Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need.

Background Regulatory bodies recommend the use of an assay based on the assessment of the endogenous thrombin potential (ETP) for the investigation of the activated protein C resistance (APCr) in the development of steroid contraceptives in women. However, the assays described in the literature are home-made and not standardized regarding the method, the reagents, the reference plasma and the quality controls. In the absence of any commercially available method, we aimed at validating the ETP-based APCr assay. Methods The validation was performed according to regulatory standards. The method targets a 90% inhibition of the ETP in healthy donors in the presence of APC compared to the same condition in the absence of APC. As a large-scale production of a pool of plasma from well-selected healthy donors is impossible, algorithms were applied to a commercial reference plasma to correlate with the selected pool. Results Repeatability and intermediate precision passed the acceptance criteria. The assay demonstrated a curvilinear dose response to protein S and APC concentrations (R2 > 0.99). Analysis of plasma samples from 47 healthy individuals (22 women not taking combined hormonal contraceptives [CHC], and 25 men not Factor V Leiden carriers) confirmed the validity of the test, with a mean inhibition percentage of 90%. Investigations in 15 women taking different contraceptives and in two subjects with Factor V Leiden confirmed the good sensitivity and performance of the assay. Conclusions This validation provides the pharmaceutical industry, the regulatory bodies and physicians with a reproducible, sensitive and validated gold-standard ETP-based APCr assay.

A safety evaluation of drotrecogin alfa (activated) in hematopoietic stem cell transplant patients with severe sepsis: lessons in clinical research.

We conducted an open-label, multicenter, single-arm clinical trial to investigate the safety and efficacy of drotrecogin alfa (activated) (Drot AA) in hematopoietic stem cell transplant (HSCT) patients with severe sepsis. Drot AA was administered as a continuous i.v. infusion of 24 microg/kg/h for 96 h. The target enrollment was 250 patients in 15-20 transplant centers over a 2-year period (March 2003-March 2005). However, after only 10 months, in December 2003, the trial was stopped due to a low enrollment of seven patients at three of the 15 sites that were open for accrual. Six of the seven patients completed the drug infusion. Two patients experienced serious bleeding events. The first patient developed a nonfatal diffuse alveolar hemorrhage 2 days after study-drug completion. The second patient had severe coagulopathy and developed a fatal intracranial hemorrhage on the third day of drug infusion. Three of the seven patients were alive 100 days after the HSCT. The slow enrollment rate was attributed to changes in transplant preparatory regimens, enhancements in antimicrobial prophylactic protocols and the use of antimicrobial-coated catheters. The small number of patients in this report precludes a definitive assessment of the safety and efficacy of Drot AA in HSCT patients.

Assay procedure optimization of a rapid, reusable protein C immunosensor for physiological samples.

A fiber-optic immunosensor for quantifying the protein C (PC) amount in a plasma sample is being developed to provide accurate, fast, cost-effective diagnosis of heterozygous PC deficiency (0.5-2.5 microg ml(-1)). As a progress report on the sensor development, this paper focuses on optimizations of vanous assay steps. These include: (1) the primary antibody concentration; (2) the effect of the primary antibody leaching on the sensitivity; (3) the fluorophore to secondary antibody ratio; and (4) the sample and secondary antibody incubation times. The optimal primary antibody concentration for the PC sensor was determined to be 65 microg ml(-1); its leaching was minor, stabilized within 3 days, and the sensor sensitivity change after 30 days of storage was minor; sample and secondary antibody incubation times were reduced from 10 to 5 and from 5 to 3 min, respectively, while maintaining a reasonable signal-to-noise level. The immunosensor was also tested with (5) human serum albumin and human plasma and (6) with and without convective flow. High viscosity of human plasma decreased signal intensity, but clear signal discrimination was possible in the concentration range of interest. (7) Application of convective flow increased the signal intensity by increasing PC mass transport rate to the sensor surface. The optimized PC immunosensor provides a smaller (100 microl sample chamber) and faster (10-15 min) tool for PC detection in human plasma.

Evaluation of a global screening assay for the investigation of the protein C anticoagulant pathway.

We have evaluated a global screening test for the protein C pathway, the 'ProC Global' (Dade Behring Ltd, Milton Keynes, UK). Patient groups tested included inherited protein C or S deficient and inherited/acquired activated protein C resistance. Results showed that protein C deficiencies and activated protein C resistance could be successfully detected with this test whereas deficiencies of protein S were less readily distinguished from the normal population. The ProC Global was unreliable in patients with antiphospholipid antibodies, raised plasma factor VIII:C and in those receiving oral anticoagulant therapy.

Preliminary study of real-time fiber optic based protein C biosensor.

Deficiency of protein C (PC), one of the human body's key anticoagulants, can lead to massive thrombotic complications. There is a diagnostic need to perform real-time assays, in order to quickly identify and treat this disease. An immuno-optical biosensor for the diagnosing of PC deficiencies and monitoring of PC concentrations is being developed for this purpose. Monoclonal antibody against PC (anti-PC) is immobilized on the surface of a tapered quartz fiber that is enclosed in a glass tube (capacity approximately 200 microL). Following sample injection, PC within a sample binds to the anti-PC in a highly specific reaction. The system is then probed with a fluorophore-tagged secondary antibody against PC. Excitation light is applied through the fiber, and the fluorescence intensity is correlated with the PC concentration in the sample. This study presents (1) a feasibility, direct binding assay, (2) a comparison of methods to immobilize anti-PC upon the fiber (direct immobilization vs an avidin-biotin bridge), and (3) effectiveness of an elution step to regenerate the fiber. PC-deficient patients typically have a concentration range less than 2.5 microg/mL. It was found that the sensor could detect PC levels down to 0.1 microg/mL in pure buffer with minimal optimization. Avidin-biotin immobilization of the primary antibody produced enhanced signals, up to 470% of the original intensities. Preliminary fiber regeneration tests achieved nearly a 50% increase in fiber lifetime with the use of a CaCl(2) elution step. Ultimately, further development may lead to automation and the use of the system as a multi-blood factor analyzer.

Hereditary protein C-deficiency: laboratory values in transmitters and guidelines for the diagnostic procedure. Report on a study of the SSC Subcommittee on Protein C and Protein S. Protein C Transmitter Study Group.

A multicenter study on protein C-antigen and -activity values was carried out in transmitter patients with hereditary protein C deficiency (diagnosis established by pedigree analysis) and in normal controls in order to (1) establish the range of protein C levels in genetically determined heterozygotes and (2) to evaluate the usefulness of statistical procedures to discriminate between protein C deficient patients and controls. In transmitters absolute protein C activity values ranged from 19 to 82% and antigen values from 22 to 88.5%. Most transmitter patients could clearly be differentiated from the control group. However, in some transmitter patients values of protein C were within the range of the control group. The discrimination between transmitters and controls could be improved by statistical procedures. Using tolerance ellipses the overlapping area of the two groups was smallest when (factor II antigen+factor X antigen)/2 was plotted against protein C antigen. To specify the degree of uncertainty likelihood ratios were calculated to obtain the posterior probability for an individual for being deficient or not. In quadratic discriminant analysis the best discrimination between transmitters and controls was obtained using protein C activity versus factor X antigen and protein C antigen versus factor X antigen. Based on these analysis an equation was derived, which allows the calculation of the likelihood ratio favouring deficiency or non-deficiency in an individual.