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Bradykinin receptors as a therapeutic target.

Biologically-active kinins, including bradykinin (BK) and Lys(0)-BK (kallidin), are short-lived peptide mediators predominantly generated by the enzymatic action of kallikreins on kininogen precursors. A diverse spectrum of physiological and pathological actions attributed to local kinin production is a consequence of the activation of G-protein-coupled receptors (GPCRs). Currently, two major subtypes of kinin receptor, designated B(1) and B(2), are recognised, although there is much evidence for pharmacological heterogeneity, particularly within the B(2) receptors. Considering these facts and the widespread distribution of kinin receptors in many human tissues, it is no surprise that the therapeutic potential of kinins and kinin receptor antagonists remains the focus of numerous investigations. Studies in animals and animal tissues, instrumental in elucidating the biological roles of kinins, are well-documented in numerous excellent reviews. Unfortunately, and despite the enormous potential illustrated by animal studies, attempts to develop kinin analogues as therapeutic agents to combat human disease have largely proven disappointing. Consequently, this review selectively focuses upon studies that are directly relevant to the targeting of human BK receptors as a therapeutic intervention. In addition to providing a succinct review of well-documented pathological conditions to which kinin receptors contribute, the authors have also included more recent data that illustrate new avenues for the therapeutic application of kinin analogues.

Analgesics↗

Individualised cancer therapeutics: dream or reality?

Traditional measures for treating metastatic cancer involve identification of the originating organ from which the neoplasm arose and empirical treatment with cytotoxic chemotherapy. Arguably, with the exception of haematological malignancies, demonstration of efficacy in solid tumours has been limited. Over the past half-decade, theoretical and technological advances have resulted in greater application of molecular science to drug design, which has enabled development of new 'targeted' therapeutics. However, generic chemotherapy paradigms have not changed. Establishment of the optimal population for 'targeted' therapeutics based on molecular diagnostics (i.e. genomic and proteomic characterisation) to identify sensitive tumour-host ecosystems in individual patients at the 'bedside', is not being done as part of routine oncology management. This review focuses on the concept of designing individualised therapeutics based on genomic and proteomic profile of malignant tissue. Genetic and epigenetic perturbations in signal pathways drive cancer growth, survival, invasion and metastatic spread. The burgeoning evidence which supports the concept that each patient's cancer has a unique complement of pathogenic genetic and molecular derangements is reviewed. Such evidence supports the strategy of individualised selection of a therapeutic complex from a menu of targeting options that best complements the specific oncomolecular profile of the 'tumour-host' system.

Antineoplastic Agents↗

The negative therapeutic reaction: the uses of negation.

The negative therapeutic reaction can be used as a lens illuminating issues of psychoanalytic technique and therapeutic change. Its paradoxical development is examined within the context of current controversies involving the concepts of borderline personality organization and empathy. Negative therapeutic reactions are seen to reflect, among other failings, the failure of theory to "contain" dialectical tensions between self and other, subject and object, health and illness. Greater theoretical sophistication can point the way toward vigorous and more hopeful therapeutic engagement of these challenging reactions.

Borderline Personality Disorder↗

Toward a conceptual alliance about therapeutic alliance: a voyage through the Inferno.

I suggest that there is not a conceptual consensus in psychoanalysis regarding the therapeutic alliance. Some argue that the unobjectionable part of the transference should be facilitated; some argue that there is no unobjectionable part of the transference, that all parts should be subjected to analysis. There are those who argue that the therapeutic alliance exists in early treatment; others who argue that it exists later. I suggest using a classical text, Dante's Inferno, as a paradigm for a journey of self-discovery. By reviewing the moments of hesitation that Dante experiences with Virgil and how these are overcome, we cast light on our current problem on the nature of the therapeutic alliance and how to facilitate it. The components of the unobjectionable are related to Winnicott's idea of the maturational processes and Hartmann's (1958) ideas of the primary and secondary autonomous function. Based on their considerations, we make recommendations for use of the therapeutic alliance.

Humans↗

The road to providing human embryo stem cells for therapeutic use: the UK experience.

Harnessing the unparalleled properties of human embryo stem cells (hESCs) for the therapeutic treatment of disease and injury will require a convergence of scientific developments with regulatory standards. In the case of the latter, it is especially critical that standards for clinically assisted reproduction be harmonized with those governing human cell and tissue transplantation, most notably with respect to procurement, donation, testing, processing, preservation, storage and distribution of cells. In the UK, existing infrastructure to address these considerations is undergoing extensive reorganization to keep pace with evolving European Union standards. The present best paradigm for defining standards for the therapeutic use of embryo-derived stem cells is experience with adult haematopoietic stem cells (HSC). However, compared with adult-derived stem cell, the origin of embryo-derived stem cells from limiting quantities of tissue and their absolute dependence on in vitro culture to realise their therapeutic potential, makes optimization of their isolation and cultivation of even greater importance. Most notable is the requirement to create animal cell product-free culture environments to reduce the risk of cross-specific disease transmission. In the present paper, we review present and emerging standards in the isolation and banking of human embryo-derived stem cells for therapeutic use in the UK and international progress in the development of defined culture systems for this purpose.

Biological Specimen Banks↗

FLT3 antibody-based therapeutics for leukemia therapy.

Antibodies represent a unique class of therapeutics because of their high specificity toward a defined target antigen. Recent clinical success with antibody-based cancer therapeutics has led to an upsurge in the development of these agents. Antibodies directed against FLT3 represent a promising approach for the treatment of human leukemia. We discuss some basic aspects of antibody-based cancer therapeutics, including their mechanisms of action, with a focus on recent progress in the generation and development of anti-FLT3 antibodies as well as their therapeutic potentials in the treatment of human hematologic malignancies.

Animals↗

Collateral therapeutics for cerebral ischemia.

Current therapeutic strategies for acute ischemic stroke focus on vessel recanalization or penumbral neuroprotection without consideration of collaterals. Collateral circulation defines the extent of the ischemic penumbra, providing blood flow to tissues at risk of infarction downstream from an occluded artery. Therefore, leptomeningeal collaterals are a principal delivery route for oxygen, nutrients and potential therapeutic agents. Understanding of collateral anatomy and physiology is essential for the development of effective stroke treatments. Diagnostic imaging modalities may illustrate the penumbra from the collateral perspective, defining regions of relative ischemic vulnerability. Although specific collateral therapeutics are unrealized, insight may be gleaned from subtle details of prior stroke studies. Future advances will result from nascent research in therapeutic arteriogenesis and gene therapy adapted to the specific features of the cerebral circulation.

Brain Ischemia↗

Towards therapeutic vaccines for colorectal carcinoma: a review of clinical trials.

Colorectal carcinoma is a leading cause of cancer-related mortality. Despite the introduction of new cytotoxic drugs, improved surgical and radiotherapeutic techniques, a large proportion of colorectal carcinomas remain incurable. New targeted therapeutic strategies, including immunotherapy, are being explored as complementary treatments. Recent advances in immunology and molecular biology have opened new avenues for the clinical testing of rationally designed vaccination strategies against cancer. The present report reviews the results of therapeutic vaccine trials in colorectal carcinoma, published mainly in the past 6 years. Tumor-associated antigens (self-antigens) have been targeted by therapeutic vaccination in more than 2000 colorectal carcinoma patients. The results demonstrate that tumor antigen-specific immune responses are reproducibly induced; that is, tolerance can be reversed, without the induction of serious adverse events or autoimmune disorders. No long-term autoimmune side effects have been observed after a minimum follow-up of 4 years in over 700 patients. Over 1300 colorectal carcinoma patients with minimal residual disease have been enrolled in randomized controlled Phase II/III trials using autologous tumor cell vaccines. A significantly improved overall survival was noted for Stages I-IV colorectal carcinoma patients utilizing Newcastle-disease virus as an adjuvant. Autologous tumor cells mixed with bacillus Calmette-Guerin (BCG) were of significant clinical benefit for patients with Stage II colon cancer. Results of randomized controlled trials targeting Ep-CAM have shown clinical benefit in subgroups of patients. Several new generation vaccines have demonstrated excellent safety profile and immunogenicity. Some studies have also demonstrated a statistically significant correlation between the induced immune response and prolonged overall survival, which should be confirmed in enlarged trials. Although it is unlikely that active specific immunotherapy will provide a standard complementary therapeutic approach for colorectal carcinoma in the near future, the results so far are encouraging. Randomized controlled vaccine trials targeting molecularly defined tumor antigens are warranted, particularly in colon carcinoma with minimal residual disease.

Cancer Vaccines↗

Optimized antiretroviral therapy: the role of therapeutic drug monitoring and pharmacogenomics.

The identification of relationships between plasma concentrations of protease inhibitors and later, the non-nucleoside reverse transcriptase inhibitors and their efficacy and toxicity has caused a growing interest in the concept of therapeutic drug monitoring in the treatment of HIV infection. Some evidence suggests a beneficial effect of therapeutic drug monitoring of protease inhibitors. More recently, plasma protease inhibitor concentrations have been combined with viral susceptibility into one parameter, the inhibitory quotient, which may be a better predictor of the response to therapy, especially in pretreated patients. This paper reviews the current literature on therapeutic drug monitoring and the inhibitory quotient in the management of HIV infection and speculates on the future role of pharmacogenomics in this therapeutic area.

Anti-HIV Agents↗

[The therapeutic communication during installation of endovenous therapy: the use of video-taped simulation].

The use of therapeutic communication contributes to nursing care quality, mainly in procedures that cause fear and anxiety in patients, such as the installation of endovenous therapy. This study aimed to identify how nurses perceive therapeutic communication during the installation of endovenous therapy, as shown in a filmed simulation. This exploratory-descriptive and comparative study was developed in a Mexican city and involved 30 clinical nurses and 12 nursing faculty. The methodological process was: Construction and validation of textual content; Filming textual content with actors and validation; Presentation of the video to nurses and faculty and application of the semistructured questionnaire to identify therapeutic communication techniques in the simulation; perception of nurse-patient communication quality; perception of similarities between care practice and simulation; and difficulties to use these techniques in daily practice. Participants perceived the interpersonal relationship shown as "good"; they identified therapeutic communication techniques, which mostly corresponded to the description of the experience and expression of thoughts and feelings; no substantial difference was found between the perceptions of educational and care personnel. The most frequent difficulty to use communicative techniques was attributed to patients' problems to establish relations.

Communication↗

[Desire for information and participation in therapeutic decisions concerning severe diseases, in patients of a university hospital].

BACKGROUND: The purpose of our study was to evaluate the desire of the patients on being informed about diagnosis of severe diseases, the desire to have their families informed about this situation and to participate in therapeutic decisions. METHODS: 363 patients (outpatients and inpatients) of a General Internal Medicine division of a University Hospital were interviewed. The questionnaire contained specific questions on their desire to be informed of the diagnosis in case of cancer or AIDS and on their desire to have their families informed as well. Specific questions on whether they wanted to be informed of and participate of the therapeutic discussion process in case of abdominal tumors were also included. RESULTS: 96.1% of men and 92.6% of women showed the desire of being informed in case of cancer diagnosis and 87.7% of men and 84.2% of women wanted to have their families informed, 94.2% of men and 91% of women wanted to know the diagnosis of AIDS. While 86% of women and 76.6% of men wanted be informed in the case of a diagnosis of an abdominal tumor, only 58.5% of women and 39.6% of men wanted to give their opinion about in the case of different therapeutic alternatives. The desire to participate in therapeutic decisions was significantly lower (p<0.05) in men, people older than 60 years and inpatients. CONCLUSIONS: Our results showed that the great majority of the population that seeks for medical support in a Brazilian university hospital wishes to be informed on this health condition, even in case of serious illness. In addition, there are intense familiar bonds that make patients want to have their families also informed.

Acquired Immunodeficiency Syndrome↗

Developing therapeutics for the treatment of multiple sclerosis.

Multiple sclerosis (MS) is both a complex and chronic neurological disease of the CNS. This poses unique challenges for drug discovery in terms of delineating specific targets related to disease mechanisms and developing safe and effective molecules for clinical application. Preclinical animal models of MS provide the necessary test bed for evaluating the effects of novel therapeutic strategies. Because the clinical manifestations and pathological consequences of disease vary dramatically from individual to individual, as well as treatment response to existing therapies, this creates a significant research endeavor in terms of translating preclinical methodologies to the clinical domain. Potentially exciting treatments have emerged in the form of natalizumab (Tysabri), an alpha4 integrin antagonist, and more recently FTY720, a sphinogosine-1 phosphate receptor modulator, providing a compelling proof-of-principle from bench to bedside. However, further research is required to discharge safety concerns associated with these therapeutic avenues. Future prospects in the guise of disease-modifying therapies that target the inflammatory and neurodegenerative components of disease have come to the forefront of preclinical research with the sole aim of reducing the underlying irreversible progressive disability of MS. Significant progress with novel therapies will be made by implementing biomarker strategies that extrapolate robustly from animal models to the divergent patient populations of MS. The future therapeutic options for MS will depend on improvements in understanding the precise factors involved in disease onset and progression and subsequently the development of oral therapeutics that translate sustained benefit from the preclinical context into clinical reality.

Animals↗

Latest developments in gene transfer technology: achievements, perspectives, and controversies over therapeutic applications.

Over the last decade, more than 300 phase I and phase II gene-based clinical trials have been conducted worldwide for the treatment of cancer and monogenic disorders. Lately, these trials have been extended to the treatment of AIDS and, to a lesser extent, cardiovascular diseases. There are 27 currently active gene therapy protocols for the treatment of HIV-1 infection in the USA. Preclinical studies are currently in progress to evaluate the possibility of increasing the number of gene therapy clinical trials for cardiopathies, and of beginning new gene therapy programs for neurologic illnesses, autoimmuno diseases, allergies, regeneration of tissues, and to implement procedures of allogeneic tissues or cell transplantation. In addition, gene transfer technology has allowed for the development of innovative vaccine design, known as genetic immunization. This technique has already been applied in the AIDS vaccine programs in the USA. These programs aim to confer protective immunity against HIV-1 transmission to individuals who are at risk of infection. Research programs have also been considered to develop therapeutic vaccines for patients with AIDS and generate either preventive or therapeutic vaccines against malaria, tuberculosis, hepatitis A, B and C viruses, influenza virus, La Crosse virus, and Ebola virus. The potential therapeutic applications of gene transfer technology are enormous. However, the effectiveness of gene therapy programs is still questioned. Furthermore, there is growing concern over the matter of safety of gene delivery and controversy has arisen over the proposal to begin in utero gene therapy clinical trials for the treatment of inherited genetic disorders. From this standpoint, despite the latest significant achievements reported in vector design, it is not possible to predict to what extent gene therapeutic interventions will be effective in patients, and in what time frame.

Adenoviridae↗

Therapeutic effect of anti-TNF-alpha antibodies in an experimental model of anti-neutrophil cytoplasm antibody-associated systemic vasculitis.

The therapeutic options for anti-neutrophil cytoplasm antibody (ANCA)-associated systemic vasculitis (AASV) remain limited and hampered by adverse effects. One potential novel therapeutic avenue involves inhibition of TNF-alpha, with encouraging uncontrolled data in humans with one agent (infliximab) but disappointing controlled data from another (etanercept). For investigating the potential role of TNF-alpha as a therapeutic target in AASV, the effect of an anti-rat TNF-alpha mAb (CNTO 1081) in a rat model of AASV was investigated. For testing the effect of TNF-alpha blockade in this model, starting on day 28 after immunization (a point when glomerulonephritis is established), animals were randomized to treatment with CNTO 1081 or control mouse IgG. Treatment with CNTO 1081 significantly reduced albuminuria (mean 1.1 +/- 0.3 mg/24 h CNTO 1081 versus 8.0 +/- 1.9 controls; P < 0.05) and crescent formation (0% CNTO 1081 versus 60% controls; P < 0.05). Lung hemorrhage was also reduced (CNTO 1081: median score 0, range 0 to 2; controls: 2, range 1 to 3; P < 0.05). When analyzed by intravital microscopy, there was a 43% inhibition of leukocyte transmigration in mesenteric venules in response to topical CXCL1 (a neutrophil chemoattractant) in the CNTO 1081 group compared with controls (P < 0.001). Anti-myeloperoxidase antibody titers were similar in both groups throughout the study. In conclusion, these findings indicate that TNF-alpha plays an important role in the pathogenesis of experimental autoimmune vasculitis and suggest that blockade of this cytokine with an mAb is effective in treating established vasculitis. The therapeutic action of anti-TNF-alpha reagents may be mediated, in part, by suppression of the enhanced leukocyte-endothelial interactions in this disorder.

Animals↗

Preventing diabetic foot disease: lessons from the Medicare therapeutic shoe demonstration.

OBJECTIVES: Every year about 38,000 elderly people with diabetes have a lower extremity amputation. Therapeutic shoes are prescribed by clinicians specializing in foot care to prevent foot ulcerations and amputations among at-risk patients with diabetes. Medicare ran a 3-year demonstration of a therapeutic-shoe benefit for beneficiaries with diabetes. Medicare added the benefit nationwide in May 1993. METHODS: This paper describes the benefit and its implementation in the demonstration based on demonstration records, a patient survey, and discussions with clinicians and shoe suppliers before and during the demonstration. RESULTS: During the demonstration, far fewer beneficiaries applied for the therapeutic shoes than were eligible for them. The paper discusses reasons for the low beneficiary application rate and the associated low participation rate among physicians treating patients with diabetes. CONCLUSIONS: The benefit is unlikely to be used any more in the national program than in the demonstration unless physicians are educated in the role therapeutic shoes can play in diabetic foot disease, they prescribe the shoes for their patients, and they increase their patients' awareness of the shoes' value.

Centers for Medicare and Medicaid Services, U.S.↗

Therapeutic ineffectiveness: heads or tails?

Reporting of therapeutic ineffectiveness through adverse drug reaction spontaneous reporting systems has been proposed by some authors. In the WHO Adverse Reactions Terminology (WHO-ART) and Medical Dictionary for Regulatory Activities (MedDRA) terminology, the term therapeutic ineffectiveness includes drug interactions, resistance, tolerance and tachyphylaxis, as well as pharmaceutical defects such as substandard, adulterated, and counterfeit drugs. Under certain circumstances, reporting therapeutic ineffectiveness may contribute to identifying pharmaceutical defects. However, the best approach to avoid their occurrence would be implementing good manufacturing practices and strengthening quality control activities. This would prevent the misuse of spontaneous reporting of adverse drug reactions (e.g. when reporting of therapeutic ineffectiveness is 'suggested' by interested parties, especially when a generic product has been substituted for a branded original product).

Adverse Drug Reaction Reporting Systems↗

Therapeutic drug monitoring in the neonate and paediatric age group. Problems and clinical pharmacokinetic implications.

Therapeutic drug monitoring should encompass not only serum concentration monitoring but also assessments of organ and clinical functions. This is especially important in children, in whom receptor drug concentration or sensitivity may be different from that seen in the adult population. Therapeutic end-points should be identified and serum drug concentrations adjusted to meet these goals. This is further complicated by the added impact of pharmacokinetic idiosyncrasies displayed by children, coupled with the routine pitfalls of therapeutic drug monitoring seen in any patient population. Neonates and infants present the additional challenge of having a set of mechanisms whose degree of maturation sometimes changes on a day-to-day basis with alarming rapidity. It is this phenomenon which makes the definition of pharmacokinetic parameters following a single dose so unreliable and potentially hazardous. Therapy should be based not only on the capacity of the infant to eliminate and respond to a particular agent, but also on the understanding of the dynamic changes that will occur on an ongoing maturational basis. A basic familiarity with the patient population under study is essential in obtaining relevant data for pharmacokinetic analysis. Special consideration in children should focus on potential problems with drug administration, drug absorption, metabolite patterns, changing drug disposition, idiosyncratic reactions, receptor sensitivity and chronopharmacokinetics. As with other patient populations, serum drug concentration monitoring is only a small part of the clinical scenario, the whole of which must be the basis for therapeutic decisions and pharmacodynamic titration.

Child↗

Clinical pharmacokinetics of therapeutic bile acids.

The pharmacokinetics of chenodeoxycholic and ursodeoxycholic acids are reviewed in this article. Chenodeoxycholic acid is well absorbed by the intestine, whereas the absorption of ursodeoxycholic acid is incomplete. They are extracted efficiently by the liver, conjugated with glycerine and taurine, secreted in bile, and then undergo enterohepatic circulation with the endogenous bile acids. Therapeutic bile acids are metabolised by intestinal bacteria to lithocholic acid which is mainly excreted with faeces. Since the large majority of bile acid is confined within the enterohepatic circulation (resulting in low serum concentrations) their volume of distribution is relatively high. Despite the high hepatic extraction, the clearance of therapeutic bile acids is relatively low because of the highly efficient enterohepatic recirculation. Elimination of therapeutic bile acids mainly occurs in the faeces either unmodified or after biotransformation. At present the main clinical indication for therapeutic bile acids is ursodeoxycholic acid treatment for chronic cholestatic liver disease. In these patients, ursodeoxycholic acid is efficiently absorbed but its hepatic uptake and biliary secretion are impaired, thus leading to reduced biliary enrichment and high serum concentrations of this exogenous bile acid. In patients with cystic fibrosis-associated liver disease, bile acid malabsorption also occurs, thus indicating the need for higher dosages. The volume of distribution and clearance of ursodeoxycholic acid reduced in the presence of liver disease. Also in this case, elimination mainly occurs with the faeces but, in the presence of severe cholestasis, renal clearance may become relevant. Sulphation or conjugation with glucose and N-acetylglucosamine facilitate urinary excretion.

Absorption↗