Suppressive Drugs Research Articles

In Vivo Selection of Mycophenolate Mofetil-Resistant T Cells for Adoptive Immunotherapy.

AbstractAbstract 3008In vivo selection of mycophenolate mofetil-resistant T cells for adoptive immunotherapy. BackgroundFollowing allogeneic solid organ or hematopoietic stem cell transplantation, adoptive transfer of therapeutic T cells may be hindered by the requirement for immune suppressive drugs to prevent rejection or graft-versus-host disease. Mycophenolate mofetil (MMF) is a non-competitive inhibitor of inosine-5’-monophosphate dehydrogenase 2 (IMPDH2), an inducible enzyme that generate guanine nucleotides for DNA and RNA synthesis in T cells. In this study, we have evaluated the potential for gene transfer to T cells of a mutated IMPDH2 that confers >2000-fold resistance to MMF (IMPDH2R; T333I, S351Y). MethodsWild type IMPDH2WT, IMPDH2R and IMPDH2 with a catalytic site mutation (IMPDH2CS; C331A) were cloned into SFG retroviral vectors as fusions to eGFP reporter sequences. Murine thymoma (BW 5147) or CD8 T cells were transduced with each vector and their phenotype and function evaluated in the presence or absence of mycophenolic acid (MPA), the active metabolite of MMF. ResultsBW thymoma cells transduced with IMPDH2R exhibited less apoptosis than cells transduced with IMPDH2CS in response to MPA (ratio % Annexin V+ MPA: no MPA- IMPDH2R = 1.2; IMPDH2CS = 2.9, p=0.01). Cells transduced with IMPDH2R were also able to overcome the G1 cell-cycle arrest induced by MPA when compared to control IMPDH2CS cells (Ratio %cells in S-G2/M phases MPA: no MPA- IMPDH2R = 1.0; IMPDH2CS = 0.3, p=0.03). This led to selective enrichment of IMPDH2R transduced cells in the presence of MPA. At low dose MPA (450nM), IMPDH2R transduced cells enriched compared to IMPDH2CS but not IMPDH2WT (ratio % GFP MPA: no MPA- IMPDH2R = 1.6 vs IMPDH2CS = 1.1, p=0.04 and IMPDH2WT = 1.5 p= 0.14). However, at high dose (4500nM) IMPDH2R exhibited enhanced enrichment (ratio % GFP MPA: no MPA- IMPDH2R = 2.8 vs IMPDH2CS = 1.0 p=0.03 and vs IMPDH2WT= 1.5 p=0.03).Gene transfer of IMPDH2R into murine CD8 T cells also led to selective enrichment compared to controls in the presence of MPA when cultured with proliferation-inducing common gamma-chain cytokines (ratio MPA: no MPA IMPDH2R = 4.4 vs. IMPDH2CS = 1.10, p=0.02). Strong selection for IMPDH2R-tranduced CD8 OT-1 T cells in the presence of MPA was also observed under conditions of antigen-induced proliferation (ratio IMPDH2R= 7.1, control = 0.8, p=0.002).To assess in vivo selection, sub-lethally irradiated (2Gy) B6.PL (Thy1.1) mice were injected with a 1:1 mix of OT1 TCR transgenic Thy1.2 CD8 T cells transduced with IMPDH2R or IMPDH2CS that could be differentiated by the congenic markers CD45.1 and CD45.2. Transferred cells were stimulated by s.c. injection with cognate peptide (SIINFEKL) in IFA and MMF (200mg/kg/day) was given by daily ip injection. As in vitro, IMPDH2R-transduced OT1 cells were preferentially selected over IMPDH2CS-transduced cells following MMF treatment (day 14 ratio IMPDH2R to IMPDHCSwas 19.3 vs 1.2 in the absence of MMF). ConclusionsT cells transduced with IMPDH2R are resistant to the anti-proliferative and apoptotic effects of MPA in vitro and demonstrate strong selection in vivo compared to controls at therapeutic levels of MMF. These data support the potential of conferring MMF resistance as a strategy to permit the survival of therapeutic T cells in immunosuppressed allograft recipients. Disclosures:Stauss:Cell Medica: Scientific Advisor Other.

Timeliness of Clinic Attendance Is a Good Predictor of Virological Response and Resistance to Antiretroviral Drugs in HIV-Infected Patients

BackgroundEnsuring long-term adherence to therapy is essential for the success of HIV treatment. As access to viral load monitoring and genotyping is poor in resource-limited settings, a simple tool to monitor adherence is needed. We assessed the relationship between an indicator based on timeliness of clinic attendance and virological response and HIV drug resistance.MethodsData from 7 virological cross-sectional studies were pooled. An adherence indicator was calculated as the number of appointments attended with delay divided by the number of months between antiretroviral treatment (ART) initiation and date of virological testing and multiplying this by 100. Delays of 1 or more to 5 or more days were considered in turn. Multivariate random-intercept logistic regression was fitted to examine the effect on outcomes, separately for adults and children.ResultsA total of 3580 adults and 253 children were included. Adults were followed for a median of 26.0 months (IQR 12.8-45.0) and attended a median of 24 visits (IQR 13–34). The 1-day delay adherence indicator was strongly associated with viral load suppression (OR 0.96, 95% CI 0.95–0.97 per unit increase), virological failure (OR 1.05, 95% CI 1.03–1.06) and HIV drug resistance (OR 1.03, 95% CI 1.01–1.05) after adjusting for initial age and CD4 count, previous ART experience, type of regimen and Tuberculosis diagnosis at start of therapy. Similar results were observed in children.ConclusionAn adherence indicator based on timeliness of clinic attendance predicts strongly both virological response and drug resistance, and could help to timely identify non-adherent patients in settings where viral load monitoring is not available.

Research Highlights: Highlights from the Latest Articles in Transplantation Pharmacogenomics

ISSN 1462-2416 10.2217/PGS.12.155 © 2012 Future Medicine Ltd Pharmacogenomics (2012) 13(15), 1679–1683 1679 The focus of pharmacogenetic research in solid-organ transplantation has shifted from ‘kinetics’ to ‘dynamics’. The impact of genetic variants encoding metabolizing enzymes or transporter proteins of immunosuppressive compounds on blood drug concentrations has been intensively studied in the last decade. Today, genetic polymorphisms coding for drug target or signaling proteins involved in pharmacodynamics pathways are intensively explored in renal disease states and translated into clinically relevant outcome indicators: efficacy and toxicity (i.e., adverse events). The reasons for this transition in pharmacogenetic research are obvious: although important genetic determi nants of immuno suppressive drug exposure have been identif ied (e.g., CYP3A5 and UGT1A9), the clinical use of this information for optimization of drug dosing has not yet succeeded to replace concentration-controlled drug dosing in terms of increased efficacy and/or reduced toxicity [1]; although most immunosuppressive drugs require concentration-controlled dosing owing to their narrow therapeutic window, the upper limit concentrations indicating increased risk for adverse events have not been estab lished. Indeed, despite controlled efforts to minimize drug exposure, most immunosuppressive drug combinations tend to retain their specif ic toxicity profiles [2]. Conversely, the minimum drug concentrations needed to maintain efficacy (avoidance of acute rejection) have not been unequivocally determined for the different immunosuppressive drug combinations [3,4].

The Transporter Spns2 Is Required for Secretion of Lymph but Not Plasma Sphingosine-1-Phosphate

Plasma sphingosine-1-phosphate (S1P) regulates vascular permeability, and plasma and lymph S1P guide lymphocyte egress from lymphoid organs. S1P is made intracellularly, and little is known about how S1P is delivered into circulatory fluids. Here, we find that mice without the major facilitator superfamily transporter Spns2 have a profound reduction in lymph S1P, but only a minor decrease in plasma S1P. Spns2-deficient mice have a redistribution of lymphocytes from the spleen to lymph nodes and a loss of circulating lymphocytes, consistent with normal egress from the spleen directed by plasma S1P and blocked egress from lymph nodes directed by lymph S1P. Spns2 is needed in endothelial cells to supply lymph S1P and support lymphocyte circulation. As a differential requirement for lymph and blood S1P, Spns2 may be an attractive target for immune suppressive drugs.

Identification of an Annonaceous Acetogenin Mimetic, AA005, as an AMPK Activator and Autophagy Inducer in Colon Cancer Cells

Annonaceous acetogenins, a large family of naturally occurring polyketides isolated from various species of the plant genus Annonaceae, have been found to exhibit significant cytotoxicity against a variety of cancer cells. Previous studies showed that these compounds could act on the mitochondria complex-I and block the corresponding electron transport chain and terminate ATP production. However, more details of the mechanisms of action remain ambiguous. In this study we tested the effects of a set of mimetics of annonaceous acetogenin on some cancer cell lines, and report that among them AA005 exhibits the most potent antitumor activity. AA005 depletes ATP, activates AMP-activated protein kinase (AMPK) and inhibits mTOR complex 1 (mTORC1) signal pathway, leading to growth inhibition and autophagy of colon cancer cells. AMPK inhibitors compound C and inosine repress, while AMPK activator AICAR enhances, AA005-caused proliferation suppression and subsequent autophagy of colon cancer cells. AA005 enhances the ATP depletion and AMPK activation caused by 2-deoxyglucose, an inhibitor of mitochondrial respiration and glycolysis. AA005 also inhibits chemotherapeutic agent cisplatin-triggered up-regulation of mTOR and synergizes with this drug in suppression of proliferation and induction of apoptosis of colon cancer cells. These data indicate that AA005 is a new metabolic inhibitor which exhibits therapeutic potentials in colon cancer.

Clinically applicable antianginal agents suppress osteoblastic transformation of myogenic cells and heterotopic ossifications in mice

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by progressive heterotopic ossification. FOP is caused by a gain-of-function mutation in ACVR1 encoding the bone morphogenetic protein type II receptor, ACVR1/ALK2. The mutant receptor causes upregulation of a transcriptional factor, Id1. No therapy is available to prevent the progressive heterotopic ossification in FOP. In an effort to search for clinically applicable drugs for FOP, we screened 1,040 FDA-approved drugs for suppression of the Id1 promoter activated by the mutant ACVR1/ALK2 in C2C12 cells. We found that that two antianginal agents, fendiline hydrochloride and perhexiline maleate, suppressed the Id1 promoter in a dose-dependent manner. The drugs also suppressed the expression of native Id1 mRNA and alkaline phosphatase in a dose-dependent manner. Perhexiline but not fendiline downregulated phosphorylation of Smad 1/5/8 driven by bone morphogenetic protein (BMP)-2. We implanted crude BMPs in muscles of ddY mice and fed them fendiline or perhexiline for 30days. Mice taking perhexiline showed a 38.0% reduction in the volume of heterotopic ossification compared to controls, whereas mice taking fendiline showed a slight reduction of heterotopic ossification. Fendiline, perhexiline, and their possible derivatives are potentially applicable to clinical practice to prevent devastating heterotopic ossification in FOP.

Valvular heart disease in a patient taking 3,4‐methylenedioxymethamphetamine (MDMA, ‘Ecstasy’)

3, 4-methylenedioxymethamphetamine, (MDMA, ‘Ecstasy’), an amphetamine-derived drug, is a psychoactive stimulant used as a recreational drug. In vitro experiments have suggested that ecstasy can lead to fenfluramine-like proliferation of cardiac valves through activation of 5-hydroxytryptamine 2B (5-HT2B) receptors and can induce mitogenic responses in human valvular interstitial cells [1]. We report the first observation of valvular heart disease (VHD) with pathological confirmation after long term use of ecstasy. A 33-year-old male patient was admitted for shortness of breath and chest pain. The only risk factor reported was active smoking. He reported long lasting exposure to ecstasy (several pills week−1 since the age of 17 years). At examination a systolic and diastolic mitral murmur was diagnosed. Mean blood pressure was 106/70 mmHg. ECG showed sinus rhythm (91 beats min−1) with a right bundle branch block. Echocardiography revealed a slight left ventricular dilation (endiastolic diameter of 55 mm) with an ejection fraction of 55% and typical features of mitral valve disease. There was a left atrial enlargement (area of 42 cm2) thick mitral valve with decreased opening of the mitral valve leaflets. Mean pressure gradient across the mitral valve was of 14.7 mmHg with mitral valve areas of 1.56 cm2. These moderate to severe mitral stenosis features were associated with severe mitral regurgitation (regurgitant orifice area = 0.49 cm2) with a central blood jet. Other valves and heart chambers were normal. This patient had pulmonary hypertension (40 mm Hg) without right heart failure. Coronary angiogram showed normal coronary arteries with a decreased cardiac index and post capillary pulmonary hypertension. Surgery was decided. Macroscopic analysis made the surgeon hypothesize about a possible cardiac tumour. Mitral valve leaflets and the chordae tendinae were markedly thickened and fibrous. The chordae tendinae were retracted (Figure 1). After resection, the surgeon decided to perform mitral valve replacement with a mechanical Saint Jude prosthesis despite severe damage of the mitral annulus. At histology, the endocardium on both sides was fibrous up to 2 mm thick. It was stratified with layers of collagen bundles and spindle cells. Density of spindle cells was heterogeneous, but more frequently low. In this abundant extracellular matrix, rare foci contained abundant elastic fibres. No inflammation or myxoid matrix accumulations were observed, ruling out rheumatic and Barlow diseases (Figure 1B, C). Common disease (Osler endocarditis, carcinoid syndrome, rheumatic fever, autoimmune disease …) or intake of other drugs (ergot derivatives, appetite-suppressant drugs including benfluorex) known to affect cardiac valves were not found. One month later, the patient came back with chest pain, fatigue and loss of weight. Trans-thoracic echocardiography showed a para-prosthetic leak with prosthesis dehiscence. The patient underwent re-operation with fixation of his prosthesis. At follow-up there were no complications. Figure 1 Anatomical and histological findings. (A) a short leaflet mitral valve (left) and a large leaflet mitral valve with a part of the left ventricle which was also removed (right). (B) Gross pathology of the mitral valve: on this section the valve is markedly ... This is the first case of VHD with pathological confirmation related to long term exposure to ecstasy. Except for an in vitro study [1], few data are available [1]. Among 29 subjects using ecstasy, eight had abnormal mitral valve echocardiography vs. 0 in controls [2]. The fact that the lesions in our patient were very similar to those described with appetite-suppressant drugs [3] and the ability of ecstasy to activate 5-HT2B receptors, like fenfluramine [1, 4], suggests its role in the pathophysiology of this VHD. VHD is unusual in young subjects. The present work allows the addition of ecstasy to the list of substances able to induce VHD [5]. The data also underline the important (and probably underestimated) harm associated with the now large use of ecstasy in young subjects. Information must be given about this risk.

Secondary skin-cancer risk after kidney transplantation

Recipients of kidney transplants who switch from calcineurin inhibitors to sirolimus are at reduced risk of develop ment of secondary skin cancer, according to fi ndings of a multicentre trial published last week. Some evidence suggests that the immunosuppressant mTOR inhibitor sirolimus could decrease tumour burden. Transplant patients are required to take immuno suppressive drugs to forestall organ rejection, but are at high risk of skin cancer. Researchers for the TUMORAPA study group assessed 120 recipients of kidney transplants who were taking calcineurin inhibitors (tacrolimus and ciclosporin) and had previously had at least one cutaneous squamous-cell carcinoma. 64 patients switched to sirolimus and 56 patients remained on calcineurin inhibitors. 14 patients (22%) in the sirolimus group developed secondary skin cancer compared with 22 patients (39%) in the control group. Moreover, patients in the sirolimus group developed new carcinomas later than did controls (15 months vs 7 months). The sooner the conversion to sirolimus occurred after the initial cancer diagnosis, the better the patient’s prognosis. “We’ve been [starting to use] sirolimus over the past few years”, Jerry Brewer (Mayo Clinic, MN, USA) told The Lancet Oncology. “This study provides further evidence that it should be used more frequently.” Complications associated with sirolimus are an important con sid eration. “We had to stop treatment for a signifi cant number of patients because of pneumonitis and proteinuria”, affi rmed study investigator Eric Goffi n (St Luc University Hospital, Brussels). 15 patients (23%) in the sirolimus group discontinued treat ment due to adverse events. Moreover, nearly all the patients had some kind of negative side-eff ect, most of which were manageable with dose reductions or complemen tary treatment. Patients who were gradually introduced to sirolimus were less prone to adverse events than were those converted with rapid protocols. As long as a transplant recipient has suffi ciently high kidney functionality, low levels of proteinuria, and can tolerate the drug, Goffi n advocates use of sirolimus. But whether patients in the immediate aftermath of a transplantation should be prescribed the drug has yet to be established. “There have been no really good studies on sirolimus right after surgery, but it does seem to inhibit wound healing”, explains Brewer.

The immunomodulatory effect of Neem (Azadirachtaindica) seed aqueous, ethanolic extracts and Candida albicans cell wall mannoproteins on immune response in mice vaccinated with Brucella Rev-1

In the present study, the immunomodulatory effect of Neem (Azadirachtaindica)seed aqueous, ethanolic extracts and Candida albicans cell wall mannoproteins on theimmune response of mice vaccinated with Brucella Rev-1 vaccine was investigated. Thestudy was conducted on two main groups(160 mice for each group), Each group wasdivided into eight subgroups 20 mice for each (I: treated with distilled water, II: treatedwith the Brucella Rev-1 vaccine, III: treated with mannoproteins, IV: treated with neemaqueous extract, V: treated with neemethanolic extract, VI, VII and VIII: treated withmannoproteins, neem aqueous extract and neemethanolic extract, respectively, then theywere vaccinated with Brucella Rev-1). All these treatments were carried out on day 1and then vaccinated with brucella Rev-1 vaccine on day 4 .Then the mice were tested asfollows , on day 8 after vaccination(serum IFN-γ level), day 21 for (anti-Brucellaantibody titer). The doses of both plant extracts and mannoproteins represented 10% ofthe calculated LD50 (neem extracts: 3.8096 g/Kg mannoproteins: 5.7144 mg/Kg), whichwere given subcutaneously. Mice of the second main group were injected with theimmune suppressive drug prednisolone (5mg/Kg) 5 days prior to the treatments, whichcarried out on mice of the first main group. The results demonstrated clearimmunomodulatory effects (improvement of non-specific, humoral immunity) of thetested immunomodulators in mice vaccinated with Brucella Rev-1 as compared withmice that were not treated with Neem extracts or mannoproteins. In this regard, Theinterferon-γ showed a significant increase (P≤ 0.01) serum level in immunomodulatortreatedand -vaccinated mice in comparison with negative and positive groups, and againgroup VII showed the highest increase. The anti-Brucella antibodies assessed by indirectImmunoflourescent test also showed a significant increase titer in immunomodulatortreatedand -vaccinated mice in comparison with negative and positive groups .Conclusion: The aqueous and ethanolicNeem seed extract reported the highestenhancement in all immunological parameters employed in comparison withmannoproteins of Candida albicans cell wall.

Microbead-Induced Ocular Hypertensive Mouse Model for Screening and Testing of Aqueous Production Suppressants for Glaucoma

To characterize the microbead-induced ocular hypertension (OHT) mouse model and investigate its potential use for preclinical screening and evaluation of ocular hypotensive agents, we tested the model's responses to major antiglaucoma drugs. Adult C57BL/6J mice were induced to develop OHT unilaterally by intracameral injection of microbeads. The effects of the most commonly used ocular hypotensive drugs, including timolol, brimonidine, brinzolamide, pilocarpine, and latanoprost, on IOP and glaucomatous neural damage were evaluated. Degeneration of retinal ganglion cells (RGCs) and optic nerve axons were quantitatively assessed using immunofluorescence labeling and histochemistry. Thickness of the ganglion cell complex (GCC) was also assessed with spectral-domain optical coherence tomography (SD-OCT). A microbead-induced OHT model promptly responded to drugs, such as timolol, brimonidine, and brinzolamide, that lower IOP through suppressing aqueous humor production and showed improved RGC and axon survival as compared to vehicle controls. Accordingly, SD-OCT detected significantly less reduction of GCC thickness in mice treated with all three aqueous production suppressants as compared to the vehicle contol-treated group. In contrast, drugs that increase aqueous outflow, such as pilocarpine and latanoprost, failed to decrease IOP in the microbead-induced OHT mice. Microbead-induced OHT mice carry dysfunctional aqueous outflow facility and therefore offer a unique model that allows selective screening of aqueous production suppressant antiglaucoma drugs or for studying the mechanisms regulating aqueous humor production. Our data set the stage for using GCC thickness assessed by SD-OCT as an imaging biomarker for noninvasive tracking of neuronal benefits of glaucoma therapy in this model.

Cyclophosphamide Creates a Receptive Microenvironment for Prostate Cancer Skeletal Metastasis

A number of cancers predominantly metastasize to bone, due to its complex microenvironment and multiple types of constitutive cells. Prostate cancer especially has been shown to localize preferentially to bones with higher marrow cellularity. Using an experimental prostate cancer metastasis model, we investigated the effects of cyclophosphamide, a bone marrow-suppressive chemotherapeutic drug, on the development and growth of metastatic tumors in bone. Priming the murine host with cyclophosphamide before intracardiac tumor cell inoculation was found to significantly promote tumor localization and subsequent growth in bone. Shortly after cyclophosphamide treatment, there was an abrupt expansion of myeloid lineage cells in the bone marrow and the peripheral blood, associated with increases in cytokines with myelogenic potential such as C-C chemokine ligand (CCL)2, interleukin (IL)-6, and VEGF-A. More importantly, neutralizing host-derived murine CCL2, but not IL-6, in the premetastatic murine host significantly reduced the prometastatic effects of cyclophosphamide. Together, our findings suggest that bone marrow perturbation by cytotoxic chemotherapy can contribute to bone metastasis via a transient increase in bone marrow myeloid cells and myelogenic cytokines. These changes can be reversed by inhibition of CCL2.

Abstract 4233A: The opposite effects of doxorubicin on bone marrow cells versus cancer cells in vivo depend on glucosylceramide synthase

Abstract Bone marrow suppression and tumor drug resistance are adverse effects observed in patients with chemotherapy severely limit cancer treatments. It is unclear by which cellular mechanism anticancer drugs suppress bone marrow while drug-resistant tumor survives. We report that due to the difference in the glucosylceramide synthase (GCS) that catalyzes ceramide glycosylation determining ceramide-induced apoptosis or glycosphingolipid mediated maintenance of stem cells, doxorubicin can eliminate bone marrow stem cells and expand cancer stem cells. Doxorubicin treatments significantly decreased the number of bone marrow stem cells (BMSCs, ABCG2+) and sphere formation in dose-dependent fashion (1-5 mg/kg). In tumor-bearing mice, doxorubicin treatments (6 days) significantly decreased bone marrow stem cells and peripheral blood cells at 2 mg/kg and 5 mg/kg. In contrast, doxorubicin increased the number of breast cancer stem cells (BCSCs, CD24-/CD44+/ESA+) more than 3 times at 5 mg/kg treatment. Furthermore, silencing GCS with MBO-asGCS prevented BCSC number increase. Similarly, therapeutic-dose of doxorubicin (1 mg/kg/week, i.p., for 42-days), decreased bone marrow stem cells and increased breast cancer stem cells. Breast cancer cells, but not bone marrow cells, highly expressed glucosylceramide synthase (GCS) which was associated with pluripotency of stem cells. These results indicate that doxorubicin may have the opposite effects, suppressing BMSC versus expanding BCSC in vivo, and GCS is a determinant for the differentiated responsiveness between bone marrow cells, and breast cancer cells. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4233A. doi:1538-7445.AM2012-4233A

Survey of lactation suppression in HIV-positive pregnant women

The risk of HIV transmission via breastfeeding is well reported. We conducted a national survey in the UK to look at the current knowledge and postpartum practice of HIV physicians caring for HIV-positive pregnant women. In total, 167 questionnaires were distributed, 85 (51%) questionnaires were returned. All the respondents advised their patients against breastfeeding, 17 (23%) respondents routinely prescribed drugs for postpartum lactation suppression and 32 (43%) detailed awareness of interactions between antiretroviral therapy and dopaminergic lactation suppression agents. Thirteen respondents reported awareness of guidance on lactation suppression. The knowledge and use of lactation suppression agents appears to be low. However, its use will not only reduce postnatal mastitis and breast engorgement but will also help women deal with social pressures to breastfeed. Increased use in specific circumstances will improve the postnatal care of HIV-positive pregnant women in the UK.

Evidence for the use of appetite suppressant drugs in Brazil: a pharmacoeconometric study

Analyze the use of appetite suppressants in Brazil in 2009, according to the characteristics of users, healthcare system, and other drugs. Pharmaconeconometric study of cross-sectional data to analyze the relationship between the use of appetite suppressants (mg/per capita) and the independent variables selected (gender, race/color, age, schooling, income, health insurance coverage, and use of fluoxetine and chlordiazepoxide) using multiple linear regression analysis. This study used these variables in level of aggregation by states for 2009. The analyses were performed using the Gretl software. We highlight that São Paulo showed the highest use of appetite suppressants with 97.3 mg/per capita, followed by Goiás with 94.8 mg/per capita. The lowest use of appetite suppressants was seen in Ceará (3.8 mg/per capita). The biggest fluoxetine users were in Rio Grande do Sul, with 58.0 mg/per capita, and in Goiás, with 51.5 mg/per capita. Ceará showed the lowest fluoxetine use (2.3 mg/per capita). For chlordiazepoxide, the highest values were seen in Minas Gerais (7.5 mg/per capita) and in Rio de Janeiro (4.8 mg/per capita), while Amazonas (0.08 mg/per capita) showed the lowest use. Based on regression analysis, we can highlight: 1) the use of appetite suppressants is related to income, education, and fluoxetine use; and 2) race/color, gender, age, health insurance coverage, and use of chlordiazepoxide showed no relation to the use of appetite suppressants. These evidences may contribute to the improvement of regulatory actions, sanitary surveillance, and ethical conduct, particularly with regard to the concomitant use of appetite suppressants and fluoxetine, which is prohibited by the Federal Council of Medicine (Conselho Federal de Medicina) and also by Anvisa (Agência Nacional de Vigilância Sanitária - National Health Surveillance Agency).

Evidence for the use of appetite suppressant drugs in Brazil: a pharmacoeconometric study

Evidence for the use of appetite suppressant drugs in Brazil: a pharmacoeconometric study

Clinical potential of antigen-specific therapies in type 1 diabetes.

In type 1 diabetes (T1D), pancreatic beta-cells are attacked and destroyed by the immune system, which leads to a loss of endogenous insulin secretion. The desirable outcome of therapeutic intervention in autoimmune diseases is the restoration of immune tolerance to prevent organ damage. Past trials with immune suppressive drugs highlight the fact that T1D is in principle a curable condition. However, the barrier in T1D therapy in terms of drug safety is set particularly high because of the predominantly young population and the good prognosis associated with modern exogenous insulin therapy. Thus, there is a general consensus that chronic immune suppression is associated with unacceptable long-term safety risks. On the other hand, immune-modulatory biologicals have recently failed to confer significant protection in phase 3 clinical trials. However, the concept of antigen-specific tolerization may offer a unique strategy to safely induce long-term protection against T1D. In this review, we analyze the potential reasons for the failure of the different tolerization therapies, and describe how the concept of antigen-specific toleraization may overcome the obstacles associated with clinical therapy in T1D.

AN EPIDEMIOLOGICAL REVIEW OF DENGUE IN PAKISTAN

Dengue fever is a viral infection, transmitted by female Aedes Aegypti Mosquito, found in tropical and subtropical climates of the world. Virus has serotype DENV-1 to DENV-4. While the major syndromes include; DSS (Dengue Shock Syndrome), febrile flu-like illness, DHF (Dengue Hemorrhagic Fever), arthralgia, rash, raised ALT/ and AST, hemoconcentration and thrombocytopenia [1]. The second dengue episode is most dangerous and present abrupt onset of sever syndromes. The antigen antibody complexes lead to the cascade of immune reactions and activation of complement system the patient with pre-existing actively or passively acquired immunity to heterologous dengue virus serotype [2]. That makes about 25% mortality of patient if left untreated. It may become fatal in immunocompromised, blood cells deprived and old aged persons. It may also be seriously aggravated in tumor, malarial, blood and heart patients taking antineoplastic, anticoagulants and bone morrow suppressive drugs

Sex-dimorphic adverse drug reactions to immune suppressive agents in inflammatory bowel disease

To analyze sex differences in adverse drug reactions (ADR) to the immune suppressive medication in inflammatory bowel disease (IBD) patients. All IBD patients attending the IBD outpatient clinic of a referral hospital were identified through the electronic diagnosis registration system. The electronic medical records of IBD patients were reviewed and the files of those patients who have used immune suppressive therapy for IBD, i.e., thiopurines, methotrexate, cyclosporine, tacrolimus and anti-tumor necrosis factor agents (anti-TNF); infliximab (IFX), adalimumab (ADA) and/or certolizumab, were further analyzed. The reported ADR to immune suppressive drugs were noted. The general definition of ADR used in clinical practice comprised the occurrence of the ADR in the temporal relationship with its disappearance upon discontinuation of the medication. Patients for whom the required information on drug use and ADR was not available in the electronic medical record and patients with only one registered contact and no further follow-up at the outpatient clinic were excluded. The difference in the incidence and type of ADR between male and female IBD patients were analyzed statistically by χ(2) test. In total, 1009 IBD patients were identified in the electronic diagnosis registration system. Out of these 1009 patients, 843 patients were eligible for further analysis. There were 386 males (46%), mean age 42 years (range: 16-87 years) with a mean duration of the disease of 14 years (range: 0-54 years); 578 patients with Crohn's disease, 244 with ulcerative colitis and 21 with unclassified colitis. Seventy percent (586 pts) of patients used any kind of immune suppressive agents at a certain point of the disease course, the majority of the patients (546 pts, 65%) used thiopurines, 176 pts (21%) methotrexate, 46 pts (5%) cyclosporine and one patient tacrolimus. One third (240 pts, 28%) of patients were treated with anti-TNF, the majority of patients (227 pts, 27%) used IFX, 99 (12%) used ADA and five patients certolizumab. There were no differences between male and female patients in the use of immune suppressive agents. With regards to ADR, no differences between males and females were observed in the incidence of ADR to thiopurines, methotrexate and cyclosporine. Among 77 pts who developed ADR to one or more anti-TNF agents, significantly more females (54 pts, 39% of all anti-TNF treated women) than males (23 pts, 23% of all anti-TNF treated men) experienced ADR to an anti-TNF agent [P = 0.011; odds ratio (OR) 2.2, 95%CI 1.2-3.8]. The most frequent ADR to both anti-TNF agents, IFX and ADA, were allergic reactions (15% of all IFX users and 7% of all patients treated with ADA) and for both agents a significantly higher rate of allergic reactions in females compared with males was observed. As a result of ADR, 36 patients (15% of all patients using anti-TNF) stopped the treatment, with significantly higher stopping rate among females (27 females, 19% vs 9 males, 9%, P = 0.024). Treatment with anti-TNF antibodies is accompanied by sexual dimorphic profile of ADR with female patients being more at risk for allergic reactions and subsequent discontinuation of the treatment.

Leading Article INFECTION IN ORTHOPAEDIC PRACTICE

Introduction Infection continues to be a real problem in orthopaedic practice. Infection is probably the first cause of failure of orthopaedic and trauma operation, it is behind prolonged suffering for our dear patients because of the morbidity and mortality. Although there have been significant reduction in infection due to better surgical techniques, improved operating room environment, more effective antibiotics and the wide spread use of prophylactic antibiotics, we all will face this bad omen in one of our patients at some time in our practice. Sadly, infection continues to happen despite our strenuous efforts to prevent it. Prolonged hospital stay to treat infection may expose the patients to resistant nosocomial pathogens. The incidence of infection varies considerably worldwide; I think the incidence in our locality is very high. The current use of ultra clean air, antibiotics, and exhaust ventilated suits during implantation of prostheses considerably reduced infection. Nevertheless, lack of agreement and controversies still exist regarding the benefit of these very strict infection prevention techniques. Infections are considered nosocomial if there is no evidence that the infection was present or incubating at the time of hospital admission. Infection is considered related to surgery if that occurs at the incision site within 30 days after surgery, if no implant is left in place or within one year if the implant is in place. Infection may occur at all anatomical levels, from the treatment point of view it is vital to precisely allocate the anatomical site of infection. Infection is usually diagnosed depending on clinical features which are to be confirmed by laboratory tests. The presence of pus does not always mean infection, because necrosis of malignant lesion may simulate purulent material. Frequently, patients who have prostheses may be readmitted to the hospital for medical care or other surgical procedures during that time, the bladder catheter, intravascular line, that involve contaminated areas of the body may increase the risk of nosocomial infection. A high risk of infection is present in collagen disease, malnutrition, steroid dependent and other immune suppression drugs, sicklers, hidden nidus of infection anywhere in the body and any operation that lasted longer than the anticipated surgical time. The presence of diabetes mellitus is a concern in patient for surgery. Diabetes impairs the immune response to infection; therefore, wound healing may be difficult in those patients. In acute infection the influence of diabetes is much than in chronic infection. Some patients may have more than one risk factor.

Sibutramine promotes amygdala activity under fasting conditions in obese women

Sibutramine, a centrally-acting selective monoamine reuptake inhibitor, has been used as an appetite suppressant drug in obesity. To gain insight into the central nervous actions of sibutramine, brain responses to pictures of food items after sibutramine vs placebo application were assessed by functional magnetic resonance imaging (fMRI) in obese women. In a randomized double-blind crossover design, 10 healthy obese women (BMI 31.8-39.9kg/m(2)) received 15mg/d of sibutramine vs placebo for 14d. Obese participants, and a group of 10 age-matched normal weight controls, viewed pictures of food items and control objects in hungry and satiated states while lying in the MR scanner. The paradigm followed a block design. In obese participants, fMRI measurements were conducted prior and after two weeks of daily sibutramine or placebo administration, whereas control participants were scanned only at one point in time. Upon food item presentation, obese participants showed increased brain activity in areas related to emotional and reward processing, perceptual processing, and cognitive control as compared to normal weight controls. Sibutramine exerted a divergent satiety-dependent effect on amygdala activity in obese participants, increasing activity in the hungry state while decreasing it under conditions of satiation. Our results demonstrate a modulatory influence of sibutramine on amygdala activity in obese women which may underlie the appetite suppressant effects of the drug.