Hair to document exposure to glibenclamide

Among the drugs that are used to incapacitate victims such as kids or elderly for sedation or for criminal gain such as sexual offences or robberies, glibenclamide, an antidiabetic was never mentioned. To document the interest of hair testing in such forensic situations, we have developed an original method to test for glibenclamide. A 30-year-old man was admitted to the Emergency Unit for coma and seizures after a party with some members of his family. Blood glucose was 0.40 g/l. A hair specimen was collected several weeks after the event and divided into two segments of 2 cm. Twenty milligrams of each segment cut into small pieces were incubated overnight in a phosphate buffer (pH 5.5), in presence of gliclazide used as internal standard (IS). A liquid/liquid extraction was realized with a mixture of diethyl ether/methylene chloride, and hair extract was separated on a XTerra MS C18 column using a gradient of acetonitrile and formate buffer. Detection of glibenclamide was achieved using two transitions: m/z 493.9 to 168.9 and 493.9 to 368.8. Linearity was observed from 5 to 1000 pg/mg (r2 = 0.956) with a limit of quantification at 5 pg/mg and a clean-up recovery of about 61%. Within-batch precision and bias were 9.0 and 9.5%, respectively. Ion suppression tested on drug-free hair was about 50%. Glibenclamide tested positive in the two consecutive segments (root to 2 cm: 23 pg/mg and 2-4 cm: 31 pg/mg). These findings were in accordance with a repetitive exposure to the drug. The concentrations were compared with those obtained after a single and a daily dose administration. In the hair of a subject receiving a single 5mg dose and collected 4 weeks later, glibenclamide was detected in the proximal segment at 5 pg/mg. After a 20 mg/day dose, the hair concentration of a subject under glibenclamide therapy was 650 pg/mg.     

Improvement to the air-injection technique to estimate xylem vulnerability to cavitation

Several techniques have been developed to quantify the degree of embolism of the xylem using hydraulic conductance. Although there have been several improvements to these techniques, their reliability is still questionable and many technical pitfalls persist. We are proposing here a manometric approach to improve the accuracy of xylem cavitation measurement by the original air-injection technique which uses twigs exposed to pressurized air to cause cavitation. The measured parameter is air bubble production (P _b) caused by xylem cavitation in birch (Betula pendula Roth) twigs from which the percent increase in bubble production is calculated to quantify xylem cavitation. Data produced by three different methods (bench-drying, air-injection, and manometric approach) are compared. Xylem vulnerability curves (VCs) constructed by the reference and reliable bench-drying technique and the manometric approach show similar sigmoid “S” shape, but a small anomaly appeared in the VC constructed by the original air-injection technique. The xylem pressure inducing 50% of embolism (P ₅₀) was the same with the three techniques. Furthermore, there was a strong positive correlation between the estimators of xylem cavitation measured by the three different methods. For its reliability, precision and ease we recommend the manometric technique as an improved version of the original hydraulic air-injection method.     

Admissions to Hospital due to Drugs

In a survey of adverse drug reactions in wards of two Belfast hospitals for 52 weeks in 1965–6, 2·9% of 1,268 patients seen were admitted to hospital because of adverse reactions to drugs taken for therapeutic reasons and 2·1% were admitted because of self-poisoning. Patients admitted because of adverse drug reactions were older than those admitted because of self-poisoning and stayed in hospital longer. Among the drugs which caused the adverse reactions were digitalis preparations, antibiotics, corticosteroids, anticoagulants, analgesics, and tranquillizers. Hypersensitivity and side-effect types of reactions were the most common. Barbiturates were the most frequently used drugs in suicidal attempts.     

Readiness to attend to visual foreground cues

Nonhuman primate genera are differentially inclined to attend to stimuli of the immediate foreground. When great apes were trained to a criterion on each of a series of two-choice visual discrimination problems and then given critical test trials with irrelevant visual cues ($\text{1}\text{2}$ in wire mesh) positioned immediately in front of each problem's objects, accuracy of performance was significantly more disrupted in orang-utans (Pongo) than in chimpanzees (Pan) and gorillas (Gorilla). Two groups of chimpanzees known to differ profoundly in complex-learning skills did not differ in their readiness to attend to irrelevant foreground cues; hence, it is concluded that the observed differences among the three genera of great apes must be species related and associated with how arboreal/terrestial they are in their natural habitats.     

Commentary Polyamines to Target Drugs to Dna

In neutral solutions polyamines are fully protonated, and hence are really polyammonium cations (PAC). Spermine, for example, carries four positive charges in a linear system, H₃N⁺(CH₂)₃N⁺H₂(CH₂)₄N⁺H₂ (CH₂)₃N⁺H₃. There is a very powerful coulombic interaction between aqueous DNA and such cations, thus the cations are attracted to the DNA over large distances, and once close to the DNA normally remain there for long periods. A key issue is; are the cations mobile, or do they remain at one preferred site for significant periods? The latter is the currently preferred concept, but NMR and EPR evidence will be presented in favour of the former. If the former is correct, then PACs may be able to act as good drug delivery systems. In its simple form the concept is that any drug that acts directly on DNA can be chemically bound to a PAC. Once in the cell, this PAC-drug complex (PAC-D) will be carried to DNA and will move very rapidly along the exposed strands until it recognises the site of action. This may be some special base sequence region, a damaged site, or the PAC-D unit may simply be present prior to potential damage, so that this can be repaired very rapidly. Some of our current studies on these systems are described.     

Failure of CD4 T-cells to respond to liver-derived antigen and to provide help to CD8 T-cells

CD4 T-cell help is required for the induction of efficient CD8 T-cells responses and the generation of memory cells. Lack of CD4 T-cell help may contribute to an exhausted CD8 phenotype and viral persistence. Little is known about priming of CD4 T-cells by liver-derived antigen. We used TF-OVA mice expressing ovalbumin in hepatocytes to investigate CD4 T-cell priming by liver-derived antigen and the impact of CD4 T-cell help on CD8 T-cell function. Naïve and effector CD4 T-cells specific for ovalbumin were transferred into TF-OVA mice alone or together with naïve ovalbumin-specific CD8 T-cells. T-cell activation and function were analyzed. CD4 T-cells ignored antigen presented by liver antigen-presenting cells (APCs) in vitro and in vivo but were primed in the liver-draining lymph node and the spleen. No priming occurred in the absence of bone-marrow derived APCs capable of presenting ovalbumin in vivo. CD4 T-cells primed in TF-OVA mice displayed defective Th1-effector function and caused no liver damage. CD4 T-cells were not required for the induction of hepatitis by CD8 T-cells. Th1-effector but not naïve CD4 T-cells augmented the severity of liver injury caused by CD8 T-cells. Our data demonstrate that CD4 T-cells fail to respond to liver-derived antigen presented by liver APCs and develop defective effector function after priming in lymph nodes and spleen. The lack of CD4 T-cell help may be responsible for insufficient CD8 T-cell function against hepatic antigens.     

How to lose resistance to Aspergillus infections

The distinct risk factors to deadly infections by Aspergillus fumigatus (Af) in intensive care unit (ICU) patients are well known; however, so far, the mechanistic link between these predisposing conditions has been unknown. Sarden et al. recently unraveled a shared B1a lymphocyte–natural antibody–neutrophil defense pathway to Af, opening new perspectives in diagnostics and therapeutics.     

Challenges to understand plant responses to wind

Understanding plant response to wind is complicated as this factor entails not only mechanical stress, but also affects leaf microclimate. In a recent study, we found that plant responses to mechanical stress (MS) may be different and even in the opposite direction to those of wind. MS-treated Plantago major plants produced thinner more elongated leaves while those in wind did the opposite. The latter can be associated with the drying effect of wind as is further supported by data on petiole anatomy presented here. These results indicate that plant responses to wind will depend on the extent of water stress. It should also be recognized that the responses to wind may differ between different parts of a plant and between plant species. Physiological research on wind responses should thus focus on the signal sensing and transduction of both the mechanical and drought signals associated with wind, and consider both plant size and architecture.Key words: biomechanics, leaf anatomy, phenotypic plasticity, plant architecture, signal transduction thigmomorphogenesis, windWind is one of the most ubiquitous environmental stresses, and can strongly affect development, growth and reproductive yield in terrestrial plants.^1–3 In spite of more than two centuries of research,⁴ plant responses to wind and their underlying mechanisms remain poorly understood. This is because plant responses to mechanical movement themselves are complicated and also because wind entails not only mechanical effects, but also changes in leaf gas and heat exchange.^5–7 Much research on wind has focused primarily on its mechanical effect. Notably, several studies that determine plant responses to mechanical treatments such as flexing, implicitly extrapolate their results to wind effects.^8–10 Our recent study¹¹ showed that this may lead to errors as responses to wind and mechanical stimuli (in our case brushing) can be different and even in the opposite direction. In this paper, we first separately discuss plant responses to mechanical stimuli, and other wind-associated effects, and then discuss future challenges for the understanding of plant responses to wind.It is often believed that responses to mechanical stress (thigmomorphogenesis) entail the production of thicker and stronger plant structures that resist larger forces. This may be true for continuous unidirectional forces such as gravity, however for variable external forces (such as wind loading or periodic flooding) avoiding such mechanical stress by flexible and easily reconfigurable structures can be an alternative strategy.^12–14 How plants adapt or acclimate to such variable external forces depends on the intensity and frequency of stress and also on plant structures. Reduced height growth is the most common response to mechanical stimuli.^15,16 This is partly because such short stature increases the ability of plants to both resist forces (e.g., real-locating biomass for radial growth rather than elongation growth), and because small plants experience smaller drag forces (Fig. 1). Some plant species show a resistance strategy in response to mechanical stress by increasing stem thickness^1,10 and tissue strength.⁷ But other species show an avoidance strategy by a reduction in stem or petiole thickness and flexural rigidity in response to MS.^11,15–18 These different strategies might be associated with plant size and structure. Stems of larger plants such as trees and tall herbs are restricted in the ability to bend as they carry heavy loads^7,10,19 (Fig. 1). Conversely short plants are less restricted in this respect and may also be prone to trampling for which stress-avoidance would be the only viable strategy.^18,20 Systematic understanding of these various responses to mechanical stress remains to be achieved.Open in a separate windowFigure 1A graphical representation of how wind effects can be considered to entail both a drying and a mechanical effect. Adaptation or acclimation to the latter can be through a force resistance strategy or a force avoidance strategy, the benefit of which may depend on the size and architecture of plants as well as the location of a given structure within a plant.Wind often enhances water stress by reducing leaf boundary layers and reduces plant temperature by transpiration cooling. The latter effect may be minor,¹¹ but the former could significantly affect plant development. Anten et al. (2010) compared phenotypic traits and growth of Plantago major that was grown under mechanical stimuli by brushing (MS) and wind in the factorial design. Both MS and wind treatments reduced growth and influenced allocation in a similar manner. MS plants, however, had more slender petioles and narrower leaf blades while wind exposed plants exhibited the opposite response having shorter and relatively thicker petioles and more round-shaped leaf blades. MS plants appeared to exhibit stress avoidance strategy while such responses could be compensated or overridden by water stress in wind exposure.¹¹ A further analysis of leaf petiole anatomy (Fig. 2) supports this view. The vascular fraction in the petiole cross-section was increased by wind but not by MS, suggesting that higher water transport was required under wind. Our results suggest that drying effect of wind can at least to some extent override its mechanical effect.Open in a separate windowFigure 2Representative images of petiole cross-sections of Plantago major grown in 45 days in continuous wind and/or mechanical stimuli (A–D). Petiole cross-section area (E) and vascular bundle fraction in the cross-section of petiole (F). mean + SD (n = 12) are shown. Significance levels of ANOVA; ***p < 0.001, **p < 0.01, *p < 0.05, ns p > 0.05.Physiological knowledge on plant mechanoreception and signal transduction has been greatly increased during the last decades. Plants sense mechanical stimuli through membrane strain with stretch activated channels²¹ and/or through some linker molecules connecting the cell wall, plasma membrane and cytoskeleton.^4,22,23 This leads to a ubiquitous increase in intracellular Ca²⁺ concentration. The increased Ca²⁺ concentration is sensed by touch induced genes (TCHs),^24,25 which activates downstream transduction machineries including a range of signaling molecules and phytohormones, consequently altering physiological and developmental processes.²⁶ Extending this knowledge to understand plant phenotypic responses to wind however remains a challenge. As responses to wind have been found to differ among parts of a plant (e.g., terminal vs. basal stem) and also across species, physiological studies should be extended to the whole-plant as integrated system rather than focusing on specific tissue level. Furthermore to understand the general mechanism across species, it is required to study different species from different environmental conditions. Advances in bioinformatics, molecular and physiological research will facilitate cross-disciplinary studies to disentangle the complicated responses of plants to wind.     

Ability of human T lymphocytes to adhere to vascular endothelial cells and to augment endothelial permeability to macromolecules is linked to their state of post-thymic maturation

The accumulation of mononuclear cells at sites of chronic inflammation is dependent on a number of factors including localized adherence of lymphocytes to vascular endothelial cells (EC), cytokine-mediated increased adhesiveness of endothelium, chemotactic factors and endothelial permeability. The present study investigates two of the above attributes of lymphocyte-EC interaction: namely, the ability of maturationally distinct subpopulations of human T lymphocytes to adhere to vascular EC and to increase vascular endothelial permeability to macromolecules in an in vitro model. Thus, human T lymphocytes were separated into CD4+ CD8-helper/inducer, CD4- CD8+ cytotoxic/suppressor, CD29+ CD45RA- CD45RO+ memory, and CD29- CD45RA+ CD45RO- naive/virgin T subpopulations, were activated with PHA and PMA, and then examined for their adherence to EC and also for their effect on endothelial permeability. Upon activation, cells within each of the above four subpopulations exhibited increased adherence to EC. In contrast, resting CD29+ CD45RA- CD45RO+ memory T lymphocytes exhibited two to three times greater ability to adhere to EC than their CD29- CD45RA+ CD45RO- naive/virgin counterparts. Consistent with their increased adherence to EC, CD29+ CD45RO+ memory T lymphocytes, when activated, significantly increased endothelial permeability to albumin. Although activated CD45RA+ naive T lymphocytes exhibited increased adherence to EC, these cells failed to increase significantly endothelial permeability. Similar to their polyclonal counterparts, Ag-specific CD4+ CD29+ CD45RO+ T cell clones, but not their actively released mediators, also increased endothelial permeability via a noncytolytic mechanism(s). This ability of CD29+ CD45RO+ memory T lymphocytes to augment endothelial permeability may facilitate their transendothelial migration into extravascular space. These observations may provide additional insights into molecular mechanism(s) underlying pathophysiology of localized chronic inflammatory responses in general and more specifically selective accumulation of CD29+/CD45RO+ memory T lymphocytes at sites of chronic inflammation such as rheumatoid synovium.     

Working together to respond to the challenges of EU policy to replace animal testing

This paper presents a personal perspective on efforts during the past 15 years to replace animal testing for assessing the safety of chemicals and products. It is based on an invited lecture--the FRAME Annual Lecture--given in October 2005, with the theme of "making progress by working together" (government-industry-academia-NGOs). Where we have achieved some successes, these have clearly been due to effective cooperation and collaboration between the relevant stakeholders. In recent times, there has not been this same level of active commitment and coordination. This needs to change, since, if we are to make good progress in the years to come in responding to the new challenges of the EU policy to replace animal testing, this will undoubtedly require us to work together, hopefully facilitated by effective leadership and coordination from the EU policy-makers themselves.     

My perpetual cycle: from student to researcher to teacher to student ..

This contribution stems from the personal experience of the author regarding how he became acquainted with embryology and how he finally entered the field of developmental biology. It reports his feelings as a student of the Histology and Embryology course as it was taught in the late 1970s, and his present efforts in teaching developmental biology to university students. In the Developmental Biology course at Pisa University today, students are taught the tissue, molecular and genetic mechanisms that regulate development of several model systems. Drosophila is introduced at the beginning, because of the great knowledge that it has brought to the unraveling of the molecular aspects of development and because it allows several basic concepts to be introduced, and vertebrate systems follow. Other topics include the classic experiments on amphibian systems, which are explained in the light of recent molecular advances, as well as the genetically more versatile vertebrate systems such as the mouse.     

Cross-resistance to antibiotics of Escherichia coli adapted to benzalkonium chloride or exposed to stress-inducers

AIMS: To study the effects of adaptation and stress on the resistance to benzalkonium chloride (BC) and cross-resistance to antibiotics in Escherichia coli. METHODS AND RESULTS: Precultivation of E. coli ATCC 11775 and E. coli DSM 682 in the presence of subinhibitory concentrations of BC or stress inducers (salicylate, chenodeoxycholate and methyl viologen) resulted in higher minimum inhibitory concentration (MIC) of BC and chloramphenicol (CHL). Adaptation to growth in sixfold of the initial MIC of BC resulted in stable BC resistance and enhanced tolerance to several antibiotics and ethidium bromide (EtBr). The MIC of CHL increased more than 10-fold for both strains. Enhanced efflux of EtBr in adapted E. coli ATCC 11775 indicated that the observed resistance was due to efflux. Changes in outer membrane protein profiles were detected in the BC-adapted cells. There were no indications of lower membrane permeability to BC. CONCLUSIONS: Induction of stress response or gradual adaptation to BC or CHL results in acquired cross-tolerance between BC and antibiotics in E. coli. Enhanced efflux was one of the observed differences in adapted cells. SIGNIFICANCE AND IMPACT OF THE STUDY: Provided not taking due precautions, extensive use of disinfectants could lead to emergence of antibiotic-resistant isolates.     

Should I want to live to 100?

Is it virtuous for someone to try to live to 100? Casting aside questions of intergenerational justice and internal obligations in families, what about the basic desire itself? Discussions of longevity and aging in bioethics are skewed to controversial end‐of‐life decisions, largely avoiding questions of how to age well before such decisions arise. Respected writers such as Atul Gawande, Daniel Callahan, and Ezekiel Emanuel champion accepting a natural life span and not trying to live beyond it. The Stoic Seneca says a desire to live to 100 is foolish because, however long people live, they waste most of their lives, so if they lived a thousand years, they would still waste most of it. Against Seneca and Emanuel, we argue that a functional, not a chronological, view of aging should guide us and that for some seniors, hoping to be centenarians may be neither foolish nor misguided. Using Cicero, we argue that the pleasures of seniors are not necessarily inferior to those of youth and may even surpass them. Finally, we agree with Emanuel that the “symptom burden” of some lives makes living to 100 unpalatable and with Seneca that, given life’s vicissitudes, we should not plan on living to 100, but heeding his wisdom, try to make the most of the time given to us.     

Resistance to xenobiotic-induced autoimmunity maps to chromosome 1

Although evidence indicates that environmental factors play a major role in precipitating systemic autoimmunity in genetically susceptible individuals, little is known about the mechanisms involved. Certain heavy metals, such as mercury, are potent environmental immunostimulants that produce a number of immunopathologic sequelae, including lymphoproliferation, hypergammaglobulinemia, and overt systemic autoimmunity. Predisposition to such metal-induced immunopathology has been shown to be influenced by both MHC and non-MHC genes, as well as susceptibility to spontaneous lupus, in mice and other experimental animals. Among the various mouse strains examined to date, the DBA/2 appears to uniquely lack susceptibility to mercury-induced autoimmunity (HgIA), despite expressing a susceptible H-2 haplotype (H-2d). To define the genetic basis for this trait, two genome-wide scans were conducted using F2 intercrosses of the DBA/2 strain with either the SJL or NZB strains, both of which are highly susceptible to HgIA. A single major quantitative trait locus on chromosome 1, designated Hmr1, was shown to be common to both crosses and encompassed a region containing several lupus susceptibility loci. Hmr1 was linked to glomerular immune complex deposits and not autoantibody production, suggesting that DBA/2 resistance to HgIA may primarily involve the later stages of disease pathogenesis. Identification and characterization of susceptibility/resistance genes and mechanisms relevant to the immunopathogenesis of mercury-induced autoimmunity should provide important insights into the pathogenesis of autoimmunity and may reveal novel targets for intervention.     

Tissue-based assay for ornithine decarboxylase to identify patients likely to respond to difluoromethylornithine.

In a previous publication, we showed that a clinical trial of DL-alpha-difluoromethyl ornithine (DFMO), in combination with PCV (procarbazine, CCNU, vincristine) increased survival of patients with anaplastic gliomas (WHO III) but not glioblastoma multiforme (WHO IV). We believe that treatment outcome (survival) is inversely related to tumor ornithine decarboxylase (ODC) levels. To prove this, we needed to develop an assay to quantify ODC levels in formalin-fixed tumor tissues, which would enable a retrospective study of tumor biopsy specimens from the landmark clinical trial. We developed an assay using a specific polyclonal antibody coupled to an Alexa fluorescent dye. Transgenic MHC-ODC mice with differing levels of ODC in heart muscle were used to establish the relationship between mean gray-scale intensity and enzymatic ODC activity. We found a direct relationship between mean gray-scale intensity of the ODC antibody coupled to Alexa 647 dye and enzymatic activity. Preliminary analysis of a human glioma tissue array shows that tumor-specific variations in levels of ODC can be semiquantitated. We show that mean gray-scale intensity of astrocytoma:glioblastoma is 1:6 and of anaplastic astrocytoma:glioblastoma is 1:4. We also compared the intensity of antibody to Ki67 coupled with phycoerythrin simultaneously in cells but failed to see a relationship that crossed histologies. We conclude that we can measure levels of ODC in formalin-fixed tumor tissue using an antibody to ODC coupled to Alexa 647 dye, and this will enable us to conduct a future study to correlate survival of patients with gliomas of different histologies treated with DFMO to tumor ODC levels.     

A ligand that Trypanosoma cruzi uses to bind to mammalian cells to initiate infection

We purified a soluble gp83 trans-sialidase (gp83-TSA), from phospholipase C-treated Trypanosoma cruzi trypomastigote membranes, which binds to myoblasts, fibroblasts and macrophages to mediate trypanosome entry. Myoblasts display a single class of receptors for the gp83-TSA present at 4x10(4) per myoblast with a K(d) of 8 nM. Monovalent Fab fragments of the monoclonal antibody 4A4 specific for gp83-TSA inhibit gp83-TSA binding to myoblasts, fibroblasts and macrophages, block the trypanosomes from attaching to and entering these cells and neutralize T. cruzi infection in BALB/c mice. This is the first demonstration that gp83-TSA is a ligand that T. cruzi uses to attach to cells.     

New method to study bacterial adhesion to meat

A new method was developed for the study of bacterial adhesion to meat surfaces. Thin slices of meat (40 microns thick) were inserted into a specially designed observation chamber. The meat slices were then exposed to a bacterial suspension (ca. 10(6) CFU.ml-1) to initiate adhesion (20 min of contact time) and subsequently rinsed to eliminate nonadherent bacteria. Because of the special chamber design, the disruptive force exerted on the bacteria during rinsing (shear stress) was uniform over the whole surface of the meat slices, was constant, and could be varied from 0 to 0.08 N.m-2. After being rinsed, the meat slices were stained with basic fuschin and observed under light microscopy to determine the number and distribution of adherent bacteria. This new method was used to study the adhesion of Acinetobacter strain LD2, a Lactobacillus sp., and Pseudomonas fluorescens to slices of beef fat and tendon. At 25 degrees C, most (greater than or equal to 99.9%) of the cells of the Lactobacillus sp. deposited on the meat were washed off the surface during rinsing (0.05 N.m-2), whereas a large number (ca. 10(5) CFU.cm-2) of Acinetobacter strain LD2 and P. fluorescens cells remained adherent. The extent of adhesion was similar on fat and tendon, and adherent bacteria were distributed evenly over the whole surface of the slices. This preliminary study indicates that the combined use of thin slices of meat and of the observation chamber provides us with the means to more accurately study bacterial adhesion to meat surfaces.     

How spermatozoa come to be confined to surfaces

In most detailed studies, sea urchin sperm movement has been analyzed mainly from observations of spermatozoa swimming at the interface between two media: water/air or water/glass. When spermatozoa are placed on a microscope slide, they rapidly appear to swim near those interfaces. The aim of this article is to determine how they become confined to the vicinity of surfaces. High-speed observations of moving spermatozoa reveal blurred portions in the flagellum images that propagate from base to tip, suggesting that flagellar waves contain an out-of-plane component. The model we have developed depicts how this tri-dimensional component tends to keep spermatozoa close to interfaces and, as a consequence, increases the time of contact between the egg surface and spermatozoa.     

New challenges to medicare beneficiary access to mAbs

Precision binding of monoclonal antibodies (mAbs) to biological targets, their relative clinical success, and expansion of indications following initial approval, are distinctive clinical features. The relatively high cost of mAbs, together with the absence of a regulatory pathway to generics, stand out as distinctive economic features. Based on both literature review and primary data collection we enumerated mAb original approvals, supplemental indications, and off-label uses, assessed payer formulary management of mAbs, and determined new challenges to Medicare beneficiary access to mAbs. We found that the FDA has approved 22 mAbs and 30 supplemental indications pertaining to the originally approved mAbs. In addition, there are 46 off-label use citations in officially recognized pharmaceutical compendia. Across Part B carriers and Part D plans, we found considerable variation in terms of coverage and conditions of reimbursement related to on- and off-label uses of mAbs. Our results point to four major challenges facing mAb developers, health care providers, Medicare beneficiaries, payers, and policymakers. These include administrative price controls, coverage variation, projected shift from physician- to self-administered mAbs, and comparative effectiveness. We suggest more systematic use of “coverage with evidence development” as a means of optimally addressing these challenges.