Miller, Virginia M.

Abstract Differences in patient characteristics, including age, sex, and race influence the safety and effectiveness of drugs, biologic products, and medical devices. Here we provide a summary of the topics discussed during the opening panel at the 2018 Johns Hopkins Center for Excellence in Regulatory Science and Innovation symposium on Assessing and Communicating Heterogeneity of Treatment Effects for Patient Subpopulations: Challenges and Opportunities . The goal of this session was to provide a brief overview of FDA‐regulated therapeutics, including drugs, biologics and medical devices, and some of the major sources of heterogeneity of treatment effects (HTE) related to patient demographics, such as age, sex and race. The panel discussed the US Food and Drug Administration's role in reviewing and regulating drugs, devices, and biologic products and the challenges associated with ensuring that diverse patient populations benefit from these therapeutics. Ultimately, ensuring diverse demographic inclusion in clinical trials, and designing basic and clinical research studies to account for the intended patient population's age, sex, race, and genetic factors among other characteristics, will lead to better, safer therapies for diverse patient populations.

Objectives Sex as a biological variable affects response to opioids. However, few reports describe the prevalence of specific adverse reactions to commonly prescribed opioids in men and women separately. A large cohort was used to investigate sex differences in type and occurrence of adverse reactions associated with use of codeine, tramadol, oxycodone and hydrocodone. Design Retrospective cohort study. Setting Participants in the Right Drug, Right Dose, Right Time (RIGHT) Study. Participants The medical records of 8457 participants in the RIGHT Study who received an opioid prescription between 1 January 2004 and 31 December 2017 were reviewed 61% women, 94% white, median age (Q1–Q3)=58 (47–66). Primary and secondary outcome measures Adverse reactions including gastrointestinal, skin, psychiatric and nervous system issues were collected from the allergy section of each patient’s medical record. Sex differences in the risk of adverse reactions due to prescribed opioids were modelled using logistic regression adjusted for age, body mass index, race and ethnicity. Results From 8457 participants (of which 449 (5.3%) reported adverse reactions), more women (6.5%) than men (3.4%) reported adverse reactions to at least one opioid (OR (95% CI)=2.3 (1.8 to 2.8), p<0.001). Women were more likely to report adverse reactions to tramadol (OR (95% CI)=2.8 (1.8 to 4.4), p<0.001) and oxycodone (OR (95% CI)=2.2 (1.7 to 2.9), p<0.001). Women were more likely to report gastrointestinal (OR (95% CI)=3.1 (2.3 to 4.3), p<0.001), skin (OR (95% CI)=2.1 (1.4 to 3.3), p=0.001) and nervous system issues (OR (95% CI)=2.3 (1.3 to 4.2), p=0.004). Conclusions These findings support the importance of sex as a biological variable to be factored into pain management studies.

A history of preeclampsia (PE) places women at higher risk for future cardiovascular disease and cognitive decline. We have previously shown that postmenopausal women with a history of PE demonstrated a reduced cerebral blood flow response to hypercapnia compared with postmenopausal women with a history of a normotensive pregnancy (NP). These findings suggest cerebrovascular effects of PE 30+ years postpartum. In addition, we have reported that women with a history of PE did not have an exaggerated pressor response to a sympathoexcitatory stimulus. However, it is possible that women with a history of PE may have an altered cerebral blood flow response to a sympathoexcitatory stimulus. In this study, middle cerebral artery blood velocity (MCAv) and beat‐to‐beat mean arterial blood pressure (MAP) were measured during isometric handgrip to fatigue (IHG) at 30% of maximal voluntary contraction followed by post‐exercise ischemia (PEI) for 90 seconds and a two minute recovery period (REC). Participants were postmenopausal women with a history of PE (n = 21; age at study = 58±5 y; years since last pregnancy = 35±3 y) and NP (n = 27; age at study = 58±5 y; years since last pregnancy = 35±3 y). Baseline MAP and MAP responses to IHG and PEI were similar between groups (p>0.05). PE women demonstrated lower MCAv at baseline (NP: 72±3 cm/s vs. PE: 57±4 cm/s), IHG (NP: 78±4 cm/s vs. PE: 63±4 cm/s), PEI (NP: 74±4 cm/s vs. PE: 60±4 cm/s), and REC (NP: 70±3 cm/s vs. PE: 58±4 cm/s) compared with NP women (p<0.05 for all). MCAv, when calculated as a percent change from baseline, was elevated during IHG in both PE and NP women as expected (p<0.05); however, PE women had an augmented MCAv response during the last third of IHG compared with NP women (NP: 9±2 % vs. PE: 13±2 %; p<0.05). PE women also had a higher MCAv response during REC compared with NP women (NP:−2±2% vs. PE: 3±2%; p<0.05). Importantly, these elevated MCAv responses occurred despite the fact that MAP was not different between groups. In summary, PE women demonstrated a lower basal cerebral blood velocity but an elevated cerebrovascular response to a sympathoexcitatory stimulus compared with NP women. This suggests that in postmenopausal women, there is an effect of pregnancy history on the sensitivity of the cerebral blood flow response to a sympathoexcitatory stimulus. Support or Funding Information NIH: AG 044170. This investigation was supported by the National Institutes of Health, under Ruth L. Kirschstein National Research Service Award T32 HL 007936 from the National Heart Lung and Blood Institute to the University of Wisconsin‐Madison Cardiovascular Research Center. This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Biologic nanoparticles (NPs) can be isolated from bovine serum, human kidney stones, and human arterial calcifications. In addition, it is possible to detect both antigen and antibody for NPs in human blood, suggesting that perhaps NPs represent a novel infectious agent participating in human disease. However, it is not known when and how persons might become exposed to NPs and if exposure produces sensitization to subsequent exposures. Experiments were designed to determine whether exposure to nanoparticles would induce an immune response in rabbits that can be detected by a delayed‐type hypersensitivity test. Rabbits were injected intravenously with bovine‐derived NPs (1ml of 1000NTU solution). Plasma was collected prior to injection and on days, 3, 7, 14, 21, 28, 35 post‐injection. At this time, NPs (1ml of 1000NTU solution) were injected subcutaneously in the ear of exposed and naïve rabbits. Areas of injection were observed daily and after three days, blood and ears were collected for analysis. Injection sites showed leukocyte infiltration only in ears of rabbits previously exposed to NPs. These data indicate that biologic NPs induce immune sensitization in rabbits.

Heterogeneous, phospholipid‐rich sub‐micron vesicles (“microvesicles”) shed by activated vascular and blood cells may reflect or influence the coagulant propensity of blood. To determine how the anticoagulant used to collect the blood affects microvesicle (Mv) recovery and characteristics, blood was collected from laboratory volunteers and participants of the Kronos Early Estrogen Prevention Study (KEEPS) into tubes containing either sodium citrate, EDTA or hirudin plus tick anticoagulant peptide (H&T). Microvesicles prepared by double centrifugation were analyzed by flow cytometry to define size and surface markers. There were 2–3 times the number of platelet‐derived (CD61 positive) Mv in preparations from citrate and H&T plasma, relative to numbers in EDTA plasmas. Procoagulant activity of Mv was determined by surface phosphatidylserine (PS) expression using annexin‐V‐fluorescein. Annexin‐V (PS) positive Mv did not differ, but total (PS positive and negative) Mv was 2 fold lower from EDTA plasma compared to citrate and H&T. These results suggest that anticoagulation of blood itself alters microvesicle characteristics. Therefore, standardization and specification of the anticoagulant is warranted to identify potential contribution of microvesicles to cardiovascular pathophysiology. Funded by, NIH HL78638, Kronos Research Institute and Mayo Foundation.

Estrogen receptor beta (βER) is present in platelets but little is known about how βER contributes to platelet physiology. Platelet mitochondrial function and circulating platelet‐derived microparticles were analyzed in aged (24 months old) female wild type (WT) and estrogen receptor beta knockout (βERKO) mice. In intact, unstimulated platelets, ERβ did not co‐localized with mitochondria. Platelet lactate production, mitochondrial membrane potential and superoxide generation were similar in both groups, but activities of cytochrome bc 1 and cytochrome c oxidase were significantly less (P<0.05) in platelets of βERKO mice. Total numbers of platelet‐derived microparticles and those positive for procoagulant phosphatidylserine (PS) were two to three times higher (P<0.05) in βERKO than WT mice. Greater than 40% of procoagulant microparticles were derived from cells other than platelets in both groups of mice. Thrombin generating capacity of microvesicles was also greater in βERKO mice. Thus, loss of βER leads to significant changes in activities of enzymes of the mitochondrial electron transport system, and to increases in circulating procoagulant microparticles which may contribute to an increased thrombotic risk with aging in persons with βER gene polymorphisms. This study is supported by HL78638, AHA30503Z and Mayo Foundation.

Biologic nanoparticles (NPs) isolated from human arterial calcifications and kidney stones form an adherent film on the bottom of flasks when placed in standard cell culture conditions. Since NPs have certain features consistent with microorganisms, we hypothesized that antibiotics and/or RNAse might inhibit this biofilm formation. NPs isolated from calcified human arterial tissue were cultured onto glass coverslips in 24‐well plates containing DMEM with 10% fetal calf serum, plus either no treatment (control), RNase, tetracycline or gentamicin. At 1, 7 and 14 days after inoculation, coverslips were fixed, mounted, and analyzed using a CytoViva darkfield scope and KS‐400 imaging software. In control wells, the percent coverslip covered by biofilm increased by 120% from day 1 to day 14, compared to 47% and 35% in wells treated with RNase and gentamicin, respectively. Wells treated with tetracycline showed a 3% decrease in biofilm by day 14. Since RNase should not enter intact cells, these results indicate that extracellular RNA may play a role in biofilm formation by NPs. Although tetracycline can chelate calcium, it also inhibits ribosomal function, as does gentamicin. Therefore these results also suggest that intact ribosomal function is required for NP‐associated biofilm growth. These experiments suggest that biofilm formation by NPs consists of biological as well as physicochemical processes.

There is large variation in response to menopausal hormone treatments among women and it remains unclear as to what genetic factors might increase risk of breast cancer in women using such treatments to relieve symptoms of menopause. SULT1A1 is a ubiquitous enzyme involved in the metabolism of steroid hormones including estrogen. A number of polymorphisms in the gene for this enzyme are associated with various cancer risks and the activity level of the enzyme is correlated closely with variation in copy number of the gene. This pilot study evaluated SNP variation and copy number of SULT1A1 in a subset of women (n=156) being screened for the Kronos Early Estrogen Prevention Study (KEEPS). All participants gave written informed consent. DNA prepared from blood was genotyped for SULT1A1 copy number, rs3760091 and rs750155 from the promoter region of SULT1A1, and rs9282861 from the coding region (SULT1A1*2 variant). In this cohort, 5.2% had 1 copy of SULT1A1, 65.2% had 2 copies, 23.9% had 3 copies, and 5.8% had 4 copies. Previously reports of the allele frequency for the three SNPs did not take into account gene copy number. When copy number was taken into account, allele frequency was significantly different, a fact that will have to be taken into account in future genotype‐phenotype correlations. (Supported by grants from the Kronos Longevity Research Institute, NIH HL90639, RR24150 and GM61388.)

Biologic nanoparticles (NPs) isolated from human atheromas propagate and form an apatite shell when placed in cell‐culture conditions. These characteristics led us to hypothesize that NPs might derive from microorganisms. NPs isolated from human aortic aneurysms and maintained in DMEM, 10% fetal bovine serum at 37 o C increased both in density (measured in nephelometric turbidity units, NTU) from 1.6 to 107.1 and in diameter (from < 0.2 μm to 0.5‐1 μm) over the course of 12 days. Crystals present on the surface of NPs were found by electron microscopy/elemental analysis to be composed of Ca 2+ and P i . NPs adhered to the surface of the culture flasks, forming a biofilm strikingly similar to that seen in microbial communities. Confocal laser scanning microscopy showed that the biofilm stained positively with concanavalin‐A, a probe for mannose and glucose, both major constituents of microbial biofilm matrix exopolysaccharides. Further, the biofilm stained positively by Bac Light Green, a bacteria‐specific cell wall label, as well as the lipid membrane‐selective dye Vybrant CM‐DiI. These results reveal that calcifying NPs isolated from human atheromas share characteristics common to bacteria since they propagate when placed in cell culture conditions, form a biofilm containing polysaccharides, and stain with agents that recognize bacterial components. Supported by grants from the Fetzer Foundation and NIH HL88988.

Experiments were designed to determine if short‐term exposure to LPS affected transdifferentiation of arterial smooth muscle cells to express bone‐related proteins. Smooth muscle cells were grown to 90% confluency (passage 4 to 5), in M199 medium (control solution). Either LPS (100pg/ml, low; 100ng/ml, mid; 10μg/ml, high) or equal volume of vehicle was added to the media for 3 days at which time the media was exchanged for control solution. Cells were collected at 3, 6, and 12 days after exposure to LPS or vehicle. Expression of smooth muscle phenotypic proteins (desmin, vimentin, αSM‐actin) and bone‐associated phenotypic proteins (matrix gla protein, MGP; osteoprotegrin, OPG, and bone sialoprotein, BSP) were determined by Western blot. Intracellular calcium was measured by colorimetric method and alkaline phosphatase activity was measured by pNPP phosphatase assay. Exposure to mid‐concentration of LPS for 3 days transiently increased then decreased only desmin expression. LPS at mid‐ and high concentrations significantly increased expression of MGP, BSP and OPG, an increase which was sustained for 9 days after removal of LPS. Intracellular calcium concentration showed a time dependent decrease in all groups. Exposure to LPS augmented the decrease 3 days after removal of LPS. Alkaline phosphatase activity decreased at 6 days in the mid and high LPS groups and in all groups at day 12. These results indicate that short‐term exposure (3 days) of smooth muscle cells to LPS specifically modulates a SMC‐phenotypic protein and dose‐dependently facilitates expression of bone‐associated proteins. These findings suggest that infection may contribute to arterial calcification by facilitating transdifferentiation of smooth muscle cells.