Do N-of-1 Trials Need IRB Review?

There is no standard policy regarding the regulatory or institutional approval of N-of-1 trials in the United States. The objective of this study was to examine whether institutional review boards (IRBs) accredited by the Association for the Accreditation of Human Research Protection Programs (AAHRPP) consider N-of-1 trials as meeting the definition of human subjects research (45CFR46.102) and requiring IRB approval. A questionnaire was distributed via email to 170 AAHRPP-accredited IRBs in the United States. Responses were analyzed using statistical and qualitative methods. Nineteen of 59 respondents reported viewing N-of-1 trials as research. Twelve respondents reported having a policy regarding N-of-1 trials, and in all cases, such policies did not consider N-of-1 trials as meeting the definition of research. This topic deserves wider examination in the IRB literature and community to inform policies and guidance as N-of-1 trials become more common in the pursuit of personalized, precision medicine.

Nocardia-induced granulocyte macrophage colony-stimulating factor is neutralized by autoantibodies in disseminated/extrapulmonary nocardiosis.

BACKGROUND: Nocardia species cause infections in both immunocompromised and otherwise immunocompetent patients, although the mechanisms defining susceptibility in the latter group are elusive. Anticytokine autoantibodies are an emerging cause of pathogen-specific susceptibility in previously healthy human immunodeficiency virus-uninfected adults, including anti-granulocyte macrophage colony-stimulating factor (GM-CSF) autoantibodies with cryptococcal meningitis. METHODS: Plasma from patients with disseminated/extrapulmonary nocardiosis and healthy controls was screened for anticytokine autoantibodies using a particle-based approach. Autoantibody function was assessed by intranuclear staining for GM-CSF-induced STAT5 phosphorylation in normal cells incubated with either patient or normal plasma. GM-CSF-mediated cellular activation by Nocardia was assessed by staining for intracellular cytokine production and intranuclear STAT5 phosphorylation. RESULTS: We identified neutralizing anti-GM-CSF autoantibodies in 5 of 7 patients studied with central nervous system nocardiosis and in no healthy controls (n = 14). GM-CSF production was induced by Nocardia in vitro, suggesting a causative role for anti-GM-CSF autoantibodies in Nocardia susceptibility and dissemination. CONCLUSIONS: In previously healthy adults with otherwise unexplained disseminated/extrapulmonary Nocardia infections, anti-GM-CSF autoantibodies should be considered. Their presence may suggest that these patients may be at risk for later development of pulmonary alveolar proteinosis or other opportunistic infections, and that patients may benefit from therapeutic GM-CSF administration.

Acute hypertension: a systematic review and appraisal of guidelines.

BACKGROUND: Few clinical practice guidelines provide management recommendations for acute hypertensive episodes except in the context of specific conditions such as pregnancy and stroke. METHODS: We performed a systematic search to identify guidelines addressing acute hypertension and appraised the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) validated quality assessment tool. Two reviewers independently appraised and one extracted key recommendations. Literature on secondary hypertension, hypertension in pregnancy, preeclampsia/eclampsia, stroke, aortic dissection, and pheochromocytoma was excluded. RESULTS: Three guidelines were identified, sponsored by the American College of Emergency Physicians (ACEP), the National Heart, Lung, and Blood Institute (NHLBI), and the European Society of Hypertension (ESH) in conjunction with the European Society of Cardiology (ESC). AGREE II yielded mean domain (%) and overall assessment scores (1-7) as follows: NHLBI: 73%, 5.5; ACEP: 67%, 5.5; and ESH/ESC: 56%, 4.5. In hypertensive emergencies, the NHLBI guideline recommends reducing mean arterial pressure by ≤25% for the first hour, and then to 160/100-110 mmHg by 2-6 hours with subsequent gradual normalization in 24-48 hours. The ESH/ESC has similar recommendations. The ACEP does not address guidelines for hypertensive emergency but focuses on whether screening for target organ damage or medical intervention in patients with asymptomatic elevated blood pressure in emergency departments reduces the rate of adverse outcomes, concluding that routine screening does not reduce adverse outcomes, but patients with poor follow-up may benefit from routine screening. CONCLUSION: NHLBI and ESH/ESC guidelines are high quality and provide similar recommendations for management of asymptomatic acute hypertensive episodes and hypertensive emergencies. Additional research is needed to inform clinical practice guidelines for this common condition.

Muscarinic agonists and antagonists: effects on gastrointestinal function.

Muscarinic agonists and antagonists are used to treat a handful of gastrointestinal (GI) conditions associated with impaired salivary secretion or altered motility of GI smooth muscle. With regard to exocrine secretion, the major muscarinic receptor expressed in salivary, gastric, and pancreatic glands is the M3 with a small contribution of the M1 receptor. In GI smooth muscle, the major muscarinic receptors expressed are the M2 and M3 with the M2 outnumbering the M3 by a ratio of at least four to one. The antagonism of both smooth muscle contraction and exocrine secretion is usually consistent with an M3 receptor mechanism despite the major presence of the M2 receptor in smooth muscle. These results are consistent with the conditional role of the M2 receptor in smooth muscle. That is, the contractile role of the M2 receptor depends on that of the M3 so that antagonism of the M3 receptor eliminates the response of the M2. The physiological roles of muscarinic receptors in the GI tract are consistent with their known signaling mechanisms. Some so-called tissue-selective M3 antagonists may owe their selectivity to a highly potent interaction with a nonmuscarinic receptor target.

Neuronally released acetylcholine acts on the M2 muscarinic receptor to oppose the relaxant effect of isoproterenol on cholinergic contractions in mouse urinary bladder.

We investigated whether M(2) muscarinic receptor activation opposes isoproterenol-induced relaxation in mouse urinary bladder and whether endogenous acetylcholine acts through a similar M(2) mechanism. When measured in urinary bladder from M(3) receptor knockout mice, the muscarinic agonist oxotremorine-M elicited only very weak contractions. In the presence of alpha,beta-methylene ATP (30 microM) and isoproterenol (1 microM), however, oxotremorine-M elicited a robust contractile response. This response was completely absent in bladder from M(2)/M(3) double knockout mice, indicating that activation of the M(2) receptor inhibits the relaxant effect of isoproterenol on the contraction to alpha,beta-methylene ATP. Similar results were obtained when prostaglandin F(2alpha) (5 microM) was used as the contractile agent but not when serotonin was used. Electrical field stimulation of the urinary bladder from wild-type mouse elicited contractions that were inhibited 20% by atropine and 40% by desensitization with alpha,beta-methylene ATP. When measured in the presence of alpha,beta-methylene ATP to desensitize the purinergic component of contraction, isoproterenol exhibited moderately greater relaxant activity in field-stimulated bladder from the M(2) knockout mouse compared with that observed in wild-type bladder. This differential relaxant effect of isoproterenol was greatly increased in the presence of physostigmine. In contrast, no differential effects were noted for isoproterenol in similar experiments on bladders from M(3) knockout and M(2)/M(3) double knockout mice in the presence of physostigmine. Our results suggest that neuronally released acetylcholine acts on the M(2) muscarinic receptor to inhibit the relaxant effect of isoproterenol on the minor, cholinergic component of contraction in the field-stimulated mouse urinary bladder.

Homocysteine and folate deficiency sensitize oligodendrocytes to the cell death-promoting effects of a presenilin-1 mutation and amyloid beta-peptide.

Although damage to white matter occurs in the brains of patients with Alzheimer's disease (AD), the underlying mechanisms are unknown. Recent findings suggest that individuals with elevated levels of homocysteine are at increased risk of AD. Here we show that oligodendrocytes from mice expressing a mutant form of presenilin-1 (PS1) that causes familial AD exhibit increased sensitivity to death induced by homocysteine compared to oligodendrocytes from wild-type control mice. Homocysteine also sensitized oligodendrocytes to the cytotoxicity of amyloid beta-peptide. Folate deficiency, which is known to result in elevated levels of homocysteine in vivo, also sensitized oligodendrocytes to the cell-death-promoting actions of mutant PS1 and amyloid beta-peptide. Inhibitors of poly (ADP-ribose) polymerase and p53 protected oligodendrocytes against cell death induced by homocysteine and amyloid beta-peptide, consistent with a role for a DNA-damage response in the cell death process. These findings demonstrate an adverse effect of homocysteine on oligodendrocytes, and suggest roles for homocysteine and folate deficiency in the white matter damage in AD and related neurodegenerative disorders.

Male-female differences in the relative contribution of endothelial vasodilators released by rat tail artery.

Several different vasodilator substances can be released by vascular endothelium in response to mechanical stimuli and vasoactive agents. The purpose of this study was to determine whether there is a male-female difference in the relative contributions of nitric oxide (NO) and endothelium-derived hyperpolarizing factor (EDHF) to endothelium-dependent vasodilation. Perfusion pressure was measured in isolated tail arteries from male and female rats. Vasodilators released by mechanical shear stress were assessed by constricting the artery with methoxamine; acetylcholine was applied to induce receptor-mediated vasodilation. We used an inhibitor of NO synthase, N(G)-monomethyl-L-arginine acetate (L-NMMA), and elevated levels of K(+) (27 mM) to reveal the relative contributions of NO and EDHF, respectively. Indomethacin was present in all experiments to block prostanoid production. The results indicate that NO was the primary vasodilator released by male tail arteries in response to both mechanical stress and acetylcholine (the L-NMMA-sensitive component of the combined L-NMMA/K(+) effect was 83 +/- 8% and 101 +/- 4%, respectively). However female tail arteries appeared to utilize both NO and EDHF for vascular relaxation (e.g., L-NMMA sensitivity: 58 +/- 9%; K+-sensitivity: 42 +/- 9% in mechanical stress experiments). These findings suggest endothelial regulation differs between males and females.