Successes Achieved and Challenges Ahead in Translating Biomarkers into Clinical Applications

Biomarkers are important tools for identifying and stratifying diseases, predicting their progression and determining the effectiveness, safety, and doses of therapeutic interventions. This is important for common chronic diseases such as diabetic nephropathy, osteoporosis, and rheumatoid arthritis which affect large numbers of patients worldwide. This article summarizes the current knowledge of established and novel biomarkers for each of these diseases as presented at the 2008 AAPS/ACCP joint symposium “Success Achieved and Challenges Ahead in Translating Biomarkers into Clinical Applications,” in Atlanta, Georgia. The advantages and disadvantages of various proteomic, metabolomic, genomic, and imaging biomarkers are discussed in relation to disease diagnosis and stratification, prognosis, drug development, and potential clinical applications. The use of biomarkers as a means to determine therapeutic interventions is also considered. In addition, we show that biomarkers may be useful for adapting therapies for individual needs by allowing the selection of patients who are most likely to respond or react adversely to a particular treatment. They may also be used to determine whether the development of a novel therapy is worth pursuing by informing crucial go/no go decisions around safety and efficacy. Indeed, regulatory bodies now suggest that effective integration of biomarkers into clinical drug development programs is likely to promote the development of novel therapeutics and more personalized medicine.     

Serological status: a predictor of response to intensive therapy in rheumatoid arthritis

BackgroundRheumatoid arthritis is the most common chronic inflammatory disease in the UK. Serological status such as rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA) positivity predict poor outcomes. Early intensive treatment regimens targeting remission reduce disease activity, structural damage, and long-term disability. However, we do not know whether all patients with active disease should have such intensive treatment regimens. Can serological status be used to predict the need for intensive therapy?MethodsWe analysed samples from a published randomised controlled trial which compared four treatment regimens in patients with early active rheumatoid arthritis (disease duration <2 years): methotrexate monotherapy, double therapy (methotrexate plus either ciclosporin or prednisolone), and triple therapy (methotrexate plus ciclosporin plus prednisolone). The trial randomised 467 patients (68% female, median age 54 years [IQR 46–63]). Disease activity was assessed with the disease activity score of 28 joints (DAS28). Remission was defined as DAS28 less than 2·6 at 24 months. RF isotypes (IgM and IgA) and ACPA levels were measured with commercial ELISA kits. Statistical analysis used Pearson's chi-squared test.Findings402 (86%) patients were positive for IgM RF, 346 (74%) for IgA RF, and 346 (74%) for ACPA. 98 (21%) patients achieved remission at 24 months. In RF IgM negative cases (n=65) the proportion of patients achieving remission at 24 months was similar in all treatment groups (25%, 22%, and 30% for monotherapy, double therapy, and triple therapy, respectively). In RF IgM positive cases, significantly fewer patients achieved remission with monotherapy (13/65, 17%) and double therapy (24/157, 15%) than with triple therapy (27/80, 34%) (p=0·001). There were similar, consistent findings with IgA RF and ACPA, with significantly more seropositive patients achieving remission with triple therapy than with monotherapy.InterpretationContemporary treatment of rheumatoid arthritis emphasises the use of intensive therapy to achieve remission. However, we have shown that not all patients require such an aggressive approach to therapy. Given the heterogeneity of the diease, treatment should be personalised to the individual, which would minimise costs of treatment as well as potentially toxic side-effects. Our study shows that only seropositive patients with rheumatoid arthritis should be given more intensive therapies.FundingNational Institute for Health Research.     

龙血竭胶囊治疗软组织挫伤230例

1 临床资料软组织挫伤460(男300,女160)例,年龄5～72(平均38)岁,面部伤86例,躯干伤98例,四肢伤200例,躯干合并四肢伤76例,均为12 h内收治病例. 实验组(n=230)给于龙血竭胶囊(龙血竭胶囊是由植物防卫素和龙血竭皂甙组成)口服,3次/d,每次1.2 g;对照组(n=230)给于跌打丸口服,2次/d,每次1丸,疗程均为6 d. 实验组总有效率为96.5%,对照组为83.5%,两组间有显著差别(P<0.01). 实验组用药后3和6 d血糖值均较对照组有明显下降(P<0.01). 实验组与对照组用药后总抗氧化能力(TAO, kU/L)均升高(12.5±0.08→42.5±0.03, 12.6±0.05→32.9±0.04),但实验组升高明显(P<0.01).     

MKK3 signalling plays an essential role in leukocyte-mediated pancreatic injury in the multiple low-dose streptozotocin model

In vitro studies have implicated activation of the p38 mitogen-activated protein kinase (MAPK) signalling pathway in cytokine-mediated pancreatic beta-cell injury. Activation of the p38 MAPK occurs through two different upstream kinases, mitogen-activated protein kinase kinase 3 (MKK3) and MKK6. This study examined the role of MKK3 signalling in an in vivo model of cytokine-dependent pancreatic injury induced by multiple low doses of streptozotocin (MLD-STZ). Groups of wild-type (WT) or Mkk3-/- C57BL/6J mice received 5 daily injections of STZ (40 mg/kg) and were killed on day 5, week 2 or week 4. MLD-STZ in WT mice exhibited two distinct phases of pancreatic damage: islet cell apoptosis (immunostaining for cleaved caspase-3) on day 5 in the absence of leukocyte infiltration, and this was followed by islet inflammation (leukocyte infiltration and cytokine production) and further islet cell apoptosis on day 14 resulting in a loss of insulin-producing beta-cells and an 80% incidence of hyperglycaemia. Mkk3-/- mice were not protected from the initial phase of STZ-induced islet cell apoptosis day 5. However, Mkk3-/- mice were completely protected from the induction of hyperglycaemia. This was attributed to inhibition of leukocyte infiltration, production of pro-inflammatory cytokines and islet cell apoptosis at day 14 of MLD-STZ. In vitro studies showed that cultured islets from Mkk3-/- and WT mice are equally susceptible to STZ and cytokine-induced apoptosis. In conclusion, MKK3 signalling plays an essential role in the development of islet inflammation leading to destruction of beta-cells and hyperglycaemia in MLD-STZ-induced pancreatic injury.     

Cytosine arabinoside, etoposide and aclarubicin (AVA) for the treatment of acute myeloid leukemia (AML) in elderly patients

Background: Elderly patients (age 60 years) with acute myeloid leukemia (AML) have unfavourable prognoses when polychemotherapy regimens are used, because therapy response is characterized by low remission rates, short remission duration and high toxicity.Patients and methods: A phase II trial in elderly AML patients was conducted to determine the efficacy of two induction courses of a moderately-dosed combination of aclarubicin (25 mg/m², 30 min i.v., days 1–4), etoposide (100 mg/m², 30 min i.v., days 1–3) and conventional-dose cytosine arabinoside (Ara-C, 100 mg/m², c.i.v., days 1–3 and 30 min i.v., q 12 hours, days 4–7) (AVA-7), followed by one consolidation treatment using a reduced-dose schedule over five days (AVA-5) after three months in CR.Results: Thirty-two AML patients with a median age of 66.2 years (range 60–76) were included in the study: three of them had histories of preexisting myelodysplasia and one of polycythemia vera. Following 1–2 courses of AVA-7 17 patients (53%) achieved CR, two PR (6%), and nine had resistant disease (28%); the overall response rate was thus 59%. Toxicity was significant but acceptable, with an overall treatment-related death rate of five of 32 patients (16%) after 63 courses of AVA. The median disease-free survival (DFS) was 12 months, and the median survival of all patients was 16.6 months.Conclusions: These results indicate that the combination of aclarubicin, etoposide and conventional-dose Ara-C is effective in elderly AML patients. The relatively brief remission duration requires new consolidation and maintenance therapy approaches.     

Modulation of the eosinophil chemotactic factor (ECF) release from various cells and their subcellular components by phospholipids

An eosinophil chemotactic factor (ECF) can be released from human polymorphonuclear neutrophils (PMN), rat mononuclear and rat mast cells by the calcium ionophore (A23187), during phagocytosis, by arachidonic acid and phospholipase A2. It has been suggested that stimuli such as the ionophore and the phagocytic event lead to phospholipid turnover with the generation of arachidonic acid which is subsequently transformed by a lipoxygenase-like enzyme into ECF. Addition of phospholipids such as phosphatidylethanolamine and phosphatidylinositol during ionophore stimulation of various cells increased the ECF release significantly. ECF activity is also enhanced in the presence of indomethacin at concentrations which inhibit prostaglandin synthesis. With bromphenylacylbromide and eicosatetraynoic acid, ECF generation as well as the chemotaxis of eosinophils is inhibited suggesting that the phospholipase A2-arachidonic acid pathway represents a common link for ECF release as well as for the chemotaxis of eosinophils. From the cytosol of human PMN an ECF-containing enzyme was obtained. Incubation of phospholipase A2 and phospholipids with the ECF-converting enzyme led to potent ECF indicating that addition of phospholipids provides the soluble ECF-generating system with an additional source of arachidonic acid. The data represent a molecular approach to analyze the mechanisms of ECF release from soluble components after immunological triggering of the cells.     

Effects of eccentric and concentric resistance training on skeletal muscle substrates, enzyme activities and capillary supply

This study compared the skeletal muscle metabolic adaptations in response to combined eccentric and concentric or concentric resistance training regimens. Twenty-six physically active males were assigned to either the combined eccentric and concentric group (n = 10), the concentric group (n = 10) or the control group (n = 6). The combined eccentric and concentric and the concentric groups performed four to five sets of maximal, voluntary bilateral quadriceps muscle actions at 1.05 rad s-1 using a speed-controlled dynamometer three times per week for 12 weeks. The concentric group performed 12 concentric actions per set, whereas the combined eccentric and concentric group performed six coupled eccentric and concentric actions per set. Bilateral percutaneous muscle biopsies were obtained from m. vastus lateralis at rest pre- and post-training. Tissue samples were analysed for contents of adenosine triphosphate, creatine phosphate and creatine and for enzyme activities of citrate synthase, lactate dehydrogenase, myokinase, phosphofructokinase, hexokinase and Mg2(+)-ATPase using fluorometric techniques. Histochemical staining procedures were employed to determine capillary supply. The overall increase (P less than 0.05) in muscle strength was greater (P less than 0.05) for the combined eccentric and concentric group than for the concentric group. Enzyme or substrate contents and capillary supply were unaltered after either type of training. It is suggested that substantial increases in muscle strength may occur in response to resistance training without enhancing or compromising metabolic function of skeletal muscle.     

Isometric muscle endurance during acute beta-adrenergic blockade

Isometric muscle endurance was measured in fourteen physically active men without (placebo) and after acute oral administration of 160 mg propranolol (Inderal). Quadriceps muscle contractions were sustained at 65% maximum voluntary contraction (MVC) to exhaustion. Muscle biopsies were obtained from m. vastus lateralis at rest for subsequent histochemical analysis for myofibrillar ATPase and amylase-PAS in order to determine fiber type composition and capillary density. The time to exhaustion was shorter (p less than 0.01) during beta-blockade (0.82 +/- 0.22) min than placebo (0.90 +/- 0.23) min. Changes in endurance time, induced by beta-blockade, were not correlated with any of the muscle morphological or histochemical variables examined. It is concluded that muscular performance is impaired as a result of beta-blockade on muscle tissue irrespective of any concomitant change in central circulation.