Citations

Abstract Immune thrombocytopenia (ITP) is commonly encountered in clinical practice. In 1996 the American Society of Hematology published a landmark guidance paper designed to assist clinicians in the management of this disorder. Since 1996 there have been numerous advances in the management of both adult and pediatric ITP. These changes mandated an update in the guidelines. This guideline uses a rigorous, evidence-based approach to the location, interpretation, and presentation of the available evidence. We have endeavored to identify, abstract, and present all available methodologically rigorous data informing the treatment of ITP. We provide evidence-based treatment recommendations using the GRADE system in those areas in which such evidence exists. We do not provide evidence in those areas in which evidence is lacking, or is of lower quality—interested readers are referred to a number of recent, consensus-based recommendations for expert opinion in these clinical areas. Our review identified the need for additional studies in many key areas of the therapy of ITP such as comparative studies of “front-line” therapy for ITP, the management of serious bleeding in patients with ITP, and studies that will provide guidance about which therapy should be used as salvage therapy for patients after failure of a first-line intervention.

Abstract Purpose: SR13668, an orally active AKT pathway inhibitor, has demonstrated cancer chemopreventive potential in preclinical studies. To accelerate the clinical development of this promising agent, we designed and conducted the first-ever phase 0 chemoprevention trial to evaluate and compare the effects of food and formulation on SR13668 bioavailability. Patients and Methods: Healthy adult volunteers were randomly assigned to receive a single 38-mg oral dose of SR13668 in one of five different formulations, with or without food. Based on existing animal data, SR13668 in a PEG400/Labrasol@ oral solution (formulation 1) was defined as the reference formulation. Four self-emulsifying solid dispersion test formulations in capsules were also investigated: Solutol@ HS 15 (formulation 2), Solutol@ HS 15/Vitamin E TGPS (50/50 w/w %) (formulation 3), Vitamin E TGPS (formulation 4), and Myrj 53 (formulation 5). SR163668 bioavailability was compared using a two-stage study design. In stage I, participants were randomized to receive the formulation 1 with or without a high-fat meal after an overnight fast. In Stage II, participants were randomly assigned to receive the test formulations, using the preferred dietary condition identified in stage I. Blood samples were obtained pre- and post-agent administration for pharmacokinetic analyses. Area under the plasma concentration-time curve (AUC) was defined as the primary endpoint. Data were analyzed and compared using established statistical methods for phase 0 trials with a limited sample size. Results: Participants (N=20) were rapidly accrued over a 5-month period. Complete pharmacokinetic data were available for 18 randomized participants. The time to peak plasma concentration and half-life values for SR13668 were 3 hours (range, 2 — 6 hours) and 11.2 ± 3.1 hours, respectively, and were not dependent on the formulation. In stage I, the oral bioavailability of SR13668 in formulation 1 was greater under the fed versus fasting dietary state (p = 0.05, Wilcoxon rank-sum test). Therefore, the fed state was selected as the preferred dietary condition for stage II. In stage II, the bioavailability of SR13668 for each of the test formulations were compared with the bioavailability of formulation 1 in the fed state. While not significantly different from formulation 1, formulation 2 AUC0-24h was significantly different (p = 0.004, ANOVA) from formulation 3, 4, and 5 (AUC0-24h, formulation 1- 222 ± 53 ng/ml·hr; AUC0-24h, formulation 2 — 302 ± 78 ng/ml·hr; AUC-177±39ng/ml·hr; AUC-144±29 0-24h, formulation30-24h, formulation 4 ng/ml·hr; AUC0-24h, formulation 5- 98 ± 21 ng/ml·hr). Formulation 1 AUC0-24h was almost 40% lower than the value achieved with formulation 2, and not significantly different from formulation 3, 4, and 5. Thus, formulation 2 provided the highest bioavailability of SR13668. Conclusions: Using a novel, highly efficient study design, we rapidly identified a lead formulation (Solutol@ HS 15) of SR13668 for further clinical testing. Our findings support application of the phase 0 trial paradigm to accelerate chemoprevention agent development. Supported by NIH grants N01-CN-35000, CA15083-34C3 and UL1 RR024150. Citation Information: Cancer Prev Res 2010;3(12 Suppl):CN02-03.

AbstractThe antithrombotic surface of endothelium is regulated in a coordinated manner. Tissue factor pathway inhibitor (TFPI) localized at the endothelial cell surface regulates the production of FXa by inhibiting the TF/VIIa complex. Systemic homozygotic deletion of the first Kunitz (K1) domain of TFPI results in intrauterine lethality in mice. Here we define the cellular sources of TFPI and their role in development, hemostasis, and thrombosis using TFPI conditional knockout mice. We used a Cre-lox strategy and generated mice with a floxed exon 4 (TFPIFlox) which encodes for the TFPI-K1 domain. Mice bred into Tie2-Cre and LysM-Cre lines to delete TFPI-K1 in endothelial (TFPITie2) and myelomonocytic (TFPILysM) cells resulted in viable and fertile offspring. Plasma TFPI activity was reduced in the TFPITie2 (71% ± 0.9%, P < .001) and TFPILysM (19% ± 0.6%, P < .001) compared with TFPIFlox littermate controls. Tail and cuticle bleeding were unaffected. However, TFPITie2 mice but not TFPILysM mice had increased ferric chloride–induced arterial thrombosis. Taken together, the data reveal distinct roles for endothelial- and myelomonocytic-derived TFPI.

Despite numerous advances in interventional radiology and vascular surgery, the clinician continues to be confronted with inoperable vascular disease. Previous studies have shown that ulceration associated with a transcutaneous oxygen pressure (tcPO 2 )of,20 mmHg is refractory to all attempts at healing. External pneumatic compression for the treatment of peripheral vascular disease has been available for several years, although there is a relative paucity of data regarding its role in clinical practice as well as its efficacy. The objective of this study was to examine the experience with circulator boot therapy in the treatment of ischemic ulcers in the absence of osteomyelitis, and specifically to determine whether such therapy can be of benefit in ischemic limb ulceration associated with a tcPO 2 of,20 mmHg. A retrospective chart review was undertaken of all patients with a lower limb ulcer who, in the absence of osteomyelitis, underwent circulator boot therapy at the Gonda Vascular Center. A total of 98 patients was identified. Two patients died within 1 month of commencing therapy and were not included in further analysis. The tcPO 2 data were unavailable in five patients. Outcome in the patient population was classified as favorable if (1) healing was achieved, (2) the ulcer decreased in size, or (3) the affected limb improved sufficiently to allow successful revascularization. An unfavorable outcome was one where a major amputation was performed or where the ulcer increased in size. Out of a total of 29 patients with a tcPO 2 ,20 mmHg at the area of ulceration, 19 had a favorable outcome following circulator boot therapy. Of the remaining 62 patients with a tcPO 2 .20 mmHg, 54 had a favorable outcome. Circulator boot therapy is associated with improved outcomes in limb ulceration due to peripheral vascular disease. Complete ulcer healing as well as preservation of the affected limb can be achieved in most cases.