The role of tivozanib in advanced renal cell carcinoma therapy

Introduction: The efficacy of VEGF-targeting therapies in clinical trials led to their recommendation in clinical guidelines for use across the advanced or metastatic renal cell carcinoma (RCC) treatment landscape, however, tolerability (including off-target effects) has remained a challenge. Tivozanib is a selective inhibitor of all three VEGFRs, with limited off-target interaction, which demonstrates efficacy with improved tolerability relative to multikinase VEGFR-TKIs.

Areas covered: Covered here is the clinical development of tivozanib in advanced RCC, including the pivotal Phase III, multicenter, open-label, randomized clinical study comparing tivozanib with sorafenib for the treatment of VEGF- and mTOR therapy-naïve advanced RCC patients. Also covered are ongoing trials, exploring the efficacy and safety of tivozanib in the setting of refractory disease and the utility of tivozanib in combination with checkpoint inhibitors for advanced RCC. Combination of a VEGFR-TKI and immunotherapy is promising in advanced RCC, if the treatment regimens have acceptable tolerability. Here the selectivity of tivozanib may contribute to an acceptable tolerability profile when used in combination therapy.

Expert commentary: The approval of tivozanib provides an additional option for the first-line treatment of advanced or metastatic RCC patients in Europe and allows use of a VEGFR-TKI with selectivity for VEGFRs in this setting.     

Quality of life in children with spinal cord injury.

PURPOSE: To compare reports of the child's quality of life (QOL) between children with spinal cord injury (SCI) and their parents using the Pediatric Quality of Life 4.0 Generic Scales (PedsQL), and assess agreement between parent and child responses. To examine the influence of level of injury on QOL and internal consistency reliability of the PedsQL in pediatric SCI. METHODS: Twenty-eight children (17 male children and 11 female children) between five and 13 years and their parents completed the PedsQL. RESULTS: Children rated their QOL better than their parents; however, there was good to excellent parent-child agreement. No differences were noted between children with tetraplegia and paraplegia. Low internal consistency reliability was obtained for various domains. CONCLUSIONS: In addition to using summary scores, specific ratings may raise important points for clinical decision-making. Results on internal consistency reliability suggest the need for condition-specific questionnaires for children with SCI.     

A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries

Social Psychiatry and Psychiatric Epidemiology - Traditional and faith healers constitute an important group of complementary and alternative mental health service providers (CAPs) in sub-Sahara...     

Homocysteine fibrillar assemblies display cross-talk with Alzheimer’s disease β-amyloid polypeptide

High levels of homocysteine are reported as a risk factor for Alzheimer’s disease (AD). Correspondingly, inborn hyperhomocysteinemia is associated with an increased predisposition to the development of dementia in later stages of life. Yet, the mechanistic link between homocysteine accumulation and the pathological neurodegenerative processes is still elusive. Furthermore, despite the clear association between protein aggregation and AD, attempts to develop therapy that specifically targets this process have not been successful. It is envisioned that the failure in the development of efficacious therapeutic intervention may lie in the metabolomic state of affected individuals. We recently demonstrated the ability of metabolites to self-assemble and cross-seed the aggregation of pathological proteins, suggesting a role for metabolite structures in the initiation of neurodegenerative diseases. Here, we provide a report of homocysteine crystal structure and self-assembly into amyloid-like toxic fibrils, their inhibition by polyphenols, and their ability to seed the aggregation of the AD-associated β-amyloid polypeptide. A yeast model of hyperhomocysteinemia indicates a toxic effect, correlated with increased intracellular amyloid staining that could be rescued by polyphenol treatment. Analysis of AD mouse model brain sections indicates the presence of homocysteine assemblies and the interplay between β-amyloid and homocysteine. This work implies a molecular basis for the association between homocysteine accumulation and AD pathology, potentially leading to a paradigm shift in the understanding of AD initial pathological processes.

Alzheimer’s disease (AD) is the most common neurodegenerative disorder, currently affecting tens of millions of individuals globally and leading to immense social and financial impacts (1, 2). Despite the vast efforts to develop a pharmacological treatment for the disease, recent clinical trials had failed (3, 4). While it is very clear that amyloid formation is associated with AD (5, 6) and genetic variations in the gene coding for the β-amyloid polypeptide are associated with early onset of the disease (7), direct targeting of the aggregation of AD-associated pathological proteins and polypeptides has so far not resulted in clinical development of any disease-modifying treatment (8–10). Therefore, there is an essential need to understand the early biological changes that may induce the diverse pathologies observed in AD and other forms of dementia in order to identify new therapeutic targets (10).In the last decades, an enormous body of research had provided important information on the amyloid cascade, oxidative stress, and inflammatory response that are involved in AD (3, 11). Specifically, the notion of β-amyloid toxicity and extracellular plaque formation as the main cause of neuronal and synaptic loss has been extensively studied (12–14). Yet, the key to AD treatment and prevention remains elusive, and the initial steps leading to the formation and accumulation of these protein aggregates and the role of nonproteinaceous agents in this process are still not understood (10). Since only 1% of AD cases result from a familial mutation and the majority of patients are sporadic (2, 4), it is important to explore new directions to understand the biological mechanisms underlying these cases. Studies of metabolite profiling in brain regions and body fluids of AD and Parkinson’s disease (PD) patients show interference with specific metabolic pathways (15–19). Homocysteine (Hcy), a noncoded amino acid, was identified as a major risk factor for AD as high plasma concentrations were associated with the progression of the disease (20–22). Higher Hcy serum concentration was also correlated with behavioral and psychological symptoms of AD (23) and was associated with changes in motor function and cognitive decline in PD as well as with a more severe cognitive impairment in elderly adults (24–26). Furthermore, it was shown that significantly decreased hippocampal and cortical volume is associated with increased Hcy plasma concentration (27).Cystathionine β-synthase (CBS) deficiency, leading to excess of Hcy, results in the hyperhomocysteinemia inborn error of metabolism (IEM) disorder characterized by severe cognitive consequences (28–30). While elevated plasma Hcy is frequently reported as a strong and independent risk factor for the development of cognitive decline and dementia, the mechanism of its involvement is elusive (20, 31–34). Interestingly, the association between Hcy and AD-related pathological proteins was also demonstrated. Hcy-rich medium was shown to be cytotoxic to hippocampal and cortical neurons, resulting in increased β-amyloid–induced cell death (35–37). In addition, Hcy was found to bind β-amyloid_1-40, thereby stimulating β-sheet structure formation to facilitate its deposition. Indeed, induced Hcy accumulation in the brains of rats caused an elevation of β-amyloid deposition (38, 39). Furthermore, Hcy increased total tau and phosphorylated tau protein levels as well as the level of tau oligomers (40). Although the involvement of Hcy accumulation in AD pathology is evidential, no mechanistic insight has so far been suggested.We have previously demonstrated that small metabolites can self-assemble into amyloid-like structures with amyloidogenic characteristics (41–44). The presence of metabolite assemblies in IEM disorders (e.g., phenylalanine in Phenylketonuria) exemplifies their physiological importance in pathologically diversified diseases. Interestingly, recent studies demonstrated that metabolite assemblies could cross-seed the aggregation of proteins under physiological conditions, thereby suggesting a possible mechanism in which accumulated metabolites interfere with protein function and folding (45, 46). Assemblies of quinolinic acid, an endogenous neurometabolite that is involved in the pathology of PD, induce the aggregation of α-synuclein both in vitro and in cell culture (45). In addition, phenylalanine preformed fibrils were shown to initiate the aggregation of several proteins under physiological conditions (46). Metabolite accumulation, structure formation, and seeding of proteins may thus underlie the unknown role of metabolites in neurodegenerative pathologies (47). Specifically, seeding of amyloidogenic proteins by preformed fibrils may be part of the mechanisms underlying the stereotypical spreading of toxic aggregates in the brains of AD patients.We recently established an in vivo yeast model for IEM disorders by genetically modifying the yeast to reflect the mutations found in patients showing accumulation of the adenine nucleobase and its derivatives (48). Yeast model systems provide a powerful platform to elucidate the pathophysiology of diseases, as well as for the screening and development of disease-modifying therapeutics (49). This model was found to be a valid system, as supported by its robust sensitivity to adenine feeding and by the fact that adenine supramolecular structures could be detected. Furthermore, the addition of a generic fibrillation-modifying polyphenolic compound rescued the toxic effect without lowering the concentration of adenine, indicating the therapeutic potential of our model for the modulation of structure formation (48, 50).Here, aiming to explore the role of Hcy in AD, we demonstrate the formation of amyloid-like fibrils by Hcy in vitro and in vivo in a yeast model. Structural characterization of the Hcy fibrils and their cytotoxic effect were both studied. In addition, we revealed that polyphenolic inhibitors could rescue the toxic effect of Hcy assemblies and inhibit its structure formation. Remarkably, immunohistochemistry allowed the detection of Hcy fibrils in the brain of AD model mice as well as the apparent interplay between Hcy and β-amyloid. Finally, we demonstrated the cross-seeding of AD-related pathological protein by Hcy assemblies. Our work suggests a research direction for the association between metabolite accumulation and the initiation of neurodegenerative processes, thus offering a path for the development of therapeutic treatments that will target the key early stages of the disease.