1
|
Zhang QD, Duan QY, Tu J, Wu FG. Thrombin and Thrombin-Incorporated Biomaterials for Disease Treatments. Adv Healthc Mater 2024; 13:e2302209. [PMID: 37897228 DOI: 10.1002/adhm.202302209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/20/2023] [Indexed: 10/29/2023]
Abstract
Thrombin, a coagulation-inducing protease, has long been used in the hemostatic field. During the past decades, many other therapeutic uses of thrombin have been developed. For instance, burn treatment, pseudoaneurysm therapy, wound management, and tumor vascular infarction (or tumor vasculature blockade therapy) can all utilize the unique and powerful function of thrombin. Based on their therapeutic effects, many thrombin-associated products have been certificated by the Food and Drug Administration, including bovine thrombin, human thrombin, recombinant thrombin, fibrin glue, etc. Besides, several thrombin-based drugs are currently undergoing clinical trials. In this article, the therapeutic uses of thrombin (from the initial hemostasis to the latest cancer therapy), the commercially available drugs associated with thrombin, and the pros and cons of thrombin-based therapeutics (e.g., adverse immune responses related to bovine thrombin, thromboinflammation, and vasculogenic "rebounds") are summarized. Further, the current challenges and possible future research directions of thrombin-incorporated biomaterials and therapies are discussed. It is hoped that this review may provide a valuable reference for researchers in this field and help them to design safer and more effective thrombin-based drugs for fighting against various intractable diseases.
Collapse
Affiliation(s)
- Qiong-Dan Zhang
- State Key Laboratory of Digital Medical Engineering, School of Biological Science and Medical Engineering, Southeast University, 2 Southeast University Road, Nanjing, Jiangsu, 211189, P. R. China
| | - Qiu-Yi Duan
- State Key Laboratory of Digital Medical Engineering, School of Biological Science and Medical Engineering, Southeast University, 2 Southeast University Road, Nanjing, Jiangsu, 211189, P. R. China
| | - Jing Tu
- State Key Laboratory of Digital Medical Engineering, School of Biological Science and Medical Engineering, Southeast University, 2 Southeast University Road, Nanjing, Jiangsu, 211189, P. R. China
| | - Fu-Gen Wu
- State Key Laboratory of Digital Medical Engineering, School of Biological Science and Medical Engineering, Southeast University, 2 Southeast University Road, Nanjing, Jiangsu, 211189, P. R. China
| |
Collapse
|
2
|
Abdelhady AM, Phillips JA, Xu Y, Stroh M. Clinical Pharmacology and Translational Considerations in the Development of CRISPR-Based Therapies. Clin Pharmacol Ther 2023; 114:591-603. [PMID: 37429825 DOI: 10.1002/cpt.3000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023]
Abstract
Genome editing holds the potential for curative treatments of human disease, however, clinical realization has proven to be a challenging journey with incremental progress made up until recently. Over the last decade, advances in clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein (Cas) systems have provided the necessary breakthrough for genome editing in the clinic. The progress of investigational CRISPR therapies from bench to bedside reflects the culmination of multiple advances occurring in parallel, several of which intersect with clinical pharmacology and translation. Directing the CRISPR therapy to the intended site of action has necessitated novel delivery platforms, and this has resulted in special considerations for the complete characterization of distribution, metabolism, and excretion, as well as immunogenicity. Once at the site of action, CRISPR therapies aim to make permanent alterations to the genome and achieve therapeutically relevant effects with a single dose. This fundamental aspect of the mechanism of action for CRISPR therapies results in new considerations for clinical translation and dose selection. Early advances in model-informed development of CRISPR therapies have incorporated key facets of the mechanism of action and have captured hallmark features of clinical pharmacokinetics and pharmacodynamics from phase I investigations. Given the recent emergence of CRISPR therapies in clinical development, the landscape continues to evolve rapidly with ample opportunity for continued innovation. Here, we provide a snapshot of selected topics in clinical pharmacology and translation that has supported the advance of systemically administered in vivo and ex vivo CRISPR-based investigational therapies in the clinic.
Collapse
Affiliation(s)
| | | | - Yuanxin Xu
- Intellia Therapeutics, Inc., Cambridge, Massachusetts, USA
| | - Mark Stroh
- Intellia Therapeutics, Inc., Cambridge, Massachusetts, USA
| |
Collapse
|
3
|
Tassin DH, Kemp Bohan PM, Cooper LE, Fletcher J, Hatem V, Caterson EJ, Cancio LC, Chan RK. Anti-human Leukocyte Antigen Immune Sensitization Effects of Cryopreserved Allograft and Blood Transfusion. J Burn Care Res 2020; 41:1216-1223. [PMID: 32725146 DOI: 10.1093/jbcr/iraa070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Vascularized composite allotransplantation (VCA) is the most advanced reconstructive technique available to patients who suffer devastating burns to the limbs or face. However, VCA requires donor-recipient matching. Burn patients have been reported to experience sensitization, or the development of anti-human leukocyte antigen antibodies, during resuscitation and wound coverage, potentially precluding them from future VCA. This study sought to investigate the contributions of both blood and allograft to sensitization in burn patients. Four groups were compared: burn patients who received blood products and allograft (group 1), burn patients who received blood products only (group 2), trauma patients who received blood products only (group 3), and healthy volunteer controls (group 4). The average calculated panel-reactive antibody (indicating sensitization) was higher in group 1 compared to group 4 (P = .035). Additionally, the incidence of severe sensitization was higher in group 1 relative to the other groups (P = .049). When comparing groups of patients who had no sensitization, mild sensitization, moderate sensitization, and severe sensitization, there were no significant differences in age, sex, blood products received, total body surface area burned, or allograft used between groups, though severely sensitized patients tended to have greater total body surface area involvement and received more units of packed red blood cells and allograft (P = .079, P = .196, and P = .072, respectively). We therefore conclude that while burn patients who received allograft and blood demonstrated a higher incidence of anti-human leukocyte antigen sensitization relative to healthy controls, this difference cannot solely be attributed to either allograft use or transfusion.
Collapse
Affiliation(s)
- David H Tassin
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas
| | | | - Laura E Cooper
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - John Fletcher
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Victoria Hatem
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - E J Caterson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Leopoldo C Cancio
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - Rodney K Chan
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| |
Collapse
|
4
|
Analysis of regulatory guidance on antidrug antibody testing for therapeutic protein products. Bioanalysis 2020; 11:2283-2296. [PMID: 31845602 DOI: 10.4155/bio-2019-0241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapeutic proteins have the potential to induce unwanted immune responses. The potential impact of immunogenicity on pharmacokinetics, pharmacodynamics, safety and efficacy are well established. Here, we analyze key aspects of current US FDA and EMA guidelines on the development and validation of antidrug antibody assays. Although FDA and EMA guidance documents are in harmony on most points, EMA allows greater leeway for scientific judgement, while FDA recommends specific approaches that may not be appropriate in some situations. Many white papers suggest approaches different from the guidance documents, however, these can conflict with each other and are themselves only scientifically valid in certain situations. Here, we indicate when alternatives to guidance may be needed and what those approaches might be.
Collapse
|
5
|
Zheng K, Kros JM, Li J, Zheng PP. DNA-nanorobot-guided thrombin-inducing tumor infarction: raising new potential clinical concerns. Drug Discov Today 2020; 25:951-955. [PMID: 32205200 DOI: 10.1016/j.drudis.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/29/2020] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
Abstract
DNA-nanorobot-guided thrombin-inducing tumor infarction (DNA NanorobotTh-ITI) is emerging as a powerful therapeutic strategy for treatment of solid cancers. The technology represents a major advance in the application of DNA nanotechnology for anticancer therapy. More importantly, the technology is being translated from preclinical studies to the clinic owing to its promising anticancer effects with fewer toxicities demonstrated in preclinical settings. However, despite these beneficial effects of the technology, it is important to point out that some important potential clinical concerns remain to be addressed. Here, we raise these clinical concerns along with these beneficial effects of the technology. Hopefully, these newly raised potential clinical concerns could drive forward research in this field to expedite its clinical translation.
Collapse
Affiliation(s)
- Kang Zheng
- Department of Orthopedics, Ningbo Medical Center Li Hui Li Hospital, Ningbo, Zhejiang, China
| | - Johan M Kros
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jin Li
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping-Pin Zheng
- Academy for Advanced Interdisciplinary Studies, Southern University of Science and Technology, Shenzhen, Guangdong, China.
| |
Collapse
|
6
|
Minkowitz H, Navarro-Puerto J, Lakshman S, Singla S, Cousar C, Kim R, Villavicencio A, Kirksey L, Ayguasanosa J, Anderson CD, Labow D, Fishbein T, Sheiner P, Lockstadt H, Courtney K, Cheng J, Barrera G, Henriquez WT. Prospective, Randomized, Phase II, Non-Inferiority Study to Evaluate the Safety and Efficacy of Topical Thrombin (Human) Grifols as Adjunct to Hemostasis During Vascular, Hepatic, Soft Tissue, and Spinal Open Surgery. J Am Coll Surg 2019; 229:497-507.e1. [DOI: 10.1016/j.jamcollsurg.2019.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
|
7
|
Wang X, Liu Y, Zhao J, Zhang J. Clinical efficacy of octreotide acetate combined with thrombin in the treatment of liver cirrhosis complicated with gastrointestinal hemorrhage. Exp Ther Med 2019; 17:3417-3422. [PMID: 30988720 PMCID: PMC6447786 DOI: 10.3892/etm.2019.7345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/11/2019] [Indexed: 12/10/2022] Open
Abstract
Clinical efficacy of octreotide acetate combined with thrombin in the treatment of liver cirrhosis complicated with gastrointestinal hemorrhage was investigated. A retrospective analysis of 157 patients with liver cirrhosis and gastrointestinal hemorrhage admitted to Weifang People's Hospital from March 2012 to September 2014 was performed. Among them, 74 patients treated with octreotide acetate were enrolled into the octreotide group, and 83 patients treated with octreotide acetate combined with thrombin were enrolled into the combination group. Comparison between the two groups was made in terms of the average hemostasis time, the hospitalization time, the amount of blood transfusion during hospitalization, the efficacy of hemostasis and visual analog scale (VAS) scores. The mean hemostasis time of the octreotide group was higher than that of the combination group, with a statistically significant difference between the two groups (P<0.05); the hospitalization time of the octreotide group was significantly longer than that of the combination group (P<0.05); the blood transfusion volume of patients in the octreotide group was significantly higher than that of the combination group (P<0.05); the overall effective rate of the combination group after treatment was higher than the overall effective rate of the octreotide group (89.19%) (P<0.05). The VAS scores of the combination group at 24 and 72 h after treatment were lower than those of the octreotide group (P<0.05); the VAS scores of both the octreotide and the combination group at 24 and 72 h after treatment were significantly lower than those before treatment (P<0.05). In conclusion, the combination of octreotide acetate and thrombin is worthy of clinical promotion as it could reduce the average hemostasis time, the bleeding volume, and the hospitalization time of patients with liver cirrhosis combined with gastrointestinal hemorrhage, with better efficacy than the use of octreotide acetate alone.
Collapse
Affiliation(s)
- Xiaoyan Wang
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Yanyan Liu
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Jingjing Zhao
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Jinmei Zhang
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| |
Collapse
|
8
|
Centeno A, Rojas S, Arias B, Miquel I, Sánchez P, Ureta C, Rincón E, López R, Murat J. Experimental Evaluation of a New Tissue Factor-Based Topical Hemostat (TT-173) for Treatment of Hepatic Bleeding. J INVEST SURG 2018; 33:339-349. [DOI: 10.1080/08941939.2018.1517840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Alberto Centeno
- Unit of Experimental Surgery, Institute of Biomedical Investigation of A Coruña, Xubias de Arriba, 84, A Coruña 15006, Spain
| | - Santiago Rojas
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
- Unit of Human Anatomy and Embryology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès 08193, Spain
| | - Belén Arias
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Ignasi Miquel
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Pilar Sánchez
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Claudia Ureta
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Esther Rincón
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Ramón López
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| | - Jesús Murat
- Thombotargets Europe S.L. Mediterranean Technology Park, Av. Canal Olímpic, s/n, Edif, B 6, 2ª, Castelldefels 08860, Spain
| |
Collapse
|
9
|
Morse DC, Silva E, Bartrom J, Young K, Bass EJ, Potter D, Bieber T. Improved bleeding scores using Gelfoam(®) Powder with incremental concentrations of bovine thrombin in a swine liver lesion model. J Thromb Thrombolysis 2017; 42:352-9. [PMID: 27334382 PMCID: PMC5010588 DOI: 10.1007/s11239-016-1388-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Topical hemostatic agents are used intra-operatively to prevent uncontrolled bleeding. Gelfoam(®) Powder contains a hemostatic agent prepared from purified pork skin gelatin, the efficacy of which is increased when combined with thrombin. However, the effect of increasing concentrations of thrombin on resultant hemostasis is not known. This study sought to evaluate the ability of various concentrations of thrombin in combination with Gelfoam Powder to control bleeding using a swine liver lesion model. Ten pigs underwent a midline laparotomy. Circular lesions were created in the left medial, right medial, and left lateral lobes; six lesions per lobe. Gelfoam Powder was hydrated with Thrombin-JMI(®) diluted to 250, 375, and 770 IU/mL. Each concentration was applied to two lesion sites per lobe. Bleeding scores were measured at 3, 6, 9, and 12 min using a 6-point system; comparison of bleeding scores was performed using ANOVA with the post hoc Tukey test. The bleeding scores with thrombin concentrations at 770 IU/mL were significantly lower than at 250 and 375 IU/mL at all four time points. The percentage of biopsies with a clinically acceptable bleeding score rose from 37.9, 46.6, and 71.2 % at 3 min to 55.2, 69.0, and 88.1 % at 12 min in the 250, 375, and 770 IU/mL thrombin groups, respectively. The study showed that the hemostatic response to thrombin was dose-related: using higher concentrations of thrombin with Gelfoam Powder yielded improved hemostasis, as determined by lower bleeding scores.
Collapse
Affiliation(s)
- Dennis C Morse
- Drug Safety Research and Development, Pfizer, 445 Eastern Point Road, Groton, CT, 06355, USA.
| | - Elif Silva
- Pfizer, 235 E 42nd Street, New York, NY, 10017, USA
| | | | - Kelli Young
- NAMSA, 6750 Wales Road, Northwood, OH, 43619, USA
| | - Eric J Bass
- NAMSA, 4050 Olson Memorial Highway, Suite 450, Minneapolis, MN, 55422, USA
| | - David Potter
- Drug Safety Research and Development, Pfizer, 445 Eastern Point Road, Groton, CT, 06355, USA
| | | |
Collapse
|
10
|
Smith JR, Winkelstein BA. The role of spinal thrombin through protease-activated receptor 1 in hyperalgesia after neural injury. J Neurosurg Spine 2017; 26:532-541. [PMID: 28059686 DOI: 10.3171/2016.9.spine16501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Painful neuropathic injuries induce blood-spinal cord barrier (BSCB) breakdown, allowing pro-inflammatory serum molecules to cross the BSCB, which contributes to nociception. The goal of these studies was to determine whether the blood-borne serine protease thrombin also crosses a permeable BSCB, contributing to nociception through its activation of protease-activated receptor-1 (PAR1). METHODS A 15-minute C-7 nerve root compression, which induces BSCB breakdown and painful behaviors by Day 1, was administered in the rat (n = 10); sham operation (n = 11) and a 3-minute compression (n = 10) that does not induce sensitivity were administered as controls. At Day 1 after root compression, spinal cord tissue was co-immunolabeled for fibrin/fibrinogen, the enzymatic product of thrombin, and IgG, a serum protein, to determine whether thrombin acts in areas of BSCB breakdown. To determine whether spinal thrombin and PAR1 contribute to hyperalgesia after compression, the thrombin inhibitor hirudin and the PAR1 antagonist SCH79797, were separately administered intrathecally before compression injuries (n = 5-7 per group). Rat thrombin was also administered intrathecally with and without SCH79797 (n = 6 per group) to determine whether spinal thrombin induces hypersensitivity in naïve rats through PAR1. RESULTS Spinal fibrin(ogen) was elevated at Day 1 after root compression in regions localized to BSCB breakdown and decreased in those regions by Day 7. Blocking either spinal thrombin or PAR1 completely prevented compression-induced hyperalgesia for 7 days. Intrathecal thrombin induced transient pain that was prevented by blocking spinal PAR1 before its injection. CONCLUSIONS The findings of this study suggest a potent role for spinal thrombin and its activation of PAR1 in pain onset following neuropathic injury.
Collapse
Affiliation(s)
| | - Beth A. Winkelstein
- Departments of 1Bioengineering and
- 2Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
11
|
Schneider AK, Vainshtein I, Roskos LK, Chavez C, Sun B, Liang M. An immunoinhibition approach to overcome the impact of pre-existing antibodies on cut point establishment for immunogenicity assessment of moxetumomab pasudotox. J Immunol Methods 2016; 435:68-76. [PMID: 27220271 DOI: 10.1016/j.jim.2016.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 05/13/2016] [Accepted: 05/16/2016] [Indexed: 01/01/2023]
Abstract
Immunogenicity can impact PK, PD, efficacy and safety of biopharmaceuticals, and is often evaluated as a secondary objective in clinical studies. Methods to detect anti-drug antibodies (ADA) and neutralizing ADA (NAb) are semi-quantitative and utilize cut points to determine positive or negative samples. Assay cut points are established by the statistical analysis of treatment-naïve subject specimens that are assumed ADA and NAb-negative. Pre-existing antibodies to various biopharmaceuticals have been observed in treatment-naïve subjects and may artificially elevate the cut point, resulting in compromised assay sensitivities, inaccuracy in immunogenicity reporting and ultimately misleading assessment of the impact of immunogenicity on clinical outcomes. Although several approaches such as removal of pre-existing antibody samples or increasing the sample dilution could be used for cut point establishment to mitigate impact of pre-existing antibodies, they each have limitations, especially when a high prevalence of pre-existing antibodies is observed. Here we describe an innovative approach used to establish cut points for ADA and NAb assays of moxetumomab pasudotox (moxetumomab), a recombinant anti-CD22 immunotoxin, to which a high prevalence of pre-existing antibodies was observed. In order to overcome the challenges associated with this high prevalence and prevent establishment of an artificially elevated cut point, we developed an immunoinhibition approach that allowed generation of pseudo ADA and NAb-negative populations for cut point determination. Immunoinhibition was performed by adding excess moxetumomab (for ADA) or a non-CD22 binding PE38-containing immunotoxin, CAT-5001 (for NAb), to treatment-naive samples prior to evaluating samples for cut point establishment. This approach successfully eliminated pre-existing antibody activity in treatment-naive samples, enabling establishment of more accurate ADA and NAb assay cut points. A comparative analysis of the clinical immunogenicity results using cut points derived with immunoinhibition and without immunoinhibition (conventional method) demonstrated that the immunoinhibition approach markedly improved detection sensitivity and accuracy of immunogenicity characterization in patient samples. This innovative approach provides an alternative, practical solution for immunogenicity assay cut point establishment when biopharmaceuticals have a high prevalence of pre-existing antibodies.
Collapse
Affiliation(s)
- Amy K Schneider
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA
| | - Inna Vainshtein
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA.
| | - Lorin K Roskos
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA
| | - Carlos Chavez
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA
| | - Bo Sun
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA
| | - Meina Liang
- Clinical Pharmacology & DMPK, Medimmune, LLC, 319 North Bernardo Avenue, Mountain View, CA 94043, USA.
| |
Collapse
|
12
|
Gorovits B, Clements-Egan A, Birchler M, Liang M, Myler H, Peng K, Purushothama S, Rajadhyaksha M, Salazar-Fontana L, Sung C, Xue L. Pre-existing Antibody: Biotherapeutic Modality-Based Review. AAPS J 2016; 18:311-20. [PMID: 26821802 PMCID: PMC4779092 DOI: 10.1208/s12248-016-9878-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/20/2016] [Indexed: 01/12/2023] Open
Abstract
Pre-existing antibodies to biotherapeutic drugs have been detected in drug-naïve subjects for a variety of biotherapeutic modalities. Pre-existing antibodies are immunoglobulins that are either specific or cross-reacting with a protein or glycan epitopes on a biotherapeutic compound. Although the exact cause for pre-existing antibodies is often unknown, environmental exposures to non-human proteins, glycans, and structurally similar products are frequently proposed as factors. Clinical consequences of the pre-existing antibodies vary from an adverse effect on patient safety to no impact at all and remain highly dependent on the biotherapeutic drug modality and therapeutic indication. As such, pre-existing antibodies are viewed as an immunogenicity risk factor requiring a careful evaluation. Herein, the relationships between biotherapeutic modalities to the nature, prevalence, and clinical consequences of pre-existing antibodies are reviewed. Initial evidence for pre-existing antibody is often identified during anti-drug antibody (ADA) assay development. Other interfering factors known to cause false ADA positive signal, including circulating multimeric drug target, rheumatoid factors, and heterophilic antibodies, are discussed.
Collapse
Affiliation(s)
- Boris Gorovits
- Pfizer Worldwide Research & Development, PDM, 1 Burtt Rd, Andover, MA, USA.
| | - Adrienne Clements-Egan
- Janssen Research & Development, LLC (Johnson & Johnson), Welsh and McKean Roads, Spring House, PA, USA
| | - Mary Birchler
- Clinical Immunology, GlaxoSmithKline, King of Prussia, PA, USA
| | - Meina Liang
- MedImmune, Clinical Pharmacology and DMPK, Mountain View, CA, USA
| | - Heather Myler
- Bristol-Myers Squibb, Analytical & Bioanalytical Development, Princeton, NJ, USA
| | - Kun Peng
- Genentech, BioAnalytical Sciences, San Francisco, CA, USA
| | | | - Manoj Rajadhyaksha
- Regeneron Pharmaceuticals, Inc. Bioanalytical Sciences, Tarrytown, NY, USA
| | - Laura Salazar-Fontana
- DSAR, Project Standards and Innovation, Immunology and Biomarkers, Sanofi R&D, Framingham, MA, USA
| | - Crystal Sung
- DSAR, Clinical Laboratory Sciences, Sanofi R&D, Framingham, MA, USA
| | - Li Xue
- Pfizer Worldwide Research & Development, PDM, 1 Burtt Rd, Andover, MA, USA
| |
Collapse
|
13
|
Khawaja IS, Kazaglis L, Hashmi A, Khurshid KA, Eiken C, Hurwitz TD. Obstructive Sleep Apnea and Depression: A Review. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20160125-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
14
|
Shander A, Kaplan LJ, Harris MT, Gross I, Nagarsheth NP, Nemeth J, Ozawa S, Riley JB, Ashton M, Ferraris VA. Topical hemostatic therapy in surgery: bridging the knowledge and practice gap. J Am Coll Surg 2014; 219:570-9.e4. [PMID: 25151345 DOI: 10.1016/j.jamcollsurg.2014.03.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/02/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, and Hyperbaric Medicine, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Lewis J Kaplan
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale School of Medicine, New Haven, CT; Tactical Medicine, Tactical Police Surgeon, Police Departments, South Central SWAT North Haven, North Branford, East Haven, CT
| | - Michael T Harris
- Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Irwin Gross
- Department of Transfusion Services, Eastern Maine Medical Center, Bangor, ME
| | - Nimesh P Nagarsheth
- Department of Obstetrics and Gynecology, Englewood Hospital & Medical Center, Englewood, NJ; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey Nemeth
- Department of Pharmacy, Englewood Hospital & Medical Center, Englewood, NJ
| | - Sherri Ozawa
- Institute for Bloodless Medicine and Patient Blood Management, Englewood Hospital & Medical Center, Englewood, NJ
| | - Jeffrey B Riley
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester MN
| | | | - Victor A Ferraris
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY
| |
Collapse
|
15
|
Howe N, Cherpelis B. Obtaining rapid and effective hemostasis. J Am Acad Dermatol 2013; 69:659.e1-659.e17. [DOI: 10.1016/j.jaad.2013.07.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 11/25/2022]
|
16
|
Xue L, Rup B. Evaluation of pre-existing antibody presence as a risk factor for posttreatment anti-drug antibody induction: analysis of human clinical study data for multiple biotherapeutics. AAPS JOURNAL 2013; 15:893-6. [PMID: 23761225 DOI: 10.1208/s12248-013-9497-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 05/14/2013] [Indexed: 11/30/2022]
Abstract
Biotherapeutic-reactive antibodies in treatment-naïve subjects (i.e., pre-existing antibodies) have been commonly detected during clinical immunogenicity assessments; however information on pre-existing antibody prevalence, physiological effects, and impact on posttreatment anti-drug antibody (ADA) induction remains limited. In this analysis, pre-existing antibody prevalence and impact on posttreatment ADA induction were determined using ADA data from 12 biotherapeutics analyzed in 32 clinical studies. Approximately half (58%) of the biotherapeutics were associated with some level of pre-existing antibodies and 67% of those were associated with posttreatment ADA induction. Across all studies, 5.6% of study subjects demonstrated presence of pre-existing antibodies, among which, 17% of the individual subjects had posttreatment increases in their ADA titers while 16% had decreased titers and 67% had no change in titers. However, in studies conducted in the rheumatoid arthritis (RA) population, 14.8% of RA patients were associated with pre-existing antibodies and 30% of those had posttreatment titer increases. The results suggest that in most study subjects, pre-existing antibodies pose a low risk for posttreatment ADA induction. That said, the high risk of induction implicated for RA patients, primarily observed in treatments evaluating novel antibody-based constructs, indicates that further understanding of the contribution of product and disease-specific factors is needed. Cross-industry efforts to collect and analyze a larger data set would enhance understanding of the prevalence, nature, and physiological consequences of pre-existing antibodies, better inform the immunogenicity risk profiles of products associated with these antibodies and lead to better fit-for-purpose immunogenicity management and mitigation strategies.
Collapse
Affiliation(s)
- Li Xue
- Pharmacokinetics, Dynamics & Metabolism (PDM-NBE), Immunogenicity Sciences, Pfizer Inc., Andover, MA, USA.
| | | |
Collapse
|
17
|
Burnouf T, Goubran HA, Chen TM, Ou KL, El-Ekiaby M, Radosevic M. Blood-derived biomaterials and platelet growth factors in regenerative medicine. Blood Rev 2013; 27:77-89. [DOI: 10.1016/j.blre.2013.02.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
18
|
Goodnough LT, Shander A. Current status of pharmacologic therapies in patient blood management. Anesth Analg 2012; 116:15-34. [PMID: 23223098 DOI: 10.1213/ane.0b013e318273f4ae] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.
Collapse
Affiliation(s)
- Lawrence Tim Goodnough
- Pathology Department, Stanford University, 300 Pasteur Drive Room H-1402, M/C 5626 Stanford, CA 94305, USA.
| | | |
Collapse
|
19
|
Sherman CH, Macivor DC. Blood utilization: fostering an effective hospital transfusion culture. J Clin Anesth 2012; 24:155-63. [PMID: 22414711 DOI: 10.1016/j.jclinane.2011.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 06/07/2011] [Accepted: 06/09/2011] [Indexed: 11/17/2022]
Abstract
An effective hospital transfusion culture should encourage clinicians to consider the possibility of transfusion in their patients well before the need actually arises, and to plan ahead in an attempt to use blood products most efficiently. Strategies for improved blood utilization include timely and adequate preoperative assessment of risk, optimization of baseline hemoglobin, anticipation of potential transfusion problems, intraoperative techniques to minimize blood loss, blood conservation technologies, transfusion guidelines and targeted therapy, point of care testing, and massive transfusion protocols. Attention to these elements promotes a safe and cost-effective transfusion culture.
Collapse
Affiliation(s)
- Carolyn Hyatt Sherman
- Department of Anesthesiology, Chandler Medical Center, University of Kentucky, Lexington, KY 40536, USA.
| | | |
Collapse
|
20
|
Malgor RD, Labropoulos N, Gasparis AP, Landau DS, Tassiopoulos AK. Results of a New Human Recombinant Thrombin for the Treatment of Arterial Pseudoaneurysm. Vasc Endovascular Surg 2012; 46:145-9. [DOI: 10.1177/1538574411431346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs). Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions. Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required. Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.
Collapse
Affiliation(s)
- Rafael D. Malgor
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Nicos Labropoulos
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Antonios P. Gasparis
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - David S. Landau
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | | |
Collapse
|
21
|
Immunogenicity and Safety of Re-Exposure to Recombinant Human Thrombin in Surgical Hemostasis. J Am Coll Surg 2011; 213:722-7. [DOI: 10.1016/j.jamcollsurg.2011.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 08/30/2011] [Accepted: 08/31/2011] [Indexed: 11/20/2022]
|
22
|
Foster KN, Mullins RF, Greenhalgh DG, Gamelli RL, Glat P, Lentz CW, Kahn SA, Brandigi C, Fredlund P, Alexander WA. Recombinant human thrombin: safety and immunogenicity in pediatric burn wound excision. J Pediatr Surg 2011; 46:1992-9. [PMID: 22008340 DOI: 10.1016/j.jpedsurg.2011.05.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 05/26/2011] [Accepted: 05/29/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population. METHODS Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics. RESULTS Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29. CONCLUSIONS In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.
Collapse
Affiliation(s)
- Kevin N Foster
- Arizona Burn Center at Maricopa Medical Center, Phoenix, AZ, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Singleton RH, Jankowitz BT, Wecht DA, Gardner PA. Iatrogenic cerebral venous sinus occlusion with flowable topical hemostatic matrix. J Neurosurg 2011; 115:576-83. [DOI: 10.3171/2011.3.jns10881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The use of commercially available topical hemostatic adjuncts has increased the safety profile of surgery as a whole. Cranial surgery has also benefited from the development of numerous agents designed to permit more rapid achievement of hemostasis. Flowable topical hemostatic agents applied via syringe injection are now commonly employed in many neurosurgical procedures, including cranial surgery. Intravascular use of these strongly thrombogenic agents is contraindicated, but in certain settings, inadvertent intravascular administration can occur, resulting in vascular occlusion, thrombosis, and potential dissemination. To date, there have no reports detailing the presence and incidence of this complication.
Methods
The authors conducted a retrospective review of all cranial surgeries performed at Presbyterian University Hospital by members of the University of Pittsburgh Medical Center's Department of Neurological Surgery between 2007 and 2009. Cases complicated by vascular occlusion due to inadvertent intravascular administration of flowable topical hemostatic matrix (FTHM) were identified and analyzed.
Results
Iatrogenic vascular occlusion induced by FTHM was identified in 5 (0.1%) of 3969 cranial surgery cases. None of these events occurred in 3318 supratentorial cases, whereas 5 cases of cerebral venous sinus occlusion occurred in 651 infratentorial cases (0.8%). The risk of accidental vessel occlusion was significantly associated with infratentorial surgery, and all events occurred in the transverse and/or sigmoid sinus. No episodes of inadvertent vascular occlusion occurred during endoscopic surgery. No cases of arterial occlusion were identified. Of the 5 patients with FTHM-related cerebral venous sinus occlusion, none developed long-term neurological sequelae referable to the event.
Conclusions
Inadvertent intravascular administration of FTHM is a rare complication associated with cranial surgery that occurs most commonly during infratentorial procedures around the transverse and/or sigmoid sinuses. Modifications in the choice of when to use an FTHM and the method of application may help prevent accidental venous sinus administration.
Collapse
|
24
|
Barbosa MD. Immunogenicity of biotherapeutics in the context of developing biosimilars and biobetters. Drug Discov Today 2011; 16:345-53. [DOI: 10.1016/j.drudis.2011.01.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 01/07/2011] [Accepted: 01/31/2011] [Indexed: 11/24/2022]
|
25
|
|
26
|
Rothwell SW, Settle T, Wallace S, Dorsey J, Simpson D, Bowman JR, Janmey P, Sawyer E. The long term immunological response of swine after two exposures to a salmon thrombin and fibrinogen hemostatic bandage. Biologicals 2010; 38:619-28. [PMID: 20705479 DOI: 10.1016/j.biologicals.2010.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 06/13/2010] [Accepted: 07/06/2010] [Indexed: 10/19/2022] Open
Abstract
Experimental salmon thrombin/fibrinogen dressings have been shown to provide effective hemostasis in severe hemorrhage situations. The hypothesis for this study was that swine would still remain healthy without coagulopathy six months after exposure to salmon thrombin/fibrinogen dressings. Initial exposure was by insertion of the salmon dressing into the peritoneal cavity. Three months after the initial exposure, the same animals were subjected to two full thickness dermal wounds on the dorsal surface. One wound was bandaged with the salmon thrombin/fibrinogen bandage and the other wound was dressed with a standard bandage. The animals were monitored for an additional three months. Blood was drawn every 14 days over the six months for immunological and coagulation function analysis. All of the animals (8 pigs) remained healthy during the six month period and the dermal wounds healed without incidence. Lymph nodes and spleen showed signs of normal immune response and Western blots showed development of antibodies against salmon fibrinogen, but none of the animals made antibodies that recognized any species of thrombin. Coagulation parameters (fibrinogen concentration, thrombin time, PT and aPTT) and hematological parameters remained normal over the course of the study when compared to initial values of the subject swine.
Collapse
Affiliation(s)
- Stephen W Rothwell
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Ham SW, Lew WK, Weaver FA. Thrombin use in surgery: an evidence-based review of its clinical use. J Blood Med 2010; 1:135-42. [PMID: 22282693 PMCID: PMC3262329 DOI: 10.2147/jbm.s6622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Indexed: 11/23/2022] Open
Abstract
When surgical ligation of bleeding fails, or is not possible, surgeons rely on a number of hemostatic aids, including thrombin. This review discusses the history, pharmacology and clinical application of thrombin as a surgical hemostat. The initial thrombin was bovine in origin, but its use has been complicated by the formation of antibodies that cross-react with human coagulation factors. This has been associated with life-threatening bleeding and in some circumstances anaphylaxis and death. Human thrombin, isolated from pooled plasma of donors, was developed in an effort to minimize these risks, but its downsides are its limited availability and the potential for transmitting blood-borne pathogens. Recently a recombinant thrombin has been developed, and approved for use by the FDA. It has the advantage of being minimally antigenic and devoid of the risk of viral transmission. Thrombin is often used in conjunction with other hemostatic aids, including absorbable agents such as Gelfoam, and with fibrinogen in fibrin glues. The last part of this review will discuss these agents in detail, and review their clinical applications.
Collapse
Affiliation(s)
- Sung W Ham
- University of Southern California, Department of Surgery, Los Angeles, CA
| | | | | |
Collapse
|