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bioRxiv2017

Distinct Solubility and Cytotoxicity Regimes of Paclitaxel-Loaded Cationic Liposomes at Low and High Drug Content Revealed by Kinetic Phase Behavior and Cancer Cell Viability Studies

Lipid-based particles are used worldwide in clinical trials as carriers of hydrophobic paclitaxel (PTXL) for cancer chemotherapy, albeit with little improvement over the standard-of-care. Improving efficacy requires an understanding of intramembrane interactions between PTXL and lipids to enhance PTXL solubilization and suppress PTXL phase separation into crystals. We studied the solubility of PTXL in cationic liposomes (CLs) composed of positively charged 2,3-dioleyloxypropyltrimethylammonium chloride (DOTAP) and neutral 1,2-dioleoyl-sn-glycero-3-phosphatidylcholine (DOPC) as a function of PTXL membrane content and its relation to efficacy. Time-dependent kinetic phase diagrams were generated from observations of PTXL crystal formation by differential-interference-contrast microscopy. Furthermore, a new Synchrotron small-angle x-ray scattering in situ methodology applied to DOTAP/DOPC/PTXL membranes condensed with DNA enabled us to detect the time-dependent depletion of PTXL from membranes by measurements of variations in the membrane interlayer and DNA interaxial spacings. Our results revealed three regimes with distinct time scales for PTXL membrane solubility: hours for > 3 mol% PTXL (low), days for {approx} 3 mol% PTXL (moderate), and [≥] 20 days for < 3 mol% PTXL (long-term). Cell viability experiments on human cancer cell lines using CLPTXL nanoparticles (NPs) in the distinct CLPTXL solubility regimes reveal an unexpected nonmonotonic dependence of efficacy on PTXL content in NPs delivered at short time scales (hours) after liposome hydration, where we see two distinct high-efficacy regimes at low (< 2 mol%) and high (9 mol%) drug loading. These newly identified high-efficacy regimes flank the membrane solubility limit ({approx} 3 mol%, where efficacy declines), which has been the focus of most previous physicochemical studies (and clinical trials) of PTXL-loaded CLs. At longer times scales (days), CLPTXL NPs with [≥] 3 mol% PTXL lose efficacy while formulations with 1-2 mol% PTXL maintain high efficacy. Our findings underscore the importance of understanding the relationship of the kinetic phase behavior and physicochemical properties of CLPTXL NPs to efficacy.

biophysics↗

bioRxiv2018

Glenohumeral Injection Using Anatomic Landmark Versus Sonographic Needle Guidance

ObjectiveWe hypothesized ultrasound (US) guidance improves outcomes of corticosteroid injection of the painful shoulder.\n\nMethods30 patients with symptomatic shoulders due to osteoarthritis were randomized to glenohumeral injection with 3 milliliters of 1% lidocaine and 60 mg of triamcinolone acetonide using the anterior approach with 1) conventional anatomic landmark palpation-guidance or 2) US-guidance. Injection pain (visual analogue pain scale (VAS)), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next-injection, and costs were determined.\n\nResultsInjection pain was less with US (VAS: 0.3{+/-}0.6 cm) vs. landmark-guidance (VAS: 1.4{+/-}2.4 cm, 95% CI of difference: 0.5<1.1<1.7, p=0.05). Pain scores were similar at 2 weeks: US: 2.2{+/-}2.4 cm; Landmark: 1.8{+/-}2.7 cm, 95% CI of difference: -2.2<-0.4<1.4, p=0.66 and 6 months: US: 5.8{+/-}2.8 cm; Landmark: 6.4{+/-}2.9 cm, 95% CI of difference: -0.4<0.6< 1.1, p =0.71. Therapeutic duration (US: 3.9{+/-}1.5 months; Landmark: 3.0{+/-}1.2 months, 95% CI of difference: - 1.4 <-0.9<-0.4, p=0.045) and time-to-next-injection (US: 8.1{+/-}3.5 months; Landmark: 5.7{+/-}2.9 months, 95% CI of difference: -3.6<-2.4<-1.3, p=0.025) were longer, and fewer injections per year (29% less) were required: US: 1.5{+/-}0.2 injections/year; Landmark: 2.1{+/-}0.2 injections/year (p<0.037; 95% CI of difference -0.9<-0.6<-0.3). However, cost/patient/year was modestly greater with US (US: $318{+/-}89, Landmark: $301{+/-}67; p=0.28).\n\nConclusionAnatomic landmark guidance in the short-term is equally effective as US for injection of the osteoarthritic shoulder and modestly less costly, however, US may reduce the need for repetitive injections by prolonging the therapeutic effect and thus time to next injection.\n\nIRB StatementThis project was in compliance with the Helsinki Declaration, was approved by the Institutional Review Board (IRB) as ultrasound subset of a syringe safety trial (Human Research Review Committee approval 04-347), and was registered at ClinicalTrials.gov (Clinical Trial Identifier NCT00651625). The subjects gave informed consent to participate prior to all studies and interventions. Patient confidentiality was protected according to the U.S. Health Insurance Portability and Accountability Act (HIPAA) and all data was de-identified.

clinical trials↗

bioRxiv2015

Measuring the Contribution of Genomic Predictors to Improving Estimator Precision in Randomized trials

The use of genomic data in the clinic has not been as widespread as was envisioned when sequencing and genomic analysis became common techniques. An underlying difficulty is the direct assessment of how much additional information genomic data are providing beyond standard clinical measurements. This is hard to quantify in the clinical setting where laboratory tests based on genomic signatures are fairly new and there are not sufficient data collected to determine how valuable these tests have been in practice. Here we focus on the potential precision gain from using the popular MammaPrint genomic signature in a covariate-adjusted, randomized clinical trial. We describe how adjustment of an estimator for the average treatment effect using baseline measurements can improve precision. This precision gain can be translated directly into sample size reduction and corresponding cost savings. We conduct a simulation study using genomic and clinical data gathered for breast cancer patients and find that adjusting for clinical factors alone provides a gain in precision of 5-6%, adjusting for genomic factors alone provides a similar gain (5%), and combining the two yields a 2-3% additional gain over only adjusting for clinical covariates.

Bioinformatics↗

bioRxiv2018

Effects of Attentional Bias Modification on Residual Symptoms in depression. A Randomized Controlled Trial.

BackgroundFollowing treatment, many depressed patients have significant residual symptoms. However, large randomised controlled trials (RCT) in this population are lacking. When Attention bias modification training (ABM) leads to more positive emotional biases, associated changes in clinical symptoms have been reported. A broader and more transparent picture of the true advantage of ABM based on larger and more stringent clinical trials have been requested.\n\nAimsTo evaluate the early effect of two weeks ABM training on blinded clinician-rated and self-reported residual symptoms, and whether changes towards more positive attentional biases (AB) would be associated with symptom reduction.\n\nMethodA total of 321 patients with a history of depression were included in a preregistered randomized controlled double-blinded trial. Patients were randomised to an emotional ABM paradigm over fourteen days or a closely matched control condition. Symptoms based on the Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory II (BDI-II) were obtained at baseline and after ABM training.\n\nResultsABM training led to significantly greater decrease in clinician-rated symptoms of depression as compared to the control condition. No differences between ABM and placebo were found for self-reported symptoms. ABM induced a change of AB towards relatively more positive stimuli associated with greater symptom reduction.\n\nConclusionThe current study demonstrates that ABM produces early changes in both AB and blinded clinician-rated depressive symptoms. ABM may have practical potential in the treatment of residual depression.\n\nClinicalTrials.gov ID: NCT02658682

clinical trials↗

bioRxiv2018

Prescription Opioid Analgesic Use and Mortality in Systemic Lupus Erythematosus

ObjectivesThis research investigated the prevalence of opioid analgesic use in patients with systemic lupus erythematosus (SLE).\n\nMethodsThis 5-year prospective cohort study of 275 SLE patients focused on prescription opioid use and 5-year outcome. Associations were determined with univariable regression analysis and then multivariable models were created to determine independent effects on dependent variables\n\nResultsPrescription opioid use was common in SLE with 24% using opioid analgesics chronically and 76% not using opioids. Opioid users had a higher rate of tobacco use (p<0.01), cocaine use (p<0.002), mean pain scores (p<0.001), disease activity (SLEDAI-2K) (p<0.001), disease damage (SLICC/ACRDI) (p<0.001), non-adherence to medical therapy (p<0.01), and total deaths at 5 years (opioids: 48.0%, no opioids 19.0%, p<0.001). Logistic regression analysis predicting death revealed opioid use (hazard ratio 2.6, p<0.001) and SLEDAI-2K (1.1, p<0.001) respectively; and opioid use (hazard ratio 2.5, p<0.002), SLEDAI-2K (hazard ratio 1.1, p<0.001), and non-adherence (hazard ratio 1.6, p=0.11), respectively. Multivariable Cox Model analysis estimating probability of death with covariates: opioid use (hazard ratio 2.6, p<0.001) and SLEDAI-2K (hazard ratio 1.1, p<0.001); opioid use (hazard ratios 3.0, p<0.001), and cocaine use (hazard ratio 3.2, p<0.001). The Kaplan-Meir survival analysis revealed a significantly higher probability of death for SLE patients using opioid analgesics.\n\nConclusionsPrescription opioid analgesic use is common in SLE and is associated with markedly increased mortality. Preferably, non-opioid approaches to treat chronic pain should be used in SLE patients.\n\nClinical trial registration numberThis was not a clinical trial.\n\nKEY MESSAGES1. Chronic opioid analgesic use is common in SLE (24%).\n\n2. Opioid use is associated with greater disease severity, tobacco use, non-adherence, and increased mortality.\n\n3. Opioids should be used cautiously in SLE; alternative non-opioid management of pain is recommended.\n\nACKNOWLEDGMENTS AND FUNDING INFORMATIONThis work was supported by US National Institutes of Health research grants to Dr. Sibbitt (R01 NS035708) and to the Clinical and Translational Research Center (UL1TR001449).

epidemiology↗

bioRxiv2018

Exploratory analyses suggest less cognitive decline on nilvadipine treatment in very mild Alzheimer’s disease subjects

BackgroundWe explored whether the effects of nilvadipine on cognition were influenced by baseline Alzheimers disease (AD) severity.\n\nMethodsExploratory analyses were performed on the modified intention-to-treat (mITT) dataset (n = 497) of a phase III randomized placebo-controlled trial to examine the response to nilvadipine in very mild, mild and moderate AD subjects. The outcome measures included total and subscale scores of the Alzheimers Disease Assessment Scale Cognitive 12 (ADAS-Cog 12), the Clinical Dementia Rating Scale sum of boxes (CDR-sb) and the AD composite score (ADCOMS), an outcome measure recently developed to detect treatment responses in subjects with prodromal AD. Cerebrospinal fluid (CSF) biomarkers A{beta}38, A{beta}40, A{beta}42, total tau and P181 tau were measured in a subset of samples (n = 55). Regression analyses were adjusted for potential confounders and effect modifiers in order to examine the interactive effects of nilvadipine and AD severity on cognitive outcomes over 78-weeks.\n\nResultsCompared to their respective placebo-controls, nilvadipine-treated, very mild AD subjects showed less decline, whereas moderate AD subjects showed greater decline on the ADAS-Cog 12. Also in very mild AD, a beneficial effect (as measured by ADCOMS), was detected in the nilvadipine treated group. Therapeutic effects of nilvadipine were also observed for a composite memory trait in very mild AD subjects and a composite language trait in mild AD subjects. CSF A{beta}42/A{beta}40 ratios were increased in mild AD and decreased in moderate AD patients treated with nilvadipine, compared to their respective controls.\n\nConclusionThese data suggest that very mild AD subjects benefited from nilvadipine and that future clinical trials of nilvadipine in this population are required to confirm these findings.\n\nTrial RegistrationNCT02017340 Registered 20 December 2013, https://clinicaltrials.gov/ct2/show/NCT02017340\n\nEUDRACT Reference Number 2012-002764-27 Registered 04 February 2013, https://www.clinicaltrialsregister.eu/ctr-search/search?query=2012-002764-27

clinical trials↗

bioRxiv2016

Chloroquine inhibits Zika Virus infection in different cellular models

Zika virus (ZIKV) infection in utero might lead to microcephaly and other congenital defects. In adults, cases of Guillain-Barre syndrome and meningoencephalitis associated with ZIKV infection have been reported, and no specific therapy is available so far. There is urgency for the discovery of antiviral agents capable of inhibiting viral replication and its deleterious effects. Chloroquine is widely administered as an antimalarial drug, anti-inflammatory agent, and it also shows antiviral activity against several viruses. Here we show that chloroquine exhibits antiviral activity against ZIKV in VERO, human brain microvascular endothelial, and neural stem cells. We demonstrated in vitro that chloroquine reduces the number of ZIKV-infected cells, virus production and cell death promoted by ZIKV infection without cytotoxic effects. Our results suggest that chloroquine is a promising candidate for ZIKV clinical trials, since it is already approved for clinical use and can be safely administered to pregnant woman.

Microbiology↗

bioRxiv2018

A double-blinded randomised placebo-controlled phase II trial to evaluate high dose rifampicin for tuberculous meningitis: a dose finding study

BackgroundHigh doses of rifampicin may help tuberculous meningitis (TBM) patients to survive. Pharmacokinetic-pharmacodynamic evaluations suggested that rifampicin doses higher than 13 mg/kg intravenously or 20 mg/kg orally (as previously studied) are warranted to maximize treatment response.\n\nMethodsIn a double-blinded, randomised, placebo-controlled phase II trial, we assigned 60 adult TBM patients in Bandung, Indonesia, to standard 450 mg, 900 mg or 1350 mg (10, 20 and 30 mg/kg) oral rifampicin combined with other TB drugs for 30 days. Endpoints included pharmacokinetic measures, adverse events and survival.\n\nResultsA double and triple dose of oral rifampicin led to three and five-fold higher geometric mean total exposures in plasma in the critical early days (2{+/-}1) of treatment (AUC0-24h: 53{middle dot}5 mg.h/L vs 170{middle dot}6 mg.h/L vs. 293{middle dot}5 mg.h/L, p<0{middle dot}001), with proportional increases in CSF concentrations and without an increase in the incidence of grade 3/4 adverse events. Six-month mortality was 7/20 (35%, 9/20 (45%) and 3/20 (15%) in the 10, 20 and 30 mg/kg groups, respectively (p=0{middle dot}12).\n\nConclusionsTripling the standard dose caused a large increase in rifampicin exposure in plasma and CSF and was safe. Survival benefit with this dose should now be evaluated in a larger phase III clinical trial.

clinical trials↗

bioRxiv2017

The effect of a lifestyle intervention in obese pregnant women on change in gestational metabolic profiles: findings form the UK Pregnancies Better Eating and Activity Trial (UPBEAT) RCT.

Background: Pregnancy metabolic disruption is believed to be enhanced in obese women and lead to adverse outcomes in them and their offspring. The UK Pregnancies Better Eating and Activity Trial (UPBEAT), a randomised controlled trial of a lifestyle intervention in obese pregnant women, has already been shown to improve diet and physical activity. We used UPBEAT to determine (a) the magnitude of change in metabolic profiles in obese pregnant women and (b) the impact of a lifestyle intervention that successfully improved diet and physical activity on these profiles. Methods: Detailed targeted metabolic profiling, with quantification of 158 metabolic features (129 lipid measures, 9 glycerides and phospholipids, and 20 low-molecular weight metabolites) was completed on three occasions (~17-, 28- and 35-weeks of gestation) in the UPBEAT participants using NMR. Random intercept and random slope models were used to quantify metabolite changes in obese women using the control (usual care) group only (N = 577). The effect of the intervention was determined by comparing rates of metabolite change between those randomised to intervention and usual care, using intention to treat analyses (N = 1158). Results: There were adverse changes across pregnancy in most lipoprotein subclasses, lipids, glycerides, phospholipids, several fatty acids and glucose. All extremely large, very large, large, medium, small and very small VLDL particles increased by 2 to 3 standard deviation units (SD), with IDL, and large, medium and small LDL particles increasing by 1 to 2SD, between 16- and 36-weeks. Triglycerides increased by 3 to 4SD and glucose increased by 2SD, with more modest changes in other metabolites. The intervention reduced the rate of increase in extremely large, very large, large and medium VLDL, in particular those containing triglycerides. Triglyceride to phosphoglyceride ratio was reduced and there were improvements in fatty acid profiles (increases in the proportion of all fatty acids that were linoleic, omega-6 and polyunsaturated and decreases in the proportion of saturated). Conclusion: Systemic metabolism is markedly disrupted in obese pregnant women, but a lifestyle intervention that improved their diet and physical activity has beneficial effects on some of these profiles; these effects might have long-term benefit. Clinical trial registration ID # ISRCTN89971375.

clinical trials↗

bioRxiv2017

Topical Silver Diamine Fluoride For Dental Caries Arrest In Preschool Children: A Randomized Controlled Trial

ObjectivesThe Stopping Cavities Trial investigated effectiveness and safety of 38% silver diamine fluoride in arresting caries lesions.\n\nMaterials and MethodsDouble-blind randomized placebo-controlled superiority trial with 2 parallel groups. Oregon preschools. 66 preschool children with [≥]1 lesion. 38% silver diamine fluoride or placebo (blue-tinted water), applied topically to the lesion. The primary endpoint was caries arrest (lesion inactivity, Nyvad criteria) 14-21 days post intervention. Dental plaque was collected from all children, and microbial composition was assessed by RNA sequencing from 2 lesions and 1 unaffected surface before treatment and at follow-up for 3 children from each group.\n\nResults and ConclusionMean fraction of arrested caries lesions in the silver diamine fluoride group was higher (0.72; 95% CI; 0.55, 0.84) than in the placebo group (0.05; 95% CI; 0.00, 0.16). Confirmatory analysis using generalized estimating equation log-linear regression, accounting for the number of treated surfaces and length of follow-up, indicated the fraction of arrested caries was significantly higher in the treatment group (relative risk, 17.3; 95% CI: 4.3 to 69.4). No harms were observed. RNA sequencing analysis identified no consistent changes in relative abundance of caries-associated microbes, nor emergence of antibiotic or metal resistance gene expression. Topical 38% silver diamine fluoride was effective and safe in arresting cavities in preschool children. The treatment is applicable to primary care practice and may reduce the burden of untreated tooth decay in the population.\n\nTrial RegistrationClinicalTrials.gov NCT02536040.\n\nClinical SignificanceIn this clinical trial, 72% of caries lesions were arrested by silver diamine fluoride, with no harms. Contrary to the presumed antibacterial mechanism, lesion bacterial composition changed negligibly. This simple topical treatment is applicable to primary care practice and may reduce the burden of untreated tooth decay in the population.

clinical trials↗

bioRxiv2017

TORC1 inhibition as an immunotherapy to reduce infections in the elderly

mTOR inhibition extends lifespan and ameliorates aging-related pathologies including declining immune function in model organisms. The objective of this Phase 2a clinical trial was to determine if low dose mTOR inhibitor therapy enhanced immune function and thereby decreased infection rates in elderly subjects. The results indicate that 6 weeks of treatment with a low dose combination of a catalytic (BEZ235) plus an allosteric (RAD001) mTOR inhibitor (that selectively inhibits TORC1 downstream of mTOR) was safe, significantly decreased the rate of infections reported by elderly subjects for a year following study drug initiation, upregulated antiviral gene expression, and significantly improved influenza vaccination response. Thus selective TORC1 inhibition with a combination of BEZ235 and RAD001 may be efficacious as immunotherapy to reduce infections, a leading cause of death in the elderly.\n\nOne Sentence SummaryTreatment of elderly subjects with a low dose mTOR inhibitor regimen that selectively inhibits TORC1 significantly decreased infection rates

clinical trials↗

bioRxiv2018

Effect of fluoxetine on adult amblyopia: a placebo-controlled study combining neuroplasticity-enhancing pharmacological intervention and perceptual training

Amblyopia is a common visual disorder that is treatable in childhood. However, therapies have limited efficacy in adult patients with amblyopia. Fluoxetine can reinstate early-life critical period-like neuronal plasticity and has been used to recover functional vision in adult rats with amblyopia. This phase 2, randomized, double-blind (fluoxetine vs. placebo), multicenter clinical trial examined whether or not fluoxetine can improve visual acuity in amblyopic adults. This interventional trial included 42 participants diagnosed with moderate to severe amblyopia. Subjects were randomized to receive either 20 mg fluoxetine (n=22) or placebo (n=20). During the 10-week treatment period, all subjects performed daily computerized perceptual training and eye patching. There was no significant difference in treatment efficacy between the groups. Visual acuity at the primary endpoint had significantly improved over baseline in both the fluoxetine (-0.167 logMAR) and placebo (-0.194 logMAR) groups (both p < 0.001). Because patching alone is not effective in adults, the visual acuity improvement likely resulted from perceptual training. There was a positive correlation between visual acuity improvement and the perceptual training time. While this study failed to provide evidence that fluoxetine enhances neuroplasticity, our data support the usefulness of perceptual training for vision improvement in adults with amblyopia.

clinical trials↗

bioRxiv2016

Using simulation to aid trial design: ring-vaccination trials

BackgroundThe 2014-5 West African Ebola epidemic highlights the need for rigorous, rapid clinical trials under difficult circumstances. Challenges include temporally and spatially patchy transmission, and the responsibility to deliver public health interventions during a randomized trial. An innovative design such as ring vaccination with an immediate arm and a delayed arm can address these issues, but complex trials raise complex analysis issues.\n\nMethods and FindingsWe present a stochastic, compartmental model for a ring vaccination trial of a vaccine for an Ebola-like disease. After identification of an index case, a ring of primary contacts is recruited and either vaccinated immediately or after a delay of 21 days. The primary outcome of the trial is effectiveness calculated from cumulative incidence in the two arms, counting cases only from a pre-specified window in which the immediate arm is assumed to be fully protected and the delayed arm is not protected. The results of simulating the trial are used to calculate the sample size necessary for 80% power and the estimates of effectiveness are reported under a variety of assumptions regarding the trial design and implementation.\n\nThe three key components of sample size calculations - attack rate in controls, estimate of incidence difference between the arms, and intracluster correlation coefficient - are dependent on trial design and implementation in a way that can be quantitatively predicted by the model. Under baseline parameter assumptions, we found that a total of 8,900 study participants were needed to achieve 80% power to detect a difference in attack rate between the two arms, whereas a standard approach with the same parameters returns a necessary sample size of 7,100 individuals. Such a study would on average return a vaccine effectiveness estimate of 69.81%, with average 95% confidence interval (41.2%, 84.2%).\n\nWe found that for this design the necessary sample size and estimated effectiveness are sensitive to properties of the vaccine - in particular, pre-exposure and post-exposure efficacy; to two setting-specific parameters over which investigators have little control - rate of infections from outside the ring and overall attack rate in the controls; and to three parameters that are determined by the study design - the time window in which cases are counted, intensity of case-detection and administrative delay in vaccinating individuals.\n\nThis approach replaces assumptions about parameters in the trial with assumptions about disease dynamics and vaccine characteristics at the individual level.\n\nConclusionsIncorporating simulation into the trial design process can improve robustness of sample size calculations. Simulation can identify optimal values for study design parameters that can be controlled. For this specific trial design, vaccine effectiveness depends on properties of the ring vaccination design and on the measurement window, as well as the epidemiologic setting. Rejecting the null likely indicates one or more types of vaccine efficacy at the individual level, but the magnitude of the effect will vary across settings.

Epidemiology↗

bioRxiv2017

Targeting stromal remodeling and cancer stem cell plasticity to overcome chemoresistance in triple negative breast cancer

The cellular and molecular basis of stromal cell recruitment, activation and crosstalk in carcinomas is poorly understood, limiting the development of targeted anti-stromal therapies. In mouse models of triple negative breast cancer (TNBC), Hh ligand produced by neoplastic cells reprogrammed cancer-associated fibroblast (CAF) gene expression, driving tumor growth and metastasis. Hh-activated CAFs upregulated expression of FGF5 and production of fibrillar collagen, leading to FGFR and FAK activation in adjacent neoplastic cells, which then acquired a stem-like, drug-resistant phenotype. Treatment with smoothened inhibitors (SMOi) reversed these phenotypes. Stromal treatment of TNBC patient-derived xenograft (PDX) models with SMOi downregulated the expression of cancer stem cell markers and sensitized tumors to docetaxel, leading to markedly improved survival and reduced metastatic burden. In the phase I clinical trial EDALINE, 3 of 12 patients with metastatic TNBC derived clinical benefit from combination therapy with the SMOi Sonidegib and docetaxel chemotherapy, with one patient experiencing a complete response. Markers of pathway activity correlated with response. These studies identify Hh signaling to CAFs as a novel mediator of cancer stem cell plasticity and an exciting new therapeutic target in TNBC.\n\nSIGNIFICANCECompared to other breast cancer subtypes, TNBCs are associated with significantly worse patient outcomes. Standard of care systemic treatment for patients with non-BRCA1/2 positive TNBC is cytotoxic chemotherapy. However, the failure of 70% of treated TNBCs to attain complete pathological response reflects the relative chemoresistance of these tumors. New therapeutic strategies are needed to improve patient survival and quality of life. Here, we provide new insights into the dynamic interactions between heterotypic cells within a tumor. Specifically, we establish the mechanisms by which CAFs define cancer cell phenotype and demonstrate that the bidirectional CAF-cancer cell crosstalk can be successfully targeted in mice and humans using anti-stromal therapy.

cancer biology↗

bioRxiv2016

Pre-Hospital Midazolam for Treatment of Status Epilepticus Before and After the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART): A National Observational Cohort Study

BackgroundImplementation of evidence-based treatment for pre-hospital status epilepticus can improve outcomes. We hypothesized that publication of a pivotal pre-hospital clinical trial (RAMPART), demonstrating superiority of intramuscular midazolam over intravenous lorazepam, altered the national utilization rates of midazolam for pre-hospital treatment of status epilepticus, while upholding its safety and efficacy outside the trial setting.\n\nMethods and FindingsThis is a retrospective, observational cohort study of pre-hospital patient encounters throughout the United States in the National Emergency Medicine Services Information System database, from January 2010 through December 2014. We compared the rates and odds of midazolam use as the first-line treatment for status epilepticus among all adult and pediatric benzodiazepine-treated seizures before and after RAMPART publication (February 2012). Secondary analyses were conducted for rates of airway interventions and rescue therapy, as proxies for safety and efficacy of seizure termination. 156,539 benzodiazepine-treated seizures were identified. Midazolam use increased from 26.1% in January 2010 to 61.7% in December 2014 (difference +35.6%, 95% CI, 32.7%-38.4%). The annual rate of midazolam adoption increased significantly from 5.9% per year to 8.9% per year after the publication of RAMPART (difference +3.0% per year; 95%CI, 1.6%-4.5% per year; adjusted OR 1.24; 95%CI, 1.17-1.32). Overall frequency of rescue therapy and airway interventions changed little after the publication of RAMPART.\n\nConclusionsThese data are consistent with effective, ongoing, but incomplete clinical translation of the RAMPART results. The effects of the trial, however, cannot be isolated. The safety and effectiveness of midazolam for treatment of seizures in prehospital clinical practice appear consistent with trial data, which should encourage continuing increases in utilization.

epidemiology↗

bioRxiv2018

Predicting clinically promising therapeutic hypotheses using tensor factorization

Determining which target to pursue is a challenging and error-prone first step in developing a therapeutic treatment for a disease, where missteps are potentially very costly given the long-time frames and high expenses of drug development. We identified examples of successes and failures of target-indication pairs in clinical trials across 875 targets and 574 disease indications to build a gold-standard data set of 6,140 known clinical outcomes. We used information from Open Targets and others databases that covered 17 different sources of evidence for target-indication association and represented the data as a matrix of 21,437x2,211x17 with over two million non-null values. We designed and executed three benchmarking strategies to examine the performance of multiple machine learning models: Logistic Regression, Elasticnet, Random Forest, Tensor Factorization and Gradient Boosting Machine. With ten-fold cross validation, tensor factorization achieved AUROC=0.82{+/-}0.02 and AUPRC=0.71{+/-}0.03. Across multiple validation schemes, this was comparable or better than other methods. Tensor factorization is a general form of matrix factorization that has been successfully exploited in recommendation systems that suggest items to users based on their existing preference on a small number of items. Our application, using Bayesian probabilistic modelling, extends the capacity of matrix factorization to model multiple relationships between and among targets and indications. We use the model to show that our predicted probabilities of success correlate with clinical phases, and within clinical phase we can predict which trials are most likely to succeed.

bioinformatics↗

bioRxiv2018

Arimoclomol as a potential therapy for neuronopathic Gaucher Disease

Gaucher Disease (GD) is caused by mutations of the GBA gene which encodes the lysosomal enzyme acid beta-glucosidase (GCase). GBA mutations commonly affect GCase function by perturbing its protein homeostasis rather than its catalytic activity. Heat shock proteins (HSPs) are well known cytoprotective molecules with numerous functions in protein homeostasis and lysosomal function and their manipulation has been suggested as a potential therapeutic strategy for GD. The investigational drug arimoclomol, which is currently in phase II/III clinical trials, is a well-characterized HSP amplifier and has been extensively clinically tested. Importantly, arimoclomol efficiently crosses the blood-brain-barrier hereby presenting an opportunity to target the neurological manifestations of GD, which remains without a disease modifying therapy.\n\nIn the present study, we found that arimoclomol induced relevant HSPs such as ER-resident HSP70 (BiP) and enhanced the folding, maturation, activity and correct cellular localization of mutated GCase across a number of genotypes including the common L444P and N370S mutations in primary cells from GD patients. These effects where recapitulated in a human neuronal model of GD obtained by differentiation of multipotent adult stem cells. Taken together, these data demonstrate the potential of HSP-targeting therapies in GCase-deficiencies and strongly support the clinical development of arimoclomol as a potential first therapeutic option for the neuronopathic forms of GD.\n\nSummaryThese studies provide proof-of-concept for the development of the Heat shock protein amplifier, arimoclomol, as a potential therapy for neuronopathic Gaucher disease as arimoclomol enhances folding, maturation, activity and correct localization of GCase in neuronopathic and non-neuronopathic Gaucher disease models.

neuroscience↗

bioRxiv2018

A standardised framework to identify optimal animal models for efficacy assessment in drug development

IntroductionPoor translation of efficacy data derived from animal models is a potential contributor to costly and unnecessary attrition in clinical trials.\n\nObjectivesTo develop a tool to assess, validate and compare the clinical translatability of animal models used for the preliminary assessment of efficacy.\n\nDesign and ResultsWe conducted an exploratory literature search to identify the key aspects to validate animal models. Eight aspects (Epidemiology, Pathophysiology, Genetic, Biochemistry, Aetiology, Histology, Pharmacology and Endpoints) were identified for which questions were drafted to evaluate the different faces of the human disease simulation. Features of the framework include standardised instructions, a weighting and scoring system to compare models as well as contextualising factors regarding model similarity and evidence uncertainty. We included a quality assessment of the internal validity of drug intervention studies included in the Pharmacological validation section for both effective and ineffective drugs in humans. A web-based survey was conducted with experts from different stakeholders to gather input on the framework. Finally, we present a case study of a preliminary validation and comparison of two animal models for Duchenne Muscular Dystrophy (mdx mouse and GRMD dog) and Diabetes Type 2 (ZDF rat and db/db mouse). We show that there are significant differences between the mdx mouse and the GRMD dog, the latter mimicking the human condition to a greater extent than the mouse despite the considerable lack of published data. In DT2, both the ZDF rat and the db/db mouse are comparable with minor differences in pathophysiology.\n\nConclusionsFIMD facilitates drug development by serving as the basis to select the most relevant model that can provide meaningful and translatable results to progress drug candidates to the clinic.

pharmacology and toxicology↗