of their molecular immunomodulatory effects, the exemplary new clinical trials.

Human natural killer cells: a comprehensive review.

The senior author of this comprehensive review observed and reported in 1969 that his lymphocytes killed allogeneic tumor cells in vitro. Some of his research associates and technicians and other healthy individuals also yielded such killer lymphocytes. The team considered pre-immunization to cancer occurring in individuals after in-family or professional exposure to patients with cancer (in an era when the concept of viral etiology of cancer was receiving major support); or that lymphocytes can acquire through blastic transformation immune reactivity to allogeneic cells anew in vitro. The phenomenon was eventually referred to as 'lymphocytes practicing Burnet's immunosurveillance.' Project site visitors of the USA NCI first viewed these observations as a matter of 'in vitro artifacts' being in opposition to strong tumor- specific cytotoxicity of tumor-bearing patients' lymphocytes recognized in the vast majority of other assays. After NCI funds were released for intramural studies on the phenomenon of non-specific cytotoxicity by lymphocytes, recipients (other than the senior author) of these NCI funds later characterized (1973-1975) the 'indiscriminately' cytotoxic lymphocyte populations as those of 'natural killer (NK) cells.' In this article, the original observations made in 1969-1971 are reviewed based on genuine material preserved by the senior author and are explained in view of recent discoveries that were not available at the time of the original observations. NK cells display a fascinating history arising first in urochordates during the cambrian explosion. At that level, NK cells protected their hosts from incompatible cell colony fusions and against intracellular, especially viral, pathogens. Since then, viruses evolved evasive maneuvers to escape NK cell attack on the infected cells. NK cells persisted after the evolution of adaptive immunity in cartilaginous fish fitting seamlessly into the new system. In mammals, NK cells assumed the role of chief arbitrators between the fetal trophoblast and maternal immune reactions to the semi-allograft fetus. Tumors induce in NK cells the same (inactivating; mediating Th2-type immunity) reactions the fetal trophoblast engenders in utero, but NK cells may overcome the host's tolerance to its tumor and kill tumor cells, especially when converted into lymphokine-activated killer (LAK) cells by molecular mediators of Th1-type immunity. The authors prepare and utilize LAK cells and IL-2 for adoptive immunotherapy of patients with metastatic melanoma and kidney carcinoma. A patient with malignant ascites due to ovarian carcinoma entered remission on LAK cell therapy. Just as dendritic cells, the major antigen presentors, may undergo malignant transformation, NK cells are also subject to transformation into FasL-producer virulent lymphoma-leukemia cells. The senior author reported in 1970 a patient with 'lymphosarcoma cell leukemia' whose circulating lymphoma cells killed indiscriminately human sarcoma and carcinoma cells. The exemplary case history of another patient with NK cell lymphoma-leukemia treated by the authors is presented.

[Erratum] Virological and immunological connotations of apoptotic and anti-apoptotic forces in neoplasia.

The authors would like to acknowledge that the Coriphosphine O stain shown in the upper panel of Figure 8 was a kind gift from Dr T.P. Loughran of the H.L. Moffitt Cancer Center, Tampa, FL, USA. [the original article was published in the International Journal of Oncology 19: 473-488, 2001; DOI: 10.3892/ijo.19.3.473].

Fatal immune restoration disease in human immunodeficiency virus type 1-infected patients with progressive multifocal leukoencephalopathy: impact of antiretroviral therapy-associated immune reconstitution.

Immune reconstitution resulting from use of highly active antiretroviral therapy in patients infected with human immunodeficiency virus type 1 (HIV-1) has been associated with a significant decrease in infectious morbidity and with improved survival. Occasionally, patients with quiescent disease due to human cytomegalovirus or nontuberculous mycobacteria may experience paradoxical worsening due to "dysregulated" restitution of the immune system (that is, immune restoration disease [IRD]). Acquired immunodeficiency syndrome-related progressive multifocal leukoencephalopathy (PML) is uncommon and often improves with immune recovery. We describe 2 HIV-1-infected patients with PML that presented with paradoxical worsening after the patients had commenced active antiretroviral therapy. After they had a transient response to high-dose corticosteroid therapy, both patients died of progressive neurological deterioration. IRD in these patients with PML was unexpected and occurred soon after they had started receiving active antiretroviral therapy, during the period of improved antigen-specific T-helper cell function. Predictors of patients' proclivity for these adverse events are uncertain. Evaluation of targeted immunomodulatory therapy directed towards disease-specific IRD is critical and may play an important role in improved survival for patients who are at risk.

Intranasal seasonal influenza vaccine and a TLR-3 agonist, rintatolimod, induced cross-reactive IgA antibody formation against avian H5N1 and H7N9 influenza HA in humans.

The intranasal use of rintatolimod, a specific TLR-3 agonist, combined with trivalent seasonal influenza vaccine generated cross-protection against highly pathogenic H5N1 avian influenza in mice. The purpose of this clinical trial is to assess the safety and impact of rintatolimod on intranasal influenza vaccine in healthy adults. During Stage I of this Phase I/II clinical trial, 12 volunteers were immunized intranasally with 3 doses of FluMist seasonal influenza vaccine on Days 0, 28, and 56 followed by intranasal rintatolimod (50 µg, 200 µg, or 500 µg) 3 days later. Parotid saliva and nasal wash samples were collected at baseline and on Days 25, 53, 84, and 417. The samples were tested for IgA and IgG specific antibodies (Ab) directed against the homologous FluMist viral hemagglutinins (HAs). In addition, viral specific responses against influenza A HAs were tested for IgA Ab cross-reactivity against 3 H5 clades: HA (H5N1) A/Indonesia/5/2005, HA (H5N1) A/Hong Kong/483/97 and HA (H5N1) A/Vietnam/1194/2004, as well as, two H7 strains, HA (H7N9) A/Shanghai/2/2013 and HA (H7N3) A/chicken/Jalisco/CPA1. The combination of the intranasal FluMist along with the rintatolimod generated specific secretory IgA responses of at least 4-fold over baseline against at least one of the homologous vaccine strains included in the vaccine in 92% of the vaccinees. Additionally, this vaccination strategy induced cross-reactive secretory IgA against highly pathogenic avian influenza virus strains H5N1, H7N9, and H7N3 with pandemic potential for humans. The combination of rintatolimod and FluMist was well-tolerated.

Cannabinoid receptor antagonist-induced striated muscle toxicity and ethylmalonic-adipic aciduria in beagle dogs.

Ibipinabant (IBI), a potent cannabinoid-1 receptor (CB1R) antagonist, previously in development for the treatment of obesity, causes skeletal and cardiac myopathy in beagle dogs. This toxicity was characterized by increases in muscle-derived enzyme activity in serum and microscopic striated muscle degeneration and accumulation of lipid droplets in myofibers. Additional changes in serum chemistry included decreases in glucose and increases in non-esterified fatty acids and cholesterol, and metabolic acidosis, consistent with disturbances in lipid and carbohydrate metabolism. No evidence of CB1R expression was detected in dog striated muscle as assessed by polymerase chain reaction, immunohistochemistry, Western blot analysis, and competitive radioligand binding. Investigative studies utilized metabonomic technology and demonstrated changes in several intermediates and metabolites of fatty acid metabolism including plasma acylcarnitines and urinary ethylmalonate, methylsuccinate, adipate, suberate, hexanoylglycine, sarcosine, dimethylglycine, isovalerylglycine, and 2-hydroxyglutarate. These results indicated that the toxic effect of IBI on striated muscle in beagle dogs is consistent with an inhibition of the mitochondrial flavin-containing enzymes including dimethyl glycine, sarcosine, isovaleryl-CoA, 2-hydroxyglutarate, and multiple acyl-CoA (short, medium, long, and very long chain) dehydrogenases. All of these enzymes converge at the level of electron transfer flavoprotein (ETF) and ETF oxidoreductase. Urinary ethylmalonate was shown to be a biomarker of IBI-induced striated muscle toxicity in dogs and could provide the ability to monitor potential IBI-induced toxic myopathy in humans. We propose that IBI-induced toxic myopathy in beagle dogs is not caused by direct antagonism of CB1R and could represent a model of ethylmalonic-adipic aciduria in humans.

Identification of mitochondrial genome concatemers in AIDS-associated lymphomas and lymphoid cell lines.

Since most oncogenic viruses persist as extrachromosomal covalently closed circular DNA (cccDNA) in tumor cells, we developed an assay to visualize and identify cccDNA in primary lymphomas. We identified concatemers of the mitochondrial genome in all samples analyzed, but not in normal lymphocytes. One AIDS-associated lymphoma (EL) was further studied in detail as its mitochondrial genome consisted of tandem head-to-tail duplications. Insertion of C-residues was noted near the origin of replication of EL mtDNA. EL cells responded weakly to Fas-apoptotic stimulus, displayed reduced mitochondrial activity and mass, and produced higher levels of reactive oxygen intermediates. Screening of several AIDS-associated lymphomas and established lymphoid cell lines also revealed the presence of mitochondrial genome concatemers consisting of interlinked monomer molecules. Taken together, our results suggest that formation of mtDNA concatemers is associated with oncogenic transformation in lymphoid cells.

Natural and genetically engineered viral agents for oncolysis and gene therapy of human cancers.

Based on personal acquaintances and experience dating back to the early 1950s, the senior author reviews the history of viral therapy of cancer. He points out the difficulties encountered in the treatment of human cancers, as opposed by the highly successful viral therapy of experimentally maintained tumors in laboratory animals, especially that of ascites carcinomas in mice. A detailed account of viral therapy of human tumors with naturally oncolytic viruses follows, emphasizing the first clinical trials with viral oncolysates. The discrepancy between the high success rates, culminating in cures, in the treatment of tumors of laboratory animals, and the moderate results, such as stabilizations of disease, partial responses, very rare complete remissions, and frequent relapses with virally treated human tumors is recognized. The preclinical laboratory testing against established human tumor cell lines that were maintained in tissue cultures for decades, and against human tumors extricated from their natural habitat and grown in xenografts, may not yield valid results predictive of the viral therapy applied against human tumors growing in their natural environment, the human host. Since the recent discovery of the oncosuppressive efficacy of bacteriophages, the colon could be regarded as the battlefield, where incipient tumor cells and bacteriophages vie for dominance. The inner environment of the colon will be the teaching ground providing new knowledge on the value of the anti-tumor efficacy of phage-induced innate anti-tumor immune reactions. Genetically engineered oncolytic viruses are reviewed next. The molecular biology of viral oncolysis is explained in details. Elaborate efforts are presented to elucidate how gene product proteins of oncolytic viruses switch off the oncogenic cascades of cancer cells. The facts strongly support the conclusion that viral therapy of human cancers will remain in the front lines of modern cancer therapeutics. It may be a combination of naturally oncolytic viruses and wild-type viruses rendered oncolytic and harmless by genetic engineering, that will induce complete remissions of human tumors. It may be necessary to co-administer certain chemotherapeutic agents, advanced cancer vaccines, or even immune lymphocytes, and targeted therapeuticals, to ascertain, that remissions induced by the viral agents will remain complete and durable; will co-operate with anti-tumor host immune reactions, and eventually will result in cures of advanced metastatic human cancers.

Coccidioidomycosis diagnosed in South Carolina.

Primary care physicians in the Eastern United States rarely consider coccidioidomycosis in the differential diagnosis of pulmonary infections or febrile illnesses. However, the mobility of the population mandates consideration of this diagnosis, particularly in patients with fever and cough that do not resolve rapidly and in patients with adenopathy on chest radiography. In this report, we describe two unrelated cases encountered during a single week in a South Carolina internal medicine practice. These cases highlight the importance of obtaining travel histories from patients with atypical pulmonary infections. Early consideration of coccidioidomycosis confers several benefits, including allaying patient anxiety by more timely diagnosis, minimizing the empiric use of antibiotics, and reducing the need for extensive and possibly invasive diagnostic testing.

A case of allergic bronchopulmonary aspergillosis leading to pneumonia with unusual organisms.

We describe the case of a 50-year-old male with a history of asthma and seizure disorder who presented with a 5-month history of dyspnea. The patient had been treated with multiple courses of antibiotics for presumed community-acquired pneumonia before being determined to have allergic bronchopulmonary aspergillosis (ABPA) by serologic and radiographic criteria. Inflammation resulting from this disease had potentiated a postobstructive pneumonia caused by Nocardia asteroides and Stenotrophomonas maltophilia. Therapy with corticosteroids, trimethoprim sulfa, and voriconazole failed to prevent subsequent destruction of the right upper lobe and the patient required surgical intervention. The discussion emphasizes the diagnostic criteria for ABPA including historic, serologic, and radiographic findings; staging, and treatment. Other possible diagnoses, such as invasive pulmonary aspergillosis, chronic necrotizing aspergillosis, and hyper-IgE syndrome are also briefly reviewed.

Antiviral treatment of human immunodeficiency virus infection: update for 2003.

Highly-active Antiretroviral Treatment (HAART) nowadays consists of 21 approved drugs in the USA. The medications belong to four classes: (1) Nucleoside/nucleotide analogues, (2) Non-nucleoside reverse transcriptase inhibitors, (3) Protease inhibitors, and (4) a fusion inhibitor. At least three effective drugs are required to reduce the viremia, aiming at nondetectable, and thus, raise the immune reserve, i.e. the CD4 lymphocyte count. HAART effectively extends the life of patients infected with HIV, in essence converting a fatal disease into a chronic infection, as eradication of HIV is not yet possible. The laurels of HAART are shadowed by its toxicity. Non-compliance with treatment is also an important contributor to its failure. HAART is continuing in development, change, benefiting the patients affected with HIV/AIDS, HCV and HBV.

Brucellosis in two hunt club members in South Carolina.

We report two cases of brucellosis in members of a hunt club, both of whom had killed and dressed wild boars. Serologic studies usually suffice for screening patients with suspected or possible brucellosis; however, and as illustrated by our index case, one should ask the laboratory to dilute serum out beyond the customary 1:160 titer if results are negative yet the clinical suspicion high. Hunters should be advised to wear gloves prior to dressing wild mammals.