Birth Control in Clinical Trials: Industry Survey of Current Use Practices, Governance, and Monitoring

The Health and Environmental Sciences Institute (HESI) Developmental and Reproductive Toxicology Technical Committee sponsored a pharmaceutical industry survey on current industry practices for contraception use during clinical trials. The objectives of the survey were to improve our understanding of the current industry practices for contraception requirements in clinical trials, the governance processes set up to promote consistency and/or compliance with contraception requirements, and the effectiveness of current contraception practices in preventing pregnancies during clinical trials. Opportunities for improvements in current practices were also considered. The survey results from 12 pharmaceutical companies identified significant variability among companies with regard to contraception practices and governance during clinical trials. This variability was due primarily to differences in definitions, areas of scientific uncertainty or misunderstanding, and differences in company approaches to enrollment in clinical trials. The survey also revealed that few companies collected data in a manner that would allow a retrospective understanding of the reasons for failure of birth control during clinical trials. In this article, suggestions are made for topics where regulatory guidance or scientific publications could facilitate best practice. These include provisions for a pragmatic definition of women of childbearing potential, guidance on how animal data can influence the requirements for male and female birth control, evidence-based guidance on birth control and pregnancy testing regimes suitable for low- and high-risk situations, plus practical methods to ascertain the risk of drug-drug interactions with hormonal contraceptives.

Identification of genetic variation exclusive to specific lineages associated with Staphylococcus aureus bacteraemia

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia cases have declined since 2003, and have mostly been due to two epidemic (E) strains, E15 (multi-locus sequence type clonal complex CC22) and E16 (CC30). By contrast, the incidence of meticillin-susceptible S. aureus (MSSA) bacteraemia has remained largely unchanged and our understanding of these isolates has remained poor.

AIM

To investigate the distribution and nucleotide sequence of heterogeneous regions between successful lineages using the 2009 British Society for Antimicrobial Chemotherapy (BSAC) Bacteraemia Resistance Surveillance Programme collection of S. aureus.

METHODS

S. aureus isolates (N = 202) comprised of 103 MRSA and 99 MSSA isolates were analysed using fluorescent amplified fragment length polymorphism (FAFLP) to detect nucleotide variations due to lineage-specific sequence motifs as well as differences in the distribution of mobile genetic elements between lineages.

FINDINGS

E15 and E16 MRSA strains comprised 79% and 6% of the collection in 2009 respectively. Six lineages, including CC22 and CC30, were associated with MRSA bacteraemia in the UK and Ireland. MSSA isolates were more diverse with 19 different lineages detected. FAFLP revealed lineage-specific sequence variations in loci encoding factors such as proteases or factors involved in haem biosynthesis, both of which may affect the success of major S. aureus lineages. Proteins encoded on certain mobile genetic elements or involved in cobalamin biosynthesis were found to be exclusive to CC8, CC22, or CC30.

CONCLUSION

Overall, the genetic diversity among regions of the core genome and mobile genetic elements may alter antimicrobial resistance and the production of virulence or fitness factors that may be linked to strain success.

Healthcare providers' knowledge of, attitudes to and practice of pre-exposure prophylaxis for HIV infection

OBJECTIVES

Pre-exposure prophylaxis (PrEP) has proven biological efficacy in reducing the risk of sexual acquisition of HIV. Healthcare providers' (HCPs) knowledge of and attitudes to PrEP will be key to successful implementation. In England, PrEP is only available to men who have sex with men (MSM) through the open-label randomized PROUD pilot study of immediate or deferred use.

METHODS

In September 2013, a cross-sectional survey of UK HCPs distributed through sexual health clinics (219) and professional societies' email lists (2599) and at a conference (80) asked about knowledge of, attitudes to and practice of PrEP.

RESULTS

Overall, 328 of 2898 (11%) completed the survey, of whom 160 of 328 (49%) were doctors, 51 (16%) sexual health advisers (SHAs), 44 (14%) nurses and 73 (22%) unspecified. Over a quarter (83 of 311; 27%) were involved in PROUD. Most respondents (260 of 326; 80%) rated their knowledge of PrEP as medium or high. Over half of respondents (166 of 307; 54%) thought PrEP should be available outside of a clinical trial. The main barriers to supporting PrEP availability outside a clinical trial were concerns about current evidence (odds ratio [OR] 0.13), lack of UK-specific guidance (OR 0.35), concerns about adherence (OR 0.38) and risk of sexual or physical coercion for patients to have condomless or higher risk sex (OR 0.42 in multivariate regression). Just over half (147 of 277; 53%) had been asked about PrEP by patients in the past year, including almost half of those working in a clinic not involved in the PROUD study (86 of 202; 43%).

CONCLUSIONS

There is support for PrEP availability outside a clinical trial, but HCPs have residual concerns about its effectiveness and negative consequences, and the absence of UK-specific implementation guidance.

Active and passive smoking in relation to lung cancer incidence in the Women's Health Initiative Observational Study prospective cohort

BACKGROUND

Lung cancer is the leading cause of worldwide cancer deaths. While smoking is its leading risk factor, few prospective cohort studies have reported on the association of lung cancer with both active and passive smoking. This study aimed to determine the relationship between lung cancer incidence with both active and passive smoking (childhood, adult at home, and at work).

PATIENTS AND METHODS

The Women's Health Initiative Observational Study (WHI-OS) was a prospective cohort study conducted at 40 US centers that enrolled postmenopausal women from 1993 to 1999. Among 93 676 multiethnic participants aged 50-79, 76 304 women with complete smoking and covariate data comprised the analytic cohort. Lung cancer incidence was calculated by Cox proportional hazards models, stratified by smoking status.

RESULTS

Over 10.5 mean follow-up years, 901 lung cancer cases were identified. Compared with never smokers (NS), lung cancer incidence was much higher in current [hazard ratio (HR) 13.44, 95% confidence interval (CI) 10.80-16.75] and former smokers (FS; HR 4.20, 95% CI 3.48-5.08) in a dose-dependent manner. Current and FS had significantly increased risk for all lung cancer subtypes, particularly small-cell and squamous cell carcinoma. Among NS, any passive smoking exposure did not significantly increase lung cancer risk (HR 0.88, 95% CI 0.52-1.49). However, risk tended to be increased in NS with adult home passive smoking exposure ≥30 years, compared with NS with no adult home exposure (HR 1.61, 95% CI 1.00-2.58).

CONCLUSIONS

In this prospective cohort of postmenopausal women, active smoking significantly increased risk of all lung cancer subtypes; current smokers had significantly increased risk compared with FS. Among NS, prolonged passive adult home exposure tended to increase lung cancer risk. These data support continued need for smoking prevention and cessation interventions, passive smoking research, and further study of lung cancer risk factors in addition to smoking. CLINICALTRIALS.GOV: NCT00000611.

Hyperimmunoglobulin syndrome due to CD40 deficiency: possibly the first case from India

Hyperimmunoglobulin M (HIGM) type 3 due to CD40 deficiency is a very rare syndrome. Only 16 cases have been reported thus far. The clinical presentation is very variable. We present the first case of this rare disorder from India. The case is of a two-and-a-half-year-old female, with a history of repeated episodes of skin infections and diarrhea since birth. Laboratory evaluation revealed elevated absolute lymphocyte count and an absolute neutrophil count (ANC) of 1026/mm3. The lymphocyte subset analysis showed normal absolute counts of Natural Killer (NK) cells and elevated absolute counts of T-cells (CD4 and CD8) and B-cells. The serum immunoglobulin estimation showed low levels of IgG, IgA, IgE and an elevated level of IgM. The CD154 analysis was normal and expression of CD40 was absent on the B-cells. Molecular analysis showed a novel mutation, with deletion of 3bp (AAG) [p.Glu107GlyfsX84] in the homozygous state, in the CD40 gene. Thus the patient was diagnosed as HIGM type 3. The parents were screened and counseled regarding prenatal diagnosis at the time of next pregnancy.

Additive effects of nicotine and high-fat diet on hepatocellular apoptosis in mice: involvement of caspase 2 and inducible nitric oxide synthase-mediated intrinsic pathway signaling

Smoking is a major risk factor for diabetes and cardiovascular disease and may contribute to nonalcoholic fatty liver disease (NAFLD). The health risk associated with smoking is exaggerated by obesity and is the leading causes of morbidity and mortality worldwide. We recently demonstrated that combined treatment with nicotine and a high-fat diet (HFD) triggers greater oxidative stress, activates hepatocellular apoptosis, and exacerbates HFD-induced hepatic steatosis. Given that hepatocellular apoptosis plays a pivotal role in the pathogenesis of NAFLD, using this model of exacerbated hepatic steatosis, we elucidated the signal transduction pathways involved in HFD plus nicotine-induced liver cell death. Adult C57BL6 male mice were fed a normal chow diet or HFD with 60% of calories derived from fat and received twice daily IP injections of 0.75 mg/kg BW of nicotine or saline for 10 weeks. High-resolution light microscopy revealed markedly higher lipid accumulation in hepatocytes from mice received HFD plus nicotine, compared to mice on HFD alone. Addition of nicotine to HFD further resulted in an increase in the incidence of hepatocellular apoptosis and was associated with activation of caspase 2, induction of inducible nitric oxide synthase (iNOS), and perturbation of the BAX/BCL-2 ratio. Together, our data indicate the involvement of caspase 2 and iNOS-mediated apoptotic signaling in nicotine plus HFD-induced hepatocellular apoptosis. Targeting the caspase 2-mediated death pathway may have a protective role in development and progression of NAFLD.

Visual illusions and plate design: the effects of plate rim widths and rim coloring on perceived food portion size

OBJECTIVE

The Delboeuf Illusion affects perceptions of the relative sizes of concentric shapes. This study was designed to extend research on the application of the Delboeuf illusion to food on a plate by testing whether a plate’s rim width and coloring influence perceptual bias to affect perceived food portion size.

DESIGN AND METHODS

Within-subjects experimental design. Experiment 1 tested the effect of rim width on perceived food portion size. Experiment 2 tested the effect of rim coloring on perceived food portion size. In both experiments, participants observed a series of photographic images of paired, side-by-side plates varying in designs and amounts of food. From each pair, participants were asked to select the plate that contained more food. Multi-level logistic regression examined the effects of rim width and coloring on perceived food portion size.

RESULTS

Experiment 1: Participants overestimated the diameter of food portions by 5% and the visual area of food portions by 10% on plates with wider rims compared to plates with very thin rims (P<0.0001). The effect of rim width was greater with larger food portion sizes. Experiment 2: Participants overestimated the diameter of food portions by 1.5% and the visual area of food portions by 3% on plates with rim coloring compared to plates with no coloring (P=0.01). The effect of rim coloring was greater with smaller food portion sizes.

CONCLUSION

The Delboeuf illusion applies to food on a plate. Participants overestimated food portion size on plates with wider and colored rims. These findings may help design plates to influence perceptions of food portion sizes.

Ontogenic expression of putative feeding peptides in the rat fetal brain and placenta

The well-demonstrated "fetal programming" paradigm is based on the observation that environmental changes can reset the developmental path and thus, gene expression during intrauterine development. As appetite-regulatory neural pathways develop in utero, we sought to determine the ontogenic expression of putative orexigenic and anorexigenic feeding-regulatory peptides in the fetal rat brain and placenta during the last third of gestation. Pregnant Sprague-Dawley rats (n = 12) at D14, D16 and D18 were sacrificed and fetal whole brain and placenta removed and examined for mRNA levels of orexigenic (neuropeptide Y (NPY), agouti-related peptide (AgRP)) and anorexigenic (cocaine and amphetamine regulated transcript (CART), pro-opiomelanocortin (POMC)) peptides and leptin receptor (OB-Rb) using real-time reverse transcription polymerase chain reactions (RT-PCR). For adult comparisons, the hypothalamus, cortex and cerebellum from male rats were also examined for feeding peptides. In the fetal brain and placenta, mRNA levels of AgRP decreased 10-fold from D14 to D16 and was undetectable at D18. Appetite inhibitory factors OB-Rb and CART mRNA levels increased from D14 to D18 in the brain and placenta. NPY and POMC expression remained unchanged from D14 to D18. The pattern of expression of feeding regulatory peptides in the fetal brain most closely resembled the expression profile of the adult cerebral cortex. The continued maturation of feeding regulatory mechanisms in late gestation indicates the potential for in utero programming of ingestive behavior.

Optogenetic drive of neocortical pyramidal neurons generates fMRI signals that are correlated with spiking activity

Local fluctuations in the blood oxygenation level-dependent (BOLD) signal serve as the basis of functional magnetic resonance imaging (fMRI). Understanding the correlation between distinct aspects of neural activity and the BOLD response is fundamental to the interpretation of this widely used mapping signal. Analysis of this question requires the ability to precisely manipulate the activity of defined neurons. To achieve such control, we combined optogenetic drive of neocortical neurons with high-resolution (9.4 T) rodent fMRI and detailed analysis of neurophysiological data. Light-driven activation of pyramidal neurons resulted in a positive BOLD response at the stimulated site. To help differentiate the neurophysiological correlate(s) of the BOLD response, we employed light trains of the same average frequency, but with periodic and Poisson distributed pulse times. These different types of pulse trains generated dissociable patterns of single-unit, multi-unit and local field potential (LFP) activity, and of BOLD signals. The BOLD activity exhibited the strongest correlation to spiking activity with increasing rates of stimulation, and, to a first approximation, was linear with pulse delivery rate, while LFP activity showed a weaker correlation. These data provide an example of a strong correlation between spike rate and the BOLD response. This article is part of a Special Issue entitled Optogenetics (7th BRES).

Mapping the genetic diversity within major clonal complexes of meticillin-resistant Staphylococcus aureus utilizing genome-wide fluorescent amplified fragment length polymorphism markers

The genetic diversity between major meticillin-resistant Staphylococcus aureus (MRSA) lineages was probed using fluorescent amplified fragment length polymorphism (FAFLP) as a random genome sampling tool. Genomic DNA was digested with endonucleases BglII and Csp6I and a subset of the restricted fragments were amplified using the primer pair BglII+A and Csp6I+0. Sixty-seven FAFLP profiles consisting of 46-68 amplified fragments ranging in size from 50 to 600 bp were exhibited amongst the 71 isolates analysed. Cluster analysis of FAFLP data revealed concordance with spa typing and MLST clonal complexes (CC), with isolates of each CC grouping in the same FAFLP cluster. Furthermore, FAFLP could differentiate subtypes within the homogeneous CC22 isolates and also between MLST sequence types 8 and 239. The discriminatory power of FAFLP was 0.998 compared to values of 0.975 and 0.909 for spa typing and MLST, respectively. Thus, FAFLP analysis proved to be a rapid, reproducible and high-resolution tool that displayed the microheterogeneity within MRSA lineages. Using FAFLP data, lineage-specific fragments were identified and sequenced; these encoded toxins, antibiotic resistance determinants and bacteriophage resistance factors. Lineage-specific sequence variations were observed, which may provide insights into the evolution and fitness of successful lineages. This will also aid in the development of rapid and high-throughput diagnostic PCR-based assays for the identification of MRSA lineages in resource-poor settings.

Patients' views and experience of intravenous and oral antimicrobial therapy: room for change

Little is known about patients' views or preferences about the route of administration of antimicrobials. In this study semi-structured interviews were carried out to assess patients' perceptions of an infection that required IV antimicrobial therapy in hospital, their preference for intravenous, IV followed by oral and discharge on oral therapy or home IV therapy. Interviews were transcribed and the content analysed. Twelve patients were interviewed while in hospital or by telephone after discharge. Patients' information about their infection was incomplete and many expressed the view that they would like more information. Many patients expressed a preference for oral therapy over IV therapy although this was dependent on it being of equal efficacy. Contrary views were related to personal difficulty with tablets. Patients varied in their acceptance of home IV therapy and expressed concern about adequate support but the majority expressed a preference for being discharged on oral therapy once they were well enough.