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Leteba GM, George SL, Mitchell DRG, Levecque PBJ, van Steen E, Macheli L, Lang CI. Synthesis of PtNi Nanoparticles to Accelerate the Oxygen Reduction Reaction. Chempluschem 2024:e202400083. [PMID: 38523404 DOI: 10.1002/cplu.202400083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/23/2024] [Accepted: 03/23/2024] [Indexed: 03/26/2024]
Abstract
We report the synthesis of core-shell Ni-Pt nanoparticles (NPs) with varying degrees of crystallographic facets and surface layers rich in Pt via a seed-mediated thermolytic approach. Mixtures of different surfactants used during synthesis resulted in preferential surface passivation, which in turn dictated the size, chemical composition, and geometric evolution of these PtNi NPs. Electrochemical investigations of these pristine core-shell Ni-Pt structures in the oxygen reduction reaction (ORR) show that their catalytic functionalities outperform the commercial Pt/C reference catalyst. The enhanced electrocatalytic ORR performances of these Pt-based PtNi NPs are correlated with the weakened oxygen binding strength or surface-adsorbed hydroxyl (OH) species on active Pt surface sites induced by the downshift of the d-band center as a result of compressive strain effects. Our studies offer a robust synthetic approach for the development of core-shell nanostructures for enhanced ORR catalysis.
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Affiliation(s)
- Gerard M Leteba
- Centre for Materials Engineering, Department of Mechanical Engineering, University of Cape Town, Cape Town, 7700, South Africa
- Catalysis Institute, Department of Chemical Engineering, University of Cape Town, Cape Town, 7700, South Africa
| | - Sarah L George
- Centre for Materials Engineering, Department of Mechanical Engineering, University of Cape Town, Cape Town, 7700, South Africa
| | - David R G Mitchell
- Electron Microscopy Centre, Innovation Campus, University of Wollongong, Wollongong, NSW 2517, Australia
| | - Pieter B J Levecque
- Catalysis Institute, Department of Chemical Engineering, University of Cape Town, Cape Town, 7700, South Africa
| | - Eric van Steen
- Catalysis Institute, Department of Chemical Engineering, University of Cape Town, Cape Town, 7700, South Africa
| | - Lebohang Macheli
- Department of Chemical Engineering, University of South Africa, Florida Campus, Johannesburg, 1710, South Africa
| | - Candace I Lang
- Centre for Materials Engineering, Department of Mechanical Engineering, University of Cape Town, Cape Town, 7700, South Africa
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George SL, Magidi-Chicuba L. Intermetallic and dispersoid structures in AA3104 aluminium alloy during two-step homogenisation. Sci Rep 2024; 14:2958. [PMID: 38316798 PMCID: PMC10844596 DOI: 10.1038/s41598-024-51890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
During homogenisation of the AA3104 cast ingot, a phase transformation of intermetallic particles from β-Al6(Fe,Mn) orthorhombic phase to harder α-Alx(Fe,Mn)3Si2 cubic phase occurs. The large constituent intermetallic particles, regardless of phase, assist in the recrystallisation nucleation process through particle stimulated nucleation (PSN). Ultimately, this helps to refine grain size. The sub-micron dispersoids act to impede grain boundary migration through a Zener drag mechanism. For this reason, the dispersoids that form during homogenisation are critical to the recrystallisation kinetics during subsequent rolling, with smaller dispersoids being better suited to instances where the minimisation of recrystallisation is required during hot rolling. This work simulates an industrial two-step homogenisation practice with variations in the peak temperature of the first step between 560 °C and 580 °C. The effect of this temperature variation on the intermetallic particle phase evolution is investigated. The aim is to identify the ideal intermetallic phase balance and the dispersoid structure that are best suited for the minimisation of recrystallisation during hot rolling through maximising Zener drag and maintaining galling resistance. The results indicate a trend where an increase in homogenisation temperature from 560 °C to 580 °C yields, firstly, an increase in the volume fraction of the α-phase particles to greater than 50% of the total volume fraction at both the edge and the centre of the ingot and, secondly, it yields an increased dispersoid size. Thus, a lower temperature homogenisation practice produces a near-ideal combination of intermetallic particle phase distribution, as well as dispersoid size, which is critical for Zener drag and the minimization of recrystallisation during the hot rolling processes.
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Affiliation(s)
- S L George
- Centre for Materials Engineering, Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa.
| | - L Magidi-Chicuba
- Centre for Materials Engineering, Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa
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Ortega-Villa AM, Hynes NA, Levine CB, Yang K, Wiley Z, Jilg N, Wang J, Whitaker JA, Colombo CJ, Nayak SU, Kim HJ, Iovine NM, Ince D, Cohen SH, Langer AJ, Wortham JM, Atmar RL, El Sahly HM, Jain MK, Mehta AK, Wolfe CR, Gomez CA, Beresnev T, Mularski RA, Paules CI, Kalil AC, Branche AR, Luetkemeyer A, Zingman BS, Voell J, Whitaker M, Harkins MS, Davey RT, Grossberg R, George SL, Tapson V, Short WR, Ghazaryan V, Benson CA, Dodd LE, Sweeney DA, Tomashek KM. Evaluating Demographic Representation in Clinical Trials: Use of the Adaptive Coronavirus Disease 2019 Treatment Trial (ACTT) as a Test Case. Open Forum Infect Dis 2023; 10:ofad290. [PMID: 37383244 PMCID: PMC10296069 DOI: 10.1093/ofid/ofad290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
Background Clinical trials initiated during emerging infectious disease outbreaks must quickly enroll participants to identify treatments to reduce morbidity and mortality. This may be at odds with enrolling a representative study population, especially when the population affected is undefined. Methods We evaluated the utility of the Centers for Disease Control and Prevention's COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), the COVID-19 Case Surveillance System (CCSS), and 2020 United States (US) Census data to determine demographic representation in the 4 stages of the Adaptive COVID-19 Treatment Trial (ACTT). We compared the cumulative proportion of participants by sex, race, ethnicity, and age enrolled at US ACTT sites, with respective 95% confidence intervals, to the reference data in forest plots. Results US ACTT sites enrolled 3509 adults hospitalized with COVID-19. When compared with COVID-NET, ACTT enrolled a similar or higher proportion of Hispanic/Latino and White participants depending on the stage, and a similar proportion of African American participants in all stages. In contrast, ACTT enrolled a higher proportion of these groups when compared with US Census and CCSS. The proportion of participants aged ≥65 years was either similar or lower than COVID-NET and higher than CCSS and the US Census. The proportion of females enrolled in ACTT was lower than the proportion of females in the reference datasets. Conclusions Although surveillance data of hospitalized cases may not be available early in an outbreak, they are a better comparator than US Census data and surveillance of all cases, which may not reflect the population affected and at higher risk of severe disease.
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Affiliation(s)
- Ana M Ortega-Villa
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Noreen A Hynes
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Corri B Levine
- Division of Infectious Disease, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Katherine Yang
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Zanthia Wiley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nikolaus Jilg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jennifer A Whitaker
- Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher J Colombo
- Department of Virtual Health and Department of Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Seema U Nayak
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Hannah Jang Kim
- Department of Community Health Systems, School of Nursing, University of California, San Francisco,San Francisco, California, USA
- National Patient Care Services, Kaiser Permanente, Oakland, California, USA
| | - Nicole M Iovine
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Dilek Ince
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Stuart H Cohen
- Division of Infectious Diseases, University of California, Davis, Sacramento, California, USA
| | - Adam J Langer
- COVID-19 Emergency Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonathan M Wortham
- COVID-19–Associated Hospitalization Surveillance Network, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robert L Atmar
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hana M El Sahly
- Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mamta K Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aneesh K Mehta
- Division of Infection Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- National Emerging Special Pathogens Treatment and Education Center, Atlanta, Georgia, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carlos A Gomez
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tatiana Beresnev
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard A Mularski
- Department of Pulmonary and Critical Care Medicine, Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Catharine I Paules
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Angela R Branche
- Division of Infectious Diseases, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Annie Luetkemeyer
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Barry S Zingman
- Department of Medicine, Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jocelyn Voell
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael Whitaker
- COVID-19–Associated Hospitalization Surveillance Network, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michelle S Harkins
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Richard T Davey
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Robert Grossberg
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sarah L George
- Department of Internal Medicine, Saint Louis University and St Louis Veterans Affairs Medical Center, St Louis, Missouri, USA
| | - Victor Tapson
- Division of Pulmonary and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - William R Short
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Varduhi Ghazaryan
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Constance A Benson
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, San Diego, California, USA
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Kay M Tomashek
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Sweeney DA, Tuyishimire B, Ahuja N, Beigel JH, Beresnev T, Cantos VD, Castro JG, Cohen SH, Cross K, Dodd LE, Erdmann N, Fung M, Ghazaryan V, George SL, Grimes KA, Hynes NA, Julian KG, Kandiah S, Kim HJ, Levine CB, Lindholm DA, Lye DC, Maves RC, Oh MD, Paules C, Rapaka RR, Short WR, Tomashek KM, Wolfe CR, Kalil AC. Baricitinib Treatment of Coronavirus Disease 2019 Is Associated With a Reduction in Secondary Infections. Open Forum Infect Dis 2023; 10:ofad205. [PMID: 37206623 PMCID: PMC10191442 DOI: 10.1093/ofid/ofad205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/13/2023] [Indexed: 05/21/2023] Open
Abstract
We performed a secondary analysis of the National Institutes of Health-sponsored Adaptive COVID-19 Treatment Trial (ACTT-2) randomized controlled trial and found that baricitinib was associated with a 50% reduction in secondary infections after controlling for baseline and postrandomization patient characteristics. This finding provides a novel mechanism of benefit for baricitinib and supports the safety profile of this immunomodulator for the treatment of coronavirus disease 2019.
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Affiliation(s)
- Daniel A Sweeney
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Neera Ahuja
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - John H Beigel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Tatiana Beresnev
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Jose G Castro
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Stuart H Cohen
- Department of Internal Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Lori E Dodd
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nathan Erdmann
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Monica Fung
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Varduhi Ghazaryan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sarah L George
- Department of Medicine, Saint Louis University and St. Louis VA Medical Center, Saint Louis, MO, USA
| | - Kevin A Grimes
- Department of Medicine, Houston Methodist, Houston, TX, USA
| | - Noreen A Hynes
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen G Julian
- Department of Medicine, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Hannah Jang Kim
- Community Health Systems Department, University of California San Francisco, San Francisco, CA, USA
- Department of Nursing, Kaiser Permanente National Patient Care Services, Oakland, CA, USA
| | - Corri B Levine
- Department of Internal Medicine Galveston, University of Texas Medical Branch, TX, USA
| | - David A Lindholm
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft Sam Houston, TX, USA
| | - David C Lye
- National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Ryan C Maves
- Departments of Internal Medicine and Anesthesiology, Wake Forest University, Winston-Salem, NC, USA
| | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University Hospital College of Medicine, Seoul, Korea
| | - Catharine Paules
- Department of Medicine, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rekha R Rapaka
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Willam R Short
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kay M Tomashek
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Andre C Kalil
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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5
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Potter GE, Bonnett T, Rubenstein K, Lindholm DA, Rapaka RR, Doernberg SB, Lye DC, Mularski RA, Hynes NA, Kline S, Paules CI, Wolfe CR, Frank MG, Rouphael NG, Deye GA, Sweeney DA, Colombo RE, Davey RT, Mehta AK, Whitaker JA, Castro JG, Amin AN, Colombo CJ, Levine CB, Jain MK, Maves RC, Marconi VC, Grossberg R, Hozayen S, Burgess TH, Atmar RL, Ganesan A, Gomez CA, Benson CA, Lopez de Castilla D, Ahuja N, George SL, Nayak SU, Cohen SH, Lalani T, Short WR, Erdmann N, Tomashek KM, Tebas P. Temporal Improvements in COVID-19 Outcomes for Hospitalized Adults: A Post Hoc Observational Study of Remdesivir Group Participants in the Adaptive COVID-19 Treatment Trial. Ann Intern Med 2022; 175:1716-1727. [PMID: 36442063 PMCID: PMC9709721 DOI: 10.7326/m22-2116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The COVID-19 standard of care (SOC) evolved rapidly during 2020 and 2021, but its cumulative effect over time is unclear. OBJECTIVE To evaluate whether recovery and mortality improved as SOC evolved, using data from ACTT (Adaptive COVID-19 Treatment Trial). DESIGN ACTT is a series of phase 3, randomized, double-blind, placebo-controlled trials that evaluated COVID-19 therapeutics from February 2020 through May 2021. ACTT-1 compared remdesivir plus SOC to placebo plus SOC, and in ACTT-2 and ACTT-3, remdesivir plus SOC was the control group. This post hoc analysis compared recovery and mortality between these comparable sequential cohorts of patients who received remdesivir plus SOC, adjusting for baseline characteristics with propensity score weighting. The analysis was repeated for participants in ACTT-3 and ACTT-4 who received remdesivir plus dexamethasone plus SOC. Trends in SOC that could explain outcome improvements were analyzed. (ClinicalTrials.gov: NCT04280705 [ACTT-1], NCT04401579 [ACTT-2], NCT04492475 [ACTT-3], and NCT04640168 [ACTT-4]). SETTING 94 hospitals in 10 countries (86% U.S. participants). PARTICIPANTS Adults hospitalized with COVID-19. INTERVENTION SOC. MEASUREMENTS 28-day mortality and recovery. RESULTS Although outcomes were better in ACTT-2 than in ACTT-1, adjusted hazard ratios (HRs) were close to 1 (HR for recovery, 1.04 [95% CI, 0.92 to 1.17]; HR for mortality, 0.90 [CI, 0.56 to 1.40]). Comparable patients were less likely to be intubated in ACTT-2 than in ACTT-1 (odds ratio, 0.75 [CI, 0.53 to 0.97]), and hydroxychloroquine use decreased. Outcomes improved from ACTT-2 to ACTT-3 (HR for recovery, 1.43 [CI, 1.24 to 1.64]; HR for mortality, 0.45 [CI, 0.21 to 0.97]). Potential explanatory factors (SOC trends, case surges, and variant trends) were similar between ACTT-2 and ACTT-3, except for increased dexamethasone use (11% to 77%). Outcomes were similar in ACTT-3 and ACTT-4. Antibiotic use decreased gradually across all stages. LIMITATION Unmeasured confounding. CONCLUSION Changes in patient composition explained improved outcomes from ACTT-1 to ACTT-2 but not from ACTT-2 to ACTT-3, suggesting improved SOC. These results support excluding nonconcurrent controls from analysis of platform trials in rapidly changing therapeutic areas. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Gail E Potter
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland (G.E.P.)
| | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland (T.B., K.R.)
| | - Kevin Rubenstein
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland (T.B., K.R.)
| | - David A Lindholm
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas (D.A.L.)
| | - Rekha R Rapaka
- University of Maryland Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland (R.R.R.)
| | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, San Francisco, California (S.B.D.)
| | - David C Lye
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Yong Loo Lin School of Medicine, and Lee Kong Chian School of Medicine, Singapore (D.C.L.)
| | - Richard A Mularski
- Department of Pulmonary and Critical Care Medicine, Northwest Permanente PC, and Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (R.A.M.)
| | - Noreen A Hynes
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (N.A.H.)
| | - Susan Kline
- Department of Medicine, Division of Infectious Diseases and International Medicine, University of Minnesota Medical School, Minneapolis, Minnesota (S.K.)
| | - Catharine I Paules
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (C.I.P.)
| | - Cameron R Wolfe
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina (C.R.W.)
| | - Maria G Frank
- Department of Medicine, Denver Health Hospital Authority, Denver, Colorado, and University of Colorado School of Medicine, Aurora, Colorado (M.G.F.)
| | - Nadine G Rouphael
- Hope Clinic, Emory Vaccine Center, Infectious Diseases Division, Atlanta, Georgia (N.G.R.)
| | - Gregory A Deye
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (G.A.D., S.U.N., K.M.T.)
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego, San Diego, California (D.A.S.)
| | - Rhonda E Colombo
- Madigan Army Medical Center, Tacoma, Washington, Infectious Diseases Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland (R.E.C.)
| | - Richard T Davey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (R.T.D.)
| | - Aneesh K Mehta
- Division of Infectious Diseases, Emory University School of Medicine, and National Emerging Special Pathogens Training and Education Center, Atlanta, Georgia (A.K.M.)
| | - Jennifer A Whitaker
- Departments of Molecular Virology and Microbiology and Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas (J.A.W.)
| | - Jose G Castro
- Division of Infectious Diseases, University of Miami, Miami, Florida (J.G.C.)
| | - Alpesh N Amin
- Department of Medicine, University of California, Irvine, Irvine, California (A.N.A.)
| | - Christopher J Colombo
- Madigan Army Medical Center, Tacoma, Washington, and Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland (C.J.C.)
| | - Corri B Levine
- Department of Internal Medicine, Division of Infectious Disease, University of Texas Medical Branch, Galveston, Texas (C.B.L.)
| | - Mamta K Jain
- Department of Internal Medicine, Division of Infectious Disease and Geographic Medicine, UT Southwestern Medical Center, and Parkland Health & Hospital System, Dallas, Texas (M.K.J.)
| | - Ryan C Maves
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, and Infectious Diseases Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland (R.C.M.)
| | - Vincent C Marconi
- Emory University School of Medicine, Rollins School of Public Health, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia (V.C.M.)
| | - Robert Grossberg
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York (R.G.)
| | - Sameh Hozayen
- Department of Medicine, Division of Hospital Medicine, University of Minnesota, Minneapolis, Minnesota (S.H.)
| | - Timothy H Burgess
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland (T.H.B.)
| | - Robert L Atmar
- Department of Medicine, Baylor College of Medicine, Houston, Texas (R.L.A.)
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and Walter Reed National Military Medical Center, Bethesda, Maryland (A.G.)
| | - Carlos A Gomez
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska (C.A.G.)
| | - Constance A Benson
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California (C.A.B.)
| | - Diego Lopez de Castilla
- Division of Infectious Diseases, Evergreen Health Medical Center, Kirkland, Washington (D.L.)
| | - Neera Ahuja
- Department of Internal Medicine, Stanford University Medical Center, Palo Alto, California (N.A.)
| | - Sarah L George
- Saint Louis University and St. Louis VA Medical Center, Saint Louis, Missouri (S.L.G.)
| | - Seema U Nayak
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (G.A.D., S.U.N., K.M.T.)
| | - Stuart H Cohen
- Division of Infectious Diseases, University of California, Davis, Sacramento, California (S.H.C.)
| | - Tahaniyat Lalani
- Naval Medical Center Portsmouth, Portsmouth, Virginia, Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland (T.L.)
| | - William R Short
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania (W.R.S.)
| | - Nathaniel Erdmann
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama (N.E.)
| | - Kay M Tomashek
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (G.A.D., S.U.N., K.M.T.)
| | - Pablo Tebas
- Division of Infectious Diseases/Clinical Trials Unit, University of Pennsylvania, Philadelphia, Pennsylvania (P.T.)
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6
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Pinski AN, Steffen TL, Zulu MZ, George SL, Dickson A, Tifrea D, Maroney KJ, Tedeschi N, Zhang Y, Scheuermann RH, Pinto AK, Brien JD, Messaoudi I. Corticosteroid treatment in COVID-19 modulates host inflammatory responses and transcriptional signatures of immune dysregulation. J Leukoc Biol 2021; 110:1225-1239. [PMID: 34730254 PMCID: PMC8667650 DOI: 10.1002/jlb.4cova0121-084rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 12/15/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19), a respiratory disease that varies in severity from mild to severe/fatal. Several risk factors for severe disease have been identified, notably age, male sex, and pre-existing conditions such as diabetes, obesity, and hypertension. Several advancements in clinical care have been achieved over the past year, including the use of corticosteroids (e.g., corticosteroids) and other immune-modulatory treatments that have now become standard of care for patients with acute severe COVID-19. While the understanding of the mechanisms that underlie increased disease severity with age has improved over the past few months, it remains incomplete. Furthermore, the molecular impact of corticosteroid treatment on host response to acute SARS-CoV-2 infection has not been investigated. In this study, a cross-sectional and longitudinal analysis of Ab, soluble immune mediators, and transcriptional responses in young (65 ≤ years) and aged (≥ 65 years) diabetic males with obesity hospitalized with acute severe COVID-19 was conducted. Additionally, the transcriptional profiles in samples obtained before and after corticosteroids became standard of care were compared. The analysis indicates that severe COVID-19 is characterized by robust Ab responses, heightened systemic inflammation, increased expression of genes related to inflammatory and pro-apoptotic processes, and reduced expression of those important for adaptive immunity regardless of age. In contrast, COVID-19 patients receiving steroids did not show high levels of systemic immune mediators and lacked transcriptional indicators of heightened inflammatory and apoptotic responses. Overall, these data suggest that inflammation and cell death are key drivers of severe COVID-19 pathogenesis in the absence of corticosteroid therapy.
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Affiliation(s)
- Amanda N Pinski
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, California, USA
- Center for Virus Research, University of California, Irvine, Irvine, California, USA
- Institute for Immunology, University of California, Irvine, California, USA
| | - Tara L Steffen
- Department of Molecular Microbiology and Immunology, Saint Louis University, St Louis, Missouri, USA
| | - Michael Z Zulu
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, California, USA
- Center for Virus Research, University of California, Irvine, Irvine, California, USA
- Institute for Immunology, University of California, Irvine, California, USA
| | - Sarah L George
- Department of Medicine, Division of Infectious Diseases, Saint Louis University, St Louis, Missouri, USA
| | - Alexandria Dickson
- Department of Molecular Microbiology and Immunology, Saint Louis University, St Louis, Missouri, USA
| | - Delia Tifrea
- Department of Pathology and Laboratory Medicine, University of California, Irvine, California, USA
| | - Kevin J Maroney
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, California, USA
| | - Neil Tedeschi
- J. Craig Venter Institute, La Jolla, California, USA
| | - Yun Zhang
- J. Craig Venter Institute, La Jolla, California, USA
| | | | - Amelia K Pinto
- Department of Molecular Microbiology and Immunology, Saint Louis University, St Louis, Missouri, USA
| | - James D Brien
- Department of Molecular Microbiology and Immunology, Saint Louis University, St Louis, Missouri, USA
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, California, USA
- Center for Virus Research, University of California, Irvine, Irvine, California, USA
- Institute for Immunology, University of California, Irvine, California, USA
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7
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Parker S, D'Angelo J, Buller RM, Smee DF, Lantto J, Nielsen H, Jensen A, Prichard M, George SL. A human recombinant analogue to plasma-derived vaccinia immunoglobulin prophylactically and therapeutically protects against lethal orthopoxvirus challenge. Antiviral Res 2021; 195:105179. [PMID: 34530009 PMCID: PMC9628779 DOI: 10.1016/j.antiviral.2021.105179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/22/2022]
Abstract
Orthopoxviruses such as variola and monkeypox viruses continue to threaten the human population. Monkeypox virus is endemic in central and western Africa and outbreaks have reached as far as the U.S. Although variola virus, the etiologic agent of smallpox, has been eradicated by a successful vaccination program, official and likely clandestine stocks of the virus exist. Moreover, studies with ectromelia virus (the etiological agent of mousepox) have revealed that IL-4 recombinant viruses are significantly more virulent than wild-type viruses even in mice treated with vaccines and/or antivirals. For these reasons, it is critical that antiviral modalities are developed to treat these viruses should outbreaks, or deliberate dissemination, occur. Currently, 2 antivirals (brincidofovir and tecovirimat) are in the U.S. stockpile allowing for emergency use of the drugs to treat smallpox. Both antivirals have advantages and disadvantages in a clinical and emergency setting. Here we report on the efficacy of a recombinant immunoglobulin (rVIG) that demonstrated efficacy against several orthopoxviruses in vitro and in vivo in both a prophylactic and therapeutic fashion. A single intraperitoneal injection of rVIG significantly protected mice when given up to 14 days before or as late as 6 days post challenge. Moreover, rVIG reduced morbidity, as measured by weight-change, as well as several previously established biomarkers of disease. In rVIG treated mice, we found that vDNA levels in blood were significantly reduced, as was ALT (a marker of liver damage) and infectious virus levels in the liver. No apparent adverse events were observed in rVIG treated mice, suggesting the immunoglobulin is well tolerated. These findings suggest that recombinant immunoglobulins could be candidates for further evaluation and possible licensure under the FDA Animal Rule.
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Affiliation(s)
- Scott Parker
- Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, and St. Louis VA Medical Center, St. Louis, MO, 63104, USA
| | - June D'Angelo
- Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, and St. Louis VA Medical Center, St. Louis, MO, 63104, USA
| | - R Mark Buller
- Department of Molecular Microbiology and Immunology, Saint Louis University, St. Louis, MO, 63104, USA
| | - Donald F Smee
- Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, UT, 84322, USA
| | - Johan Lantto
- Symphogen, Pederstrupvej 93, DK-2750, Ballerup, Denmark
| | | | - Allan Jensen
- Symphogen, Pederstrupvej 93, DK-2750, Ballerup, Denmark
| | - Mark Prichard
- Department of Pediatrics, University of Alabama, Birmingham, AL, 35233, USA
| | - Sarah L George
- Division of Infectious Diseases, Department of Internal Medicine, Saint Louis University, and St. Louis VA Medical Center, St. Louis, MO, 63104, USA.
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8
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Colombo CJ, Colombo RE, Maves RC, Branche AR, Cohen SH, Elie MC, George SL, Jang HJ, Kalil AC, Lindholm DA, Mularski RA, Ortiz JR, Tapson V, Liang CJ. Performance Analysis of the National Early Warning Score and Modified Early Warning Score in the Adaptive COVID-19 Treatment Trial Cohort. Crit Care Explor 2021; 3:e0474. [PMID: 34278310 PMCID: PMC8280088 DOI: 10.1097/cce.0000000000000474] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We sought to validate prognostic scores in coronavirus disease 2019 including National Early Warning Score, Modified Early Warning Score, and age-based modifications, and define their performance characteristics. DESIGN We analyzed prospectively collected data from the Adaptive COVID-19 Treatment Trial. National Early Warning Score was collected daily during the trial, Modified Early Warning Score was calculated, and age applied to both scores. We assessed prognostic value for the end points of recovery, mechanical ventilation, and death for score at enrollment, average, and slope of score over the first 48 hours. SETTING A multisite international inpatient trial. PATIENTS A total of 1,062 adult nonpregnant inpatients with severe coronavirus disease 2019 pneumonia. INTERVENTIONS Adaptive COVID-19 Treatment Trial 1 randomized participants to receive remdesivir or placebo. The prognostic value of predictive scores was evaluated in both groups separately to assess for differential performance in the setting of remdesivir treatment. MEASUREMENTS AND MAIN RESULTS For mortality, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.60-0.68), and improved with addition of age (c-index, 0.66-0.74). For recovery, baseline National Early Warning Score and Modified Early Warning Score demonstrated somewhat better prognostic ability (c-index, 0.65-0.69); however, National Early Warning Score+age and Modified Early Warning Score+age further improved performance (c-index, 0.68-0.71). For deterioration, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.59-0.69) and improved with addition of age (c-index, 0.63-0.70). All prognostic performance improvements due to addition of age were significant (p < 0.05). CONCLUSIONS In the Adaptive COVID-19 Treatment Trial 1 cohort, National Early Warning Score and Modified Early Warning Score demonstrated moderate prognostic performance in patients with severe coronavirus disease 2019, with improvement in predictive ability for National Early Warning Score+age and Modified Early Warning Score+age. Area under receiver operating curve for National Early Warning Score and Modified Early Warning Score improved in patients receiving remdesivir versus placebo early in the pandemic for recovery and mortality. Although these scores are simple and readily obtainable in myriad settings, in our data set, they were insufficiently predictive to completely replace clinical judgment in coronavirus disease 2019 and may serve best as an adjunct to triage, disposition, and resourcing decisions.
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Affiliation(s)
- Christopher J Colombo
- Madigan Army Medical Center, Tacoma, WA
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rhonda E Colombo
- Madigan Army Medical Center, Tacoma, WA
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Ryan C Maves
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD
- Naval Medical Center, San Diego, CA
| | | | | | | | - Sarah L George
- Saint Louis University and St. Louis VA Medical Center, Saint Louis, MO
| | - Hannah J Jang
- Department of Community Health Systems, School of Nursing and Center for Nursing Excellence and Innovation, University of California San Francisco, San Francisco, CA
| | | | - David A Lindholm
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD
- Brooke Army Medical Center, San Antonio, TX
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Justin R Ortiz
- University of Maryland School of Medicine, Baltimore, MD
| | | | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, MD
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9
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Khojandi N, Kuehm LM, Piening A, Donlin MJ, Hsueh EC, Schwartz TL, Farrell K, Richart JM, Geerling E, Pinto AK, George SL, Albert CJ, Ford DA, Chen X, Kline J, Teague RM. Oxidized Lipoproteins Promote Resistance to Cancer Immunotherapy Independent of Patient Obesity. Cancer Immunol Res 2021; 9:214-226. [PMID: 33303575 PMCID: PMC7864876 DOI: 10.1158/2326-6066.cir-20-0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/07/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022]
Abstract
Antitumor immunity is impaired in obese mice. Mechanistic insight into this observation remains sparse and whether it is recapitulated in patients with cancer is unclear because clinical studies have produced conflicting and controversial findings. We addressed this by analyzing data from patients with a diverse array of cancer types. We found that survival after immunotherapy was not accurately predicted by body mass index or serum leptin concentrations. However, oxidized low-density lipoprotein (ox-LDL) in serum was identified as a suppressor of T-cell function and a driver of tumor cytoprotection mediated by heme oxygenase-1 (HO-1). Analysis of a human melanoma gene expression database showed a clear association between higher HMOX1 (HO-1) expression and reduced progression-free survival. Our in vivo experiments using mouse models of both melanoma and breast cancer revealed HO-1 as a mechanism of resistance to anti-PD1 immunotherapy but also exposed HO-1 as a vulnerability that could be exploited therapeutically using a small-molecule inhibitor. In conclusion, our clinical data have implicated serum ox-LDL as a mediator of therapeutic resistance in patients with cancer, operating as a double-edged sword that both suppressed T-cell immunity and simultaneously induced HO-1-mediated tumor cell protection. Our studies also highlight the therapeutic potential of targeting HO-1 during immunotherapy, encouraging further translational development of this combination approach.See article by Kuehm et al., p. 227.
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Affiliation(s)
- Niloufar Khojandi
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Lindsey M Kuehm
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Alexander Piening
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Maureen J Donlin
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Eddy C Hsueh
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Theresa L Schwartz
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Kaitlin Farrell
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - John M Richart
- Department of Internal Medicine, Division of Hematology and Oncology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Elizabeth Geerling
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Amelia K Pinto
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Sarah L George
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Carolyn J Albert
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - David A Ford
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Xiufen Chen
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin Kline
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ryan M Teague
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri.
- Alvin J. Siteman National Cancer Institute Comprehensive Cancer Center, St. Louis, Missouri
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10
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George SL, Parmar V, Lorenzi F, Marshall LV, Jamin Y, Poon E, Angelini P, Chesler L. Novel therapeutic strategies targeting telomere maintenance mechanisms in high-risk neuroblastoma. J Exp Clin Cancer Res 2020; 39:78. [PMID: 32375866 PMCID: PMC7201617 DOI: 10.1186/s13046-020-01582-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
The majority of high-risk neuroblastomas can be divided into three distinct molecular subgroups defined by the presence of MYCN amplification, upstream TERT rearrangements or alternative lengthening of telomeres (ALT). The common defining feature of all three subgroups is altered telomere maintenance; MYCN amplification and upstream TERT rearrangements drive high levels of telomerase expression whereas ALT is a telomerase independent telomere maintenance mechanism. As all three telomere maintenance mechanisms are independently associated with poor outcomes, the development of strategies to selectively target either telomerase expressing or ALT cells holds great promise as a therapeutic approach that is applicable to the majority of children with aggressive disease.Here we summarise the biology of telomere maintenance and the molecular drivers of aggressive neuroblastoma before describing the most promising therapeutic strategies to target both telomerase expressing and ALT cancers. For telomerase-expressing neuroblastoma the most promising targeted agent to date is 6-thio-2'-deoxyguanosine, however clinical development of this agent is required. In osteosarcoma cell lines with ALT, selective sensitivity to ATR inhibition has been reported. However, we present data showing that in fact ALT neuroblastoma cells are more resistant to the clinical ATR inhibitor AZD6738 compared to other neuroblastoma subtypes. More recently a number of additional candidate compounds have been shown to show selectivity for ALT cancers, such as Tetra-Pt (bpy), a compound targeting the telomeric G-quadruplex and pifithrin-α, a putative p53 inhibitor. Further pre-clinical evaluation of these compounds in neuroblastoma models is warranted.In summary, telomere maintenance targeting strategies offer a significant opportunity to develop effective new therapies, applicable to a large proportion of children with high-risk neuroblastoma. In parallel to clinical development, more pre-clinical research specifically for neuroblastoma is urgently needed, if we are to improve survival for this common poor outcome tumour of childhood.
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Affiliation(s)
- S L George
- Paediatric Tumour Biology, Division of Clinical Studies, The Institute of Cancer Research, London, UK.
- Children and Young People's Unit, Royal Marsden NHS Foundation Trust, London, UK.
| | - V Parmar
- Children and Young People's Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - F Lorenzi
- Paediatric Tumour Biology, Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - L V Marshall
- Paediatric Tumour Biology, Division of Clinical Studies, The Institute of Cancer Research, London, UK
- Children and Young People's Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Y Jamin
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - E Poon
- Paediatric Tumour Biology, Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - P Angelini
- Children and Young People's Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - L Chesler
- Paediatric Tumour Biology, Division of Clinical Studies, The Institute of Cancer Research, London, UK
- Children and Young People's Unit, Royal Marsden NHS Foundation Trust, London, UK
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11
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Modjarrad K, Lin L, George SL, Stephenson KE, Eckels KH, De La Barrera RA, Jarman RG, Sondergaard E, Tennant J, Ansel JL, Mills K, Koren M, Robb ML, Barrett J, Thompson J, Kosel AE, Dawson P, Hale A, Tan CS, Walsh SR, Meyer KE, Brien J, Crowell TA, Blazevic A, Mosby K, Larocca RA, Abbink P, Boyd M, Bricault CA, Seaman MS, Basil A, Walsh M, Tonwe V, Hoft DF, Thomas SJ, Barouch DH, Michael NL. Preliminary aggregate safety and immunogenicity results from three trials of a purified inactivated Zika virus vaccine candidate: phase 1, randomised, double-blind, placebo-controlled clinical trials. Lancet 2018; 391:563-571. [PMID: 29217375 PMCID: PMC5884730 DOI: 10.1016/s0140-6736(17)33106-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND A safe, effective, and rapidly scalable vaccine against Zika virus infection is needed. We developed a purified formalin-inactivated Zika virus vaccine (ZPIV) candidate that showed protection in mice and non-human primates against viraemia after Zika virus challenge. Here we present the preliminary results in human beings. METHODS We did three phase 1, placebo-controlled, double-blind trials of ZPIV with aluminium hydroxide adjuvant. In all three studies, healthy adults were randomly assigned by a computer-generated list to receive 5 μg ZPIV or saline placebo, in a ratio of 4:1 at Walter Reed Army Institute of Research, Silver Spring, MD, USA, or of 5:1 at Saint Louis University, Saint Louis, MO, USA, and Beth Israel Deaconess Medical Center, Boston, MA, USA. Vaccinations were given intramuscularly on days 1 and 29. The primary objective was safety and immunogenicity of the ZPIV candidate. We recorded adverse events and Zika virus envelope microneutralisation titres up to day 57. These trials are registered at ClinicalTrials.gov, numbers NCT02963909, NCT02952833, and NCT02937233. FINDINGS We enrolled 68 participants between Nov 7, 2016, and Jan 25, 2017. One was excluded and 67 participants received two injections of Zika vaccine (n=55) or placebo (n=12). The vaccine caused only mild to moderate adverse events. The most frequent local effects were pain (n=40 [60%]) or tenderness (n=32 [47%]) at the injection site, and the most frequent systemic reactogenic events were fatigue (29 [43%]), headache (26 [39%]), and malaise (15 [22%]). By day 57, 52 (92%) of vaccine recipients had seroconverted (microneutralisation titre ≥1:10), with peak geometric mean titres seen at day 43 and exceeding protective thresholds seen in animal studies. INTERPRETATION The ZPIV candidate was well tolerated and elicited robust neutralising antibody titres in healthy adults. FUNDING Departments of the Army and Defense and National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
| | - Leyi Lin
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Sarah L George
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA; Saint Louis VA Medical Center, Saint Louis, MO, USA
| | - Kathryn E Stephenson
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | | | | | | | | | - Janice Tennant
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Jessica L Ansel
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kristin Mills
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Michael Koren
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Merlin L Robb
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | | | | | | | | | - Andrew Hale
- University of Vermont Medical Center and Larner College of Medicine, Burlington, VT, USA
| | - C Sabrina Tan
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stephen R Walsh
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Keith E Meyer
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - James Brien
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Trevor A Crowell
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Azra Blazevic
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Karla Mosby
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Rafael A Larocca
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Abbink
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael Boyd
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christine A Bricault
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael S Seaman
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anne Basil
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Melissa Walsh
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Veronica Tonwe
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Daniel F Hoft
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA; Saint Louis VA Medical Center, Saint Louis, MO, USA
| | | | - Dan H Barouch
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA.
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12
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Thomas BS, Bailey TC, Bhatnagar J, Ritter JM, Emery BD, Jassim OW, Hornstra IK, George SL. Mycobacterium ulcerans infection imported from Australia to Missouri, USA, 2012. Emerg Infect Dis 2015; 20:1876-9. [PMID: 25341024 PMCID: PMC4214291 DOI: 10.3201/eid2011.131534] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Buruli ulcer, the third most common mycobacterial disease worldwide, rarely affects travelers and is uncommon in the United States. We report a travel-associated case imported from Australia and review 3 previous cases diagnosed and treated in the United States. The differential diagnoses for unusual chronic cutaneous ulcers and those nonresponsive to conventional therapy should include Mycobacterium ulcerans infection.
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13
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Chu H, George SL, Stinchcomb DT, Osorio JE, Partidos CD. CD8+ T-cell Responses in Flavivirus-Naive Individuals Following Immunization with a Live-Attenuated Tetravalent Dengue Vaccine Candidate. J Infect Dis 2015; 212:1618-28. [PMID: 25943203 DOI: 10.1093/infdis/jiv258] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/21/2015] [Indexed: 02/06/2023] Open
Abstract
We are developing a live-attenuated tetravalent dengue vaccine (TDV) candidate based on an attenuated dengue 2 virus (TDV-2) and 3 chimeric viruses containing the premembrane and envelope genes of dengue viruses (DENVs) -1, -3, and -4 expressed in the context of the attenuated TDV-2 genome (TDV-1, TDV-3, and TDV-4, respectively). In this study, we analyzed and characterized the CD8(+) T-cell response in flavivirus-naive human volunteers vaccinated with 2 doses of TDV 90 days apart via the subcutaneous or intradermal routes. Using peptide arrays and intracellular cytokine staining, we demonstrated that TDV elicits CD8(+) T cells targeting the nonstructural NS1, NS3, and NS5 proteins of TDV-2. The cells were characterized by the production of interferon-γ, tumor necrosis factor-α, and to a lesser extent interleukin-2. Responses were highest on day 90 after the first dose and were still detectable on 180 days after the second dose. In addition, CD8(+) T cells were multifunctional, producing ≥2 cytokines simultaneously, and cross-reactive to NS proteins of the other 3 DENV serotypes. Overall, these findings describe the capacity of our candidate dengue vaccine to elicit cellular immune responses and support the further evaluation of T-cell responses in samples from future TDV clinical trials.
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Affiliation(s)
- Haiyan Chu
- Takeda Vaccines, Inc, Deerfield, Illinois
| | - Sarah L George
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine St. Louis Veterans Administration Medical Center, Missouri
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14
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George SL, Wong MA, Dube TJT, Boroughs KL, Stovall JL, Luy BE, Haller AA, Osorio JE, Eggemeyer LM, Irby-Moore S, Frey SE, Huang CYH, Stinchcomb DT. Safety and Immunogenicity of a Live Attenuated Tetravalent Dengue Vaccine Candidate in Flavivirus-Naive Adults: A Randomized, Double-Blinded Phase 1 Clinical Trial. J Infect Dis 2015; 212:1032-41. [PMID: 25791116 DOI: 10.1093/infdis/jiv179] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/16/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dengue viruses (DENVs) infect >300 million people annually, causing 96 million cases of dengue disease and 22 000 deaths [1]. A safe vaccine that protects against DENV disease is a global health priority [2]. METHODS We enrolled 72 flavivirus-naive healthy adults in a phase 1 double-blinded, randomized, placebo-controlled dose-escalation trial (low and high dose) of a live attenuated recombinant tetravalent dengue vaccine candidate (TDV) given in 2 doses 90 days apart. Volunteers were followed for safety, vaccine component viremia, and development of neutralizing antibodies to the 4 DENV serotypes. RESULTS The majority of adverse events were mild, with no vaccine-related serious adverse events. Vaccinees reported injection site pain (52% vs 17%) and erythema (73% vs 25%) more frequently than placebo recipients. Low levels of TDV-serotype 2 (TDV-2), TDV-3, and TDV-4 viremia were observed after the first but not second administration of vaccine. Overall seroconversion rates and geometric mean neutralization titers after 2 doses were 84.2% and 54.1, respectively, for DENV serotype 1 (DENV-1); 92.1% and 292.8, respectively, for DENV-2; 86.8% and 32.3, respectively, for DENV-3; and 71.1% and 15.0, respectively, for DENV-4. More than 90.0% of high-dose recipients had trivalent or broader responses. CONCLUSIONS TDV was generally well tolerated, induced trivalent or broader neutralizing antibodies to DENV in most flavivirus-naive vaccinees, and is undergoing further development. CLINICAL TRIALS REGISTRATION NCT01110551.
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Affiliation(s)
- Sarah L George
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine St. Louis Veterans Administration Medical Center, Missouri
| | | | | | - Karen L Boroughs
- Arboviral Diseases Branch, Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Janae L Stovall
- Arboviral Diseases Branch, Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Betty E Luy
- Arboviral Diseases Branch, Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | - Aurelia A Haller
- Arboviral Diseases Branch, Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
| | | | - Linda M Eggemeyer
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine
| | - Sharon Irby-Moore
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine
| | - Sharon E Frey
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine
| | - Claire Y-H Huang
- Arboviral Diseases Branch, Division of Vector-Borne Disease, Centers for Disease Control and Prevention, Fort Collins, Colorado
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George SL. Chikungunya update. Mo Med 2014; 111:343. [PMID: 25211866 PMCID: PMC6179478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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George SL. Prospects for a dengue vaccine: progress and pitfalls. Mo Med 2014; 111:337-342. [PMID: 25211865 PMCID: PMC6179479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Dengue virus is now the world's most common arboviral infection and has spread to the continental United States. The Aedes mosquito which transmits dengue is prevalent throughout Missouri, so clinicians should be familiar with dengue. While there are no licensed vaccines, five are in human trials including two tested at the Saint Louis University Center for Vaccine Development. Our deepening understanding of the correlates of protective immunity to dengue improves near-term prospects for a vaccine.
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El Sahly HM, Davis C, Kotloff K, Meier J, Winokur PL, Wald A, Johnston C, George SL, Brady RC, Lehmann C, Stokes-Riner A, Keitel WA. Higher antigen content improves the immune response to 2009 H1N1 influenza vaccine in HIV-infected adults: a randomized clinical trial. J Infect Dis 2012; 205:703-12. [PMID: 22275399 DOI: 10.1093/infdis/jir837] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The immunogenicity of a high hemagglutinin (HA) dose or a second dose of influenza vaccine in human immunodeficiency virus (HIV)-infected individuals has not been fully explored. METHODS One hundered ninety-two HIV-infected individuals aged 18-64 years were stratified by CD4 cell count (<200 cells/mL or ≥200 cells/mL) and randomized to receive 2 doses of 15 μg or 30 μg HA 2009 H1N1 vaccine 21 days apart. Hemagglutination inhibition (HAI) and microneutralization (MN) antibodies were measured on days 0, 10, 21, 31, 42, and 201. RESULTS Recipients of 30 μg HA had significantly higher HAI geometric mean titers (GMTs), compared with recipients of 15 μg HA on days 10 (139.0 vs 51.9; P = .01), 21 (106.7 vs 51.9; P = .001), and 31 (130.0 vs 73.7; P = .03) but not on days 42 (91.8 vs 61.6; P = .11) and 201 (43.0 vs 27.0; P = .08). When analyzed by CD4 cell count stratum, HAI GMTs were significantly higher among 30 μg HA recipients than among 15 μg HA in the CD4 cell count <200 cells/mL stratum on days 21 and 31 and the MN GMTs on days 10, 21, 31, and 42 (P < .05). In the CD4 cell count ≥200 cells/mL stratum, MN GMTs were significantly higher among recipients of 30 μg HA than among recipients of 15 μg HA on day 10 (P = .03). CONCLUSION Increasing the HA dose of the 2009 H1N1 vaccine improves the vaccine's immunogenicity in HIV-infected individuals. CLINICAL TRIALS REGISTRATION NCT00992433.
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Affiliation(s)
- Hana M El Sahly
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA.
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George SL, Varmaz D, Tavis JE, Chowdhury A. The GB virus C (GBV-C) NS3 serine protease inhibits HIV-1 replication in a CD4+ T lymphocyte cell line without decreasing HIV receptor expression. PLoS One 2012; 7:e30653. [PMID: 22292009 PMCID: PMC3264616 DOI: 10.1371/journal.pone.0030653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 12/26/2011] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Persistent infection with GBV-C (GB Virus C), a non-pathogenic virus related to hepatitis C virus (HCV), prolongs survival in HIV infection. Two GBV-C proteins, NS5A and E2, have been shown previously to inhibit HIV replication in vitro. We investigated whether the GBV-C NS3 serine protease affects HIV replication. RESULTS GBV-C NS3 protease expressed in a human CD4+ T lymphocyte cell line significantly inhibited HIV replication. Addition of NS4A or NS4A/4B coding sequence to GBV-C NS3 increased the effect on HIV replication. Inhibition of HIV replication was dose-dependent and was not mediated by increased cell toxicity. Mutation of the NS3 catalytic serine to alanine resulted in loss of both HIV inhibition and protease activity. GBV-C NS3 expression did not measurably decrease CD4 or CXCR4 expression. CONCLUSION GBV-C NS3 serine protease significantly inhibited HIV replication without decreasing HIV receptor expression. The requirement for an intact catalytic serine at the active site indicates that inhibition was mediated by proteolytic cleavage of an unidentified target(s).
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Affiliation(s)
- Sarah L George
- Division of Infectious Diseases, Department of Internal Medicine, St. Louis University, St. Louis, Missouri, United States of America.
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George SL, Bacon BR, Brunt EM, Mihindukulasuriya KL, Hoffmann J, Di Bisceglie AM. Clinical, virologic, histologic, and biochemical outcomes after successful HCV therapy: a 5-year follow-up of 150 patients. Hepatology 2009; 49:729-38. [PMID: 19072828 PMCID: PMC2731713 DOI: 10.1002/hep.22694] [Citation(s) in RCA: 286] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
UNLABELLED One hundred fifty patients with sustained virologic response (SVR) after treatment of chronic hepatitis C were enrolled in a long-term clinical follow-up study; patients were followed for 5 years for liver-related outcomes and evidence of biochemical or virologic relapse. Patients with stage 2 or greater fibrosis on pretreatment biopsy were invited to undergo a long-term follow-up biopsy after their fourth year of follow-up. One hundred twenty-eight patients (85%) were followed through their fourth year, and long-term follow-up biopsies were obtained from 60 patients (40%). Forty-nine patients had paired pretreatment and long-term follow-up biopsies blindly rescored. Forty of these patients (82%) had a decrease in fibrosis score, and 45 (92%) had a decrease in combined inflammation score. Ten patients (20%) had normal or nearly normal livers on long-term follow-up biopsy. Two patients with pretreatment cirrhosis developed hepatocellular carcinoma (HCC), and one died. All the other patients with pretreatment cirrhosis or advanced fibrosis had improved fibrosis scores on long-term follow-up biopsy. No patient had conclusive evidence of virologic relapse. Three patients had persistently elevated alanine aminotransferase levels; two of these had new liver disease. CONCLUSION In a cohort of 150 patients with SVR followed for 5 years, the majority of patients had good outcomes. Serum virologic relapse was not seen, but two patients with pretreatment cirrhosis developed HCC, and one died. In a blind rescoring of 49 paired pretreatment and long-term follow-up biopsies, 82% improved fibrosis scores and 92% improved at least one component of inflammation. A minority of patients had normal or nearly normal liver tissue on long-term follow-up biopsy. Patients with cirrhosis pretreatment are at a low but real risk of HCC after SVR.
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Affiliation(s)
- Sarah L George
- Department of Internal Medicine, Division of Gastroenterology, Saint Louis University Liver Center, St Louis, MO, USA.
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Abstract
GB virus C (GBV-C) is a nonpathogenic member of the Flaviviridae family most closely related to hepatitis C virus (HCV). Infection is common in healthy and immunocompromised people and may persist for years. GBV-C infection is associated with improved survival, improved AIDS-free survival, higher CD4(+) T-cell counts, and lower HIV viral loads in HIV-infected people compared with people infected with HIV but not GBV-C. The mechanism of this effect is not yet clear, but GBV-C has been shown to inhibit HIV replication in vitro through increased synthesis and secretion of anti-HIV b-chemokines MIP-1a, MIP-1b, RANTES, SDF-1, and SDF-2 and downregulation of CCR5 receptor expression. GBV-C also inhibits apoptosis of its host cell, similar to HCV. GBV-C E2 protein in serum has also been associated with prolonged survival in HIV infection; recent evidence indicates that GBV-C E2 protein may neutralize HIV infection in vitro.
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Affiliation(s)
- Sarah L George
- Division of Infectious Diseases, Saint Louis University School of Medicine, FDT-8N, 3635 Vista Avenue, St. Louis, MO 63110, USA.
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Abstract
GB virus C (GBV-C) infection is common in humans and may persist for decades, although most infected persons clear the virus and subsequently develop antibodies to the envelope glycoprotein. GBV-C replicates in peripheral blood mononuclear cells (PBMCs) and CD4(+) T lymphocytes in vitro, and depletion of CD4(+) T lymphocytes has been proposed as the reason for clearance of GBV-C among persons positive for human immunodeficiency virus. We identified GBV-C RNA in purified CD4(+) and CD8(+) T lymphocytes and CD19(+) B lymphocytes removed ex vivo from infected donors and found that GBV-C replicated in vitro in these PBMC subsets, suggesting that GBV-C is a panlymphotropic virus.
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Affiliation(s)
- Sarah L George
- Research Service and Department of Internal Medicine, Saint Louis University Hospital and St. Louis Veterans Affairs Medical Center, MO 63110, USA.
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George SL. Persistent GB virus C infection is associated with decreased HIV-1 disease progression in the Amsterdam Cohort Study. J Infect Dis 2005; 191:2156-7; author reply 2158-60. [PMID: 15898007 DOI: 10.1086/430504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Johnson CD, Howse F, Fitzsimmons D, Harris S, Pickering R, George SL. Quality of life and functional long-term outcome after partial pancreatoduodenectomy: pancreatogastrostomy versus pancreatojejunostomy. Ann Surg Oncol 2005; 14:750-1. [PMID: 17151790 DOI: 10.1245/s10434-006-9173-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 04/18/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND To determine the effects of pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) as types of reconstruction after partial pancreatoduodenectomy on postoperative quality of life and long-term gastrointestinal morbidity, the outcomes of 104 patients (PG, n = 63; PJ, n = 41) were evaluated. METHODS To compare the two groups, the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (QLQ-PAN 26) standard and an additional self-developed questionnaire were used. The mean time after surgery was 6.4 +/- 3.4 years. RESULTS In the PG group, there was a significant reduction of gastric acid reflux, gastroduodenal ulcers, and pain compared with before surgery. However, a significant increase in steatorrhea, intolerance toward larger meals, and aversion against certain foods were observed. In the PJ group, no significant change of preoperative symptoms was present except for jaundice. The incidence of diabetes mellitus and the need for pancreatic enzyme substitution had increased significantly but similarly in both groups. The global quality of life was identical in both groups of patients. CONCLUSIONS This analysis demonstrates that the global quality of life was not affected by the type of reconstruction after partial pancreatoduodenectomy. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed an impaired exocrine and endocrine pancreatic function of a similar extent.
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Xiang J, George SL, Wünschmann S, Chang Q, Klinzman D, Stapleton JT. Inhibition of HIV-1 replication by GB virus C infection through increases in RANTES, MIP-1alpha, MIP-1beta, and SDF-1. Lancet 2004; 363:2040-6. [PMID: 15207954 DOI: 10.1016/s0140-6736(04)16453-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background People coinfected with HIV and GB virus C (GBV-C) have lower mortality than HIV-positive individuals without GBV-C infection. HIV uses either of the chemokine receptors CCR5 and CXCR4 for entry into CD4-positive cells. Longer survival in HIV-positive individuals is associated with high serum concentrations of ligands for CCR5 (RANTES [regulated on activation, normal T-cell expressed and secreted] and macrophage inflammatory proteins [MIP] 1alpha and 1beta) and CXCR4 (stromal-derived factor [SDF-1]), and with decreased expression of CCR5 on lymphocytes. Methods Peripheral-blood mononuclear cells were coinfected with GBV-C and HIV, and HIV replication was monitored by measuring infectivity and HIV p24 antigen production. Chemokine secretion was measured by ELISA, chemokine-receptor expression by flow cytometry, and cellular chemokine mRNA expression by differential hybridisation. Findings GBV-C infection of peripheral-blood mononuclear cells resulted in decreased replication of both clinical and laboratory HIV strains that use either CCR5 or CXCR4 as their coreceptor. Inhibition was related to the dose and timing of the GBV-C infection. Expression of mRNA for RANTES, MIP-1alpha, MIP-1beta, and SDF-1 and secretion of the chemokines into culture supernatants were higher in GBV-C-infected cells than in mock-infected cells. The inhibitory effect of GBV-C on HIV replication was blocked by incubation with neutralising antibodies against the relevant chemokines, and surface expression of CCR5 was significantly lower in GBV-C-infected cells than in mock-infected cells. Interpretation GBV-C induces HIV-inhibitory chemokines and reduces expression of the HIV coreceptor CCR5 in vitro. This study provides insight into the epidemiological association between GBV-C infection and longer survival in HIV-infected individuals.
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Affiliation(s)
- Jinhua Xiang
- Research Service and Department of Internal Medicine, Iowa City VA Medical Center and University of Iowa, Iowa City, IA, USA
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George SL, Xiang J, Stapleton JT. Clinical isolates of GB virus type C vary in their ability to persist and replicate in peripheral blood mononuclear cell cultures. Virology 2004; 316:191-201. [PMID: 14644602 DOI: 10.1016/s0042-6822(03)00585-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
GB virus C/hepatitis G virus (GBV-C) replication in vitro is inefficient and inconsistent. In this study, clinical isolates of GBV-C were evaluated using peripheral blood mononuclear cell (PBMC) based culture methods. Isolates varied consistently in their ability to persistently replicate, and yield increased in cells grown without PHA/IL-2 stimulation. The deduced polyprotein sequence of an isolate that replicated well was determined (GenBank AY196904) and compared to 20 full-length GBV-C sequences. Fourteen of the 16 unique amino acid polymorphisms identified were in the coding regions for nonstructural proteins associated with interferon resistance and RNA replication. These data indicate that clinical GBV-C isolates vary in their ability to persist in culture, do not require PHA/IL-2 stimulation, and that sequence variability in key regulatory regions may affect growth in PBMC cultures. Since GBV-C appears to inhibit HIV replication in a coinfection model, these studies should facilitate determination of the mechanism of this interaction.
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Affiliation(s)
- Sarah L George
- Departments of Internal Medicine and Research, Iowa City VA Medical Center, University of Iowa, and the Helen C. Levitt Center for Viral Pathogenesis, Iowa City, IA 52242, USA
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Xiang J, Wünschmann S, George SL, Klinzman D, Schmidt WN, LaBrecque DR, Stapleton JT. Recombinant hepatitis C virus-like particles expressed by baculovirus: utility in cell-binding and antibody detection assays. J Med Virol 2002; 68:537-43. [PMID: 12376962 DOI: 10.1002/jmv.10237] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hepatitis C virus (HCV) is difficult to study due to the lack of an efficient cell culture system or small animal model. As a result, HCV-cell interactions are not well-defined. In addition, several studies have identified a subset of patients in whom HCV RNA is present, but HCV antibody is not detected. We produced recombinant baculoviruses that expressed HCV structural proteins (core, E1 and E2, nt 342-2651) or control proteins. The HCV structural protein precursor was processed into immunoreactive proteins of appropriate size, and sucrose density sedimentation and electron microscopy of infected cell lysates demonstrated particle formation. To evaluate HCV antigenicity, particularly in patients who tested negative for HCV antibody in commercial HCV immunoassays but had persistent viremia, we evaluated the virus-like particles (VLPs) in solid-phase immunoassays. VLPs reacted with sera from HCV antibody positive subjects in these solid phase immunoassays, but not with control sera. Plasma samples from 19% (5/26) of HCV antibody negative subjects who were persistently HCV RNA positive also reacted with the HCV VLPs. When incubated with MOLT-4 cells at 4 degrees C, HCV VLPs demonstrated cell binding, and behaved similar to plasma-derived HCV preparations in a flow cytometry-based cell binding assay. These data suggest that recombinant HCV VLPs may allow identification of HCV antibody in patients, including some patients with persistent viremia and who are seronegative with current assays. In addition, HCV VLPs seem useful for evaluating HCV-cell interactions.
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Affiliation(s)
- Jinhua Xiang
- Department of Internal Medicine, Iowa City Veterans Administration Medical Center, Iowa City, Iowa, USA
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Abstract
GB virus C (GBV-C, also known as hepatitis G virus) commonly causes human infection. Genetically, it is closely related to hepatitis C virus, but GBV-C appears to grow primarily in lymphocytes, not hepatocytes. Although it causes persistent infection in about 25% to 50% of infected individuals, numerous studies have failed to connect GBV-C with any disease process. GBV-C is transmitted sexually, parenterally, and vertically, and due to these shared modes of transmission, coinfection is common among HIV-infected individuals. Of 10 studies done of HIV-GBV-C coinfection, eight found a beneficial effect of GBV-C viremia on HIV-related mortality or response to therapy. The mechanism by which GBV-C may improve survival of HIV-positive people is not known; however, in vitro studies suggest that GBV-C inhibits HIV replication, and preliminary data also point toward alterations in cytokine and/or chemokine expression by GBV-C-infected cells.
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Affiliation(s)
- Sarah L. George
- Internal Medicine, SW34-P,GH, 200 Hawkins Drive, UIHC, Iowa City, IA 52242, USA.
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Abstract
BACKGROUND Most stroke-related studies have consisted of people over the age of 65. This study examined the unmet needs of young people with stroke, living in community housing in the UK. METHOD People with a stroke (>1 year ago), in two age bands (18-45; 46-65) were sent the Southampton Needs Assessment Questionnaire for people with Stroke. RESULTS 315 out of 639 (49%) questionnaires were returned (mean age 55, SD 9; 189 males, 126 females). The median number of unmet needs reported was two (IQR 0-6). The most frequently reported unmet needs were: provision of information about the responders' stroke (45%); assistance with finances (24%); non-care activities (19%); and intellectual fulfillment (17%). Responders in the younger age group reported significantly more unmet needs than responders in the older age group (for a holiday, intellectual fulfillment and family support). Responders with poor mobility reported significantly more unmet needs than responders with average and good mobility for 15 unmet needs (three most pressing: respite care/short breaks; adaptations; and access to community environment). Responders who did not return to work reported significantly more unmet needs than responders who had reduced hours or changed jobs and people who returned to the same job with the same hours for seven unmet needs (three most pressing: help with finances; a holiday and speech therapy). CONCLUSION People of younger age, with poorer mobility and those unable to return to work, report most unmet needs. Further work needs to be done within the community, with employers and professionals, in relation to education and the provision of specifically targeted information in order to facilitate participation and autonomy for people with stroke.
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Affiliation(s)
- P Kersten
- Health and Rehabilitation Research Unit, School of Health Professions and Rehabilitation Sciences, University of Southampton, SO17 1BJ, UK.
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George SL, Gebhardt J, Klinzman D, Foster MB, Patrick KD, Schmidt WN, Alden B, Pfaller MA, Stapleton JT. Hepatitis C virus viremia in HIV-infected individuals with negative HCV antibody tests. J Acquir Immune Defic Syndr 2002; 31:154-62. [PMID: 12394793 DOI: 10.1097/00126334-200210010-00005] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Hepatitis C virus (HCV) viremia may occur in persons without detectable HCV antibodies and has been reported in as many as 5.5% of HIV-positive persons. To better characterize serosilent HCV infection, the authors prospectively tested 131 HIV-positive persons and 102 HIV-negative control subjects with diabetes for the presence of HCV antibody (Ab) and HCV RNA. Thirty of 31 HCV Ab-positive (AbP) HIV-positive people tested positive for HCV RNA as did both HCV AbP, HIV-negative control subjects. Similarly, none of the 100 HIV-negative, HCV Ab-negative (AbN) control subjects was HCV RNA positive (p<.001). In contrast, 19 of 100 HIV-positive, HCV AbN persons met stringent criteria for HCV viremia, and 9 of these 19 people were HCV RNA positive when tested by a commercially available HCV RNA detection method. The mean duration of HCV viremia in HCV AbN people was 26.8 months (range, 1-99 months). None of the subjects developed HCV antibody during the study. The HIV-positive, HCV AbP, and RNA-positive group was significantly more likely to have acquired HIV parenterally (p<.001), have higher initial CD4 counts (p=.029), and have higher ALT values than the HCV AbN group (p<.002). In summary, HCV infection appears to occur more frequently among HIV-infected, HCV-seronegative persons than appreciated, especially if HIV acquisition was through sexual as opposed to parenteral risk factors and was associated with a lower initial CD4 count and lower ALT values.
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Affiliation(s)
- Sarah L George
- Department of Internal Medicine, Iowa City Veterans Administration Medical Center, University of Iowa, College of Medicine, 52242, USA
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Whitman SP, Archer KJ, Feng L, Baldus C, Becknell B, Carlson BD, Carroll AJ, Mrózek K, Vardiman JW, George SL, Kolitz JE, Larson RA, Bloomfield CD, Caligiuri MA. Absence of the wild-type allele predicts poor prognosis in adult de novo acute myeloid leukemia with normal cytogenetics and the internal tandem duplication of FLT3: a cancer and leukemia group B study. Cancer Res 2001; 61:7233-9. [PMID: 11585760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The FLT3 gene is mutated by an internal tandem duplication (ITD) in 20-25% of adults with acute myeloid leukemia (AML). We studied 82 adults <60 years of age with primary AML and normal cytogenetics, who received uniform high-dose therapy and found FLT3 ITD in 23 (28%) patients. When the 23 FLT3 ITD+ cases were compared with the 59 cases with wild-type (WT) FLT3, disease-free survival (DFS) was inferior (P = 0.03), yet overall survival (OS) was not different (P = 0.14). However, 8 (35%) of 23 FLT3 ITD/+ cases also lacked a FLT3 WT allele (FLT3(ITD-R)) as determined by PCR and loss of heterozygosity. Thus, three genotypic groups were identified: normal FLT3(WT/WT), heterozygous FLT3(ITD/WT), and hemizygous FLT3(ITD/-). DFS and OS were significantly inferior for patients with FLT3(ITD/-) (P = 0.0017 and P = 0.0014, respectively). Although DFS and OS for FLT3(WT/WT) and FLT3(ITD/WT) groups did not differ (P = 0.32 and P = 0.98, respectively), OS of the FLT3(ITD/-) group was worse than the FLT3(WT/WT) (P = 0.0005) and FLT3(ITD/WT) (P = 0.008) groups. We propose a model in which FLT3(ITD/-) represents a dominant positive, gain-of-function mutation providing AML cells with a greater growth advantage compared with cells having the FLT3(WT/WT) or FLT3(ITD/WT) genotypes. In conclusion, we have identified the FLT3(ITD/-) genotype as an adverse prognostic factor in de novo AML with normal cytogenetics. A poor prognosis of the relatively young FLT3(ITD/-) adults (median age, 37 years), despite treatment with current dose-intensive regimens, suggests that new treatment modalities, such as therapy with a FLT3 tyrosine kinase inhibitor, are clearly needed for this group of patients.
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Affiliation(s)
- S P Whitman
- The Ohio State University, Columbus, Ohio 43210, USA
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Xiang J, Wünschmann S, Diekema DJ, Klinzman D, Patrick KD, George SL, Stapleton JT. Effect of coinfection with GB virus C on survival among patients with HIV infection. N Engl J Med 2001; 345:707-14. [PMID: 11547739 DOI: 10.1056/nejmoa003364] [Citation(s) in RCA: 255] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have suggested that people with human immunodeficiency virus (HIV) infection who are coinfected with GB virus C (GBV-C, or hepatitis G virus) have delayed progression of HIV disease. GBV-C is related to hepatitis C virus but does not appear to cause liver disease. METHODS We examined the effect of coinfection with GBV-C on the survival of patients with HIV infection. We also evaluated cultures of peripheral-blood mononuclear cells infected with both viruses to determine whether GBV-C infection alters replication in vitro. RESULTS Of 362 HIV-infected patients, 144 (39.8 percent) had GBV-C viremia in two tests. Forty-one of the patients with GBV-C viremia (28.5 percent) died during the follow-up period, as compared with 123 of the 218 patients who tested negative for GBV-C RNA (56.4 percent; P<0.001). The mean duration of follow-up for the entire cohort was 4.1 years. In a Cox regression analysis adjusted for HIV treatment, baseline CD4+ T-cell count, age, sex, race, and mode of transmission of HIV, the mortality rate among the 218 HIV-infected patients without GBV-C coinfection was significantly higher than that among the 144 patients with GBV-C coinfection (relative risk, 3.7; 95 percent confidence interval, 2.5 to 5.4). HIV replication, as measured by the detection of p24 antigen in culture supernatants, was reproducibly inhibited in cultures of peripheral-blood mononuclear cells by GBV-C coinfection. Coinfection did not alter the surface expression of HIV cellular receptors on peripheral-blood mononuclear cells, as determined by flow cytometry. CONCLUSIONS GBV-C infection is common in people with HIV infection and is associated with significantly improved survival.
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Affiliation(s)
- J Xiang
- Department of Internal Medicine and Research, Iowa City Veterans Affairs Medical Center, and the University of Iowa College of Medicine, USA
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Stone RM, Berg DT, George SL, Dodge RK, Paciucci PA, Schulman PP, Lee EJ, Moore JO, Powell BL, Baer MR, Bloomfield CD, Schiffer CA. Postremission therapy in older patients with de novo acute myeloid leukemia: a randomized trial comparing mitoxantrone and intermediate-dose cytarabine with standard-dose cytarabine. Blood 2001; 98:548-53. [PMID: 11468148 DOI: 10.1182/blood.v98.3.548] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The treatment of older patients with acute myeloid leukemia (AML) remains unsatisfactory, with complete remission (CR) achieved in only approximately 50% and long-term disease-free survival in 10% to 20%. Three hundred eighty-eight patients (60 years of age and older) with newly diagnosed de novo AML were randomly assigned to receive placebo (P) or granulocyte-macrophage colony-stimulating factor (GM-CSF) or GM in a double-blind manner, beginning 1 day after the completion of 3 days of daunorubicin and 7 days of cytarabine therapy. No differences were found in the rates of leukemic regrowth, CR, or infectious complications in either arm. Of 205 patients who achieved CR, 169 were medically well and were randomized to receive cytarabine alone or a combination of cytarabine and mitoxantrone. With a median follow-up of 7.7 years, the median disease-free survival times were 11 months and 10 months for those randomized to cytarabine or cytarabine/mitoxantrone, respectively. Rates of relapse, excluding deaths in CR, were 77% for cytarabine and 82% for cytarabine/mitoxantrone. Induction randomization had no effect on leukemic relapse rate or remission duration in either postremission arm. Because cytarabine/mitoxantrone was more toxic and no more effective than cytarabine, it was concluded that this higher-dose therapy had no benefit in the postremission management of older patients with de novo AML. These results suggest the need to develop novel therapeutic strategies for these patients. (Blood. 2001;98:548-553)
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Affiliation(s)
- R M Stone
- Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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Abstract
BACKGROUND The authors tested the hypothesis that children with a longer duration of symptoms prior to diagnosis of medulloblastoma have more advanced disease. In addition, they evaluated whether there are correlations between gender, duration of presenting symptoms, and disease stage. METHODS The study population consisted of 122 patients with medulloblastoma who were evaluated between 1974 and 1999. The data abstracted from each chart included the date of diagnosis, date of birth, gender, race, presenting symptoms, duration of symptoms in weeks, and disease stage. RESULTS There were 70 males (57%) and 52 females (43%); 105 Caucasians (86%), 16 non-Caucasians (13%), and 1 patient of unknown race. Eighteen percent of the patients were age < or = 3 years, 59% were ages 4-16 years, and 23% were age > or = 17 years. The presenting stage was determined in 108 patients. Thirty-eight patients (35%) had high stage disease (T1-T4 M1-M4), and 70 patients (65%) had low stage disease (T1-T4 M0). The most common presenting symptoms were emesis (68%), headache (66%), nausea (40%), and ataxia (40%). The median symptom durations for patients ages 0-3 years were 4 weeks and 8 weeks for both those ages 4-16 years and those age > or = 17 years, respectively (P > 0.11). The median symptom duration for males (8 weeks) was longer than for females (5 weeks; P = 0.08). Patients with low stage disease had a median duration of symptoms (8 weeks) that was significantly greater compared with patients with high stage disease (4 weeks; P = 0.01). Relating patient age to disease stage, 47% of patients ages 0-3 years had high stage disease; 36% of patients ages 4-16 years had high stage disease; and 24% of patients age > or = 17 years had high stage disease (P = 0.20). Relating disease stage to gender, 40% of males had high stage disease compared with 28% of females (P = 0.20). Of the factors age, gender, race, and duration of symptoms, only the later was correlated significantly with disease stage at the time of presentation in both univariate and multivariate analyses. CONCLUSIONS Contrary to expectations, the duration of presenting symptoms was correlated inversely with disease state at the time of presentation. This finding has implications for lawsuits alleging that a "delay in diagnosis" leads to more advanced disease. There is weak evidence (P = 0.08) that males have a longer duration of symptoms than females. This may be related to gender-associated behavior expectations.
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Affiliation(s)
- E C Halperin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
This paper considers several permutation tests for treatment-by-centre interaction in multi-centre clinical trials in which the endpoint is survival time subject to censoring. Some of the tests are based on existing tests and some are new. To evaluate and compare the tests with respect to power under different conditions, we generated survival times and censoring times through simulation. We used special methodology to handle the unusual problems that arise in power simulations when the tests under study are permutation tests. Different conditions yielded different interaction tests as the best performers. Although one test gave comparatively good power under almost all conditions, some of the other tests also appear to be useful. For the sample sizes and configurations in the simulations, power is generally low; thus it may not be possible to detect interaction reliably when it exists, a finding in agreement with the known low power for interaction tests in general.
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Affiliation(s)
- R F Potthoff
- Cancer Center Biostatistics, Duke University Medical Center, P.O. Box 3958, Durham, North Carolina 27710, USA.
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Ranstam J, Buyse M, George SL, Evans S, Geller NL, Scherrer B, Lesaffre E, Murray G, Edler L, Hutton JL, Colton T, Lachenbruch P. Fraud in medical research: an international survey of biostatisticians. ISCB Subcommittee on Fraud. Control Clin Trials 2000; 21:415-27. [PMID: 11018560 DOI: 10.1016/s0197-2456(00)00069-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The characteristics of scientific fraud and its impact on medical research are in general not well known. However, the interest in the phenomenon has increased steadily during the last decade. Biostatisticians routinely work closely with physicians and scientists in many branches of medical research and have therefore unique insight into data. In addition, they have methodological competence to detect fraud and could be expected to have a professional interest in valid results. Biostatisticians therefore are likely to provide reliable information on the characteristics of fraud in medical research. The objective of this survey of biostatisticians, who were members of the International Society for Clinical Biostatistics, was to assess the characteristics of fraud in medical research. The survey was performed between April and July 1998. The participation rate was only 37%. We report the results because a majority (51%) of the participants knew about fraudulent projects, and many did not know whether the organization they work for has a formal system for handling suspected fraud or not. Different forms of fraud (e.g., fabrication and falsification of data, deceptive reporting of results, suppression of data, and deceptive design or analysis) had been observed in fairly similar numbers. We conclude that fraud is not a negligible phenomenon in medical research, and that increased awareness of the forms in which it is expressed seems appropriate. Further research, however, is needed to assess the prevalence of different types of fraud, as well as its impact on the validity of results published in the medical literature.
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Abstract
Health Related Quality of Life (HRQoL) instruments are increasingly important in evaluating health care, especially in cancer trials. When planning a trial, one essential step is the calculation of a sample size, which will allow a reasonable chance (power) of detecting a pre-specified difference (effect size) at a given level of statistical significance. It is almost mandatory to include this calculation in research protocols. Many researchers quote means and standard deviations to determine effect sizes, and assume the data will have a Normal distribution to calculate their required sample size. We have investigated the distribution of scores for two commonly used HRQoL instruments completed by lung cancer patients, and have established that scores do not have the Normal distribution form. We demonstrate that an assumption of Normality can lead to unrealistically sized studies. Our recommendation is to use a technique that is based on the fact that the HRQoL data are ordinal and makes minimal but realistic assumptions.
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Affiliation(s)
- S A Julious
- Clinical Pharmacology Statistics, SmithKline Beecham, New Frontiers Science Park (South), Third Avenue, Harlow, Essex, CM19 5AW
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Buyse M, George SL, Evans S, Geller NL, Ranstam J, Scherrer B, Lesaffre E, Murray G, Edler L, Hutton J, Colton T, Lachenbruch P, Verma BL. The role of biostatistics in the prevention, detection and treatment of fraud in clinical trials. Stat Med 1999; 18:3435-51. [PMID: 10611617 DOI: 10.1002/(sici)1097-0258(19991230)18:24<3435::aid-sim365>3.0.co;2-o] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Recent cases of fraud in clinical trials have attracted considerable media attention, but relatively little reaction from the biostatistical community. In this paper we argue that biostatisticians should be involved in preventing fraud (as well as unintentional errors), detecting it, and quantifying its impact on the outcome of clinical trials. We use the term 'fraud' specifically to refer to data fabrication (making up data values) and falsification (changing data values). Reported cases of such fraud involve cheating on inclusion criteria so that ineligible patients can enter the trial, and fabricating data so that no requested data are missing. Such types of fraud are partially preventable through a simplification of the eligibility criteria and through a reduction in the amount of data requested. These two measures are feasible and desirable in a surprisingly large number of clinical trials, and neither of them in any way jeopardizes the validity of the trial results. With regards to detection of fraud, a brute force approach has traditionally been used, whereby the participating centres undergo extensive monitoring involving up to 100 per cent verification of their case records. The cost-effectiveness of this approach seems highly debatable, since one could implement quality control through random sampling schemes, as is done in fields other than clinical medicine. Moreover, there are statistical techniques available (but insufficiently used) to detect 'strange' patterns in the data including, but no limited to, techniques for studying outliers, inliers, overdispersion, underdispersion and correlations or lack thereof. These techniques all rest upon the premise that it is quite difficult to invent plausible data, particularly highly dimensional multivariate data. The multicentric nature of clinical trials also offers an opportunity to check the plausibility of the data submitted by one centre by comparing them with the data from all other centres. Finally, with fraud detected, it is essential to quantify its likely impact upon the outcome of the clinical trial. Many instances of fraud in clinical trials, although morally reprehensible, have a negligible impact on the trial's scientific conclusions.
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Affiliation(s)
- M Buyse
- International Institute for Drug Development, Brussels, and Limburgs Universitair Centrum, Diepenbeek, Belgium.
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Affiliation(s)
- S L George
- Department of Internal Medicine, Iowa City Veterans Administration Medical Center, and the University of Iowa College of Medicine, USA
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Abstract
Most large randomized clinical trials have a data monitoring committee that periodically examines efficacy and safety results. A typical data monitoring committee meets every 6 months, but the interim monitoring guidelines for many trials specify formal analyses that are years apart. In this article we argue that study protocols should include monitoring guidelines with formal looks at each data monitoring committee meeting. Such guidelines are shown to reduce the average duration of a trial with negligible effect on power and estimation bias. Some of the common statistical monitoring guidelines require extreme evidence to stop a trial early and do not distinguish between stopping a trial during active accrual and follow-up stages. We propose practical solutions for these issues.
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Affiliation(s)
- B Freidlin
- Biometric Research Branch, National Cancer Institute, Bethesda, Maryland 20892, USA
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40
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Lee EJ, George SL, Caligiuri M, Szatrowski TP, Powell BL, Lemke S, Dodge RK, Smith R, Baer M, Schiffer CA. Parallel phase I studies of daunorubicin given with cytarabine and etoposide with or without the multidrug resistance modulator PSC-833 in previously untreated patients 60 years of age or older with acute myeloid leukemia: results of cancer and leukemia group B study 9420. J Clin Oncol 1999; 17:2831-9. [PMID: 10561359 DOI: 10.1200/jco.1999.17.9.2831] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Cancer and Leukemia Group B conducted parallel phase I trials of cytarabine, daunorubicin, and etoposide (ADE) with or without PSC-833 (P), a modulator of p-glycoprotein-mediated multidrug resistance. PATIENTS AND METHODS One hundred ten newly diagnosed patients > or = 60 years of age with de novo acute myeloid leukemia (AML) were treated. All patients received cytarabine by continuous infusion for 7 days at 100 mg/m(2)/d. The starting dose of daunorubicin was 30 mg/m(2)/d for 3 days. Etoposide was administered at a dose of 100 mg/m(2)/d for 3 days, except in the last cohort administered ADEP, who received 60 mg/m(2). PSC-833 was given intravenously with a loading dose of 1.5 mg/kg over 2 hours and a simultaneous continuous infusion of 10 mg/kg/d continued until 24 hours after the last dose of daunorubicin or etoposide. RESULTS There was no toxicity attributed to the PSC-833. Dose-limiting toxicity was primarily gastrointestinal (diarrhea, mucositis in the ADEP group). The estimated maximum-tolerated doses, calculated using a logistic regression model, were daunorubicin 40 mg/m(2)/d for 3 days with etoposide 60 mg/m(2) for 3 days in the ADEP group and daunorubicin 60 mg/m(2)/d for 3 days and etoposide 100 mg/m(2)/d for 3 days in the ADE group. Twenty-one (48%) of 44 patients achieved complete remission with ADE, compared with 29 (44%) of 66 patients treated with ADEP. CONCLUSION It is necessary to decrease the doses of daunorubicin and etoposide when they are administered with PSC-833, presumably because of the effect of the modulator on the pharmacokinetics of these agents. A phase III trial comparing the regimens derived from this phase I trial has recently begun.
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Affiliation(s)
- E J Lee
- Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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41
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Thrall DE, Larue SM, Powers BE, Page RL, Johnson J, George SL, Kornegay JN, McEntee MC, Levesque DC, Smith M, Case BC, Dewhirst MW, Gillette EL. Use of whole body hyperthermia as a method to heat inaccessible tumours uniformly: a phase III trial in canine brain masses. Int J Hyperthermia 1999; 15:383-98. [PMID: 10519690 DOI: 10.1080/026567399285576] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
In this study, whole body hyperthermia (WBH) was assessed as a means of heating intracranial tumours uniformly. Twenty-five dogs received radiation therapy and 20 the combination of radiation and WBH. Total radiation dose was randomly assigned and was either 44, 48, 52, 56 or 60 Gy. Because of WBH toxicity, intercurrent disease or tumour progression, seven of the 45 dogs received less than the prescribed radiation dose. For WBH, the target rectal temperature was 42 degrees C for 2h and three treatments were planned. In five of the 20 dogs randomized to receive WBH, only one WBH treatment was given because of toxicity. WBH toxicity was severe in six dogs, and resulted in death or interruption in treatment. Most tumours did not undergo a complete response, making it impossible to differentiate tumour recurrence from brain necrosis as a cause of progressive neuropathy. Therefore, survival was the major study endpoint. There was no survival difference between groups. One-year survival probability (95% CI) for dogs receiving radiation therapy alone was 0.44 (0.25, 0.63) versus 0.40 (0.19, 0.63) for dogs receiving radiation and WBH. There was no difference in the incidence of brain necrosis in the two treatment groups. Results suggest that use of WBH alone to increase the temperature of intracranial tumours as a means to improve radiation therapy outcome is not a successful strategy.
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Affiliation(s)
- D E Thrall
- College of Veterinary Medicine, North Carolina State University, Raleigh 27606, USA.
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George SL, Schlesinger LS. Mycobacterium neoaurum--an unusual cause of infection of vascular catheters: case report and review. Clin Infect Dis 1999; 28:682-3. [PMID: 10194099 DOI: 10.1086/517216] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- S L George
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City 52242, USA
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Abstract
OBJECTIVE To describe the current policies regarding statistical review of clinical research in biomedical journals. DESIGN Cross-sectional survey. PARTICIPANTS Editors of biomedical journals that publish original clinical research. MEASUREMENTS General policies on statistical review, types of persons used for statistical reviewing, compensation of statistical reviewers, percentage of articles subject to such review, percentage of time statistical review makes an important difference, journal circulation, and selectivity. MAIN RESULTS Of 171 journals, 114 (67%) responded to the survey. About one third of journals had policies that guaranteed statistical review for all accepted manuscripts. In approximately half of the journals, articles were sent for statistical review at the discretion of the editor. There was some evidence that statistical review policies differed between journals of different circulation size. In journals in the top quartile of circulation (> 25,000) the probability of definitely having a statistical review before an acceptance decision was 52%, but it was only 27% in journals in the lower three quartiles (p = .09). The probability of a statistical consultant on staff ranged from 31% in the bottom quarter, to 58% in the middle two, to 82% in the highest quarter (p < .001). Editors judged that statistical review resulted in an important change in a manuscript about half of the time. CONCLUSIONS Except in the largest circulation medical journals, the probability of formal methodologic review of original clinical research is fairly low. As readers and researchers depend on the journals to assess the validity of the statistical methods and logic used in published reports, this is potentially a serious problem. This situation may exist because the cost of such statistical review can be considerable, and because finding appropriate reviewers can be difficult. It may also exist partly because editors or publishers may not regard such review as important. The professions of medical publishing, statistics, epidemiology, and other quantitative disciplines should work together to address this problem.
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Affiliation(s)
- S N Goodman
- Johns Hopkins University School of Medicine, Division of Biostatistics, Oncology Center, Baltimore, MD, USA
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Knatterud GL, Rockhold FW, George SL, Barton FB, Davis CE, Fairweather WR, Honohan T, Mowery R, O'Neill R. Guidelines for quality assurance in multicenter trials: a position paper. Control Clin Trials 1998; 19:477-93. [PMID: 9741868 DOI: 10.1016/s0197-2456(98)00033-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the wake of reports of falsified data in one of the trials of the National Surgical Adjuvant Project for Breast and Bowel Cancer supported by the National Cancer Institute, clinical trials came under close scrutiny by the public, the press, and Congress. Questions were asked about the quality and integrity of the collected data and the analyses and conclusions of trials. In 1995, the leaders of the Society for Clinical Trials (the Chair of the Policy Committee, Dr. David DeMets, and the President of the Society, Dr. Sylvan Green) asked two members of the Society (Dr. Genell Knatterud and Dr. Frank Rockhold) to act as co-chairs of a newly formed subcommittee to discuss the issues of data integrity and auditing. In consultation with Drs. DeMets and Green, the co-chairs selected other members (Ms. Franca Barton, Dr. C.E. Davis, Dr. Bill Fairweather, Dr. Stephen George, Mr. Tom Honohan, Dr. Richard Mowery, and Dr. Robert O'Neill) to serve on the subcommittee. The subcommittee considered "how clean clinical trial data should be, to what extent auditing procedures are required, and who should conduct audits and how often." During the initial discussions, the subcommittee concluded that data auditing was insufficient to achieve data integrity. Accordingly, the subcommittee prepared this set of guidelines for standards of quality assurance for multicenter clinical trials. We include recommendations for appropriate action if problems are detected.
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Affiliation(s)
- G L Knatterud
- Maryland Medical Research Institute, Baltimore 21210, USA
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Larson RA, Dodge RK, Linker CA, Stone RM, Powell BL, Lee EJ, Schulman P, Davey FR, Frankel SR, Bloomfield CD, George SL, Schiffer CA. A randomized controlled trial of filgrastim during remission induction and consolidation chemotherapy for adults with acute lymphoblastic leukemia: CALGB study 9111. Blood 1998; 92:1556-64. [PMID: 9716583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Recombinant human granulocyte colony-stimulating factor (G-CSF; filgrastim) shortens the time to neutrophil recovery after intensive chemotherapy, but its role in the treatment of adults with acute lymphoblastic leukemia (ALL) is uncertain. We randomly assigned 198 adults with untreated ALL (median age, 35 years; range, 16 to 83) to receive either placebo or G-CSF (5 microgram/kg/d) subcutaneously, beginning 4 days after starting intensive remission induction chemotherapy and continuing until the neutrophil count was >/=1, 000/microL for 2 days. The study assignment was unblinded as individual patients achieved a complete remission (CR). Patients initially assigned to G-CSF then continued to receive G-CSF through 2 monthly courses of consolidation therapy. Patients assigned to placebo received no further study drug. The median time to recover neutrophils >/=1,000/microL during the remission induction course was 16 days (interquartile range [IQR], 15 to 18 days) for the patients assigned to receive G-CSF and 22 days (IQR, 19 to 29 days) for the patients assigned to placebo (P < .001). Patients in the G-CSF group had significantly shorter durations of neutropenia (<1, 000/microL) and thrombocytopenia (<50,000/microL) and fewer days in the hospital (median, 22 days v 28 days; P = .02) compared with patients receiving placebo. The patients assigned to receive G-CSF had a higher CR rate and fewer deaths during remission induction than did those receiving placebo (P = .04 by the chi-square test for trend). During Courses IIA and IIB of consolidation treatment, patients in the G-CSF group had significantly more rapid recovery of neutrophils >/=1,000/microL than did the control group by approximately 6 to 9 days. However, the patients in the G-CSF group did not complete the planned first 3 months of chemotherapy any more rapidly than did the patients in the placebo group. Overall toxicity was not lessened by the use of G-CSF. After a median follow-up of 4. 7 years, there were no significant differences in either the disease-free survival (P = .53) or the overall survival (P = .25) for the patients assigned to G-CSF (medians, 2.3 years and 2.4 years, respectively) compared with those assigned to placebo (medians, 1.7 and 1.8 years, respectively). Adults who received intensive chemotherapy for ALL benefited from G-CSF treatment, but its use did not markedly affect the ultimate outcome.
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Affiliation(s)
- R A Larson
- University of Chicago Medical Center, Chicago, IL 60637-1470, USA.
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Brizel DM, Albers ME, Fisher SR, Scher RL, Richtsmeier WJ, Hars V, George SL, Huang AT, Prosnitz LR. Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer. N Engl J Med 1998; 338:1798-804. [PMID: 9632446 DOI: 10.1056/nejm199806183382503] [Citation(s) in RCA: 903] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Radiotherapy is often the primary treatment for advanced head and neck cancer, but the rates of locoregional recurrence are high and survival is poor. We investigated whether hyperfractionated irradiation plus concurrent chemotherapy (combined treatment) is superior to hyperfractionated irradiation alone. METHODS Patients with advanced head and neck cancer who were treated only with hyperfractionated irradiation received 125 cGy twice daily, for a total of 7500 cGy. Patients in the combined-treatment group received 125 cGy twice daily, for a total of 7000 cGy, and five days of treatment with 12 mg of cisplatin per square meter of body-surface area per day and 600 mg of fluorouracil per square meter per day during weeks 1 and 6 of irradiation. Two cycles of cisplatin and fluorouracil were given to most patients after the completion of radiotherapy. RESULTS Of 122 patients who underwent randomization, 116 were included in the analysis. Most patients in both treatment groups had unresectable disease. The median follow-up was 41 months (range, 19 to 86). At three years the rate of overall survival was 55 percent in the combined-therapy group and 34 percent in the hyperfractionation group (P=0.07). The relapse-free survival rate was higher in the combined-treatment group (61 percent vs. 41 percent, P=0.08). The rate of locoregional control of disease at three years was 70 percent in the combined-treatment group and 44 percent in the hyperfractionation group (P=0.01). Confluent mucositis developed in 77 percent and 75 percent of the two groups, respectively. Severe complications occurred in three patients in the hyperfractionation group and five patients in the combined-treatment group. CONCLUSIONS Combined treatment for advanced head and neck cancer is more efficacious and not more toxic than hyperfractionated irradiation alone.
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Affiliation(s)
- D M Brizel
- Department of Radiation Oncology, Duke Comprehensive Cancer Center, Duke University Medical Center, Durham, NC 27710, USA
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Lee EJ, George SL, Amrein PC, Paciucci PA, Allen SL, Schiffer CA. An evaluation of combinations of diaziquone, etoposide and mitoxantrone in the treatment of adults with relapsed or refractory acute myeloid leukemia: results of 8722, a randomized phase II study conducted by Cancer and Leukemia Group B. Leukemia 1998; 12:139-43. [PMID: 9519774 DOI: 10.1038/sj.leu.2400905] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A phase II trial was conducted to determine which of the three possible two-drug combinations of diaziquone, etoposide and mitoxantrone was associated with the highest response rate in patients with relapsed or refractory acute myeloid leukemia (AML). Of the 167 patients (median age 55) with AML who entered the trial, 123 were in first relapse, 22 were in second relapse and 22 had failed to achieve complete remission (CR). CR rates were 30% for diaziquone and mitoxantrone, and 23% for the other two combinations (mitoxantrone/etoposide and diaziquone/etoposide), NS. Patients in first relapse had higher CR rates (40%) than other patients. Of the 166 patients who actually received treatment, 43 died before having either a CR or persistent leukemia. Non-hematologic toxicity was primarily mucosal with 24% of patients experiencing grade 3 or greater stomatitis on the two diaziquone arms, and 43% on the mitoxantrone/etoposide arm. The combination of diaziquone and mitoxantrone was selected for further testing in patients with AML.
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Affiliation(s)
- E J Lee
- Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, USA
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Abstract
PURPOSE To discuss patient eligibility criteria in phase III cancer clinical trials in the larger setting of the complexity of these trials, to review the various reasons for imposing restrictive eligibility requirements, to discuss the problems caused by these requirements, to argue that these requirements should be greatly relaxed in most cancer clinical trials, to provide some guiding principles and practical suggestions to facilitate such a relaxation, and to give an example of how eligibility requirements were reduced in a recent clinical trial in acute lymphocytic leukemia. METHODS Implicit and explicit reasons for including eligibility criteria in clinical trials are reviewed. Safety concerns and sample size issues receive special attention. The types of problems restrictive eligibility criteria cause with respect to scientific interpretation, medical applicability, complexity, costs, and patient accrual are described. RESULTS A list of three items that each eligibility criterion should meet in order to be included is proposed and applied to a recent trial in acute lymphocytic leukemia. CONCLUSION Phase III clinical trials in cancer should have much broader eligibility criteria than the traditionally restrictive criteria commonly used. Adoption of less restrictive eligibility criteria for most studies would allow broader generalizations, better mimic medical practice, reduce complexity and costs, and permit more rapid accrual without compromising patient safety or requiring major increases in sample size.
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Affiliation(s)
- S L George
- Division of Biometry, Duke University Medical Center, Durham, NC, USA
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Bennett CL, Smith TJ, George SL, Hillner BE, Fleishman S, Niell HB. Free-riding and the prisoner's dilemma: problems in funding economic analyses of phase III cancer clinical trials. J Clin Oncol 1995; 13:2457-63. [PMID: 7545222 DOI: 10.1200/jco.1995.13.9.2457] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Both economic and clinical data on new agents are important to policy-makers who approve pharmaceuticals for widespread use. Randomized clinical trials have been used to evaluate both clinical results and total medical costs associated with new agents. With new expensive pharmaceutical agents, early assessments of economic benefit have taken on greater importance to physicians and patients. Who should provide financial support to these integrated economic and clinical analyses in clinical trials? Here we describe issues that hinder funding of economic analyses and propose potential support mechanisms. RESULTS The Cancer and Leukemia Group B (CALGB), a large, national cooperative group of academic and community hospitals in the United States, designed a non-small-cell lung cancer (NSCLC) treatment trial to compare two widely used supportive care regimens that varied 20-fold in cost. One important objective of this trial was to compare the cost-effectiveness of the two regimens. While funding for the clinical trial was supported by grants from the National Cancer Institute and the pharmaceutical companies involved in the trial, no specific funding agency was willing and/or able to provide financial support for the economic analyses. After 2 years of planning, the clinical trial was retracted when the funding for the economic analyses could not be secured. The prisoner's dilemma, individual reluctance to support a common social good, explains the lack of funding. CONCLUSION Economic theory predicts difficulties in evaluating cost-effectiveness of new pharmaceuticals and reluctance to support economic analyses of clinical trials. Economic analyses will require new sources of funds that will not take scarce resources from clinical trials groups. Options for funding include a new federal agency, coordinated work by existing agencies, or academic centers for economic analysis.
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Affiliation(s)
- C L Bennett
- Division of Health Services Research and Development, Lakeside Veterans Administration, Chicago, IL, USA
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Bennett CL, George SL, Vose JM, Nemunaitis JJ, Armitage JL, Armitage JO, Gorin NC, Gulati SC. Granulocyte-macrophage colony-stimulating factor as adjunct therapy in relapsed lymphoid malignancy: implications for economic analyses of phase III clinical trials. Stem Cells 1995; 13:414-20. [PMID: 7549900 DOI: 10.1002/stem.5530130412] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the increasing concern over the high cost of health care, policy makers have incorporated economic analyses into phase III clinical trials as the randomized clinical trials can provide important information on the efficacy and potential cost-effectiveness of new pharmaceutical agents. Economic analyses of single-hospital experience during phase III trials of granulocyte-macrophage colony-stimulating factor (GM-CSF) as adjunct therapy for high dose chemotherapy with autologous stem cell support found significant shortening of neutropenia with GM-CSF at each hospital, but shortened hospitalization (and lower costs) at only two of three hospitals. In this study, we added data from three additional hospitals and found that the 103 patients who received GM-CSF had, on average, 5.7 days shorter durations of severe neutropenia than the 95 patients who received placebo (p < 0.0001) and 3.4 days shorter in hospitalization (p = 0.06). However, the duration of hospitalization, the primary determinant of health care costs, was shorter for GM-CSF patients in only four of the six centers and the duration of hospitalization of placebo patients was shorter at the other two centers. Careful analyses must be carried out when phase III clinical trial results are used to derive estimates of cost-effectiveness of new pharmaceutical agents. The interpretation of economic analyses of phase III clinical trials raises issues related to the perspective of the investigators, study design, collection of data on resource utilization, learning curve effects and generalizability of the results to other settings.
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Affiliation(s)
- C L Bennett
- Lakeside Veterans Affairs Hospital, Chicago, Illinois, USA
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