Publications by authors named "Emily Pinheiro"

13 Publications

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Drugs in pregnancy: Pharmacologic and physiologic changes that affect clinical care.

Semin Perinatol 2020 Apr 25;44(3):151221. Epub 2020 Jan 25.

Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 3-2303, Chicago, IL 60611, USA. Electronic address:

Pharmacologic interventions play a major role in obstetrical care throughout pregnancy, labor and delivery and the postpartum. Traditionally, obstetrical providers have utilized standard dosing regimens developed for non-obstetrical indications based on pharmacokinetic knowledge from studies in men or non-pregnant women. With the recognition of pregnancy as a special pharmacokinetic population in the late 1990s, investigators have begun to study drug disposition in this unique patient dyad. Many of the basic physiologic changes that occur during pregnancy have significant impact on drug absorption, distribution and clearance. Activity of Phase I and Phase II drug metabolizing enzymes are differentially altered by pregnancy, resulting in drug concentrations sufficiently different for some medications that efficacy or toxicity is affected. Placental transporters play a major dynamic role in determining fetal drug exposure. In the past two decades, we have begun to expand our understanding of obstetrical pharmacology; however, to truly optimize pharmacologic care of our pregnant patients and their developing fetus, additional research is critically needed.
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http://dx.doi.org/10.1016/j.semperi.2020.151221DOI Listing
April 2020

Human In Vitro Models for Assessing the Genomic Basis of Chemotherapy-Induced Cardiovascular Toxicity.

J Cardiovasc Transl Res 2020 06 20;13(3):377-389. Epub 2020 Feb 20.

Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Chemotherapy-induced cardiovascular toxicity (CICT) is a well-established risk for cancer survivors and causes diseases such as heart failure, arrhythmia, vascular dysfunction, and atherosclerosis. As our knowledge of the precise cardiovascular risks of each chemotherapy agent has improved, it has become clear that genomics is one of the most influential predictors of which patients will experience cardiovascular toxicity. Most recently, GWAS-led, top-down approaches have identified novel genetic variants and their related genes that are statistically related to CICT. Importantly, the advent of human-induced pluripotent stem cell (hiPSC) models provides a system to experimentally test the effect of these genomic findings in vitro, query the underlying mechanisms, and develop novel strategies to mitigate the cardiovascular toxicity liabilities due to these mechanisms. Here we review the cardiovascular toxicities of chemotherapy drugs, discuss how these can be modeled in vitro, and suggest how these models can be used to validate genetic variants that predispose patients to these effects.
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http://dx.doi.org/10.1007/s12265-020-09962-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365753PMC
June 2020

Negligible-Cost and Weekend-Free Chemically Defined Human iPSC Culture.

Stem Cell Reports 2020 02 9;14(2):256-270. Epub 2020 Jan 9.

Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address:

Human induced pluripotent stem cell (hiPSC) culture has become routine, yet the cost of pluripotent cell media, frequent medium changes, and the reproducibility of differentiation have remained restrictive. Here, we describe the formulation of a hiPSC culture medium (B8) as a result of the exhaustive optimization of medium constituents and concentrations, establishing the necessity and relative contributions of each component to the pluripotent state and cell proliferation. The reagents in B8 represent only 3% of the costs of commercial media, made possible primarily by the in-lab generation of three E. coli-expressed, codon-optimized recombinant proteins: fibroblast growth factor 2, transforming growth factor β3, and neuregulin 1. We demonstrate the derivation and culture of 34 hiPSC lines in B8 as well as the maintenance of pluripotency long term (over 100 passages). This formula also allows a weekend-free feeding schedule without sacrificing capacity for differentiation.
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http://dx.doi.org/10.1016/j.stemcr.2019.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7013200PMC
February 2020

hiPSCs in cardio-oncology: deciphering the genomics.

Cardiovasc Res 2019 04;115(5):935-948

Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

The genomic predisposition to oncology-drug-induced cardiovascular toxicity has been postulated for many decades. Only recently has it become possible to experimentally validate this hypothesis via the use of patient-specific human-induced pluripotent stem cells (hiPSCs) and suitably powered genome-wide association studies (GWAS). Identifying the individual single nucleotide polymorphisms (SNPs) responsible for the susceptibility to toxicity from a specific drug is a daunting task as this precludes the use of one of the most powerful tools in genomics: comparing phenotypes to close relatives, as these are highly unlikely to have been treated with the same drug. Great strides have been made through the use of candidate gene association studies (CGAS) and increasingly large GWAS studies, as well as in vivo whole-organism studies to further our mechanistic understanding of this toxicity. The hiPSC model is a powerful technology to build on this work and identify and validate causal variants in mechanistic pathways through directed genomic editing such as CRISPR. The causative variants identified through these studies can then be implemented clinically to identify those likely to experience cardiovascular toxicity and guide treatment options. Additionally, targets identified through hiPSC studies can inform future drug development. Through careful phenotypic characterization, identification of genomic variants that contribute to gene function and expression, and genomic editing to verify mechanistic pathways, hiPSC technology is a critical tool for drug discovery and the realization of precision medicine in cardio-oncology.
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http://dx.doi.org/10.1093/cvr/cvz018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6452310PMC
April 2019

Validity of the WHIPLASHED as a tool to identify bipolar disorder in women.

J Affect Disord 2019 03 17;246:69-73. Epub 2018 Dec 17.

Department of Psychiatry and Behavioral Sciences, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.

Background: The aim of this study was to investigate the validity of the WHIPLASHED clinician-administered interview, a mnemonic of questions on clinical factors and illness course used to screen for bipolar disorder, as a self-report questionnaire.

Methods: Participants (n = 82) were females recruited from an outpatient academic women's mental health clinic. Relevant symptom data were extracted from a self-report questionnaire designed to parallel the WHIPLASHED interview questions. A score of ≥5 on WHIPLASHED was defined as a positive screen for bipolar spectrum disorder by its developer. We examined the capacity of self-reported WHIPLASHED scores ≥5 to differentiate bipolar from unipolar depression in women. Diagnostic assessments were conducted with the Mini International Neuropsychiatric Interview.

Results: Women were diagnosed with unipolar (n = 54) and bipolar (n = 28) depression. The majority of subjects were white (67%), employed (68%) and married (57%) with a mean age of 36.8 years. The receiver operating characteristic curve demonstrated that WHIPLASHED had strong predictive ability (AUC = 0.877) in differentiating bipolar from unipolar depression. A cutoff score of ≥5 generated 96% sensitivity and 52% specificity, while raising the threshold to 6 generated 89% sensitivity and 76% specificity for a bipolar disorder diagnosis.

Limitations: Our sample was small and composed of female patients at a single treatment center.

Conclusions: In this sample, WHIPLASHED was a valid screening tool to differentiate bipolar from unipolar depression. While existing instruments focus on primary symptoms of bipolar disorder, the WHIPLASHED is useful in exploring subtypes of bipolar disorder in which depression dominates the clinical course.
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http://dx.doi.org/10.1016/j.jad.2018.12.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563604PMC
March 2019

Bipolar disorder and psychotropic medication: Impact on pregnancy and neonatal outcomes.

J Affect Disord 2019 01 18;243:220-225. Epub 2018 Sep 18.

Department of Preventive Medicine, Northwestern University, Chicago, IL, USA.

Objective: The hypotheses were: (1) pregnant women with bipolar disorder (BD) have less favorable pregnancy outcomes than unaffected women, and (2) psychotropic treated women with BD have better outcomes than un-medicated women.

Method: This prospective study included 174 mother-infant dyads. Women had BD without psychotropic exposure (BD-NP, n = 38), BD with psychotropic treatment (BD-P, n = 49), or neither psychotropic exposure nor major mood disorder (Comp, n = 87). Maternal characteristics were completed at 20 weeks gestation and evaluated for associations with delivery and birth outcomes. We performed multiple regressions on infant outcomes with adjustment for maternal age, race, employment status, use of illicit drugs and pre-pregnancy BMI.

Results: The BP-P, BP-NP and Comp groups varied significantly on sociodemographic characteristics. Women with BD were more likely to be less educated, unemployed, single, and use tobacco and illicit drugs than women in the Comp group. Compared to women with BD-NP, women with BD-P were more likely to be older and educated. Approximately 10% of all infants were delivered preterm. No significant differences in outcome occurred for APGAR scores < 8, NICU admissions, sex or infant length. Infants of mothers with BD-NP had significantly smaller head circumferences (HC) than the other groups, adjustment for confounding variables mitigated this association.

Conclusions: The overall pregnancy outcomes for women with BD were similar to those in the Comp group. The reduced HC in women with untreated BD appears due to factors related to disadvantaged sociodemographic status, a higher proportion of female births, and/or a protective effect of medication in the BD-P group.
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http://dx.doi.org/10.1016/j.jad.2018.09.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548542PMC
January 2019

The association of serum C-reactive protein with the occurrence and course of postpartum depression.

Arch Womens Ment Health 2019 02 13;22(1):129-132. Epub 2018 Apr 13.

Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

CRP has been positively correlated with depressive symptomatology but this has received less study in postpartum depression (PPD). In this secondary analysis of a trial of PPD treatment, depressive symptoms (Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Symptoms (SIGH-ADS)) and serum CRP levels were assessed and associations between CRP and SIGH-ADS scores evaluated. The associations between baseline log CRP and depression response and remission were also assessed. Of the 35 women included, neither baseline log CRP nor exit log CRP was significantly associated with SIGH-ADS score. Baseline CRP was not associated with response or remission. In this sample of women with PPD, CRP was not associated with depressive symptoms nor response to treatment.
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http://dx.doi.org/10.1007/s00737-018-0841-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186200PMC
February 2019

Quetiapine Dose Adjustments in Pregnant and Postpartum Women With Bipolar Disorder.

J Clin Psychopharmacol 2018 02;38(1):89-91

Northwestern University Feinberg, School of Medicine, Chicago, IL The Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry, Northwestern University Feinberg, School of Medicine, Chicago, IL.

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http://dx.doi.org/10.1097/JCP.0000000000000820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734989PMC
February 2018

Mood symptoms in pregnant and postpartum women with bipolar disorder: a naturalistic study.

Bipolar Disord 2017 06 30;19(4):295-304. Epub 2017 Jun 30.

Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.

Objective: We conducted a prospective naturalistic study of pregnant women with bipolar disorder (BD) to evaluate symptoms of BD across childbearing and assess whether pharmacotherapy reduced their severity.

Methods: Assessments were scheduled at 20, 30, and 36 weeks' gestation and 2, 12, 26, and 52 weeks postpartum. Symptoms were assessed using the Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Supplement (SIGH-ADS) and Mania Rating Scale (MRS).

Results: Pregnant women (N=152) with BD were evaluated; 88 women (58%) were treated and 64 untreated (42%) with psychotropic drugs during pregnancy. Among the 88 women treated, 23 (26%) discontinued their medication in the first trimester and the remaining 65 (74%) were exposed throughout pregnancy or in the second and third trimesters. More than two-thirds (73%) of the women who remained in the study took psychotropic agents postpartum. The mean scores on the SIGH-ADS were in the mild range of depressive symptoms in both the psychotropic-treated and untreated groups in both pregnancy and postpartum. The majority of women had no or few symptoms of mania. Of the pregnant women treated with psychotropic agents, 66% received a guideline-concordant drug, and 34% received either antidepressant monotherapy (for BD I) or mono- or polypharmacy with a variety of other agents.

Conclusions: This sample of perinatal women with BD was characterized by mild residual symptoms of depression independent of pharmacotherapy, which poses a risk for recurrence and impaired parenting. The treatment of childbearing women with BD deserves urgent clinical and research attention to improve psychiatric outcomes.
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http://dx.doi.org/10.1111/bdi.12500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594856PMC
June 2017

Neonatal Discontinuation Syndrome in Serotonergic Antidepressant-Exposed Neonates.

J Clin Psychiatry 2017 May;78(5):605-611

Asher Center for the Study and Treatment of Depressive Disorders Northwestern University Feinberg School of Medicine, 676 North Saint Clair St, Ste 1000, Chicago, IL 60611.

Objective: To determine whether infants exposed in utero to serotonin reuptake inhibitor (SRI) antidepressants or a DSM-IV-TR-defined mood disorder have significantly more neonatal discontinuation signs compared to an unexposed group of infants at 2-4 weeks after birth.

Methods: This secondary analysis was derived from 2 observational studies with enrollment from July 2000 to December 2011 in Cleveland, Ohio, and Pittsburgh, Pennsylvania. Mothers (n = 214) belonged to one of 3 groups based on exposure status during pregnancy: (1) Comparison-women who did not take psychotropics during pregnancy and had no major mood disorder; (2) SRI-exposed-women with a mood disorder who were taking an SRI but no benzodiazepines; and (3) Mood Disorder-women with depression or bipolar disorder who did not take psychotropic medications. The infants were examined for signs according to the Finnegan Scale by evaluators blind to maternal exposure status.

Results: The rates of sign presence (defined as a score ≥ 2 on the Finnegan Scale) in the SRI, Mood Disorder, and Comparison groups were similar at 34.1%, 35.1%, and 30.4%, respectively. Women in the SRI group had a significantly higher preterm birth rate (24.4%) compared to the other 2 groups (7.4% and 8.9% in the Mood Disorder and Comparison groups, respectively; P = .012). Preterm newborns had a significantly higher sign rate compared to full-term newborns (54% vs 31%, P = .020). We observed a significant relationship between Finnegan signs and preterm birth.

Conclusions: The presence of neonatal signs at 2-4 weeks was more closely associated with prematurity than with in utero SRI or mood disorder exposure.

Trial Registration: ClinicalTrials.gov identifiers: NCT00279370 and NCT00585702.
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http://dx.doi.org/10.4088/JCP.16m11044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7087396PMC
May 2017

Is third trimester serotonin reuptake inhibitor use associated with postpartum hemorrhage?

J Psychiatr Res 2016 Feb 19;73:79-85. Epub 2015 Nov 19.

Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA.

As serotonin reuptake inhibitor (SRI) use may decrease platelet function, previous research has shown a relationship between SRI use and an increased risk for bruising and bleeding. The literature regarding the association between SRI use during pregnancy and increased bleeding at delivery, referred to as postpartum hemorrhage (PPH), is mixed. In secondary analyses from two prospective observational studies of pregnant women with mood disorders, 263 women were exposed to an SRI (n = 51) or not (n = 212) in the third trimester. To be precise, we used the terminology estimated blood loss (EBL) >600 cc rather than the term PPH because the current definition of PPH differs. The occurrence of EBL >600 cc was determined using the Peripartum Events Scale (PES) completed from obstetrical records by a blinded medically trained member of the study team. EBL >600 cc occurred in 8.7% of women in this cohort. There was no statistically significant difference in the rates of EBL >600 cc in the 24 h after delivery in women taking SRIs during the third trimester (9.8%) compared to non-exposed women (8.5%). Utilizing generalizing estimating equations, the odds of EBL >600 cc in each group were not significantly different (OR 1.17, CI-0.41-3.32, p = 0.77). When the SRI group was limited to women with exposure at the time of delivery, the difference in the odds of EBL >600 cc was unchanged (OR 1.16, CI = 0.37-3.64, p = 0.79). In population, both third trimester and use at delivery of SRIs during pregnancy was not associated with an increased risk of excessive blood loss.
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http://dx.doi.org/10.1016/j.jpsychires.2015.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738036PMC
February 2016

Transdermal estradiol treatment during breastfeeding: maternal and infant serum concentrations.

Arch Womens Ment Health 2016 Apr 10;19(2):409-13. Epub 2015 May 10.

Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, 676. N. St. Clair Street, Suite 1000, Chicago, IL, 60611, USA.

We examined estradiol (E2) and estrone (E1) concentrations in breastfeeding mother-infant dyads. The mothers had postpartum depression and were participants in a randomized clinical trial with three treatments (transdermal E2, sertraline, and placebo). Neither infant E1 and E2 concentrations nor infant growth differed across the treatments. Transdermal E2 administration of 50 to 200 mcg/day for breastfeeding women did not affect infant E1 or E2 concentrations or infant growth.
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http://dx.doi.org/10.1007/s00737-015-0532-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641053PMC
April 2016

Sertraline and breastfeeding: review and meta-analysis.

Arch Womens Ment Health 2015 Apr 15;18(2):139-146. Epub 2015 Jan 15.

Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 1000, Chicago, IL, 60611, USA.

We examined the risk-benefit profile of sertraline treatment during breastfeeding, summarized the available literature on sertraline use, presented previously unpublished data, and performed a correlation-based meta-analysis of sertraline serum levels in mother-infant pairs. We conducted a search of PubMed and the National Library of Medicine LactMed database. We performed a meta-analysis to examine correlations between maternal and infant serum sertraline levels in the existing literature and in previously unpublished data. Of 167 available infant sertraline levels, 146 (87.4 %) were below the limit of detection, and the meta-analysis found no significant relationship between maternal and infant sertraline concentrations. Of 150 infant desmethylsertraline levels, 105 (70.0 %) were below the limit of detection. The correlation analysis revealed a significant relationship between maternal and infant desmethylsertraline concentrations, but this metabolite has only a fraction of the activity of sertraline. A significant relationship was also found for the sum of sertraline and desmethylsertraline, which stems primarily from the contribution of desmethylsertraline. Sertraline is a first-line drug for breastfeeding women due to documented low levels of exposure in breastfeeding infants and very few adverse events described in case reports. Based on the current literature, neither routine serum sampling nor genotyping is warranted for breastfeeding mothers taking sertraline and/or their infants. Routine pediatric care is appropriate monitoring for breastfed infants of women who take sertraline monotherapy.
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http://dx.doi.org/10.1007/s00737-015-0499-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366287PMC
April 2015