Liver injury associated with dimethyl fumarate in multiple sclerosis patients

BACKGROUND

In pre-approval trials, there was an increased incidence of mild, transient elevations of liver aminotransferases in study subjects treated with dimethyl fumarate (DMF).

OBJECTIVE/METHODS

To evaluate post-marketing cases of drug-induced liver injury associated with DMF.

RESULTS

We identified 14 post-marketing cases of clinically significant liver injury. Findings included newly elevated serum liver aminotransferase and bilirubin levels that developed as early as a few days after the first dose of DMF. The pattern of liver injury was primarily hepatocellular. No cases resulted in liver failure.

CONCLUSION

Health professionals should be alerted to possible serious liver injury in patients receiving DMF.

Chemical Leukoderma Associated with Methylphenidate Transdermal System: Data From the US Food and Drug Administration Adverse Event Reporting System

OBJECTIVE

To identify and characterize cases of chemical leukoderma, an underrecognized adverse event, associated with the methylphenidate transdermal system (MTS) reported to the US Food and Drug Administration Adverse Event Reporting System (FAERS).

STUDY DESIGN

We searched the Food and Drug Administration Adverse Event Reporting System for reports of chemical leukoderma associated with MTS, received by the Food and Drug Administration from April 6, 2006 to December 23, 2014.

RESULTS

We identified 51 cases of chemical leukoderma reported with the use of MTS. The median age was 11 years; 43 cases reported leukoderma at or near the application site only, and 7 reported leukoderma at other parts of the body in addition to the application site; 1 case did not provide enough information to confirm the affected site. The time to onset ranged from 2 months to 4 years after the initiation of MTS. MTS was discontinued in 31 cases. Thirteen patients were prescribed treatment for repigmentation. Three cases reported continued spread of leukoderma after MTS was discontinued. Nineteen cases were diagnosed as vitiligo, including 5 cases reporting histologic features consistent with vitiligo. Leukoderma was persistent in all cases. The median follow-up interval after the discontinuation of MTS in 23 cases was 14 months.

CONCLUSIONS

As outlined in recent changes to the prescribing information for MTS, health care professionals need to be aware of the potential risk of chemical leukoderma caused by MTS, especially given that chemical leukoderma is often misdiagnosed as idiopathic vitiligo. MTS should be discontinued at the earliest sign of pigment loss and other treatment options considered.

Vilazodone: clinical basis for the US Food and Drug Administration's approval of a new antidepressant

OBJECTIVE

Vilazodone was recently approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorder (MDD). The purpose of this review is to summarize the FDA's approach to its review of the clinical pharmacology and the clinical efficacy and safety data for this new drug application, important issues in its decision-making, and its conclusions.

DATA SOURCES

The data sources for this review were the original raw data sets for all clinical trials included in the development program for vilazodone, as well as the sponsor's original analyses of these data.

STUDY SELECTION

Data were available from 24 human trials involving vilazodone, and included a total of 2,898 human subjects exposed to 1 or more doses of this drug.

DATA EXTRACTION

The FDA had access to original raw data sets for these trials.

RESULTS

Vilazodone is effective in treating MDD at a dose of 40 mg/d, but it needs to be incrementally adjusted to this dose to minimize gastrointestinal symptoms. It needs to be taken with food to ensure adequate plasma concentrations. Vilazodone's profile of adverse events is similar to that seen with selective serotonin reuptake inhibitors. No dose adjustment is needed based on age, gender, or renal or hepatic impairment. It is recommended that the vilazodone dose be reduced to 20 mg when it is taken with strong cytochrome P450 (CYP) 3A4 inhibitors, eg, ketoconazole. Vilazodone is not expected to have important effects on the clearance of other drugs that are cytochrome P450 substrates.

CONCLUSIONS

Vilazodone is a new treatment for MDD, but it is unknown whether it has any advantages compared to other drugs in the antidepressant class.

Technical solution for an interactive functional MR imaging examination: application to a physiologic interview and the study of cerebral physiology

Studies with functional magnetic resonance (MR) imaging produce large unprocessed raw data sets in minutes. The analysis usually requires transferring of the data to an off-line workstation, and this process frequently occurs after the subject has left the MR unit. The authors describe a hardware configuration and processing software that captures whole-brain raw data files as they are being produced from the MR unit. It then performs the reconstruction, registration, and statistical analysis, and displays the results in seconds after completion of the MR image acquisition.

Analysis of interpolation effects in the reslicing of functional MR images

PURPOSE

Typically, the final step in volume registration is the reslicing of the volume of interest. The purpose of this work is to examine the effects of this reslicing on functional MRI (fMRI) data using different interpolation methods.

METHOD

Functional whole-brain echo planar imaging (EPI) volumes were resliced using six different interpolation methods: trilinear, tricubic splines, and a 3D sinc function using a rectangular and a Hanning window, both with half-window lengths of 3 and 4 voxels.

RESULTS

Interpolation by tricubic spline and 3D sinc using a Hanning window had comparable errors, although tricubic spline interpolation was computationally the fastest. Interpolation by trilinear and 3D sinc using a rectangular window had relatively large errors, although the speed of trilinear makes it desirable for some applications.

CONCLUSION

Interpolations using all of the tested methods adversely affected the fMRI data, although these effects differed for each method.

Correspondence of closest gradient voxels--a robust registration algorithm

A robust, automatic volume registration algorithm based on intensity gradients is presented. This algorithm can successfully perform registrations under conditions of unrelated intervolume voxel intensities, significant object displacements, and/or significant amounts of missing data. It also allows the user to visualize the registration convergence, clearly illustrating any source of registration errors. This algorithm consists of a matching algorithm based on iteratively finding the correspondence of the closest voxels containing a high three-dimensional intensity gradient magnitude. This algorithm was tested by registering T2-weighted MR volumes that had undergone varying displacement transformations to simultaneously acquired proton-density volumes. These transformations involved rotations of up to 25 degrees followed by translations of up to 25 mm along the axis of rotation. For all registrations, the mean registration error was less than one-fifth of a voxel and the mean registration time was less than 30 minutes. In conclusion, this algorithm is shown to be a powerful method of sequence-independent MR volume registration that is simple to both use and understand.

On the accuracy of noninvasive thermometry using molecular diffusion magnetic resonance imaging

Temperature measurement using magnetic resonance imaging (MRI) of water self-diffusion is investigated. Diffusion images and derived temperatures are obtained in polyacrylamide gel phantom. The temperatures measured from MRI are compared with those from temperature probes to verify their accuracy. In general, the difference between temperatures determined from MRI diffusion images over 0.3 cm3 regions of interest and from temperature probes were 0.2 degrees C. It is concluded that current MRI technology allows noninvasive temperature tomography that is comparable with invasive thermometry with respect to temperature accuracy, has spatial and time resolutions that would be useful in hyperthermic oncology.

A three-dimensional thermal and electromagnetic model of whole limb heating with a MAPA

Previous studies by the authors have shown that if properly implemented, the Pennes assumptions can be applied to quantify bioheat transfer during extremity heating. Given its relative numerical simplicity and its ability to predict temperatures in thermoregulated tissue, the Pennes model of bioheat transfer was utilized in a three-dimensional thermal model of limb heating. While the arterial blood temperature was assumed to be radially uniform within a cross section of the limb, axial gradients in the arterial and venous blood temperatures were computed with this three-dimensional model. A realistically shaped, three-dimensional finite element model of a tumor-bearing human lower leg was constructed and was "attached" mathematically to the whole body thermal model of man described in previous studies by the authors. The central as well as local thermoregulatory feedback control mechanisms which determine blood perfusion to the various tissues and rate of evaporation by sweating were input into the limb model. In addition, the temperature of the arterial blood which feeds into the most proximal section of the lower leg was computed by the whole body thermal model. The variations in the shape of the tissues which comprise the limb were obtained from computerized tomography scans. Axial variations in the energy deposition patterns along the length of the limb exposed to a miniannular phased array (MAPA) applicator were also input into this model of limb heating. Results indicate that proper positioning of the limb relative to the MAPA is a significant factor in determining the effectiveness of the treatment. A patient-specific hyperthermia protocol can be designed using this coupled electromagnetic and thermal model.

Noninvasive temperature imaging using diffusion MRI

Efficacy and safety considerations for cancer therapy with hyperthermia require accurate temperature measurements throughout the heated volume. We report the use of molecular diffusion, whose temperature dependence is well known. A dedicated hyperthermia applicator was built, combining a MRI gradient coil and a rf coil. Diffusion and derived temperature images were obtained with a 1 x 2 mm pixel size on a polyacrylamide gel phantom using a clinical 1.5-T whole body MRI system. Temperatures determined from these images using 1 cm2 regions of interest were found to be within 0.2 degrees C of those recorded from the thermocouples and fiber-optic probes placed inside the gel.

Hyperthermia system combined with a magnetic resonance imaging unit

Magnetic resonance imaging (MRI) has recently been proposed as a method to monitor, noninvasively, temperature, blood flow, and cell metabolism during oncologic hyperthermia (HT). To heat and "image" simultaneously, it is necessary to combine a HT device and a MRI unit. As a demonstrative example of the problems associated with implementing such a system, a mini-annular phased array hyperthermia applicator was combined with a 0.5-T whole body MRI unit. With the aid of filters, baluns, and switches, the HT applicator and the MRI unit were made compatible. The overall system was tested using a muscle-equivalent, cylindrically shaped polyacrylamide gel phantom. No interference between the HT device and the MRI unit was observed. Noninvasive temperature images, with a resolution better than 1 degree C/cm, were obtained from images of molecular diffusion recorded before and during heating.

An evaluation of the Weinbaum-Jiji bioheat equation for normal and hyperthermic conditions

The predictions of the simplified Weinbaum-Jiji (WJ) bioheat transfer equation in one dimension are compared to those of the complete one-dimensional three-equation model that represented the starting point for the derivation of the WJ equation, as well as results obtained using the traditional bioheat transfer equation of Pennes [6]. The WJ equation provides very good agreement with the three-equation model for vascular generations 2 to 9, which are located in the outer half of the muscle layer, where the paired vessel diameters are less than 500 microns, under basal blood flow conditions. At the same time, the Pennes equation yields a better description of heat transfer in the first generation, where the vessels' diameters are greater than 500 microns and epsilon, the vessels' normalized thermal equilibration length, is greater than 0.3. These results were obtained under both normothermic and hyperthermic conditions. A new conceptual view of the blood source term in the Pennes equation has emerged from these results. This source term, which was originally intended to represent an isotropic heat source in the capillaries, is shown to describe instead the heat transfer from the largest countercurrent microvessels to the tissue due to small vessel bleed-off. The WJ equation includes this effect, but significantly overestimates the second type of tissue heat transfer, countercurrent convective heat transfer, when epsilon greater than 0.3. Indications are that a "hybrid" model that applies the Pennes equation in the first generation (normothermic) and first two to three generations (after onset of hyperthermia) and the Weinbaum-Jiji equation in the subsequent generations would be most appropriate for simulations of bioheat transfer in perfused tissue.

Bioheat transfer in a branching countercurrent network during hyperthermia

A bioheat transfer model which computes the spatial variations in the arteriole, venule, and muscle temperatures in a human extremity under both resting and hyperthermic conditions is presented. This model uses the two-parameter model first proposed by Baish et al. to account for the heat exchange between tissue and the paired arterioles and venules that comprise the microcirculation. Thermoregulation of the muscle blood flow during hyperthermia is also incorporated into the model. Results show that even when the paired arteriole and venule are assumed to have equal radii, the mean temperature under both steady and transient conditions is not equal to the mean of the arteriole and venule blood temperatures. Tissue temperature profiles during hyperthermia computed with the three-equation model presented in this study are similar in shape and magnitude to those predicted by the traditional one-equation Pennes bioheat transfer model. This is due primarily to the influence of thermoregulatory mechanism in the heated muscle. The unexpected agreement is significant given the inherent relative simplicity of the traditional Pennes model. An "experimental" thermal conductivity is presented to relate the theoretical results to experimental procedures that are widely used to estimate the enhancement of conductivity by perfusion.

Temperature mapping with MR imaging of molecular diffusion: application to hyperthermia

Efficacy and safety considerations for hyperthermia (HT) cancer therapy require accurate temperature measurements throughout the heated volume. Noninvasive thermometry methods have been proposed, including magnetic resonance (MR) imaging based on the temperature dependence of the relaxation time T1. However, the temperature accuracy achieved to date with T1 measurements does not fulfill the HT requirements (1 degree C/cm). The authors propose to use molecular diffusion, for which temperature dependence is well known. Molecular diffusion is more sensitive than T1 and can be determined with high accuracy with MR imaging. Diffusion and derived temperature images were obtained with a 2 X 2-mm pixel size in a polyacrylamide gel phantom heated inside the head coil of a clinical 0.5-T whole-body MR imaging system by means of a modified clinical HT device made compatible with the system. Temperatures determined from these images with 0.8-cm2 regions of interest were found to be within 0.5 degrees C of those recorded with thermocouples placed inside the gel. The utility of this method in clinical hyperthermia is enhanced by its potential to also help monitor blood perfusion.

Heat transfer normal to paired arterioles and venules embedded in perfused tissue during hyperthermia

A numerical model of the heat transer normal to an arteriole-venule pair embedded in muscle tissue has been constructed. Anatomical data describing the blood vessel size, spacing, and density have been incorporated into the model. This model computes temperatures along the vessel walls as well as the temperature throughout the tissue which comprises an infinitely long Krogh cylinder around the vessel pair. Tissue temperatures were computed in the steady-state under resting conditions, while transient calculations were made under hyperthermic conditions. Results show that for both large- (1st generation) and medium-sized (5th generation) vessel pairs, the mean tissue temperature within the tissue cylinder is not equal to the mean of the arteriole and venule blood temperatures under both steady-state and transient conditions. The numerical data were reduced so that a comparison could be made with the predictions of a simple two-dimensional superposition of line sources and sinks presented by Baish et al. This comparison reveals that the superposition model accurately describes the heat transfer effects during hyperthermia, permitting subsequent incorporation of this theory into a realistic three-dimensional model of heat transfer in a whole limb during hyperthermia.

Energy deposition patterns in an amputated human lower leg heated with a miniannular phased array

The energy deposition patterns in both alcohol-fixed and unfixed amputated human lower legs produced by a miniannular phased array (MAPA) applicator have been determined. The nontumor bearing portions of four human legs, amputated for therapeutic purposes, were heated within the MAPA. Experimental measurements of the time rate of temperature rise at many locations inside the leg (between 125 and 150) were transformed to specific absorption rate (SAR) values at each point. A simple model was developed which predicts the axial variations in SAR inside the heated limb based upon quantitative details of the leg's geometry obtained from computerized tomography scans. The axial location of the region of maximum energy deposition was predicted by the model with a precision of approximately 1 to 2 cm. Significant time rate of temperature rise was measured inside the cortical portion of the tibia, while the temperature rise in the cancellous (marrow) portion of the tibia was negligible. The alcohol fixation process appears to have no significant effect on the energy deposition patterns within the various leg tissues.

Experimental characterization of the miniannular phased array as a hyperthermia applicator

A series of experiments has been carried out in order to characterize a miniannular phased array applicator prior to possible clinical implementation. The energy deposition patterns over the frequency range of 100 to 200 MHz were determined in several human limb models of different complexities by measuring the electric field strength patterns. The point of maximum energy deposition within a homogeneous, muscle-equivalent cylindrical phantom positioned coaxially within the MAPA was found to be at the center of the applicator. The energy deposition patterns seem to be more uniform at the lower frequencies. Inclusion of a cylindrical bone-equivalent phantom positioned coaxially with this muscle-equivalent phantom does not seem to significantly alter the energy deposition patterns in the muscle-equivalent region. For more realistically shaped, homogeneous muscle-equivalent limb models, the resulting energy deposition patterns appear to be confined mostly to the intended treatment region. However, the point of maximum energy deposition was not at the middle of the applicator as with the cylindrical model, but shifted towards a smaller cross-sectional region. This shift in location of the point of maximum energy deposition varies with the location of the MAPA on the limb. A secondary region of high-field strength was also observed at the ankle for a MAPA centered about the knee. In this study, the energy deposition patterns appear to be significantly dependent on the shape of the model. Therefore, this factor must be taken into consideration for the proper prediction and control of the heating patterns resulting from the use of this type of applicator for clinical hyperthermia treatment.

Human leg heating using a mini-annular phased array

The energy deposition pattern within an isolated human leg heated with a mini-annular phased array (MAPA) hyperthermia applicator has been determined. The non-tumor-bearing lower portion of a human leg amputated at the hip due to the presence of a large tumor in the thigh was "fixed" in a 50% ethanol in 0.9% saline solution. Subsequent to this fixation process, the leg was rehydrated in 0.9% saline and heated four times using a MAPA operating at 122 MHz. Specific absorption rates and electric field strengths were calculated from the rates of change of temperature with time measured at 143 different anatomical locations within the leg. When the leg was coaxial with the MAPA and the MAPA was axially positioned midway between the knee and the ankle, the points of maximum heating were skewed away from the center of the MAPA, towards the ankle of the leg and along the central axis of the MAPA. Significant temperature rise was measured inside the bone and the fat as well as inside the muscle of the leg. Bone heating was reduced when the leg was shifted away from the MAPA axis.

A generalized method for the minimization of cellular osmotic stresses and strains during the introduction and removal of permeable cryoprotectants

The successful freeze preservation of mammalian cells and tissues usually requires the presence of high concentrations of cryoprotective agents (CPAs) such as glycerol, ethylene glycol, or dimethylsulfoxide. Unfortunately, the addition of these permeable agents to cells and tissues prior to freezing and their removal after thawing has been documented to be as damaging as the freeze-thaw process itself. This damaging process has been hypothesized to result from the drastic alterations in cell size caused by the osmotic stresses usually imposed upon cells during the introduction and removal of the cryoprotectants. Consequently, on the basis of a nonequilibrium thermodynamic model for the transport of water and a permeable CPA across cell membranes, a method has been developed to minimize these potentially lethal transient changes in cell size. This method involves the simultaneous variation of both the extracellular CPA and electrolyte or osmotic extender osmolalities in a balance, prescribed manner so that both the cellular water content and the total intracellular ionic strength remain constant as the intracellular CPA osmolarity is either raised or lowered. The theoretical analysis indicates that many of the resulting protocols are practical from the clinical point of view.

Improved stop-flow apparatus to measure permeability of human red cells and ghosts

An improved stop-flow apparatus has been designed and constructed to measure the permeability characteristics of human red cells, which can be inferred from the time course of red cell volume changes following a sudden change in cellular environment produced by a raped mixing device. The improved apparatus is directly coupled to a computer which automates the subtraction and averaging procedures that have been developed to minimize the noise generated in the system by the cessation of red cell forward motion when the flow is suddenly stopped. Real time data acquisition also makes it possible to increase the number of data points by an order of magnitude, thus improving accuracy significantly. The apparatus has been tested by measurements of the human red cell hydraulic permeability coefficient. Data are presented to validate the subtraction procedure. Experiments have also been carried out on red cell ghosts which indicate that the hydraulic conductivity of the ghost is similar to that of the undisturbed red cell.

Water permeability of yeast cells at sub-zero temperatures

A combined cryomicroscopic-multiple nonlinear regression analysis technique has been used to determine the water permeability of the yeast cell Saccharomyces cerevisiae during freezing. The time rate of change in volume of "supercooled" yeast cells was photographically monitored using a "cryomicroscope" which is capable of controlling in a programmable manner both the temperature and the time rate of change in temperature of the cell suspension being studied. Multiple nonlinear regression analysis together with a thermodynamic model of cell water transport during freezing was then used to statistically deduce the subzero temperature dependence of the cell water permeability. The water permeability process for S. cerevisiae being cooled at subzero temperatures was found to be rate-limited by the passage of water through either the plasmalemma, the cell wall, or a combination of these two permeability barriers. The hydraulic water permeability coefficient for yeast at 20 degrees C is approximately 1--2 x 10(-13) cm3/dyne sec, if extrapolation from subzero temperatures to room temperature is permissible, while the apparent activation energy governing the permeability process at subzero temperatures is approximately 45--68 kJ/mol (11--16 kcal/mol).

Effect of solution non-ideality on erythrocyte volume regulation

A non-ideal, hydrated, non-dilute pseudo-binary salt-protein-water solution model of the erythrocyte intracellular solution is presented to describe the osmotic behavior of human erythrocytes. Existing experimental activity data for salts and proteins in aqueous solutions are used to formulate van Laar type expressions for the solvent and solute activity coefficients. Reasonable estimates can therefore be made of the non-ideality of the erythrocyte intracellular solution over a wide range of osmolalities. Solution non-ideality is shown to affect significantly the degree of solute polarization within the erythrocyte intracellular solution during freezing. However, the non-ideality has very little effect upon the amount of water retained within erythrocytes cooled at sub-zero temperatures.

Effect of hydration on the water content of human erythrocytes

An ideal, hydrated, nondilute pseudobinary salt-protein-water solution model of the RBC intracellular solution has been developed to describe the osmotic behavior of human erythrocytes during freezing and thawing. Because of the hydration of intracellular solutes (mostly cell proteins), our analytical results predict that at least 16.65% of the isotonic cell water content will be retained within RBCs placed in hypertonic solutions. These findings are consistent not only with the experimental measurements of the amount of isotonic cell water retained within RBCs subjected to nonisotonic extracellular solutions (20-32%) but also with the experimental evidence that all of the water within RBCs is solvent water. By modeling the RBC intracellular solution as a hydrated salt-protein-water solution, no anomalous osmotic behavior is apparent.

A membrane model describing the effect of temperature on the water conductivity of erythrocyte membranes at subzero temperatures

Thermodynamic models show that the loss of intracellular water from human erythrocytes during freezing depends heavily upon the water conductivity of the erythrocyte membrane. These calculations, which are based on the simple extrapolation of ambient conductivity data to subzero temperatures, show that more than 95% of cell water is transferable during freezing, whereas experiments show that at least 20% of cell water is retained. A study of the effects of different published values for the membrane water conductivity on cell water retained during freezing shows that this discrepancy may be a consequence of the simple extrapolation procedure. For a homogeneous membrane system, absolute reaction rate theory was used to develop a surface-limited permeation model that includes the resistance to the flow of water not only through the interior region of the membrane but also across possible rate-limiting barriers at the solution-membrane interfaces. The model shows that it is unlikely that a single rate-limiting process dominates water transport in the red cell as it is being cooled from ambient to subzero temperatures. The effective membrane conductivity at subzero temperatures could possible be much lower than a simple extrapolation of existing data would predict. With the aid of this model analytical predictions of intracellular water during freezing are more consistent with experimental observations.