3Rs implementation in veterinary vaccine batch-release testing: Current state-of-the-art and future opportunities. A webinar and workshop report

Regulatory authorities require veterinary batch-release testing to confirm vaccine potency and safety, but these tests have traditionally relied on large numbers of laboratory animals. Advances in vaccine research and development offer increasing opportunities to replace in vivo testing, and some stakeholders have made significant progress in incorporating 3Rs elements in quality control strategies. A three-part event series entitled "3Rs Implementation in Veterinary Vaccine Batch-Release Testing: Current state-of-the-art and future opportunities" was jointly organized by the Animal-Free Safety Assessment Collaboration, HealthforAnimals, and the International Alliance of Biological Standardization. Two webinars and a workshop aimed to outline the state-of-the-art non-animal approaches for veterinary batch-release testing. The events included information on the state of the deletion of obsolete safety testing and the current initiatives implemented by European, North American, and Asian-Pacific stakeholders on 3Rs implementation and regulatory acceptance. The events contributed to a better understanding of the barriers to 3Rs implementation. Participants highlighted the need for open communication, continued collaboration between stakeholders, and international harmonization of regulatory requirements to help accelerate acceptance. Despite the challenges, the countries represented at this three-part event have shared their commitments to advancing the acceptance of alternative methods.

Achieving scientific and regulatory success in implementing non-animal approaches to human and veterinary rabies vaccine testing: A NICEATM and IABS workshop report

This two-day workshop, co-sponsored by NICEATM and IABS-NA, brought together over 60 international scientists from government, academia, and industry to advance alternative methods for human and veterinary Rabies Virus Vaccine (RVV) potency testing. On day one, workshop presentations focused on regulatory perspectives related to in vitro potency testing, including recent additions to the European Pharmacopoeia (5.2.14) that provide a scientific rationale for why in vivo methods may be less suitable for vaccine quality control than appropriately designed in vitro methods. Further presentations reviewed the role of the consistency approach to manufacturing and vaccine batch comparison to provide supportive data for the substitution of existing animal-based methods with in vitro assays. In addition, updates from research programs evaluating and validating RVV glycoprotein (G) quantitation by ELISA as an in vitro potency test were presented. On the second day, RVV stakeholders participated in separate human and veterinary vaccine discussion groups focused on identifying potential obstacles or additional requirements for successful implementation of non-animal alternatives to the in vivo potency test. Workshop outcomes and proposed follow up activities are discussed herein.

One science-driven approach for the regulatory implementation of alternative methods: A multi-sector perspective

EU regulations call for the use of alternative methods to animal testing. During the last decade, an increasing number of alternative approaches have been formally adopted. In parallel, new 3Rs-relevant technologies and mechanistic approaches have increasingly contributed to hazard identification and risk assessment evolution. In this changing landscape, an EPAA meeting reviewed the challenges that different industry sectors face in the implementation of alternative methods following a science-driven approach. Although clear progress was acknowledged in animal testing reduction and refinement thanks to an integration of scientifically robust approaches, the following challenges were identified: i) further characterization of toxicity pathways; ii) development of assays covering current scientific gaps, iii) better characterization of links between in vitro readouts and outcome in the target species; iv) better definition of alternative method applicability domains, and v) appropriate implementation of the available approaches. For areas having regulatory adopted alternative methods (e.g., vaccine batch testing), harmonised acceptance across geographical regions was considered critical for broader application. Overall, the main constraints to the application of non-animal alternatives are the still existing gaps in scientific knowledge and technological limitations. The science-driven identification of most appropriate methods is key for furthering a multi-sectorial decrease in animal testing.

Recommendations of the VAC2VAC workshop on the design of multi-centre validation studies

Within the Innovative Medicines Initiative 2 (IMI 2) project VAC2VAC (Vaccine batch to vaccine batch comparison by consistency testing), a workshop has been organised to discuss ways of improving the design of multi-centre validation studies and use the data generated for product-specific validation purposes. Moreover, aspects of validation within the consistency approach context were addressed. This report summarises the discussions and outlines the conclusions and recommendations agreed on by the workshop participants.

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In Europe, use of non-animal methods is encouraged and being informed is key.

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Manufacturers should engage in validation studies at an early stage.

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Participants in validation studies can use data for product-specific validation.

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More regulatory guidance on setting specifications and validity criteria needed.

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Communication of key players crucial for implementation/acceptance of methods.

A unique case of acute embolus in a renal transplant with salvage by catheter-directed thrombolysis

INTRODUCTION

Acute renal transplant emboli can be disastrous and result in loss of the renal transplant. This case was successfully treated with thrombolysis.

CASE PRESENTATION

A 66-year-old female underwent a right-sided deceased heart-beating donor renal transplant. She had excellent transplant function but presented acutely three years later with pain in the transplanted kidney, an acute rise in serum creatinine and new onset atrial fibrillation. Bedside ultrasound scan demonstrated absent transplant perfusion. Emergency angiogram confirmed acute emboli in the transplant renal artery with some kidney perfusion. Thrombolysis with alteplase and anticoagulation with heparin was commenced. Serial imaging at 24 and 36 h demonstrated significant improvement in transplant perfusion. Following a period of supportive therapy, her transplant function recovered, although not to pre-morbid baseline levels.

CONCLUSION

Consider acute embolus in a renal transplant patient with acute kidney injury, transplant tenderness and cardiac arrhythmia. Early thrombolysis may salvage renal transplants and good transplant function may be regained.

Perceptions of supported and unsupported prone-restraint positions

WHAT IS KNOWN ON THE SUBJECT?: Although the use of prone restraint should be avoided, it may remain a last resort emergency intervention for violent behaviour in psychiatric settings. However, when used as a last resort, concerns remain about the ability of staff to maintain the dignity, welfare and safety of the patient and minimize the potential adverse outcomes associated with restraint. This study builds on existing research regarding the risks of prone restraint by focusing on the psychological perceptions of individuals held in this position. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Individuals, who were asked to rate the psychological impact of two different prone-restraint positions (Supported and Unsupported Prone Positions) reported that the Supported Prone Position was more comfortable, less anxiety inducing and less limiting to breathing. Although no individual found prone restraint a positive experience, it shows that individuals found the psychological impact of the Supported Prone Position was less than the Unsupported Prone Position. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals have a clear responsibility to maintain the dignity, safety and wellbeing of individuals subject to prone restraint as a short-term emergency procedure for the management of violent behaviour. Reducing both the physiological and psychological impact of prone restraint will help to reduce any adverse impact on individuals subject to such interventions. The findings will help influence current practice and promote the removal of the USPP as a specific prone-restraint intervention.

ABSTRACT

Aim Restraint-related deaths are multi-factorial with prone restraint remaining a concern due to the physiological and psychological risks. This study builds on evidence presented by (Barnett et al. Medicine, Science and the Law (2012b): 1) that the Supported Prone Position (SPP) reduces physiological risks, by examining if the SPP also reduces the psychological impact of prone restraint. Methods Twenty participants ran to near maximal exertion before being held in two prone-restraint positions: SPP and Unsupported Prone Position (USPP). Perceptions of comfort, anxiety and breathing limitation were measured using Visual Analogue Scales. Results Results showed that (1) comfort was 23% greater in the SPP; (2) anxiety was 55% less in the SPP; and (3) perception of breathing limitation was 32% less in the SPP when compared with the USPP. Negative perceptions expressed for the USPP included feeling trapped, vulnerable and concern over heart rate. Discussion In addition to reducing physiological risks, this study shows that the SPP reduced the psychological impact of prone restraint compared to USPP. Implications for Practice Settings where prone restraint cannot be avoided should remove the USPP as an emergency procedure in favour of the SPP as a way of maintaining safety and reducing the psychological impact of prone restraint.

Vaccination of dogs with canine parvovirus type 2b (CPV-2b) induces neutralising antibody responses to CPV-2a and CPV-2c

Since the identification of canine parvovirus type 2, three variants have subsequently been observed differing from the historical CPV-2 and each other by 1-2 amino acids only. As a result there has been considerable research into differential diagnostics, with some researchers indicating there is a need for new vaccines containing different strains of CPV-2. In this study we investigated whether vaccination with a CPV-2b containing vaccine would induce cross-reactive antibody responses to the other CPV-2 variants. Two studies where dogs were vaccinated with a multivalent vaccine, subsequently challenged with CPV-2b and sera samples analysed are presented. Six week old pups with defined serological status were vaccinated twice, three weeks apart and challenged either 5 weeks (MDA override study) or one year after vaccination (duration of immunity study). Sera samples were collected before each vaccination and at periods throughout each study. In each study the antibody profiles were very similar; serological responses against CPV-2a, CPV-2b and CPV-2c were higher than those for CPV-2. Nevertheless, responses against CPV-2 were well above levels considered clinically protective. In each study dogs also showed a rapid increase in antibody titres following vaccination, reached a plateau following second vaccination with a slight decline to challenge after which rapid anamnestic responses were seen. Evaluation of the serological responses suggests vaccination with CPV-2b would cross-protect against CPV-2a and CPV-2c, as well as against CPV-2 which is now extinct in the field. In conclusion we have demonstrated that vaccination of minimum aged dogs with a multivalent vaccine containing the CPV-2b variant strain will induce serological responses which are cross-reactive against all currently circulating field strains, CPV-2a and CPV-2c, and the now extinct field strain CPV-2.

Validation of the Global Rating Scale for endoscopy

The Global Rating Scale for endoscopy is a web-based tool that can be used to assess and improve the quality of an endoscopy service. It was developed by asking endoscopy health professionals what they would want from the service for themselves or their relatives if they were undergoing an endoscopic procedure. To date, the Global Rating Scale has not been validated by patients themselves. We used focus groups in order to access the views and opinions of patients who had recently had experience of endoscopy services. Six focus groups were undertaken in five different Health Board areas across Scotland; in total 26 people participated. The results indicated that from the patients' perspective the 12 items of the GRS covered all areas of the endoscopy experience. There were no specific concerns identified that were not already covered within the Global Rating Scale. We conclude that the Global Rating Scale does address quality issues that matter to patients undergoing endoscopy, and validates the use of the GRS as a quality assessment tool for endoscopy services.

Report on the international workshop on alternative methods for Leptospira vaccine potency testing: state of the science and the way forward

Routine potency testing of Leptospira vaccines is mostly conducted using a vaccination-challenge test that involves large numbers of hamsters and unrelieved pain and distress. NICEATM, ICCVAM, and their international partners organized a workshop to review the state of the science of alternative methods that might replace, reduce, and refine the use of animals for veterinary Leptospira vaccine potency testing and to identify ways to advance improved alternative methods. Vaccine manufacturers were encouraged to initiate or continue product-specific validation using in vitro enzyme-linked immunosorbent assays as replacements for potency testing of four common Leptospira serogroups. Participants discussed the potential for eliminating the back-titration procedure in the hamster challenge assay, which could reduce animal use by 50% for each individual potency test. Further animal reduction may also be possible by using cryopreserved Leptospira stock to replace continual passaging through hamsters. Serology assays were identified as a way to further reduce and refine animal use but should be considered only after attempting in vitro assays. Workshop participants encouraged consideration of analgesics and use of earlier humane endpoints when the hamster vaccination-challenge potency assay is used. International harmonization of alternative potency methods was recommended to avoid duplicative potency testing to meet regionally different requirements.

Product-specific validation of a serological potency test for release of Leptospira vaccines in the European Union

Historically in the European Union, all Leptospira vaccines were released using the European Pharmacopoeia (Ph. Eur.) hamster potency assay. Recently, there has been a shift toward alternatives that offer either refinement of testing or replacement of animals for product release. This is being driven by animal welfare concerns but also by a drive to have more consistent, cheaper, and faster batch release tests. This publication discusses one such example of a multicomponent canine vaccine that includes three Leptospira serovars and has recently been registered in the European Union. The potency release test is a refinement because it uses rabbit serology rather than hamster challenge. This publication covers the principles of the test method, challenges faced during its development and registration, and discussion about benefits and limitations of this method. It concludes with a view of how the use of serology testing could fit into an overall strategy to move to fully in vitro testing by adopting a consistency approach.

A new multivalent (DHPPi/L4R) canine combination vaccine prevents infection, shedding and clinical signs following experimental challenge with four Leptospira serovars

Although effective vaccines have been developed against the common Leptospira serovars, they are still reported in clinical cases, while others are increasingly prevalent. The results from four challenge studies following vaccination of dogs with a new combination vaccine (DHPPi/L4R) containing inactivated L. serovars, L. canicola, L. icterohaemorrhagiae, L. bratislava and L. grippotyphosa conducted to satisfy the requirements of the European Pharmacopoeia monograph (01/2008:0447), are reported. Six week old dogs received two vaccinations, three weeks apart, and were challenged 25 days later with different isolates of the L. serovars. Clinical observations were recorded, and blood, urine and tissue samples were collected for analysis. Following challenge, non-vaccinated dogs demonstrated various clinical signs, while no vaccinated dogs were affected; significant differences in mean clinical scores were observed. Measurable antibody titres to each Leptospira antigen were seen in vaccinated dogs 21 days following the first vaccination, with further increases in antibody titres observed following challenge with the respective Leptospira strain. Non-vaccinated dogs remained seronegative until challenge. Leptospira were re-isolated from the blood, urine, kidney and liver of all non-vaccinated dogs following challenge. In contrast no vaccinated dogs had Leptospira re-isolated from the same tissues. Significant differences were seen in number of days with positive isolation (blood and urine) and in number of dogs with positive samples (kidney and liver). In conclusion, vaccination of dogs with the new vaccine induces protective immunity 25 days after second vaccination with protection against infection, renal infection and clinical signs following challenge.

Vaccination of dogs with Duramune DAPPi+LC protects against pathogenic canine parvovirus type 2c challenge

In this study, we determined whether vaccination with Duramune DAPPi+LC containing canine parvovirus (CPV) type 2b protects against challenge with virulent CPV antigenic type 2c. Seven healthy dogs, seronegative for CPV2, were enrolled into two treatment groups; five were vaccinated twice, 21 days apart, with minimum titre vaccine, and two were given saline. Dogs were challenged with CPV 2c three weeks later. Clinical observations, body weight and rectal temperature measurements, blood samples for serology and white blood cell counts and faecal samples for virus excretion were collected. Control dogs remained seronegative until challenge; vaccinated dogs seroconverted and were positive for antibodies to CPV2 from day 21. Four days after challenge, clinical signs associated with parvovirus infection (vomiting, paroxysmal shivering, depression, loose stools) were observed in the control dogs. Both animals were withdrawn from the study for welfare reasons one day later. On day 47, leucopenia was observed in controls, with white blood cell counts less than 50 per cent prechallenge values. No specific clinical sign of parvovirus infection were observed in the vaccinated dogs, nor was (detectable) challenge virus shed in faeces suggesting that antibodies generated contributed sterilising immunity. We conclude that vaccination of dogs with Duramune DAPPi+LC protects against challenge with a virulent field strain of CPV 2c.

Consistency as tool to support in vitro batch potency testing in GMP production

There is great interest in the veterinary vaccine field to move away from in vivo release tests for vaccines to reduce cost and testing time, improve consistency and of course the 3Rs (reduce, refine, replace). A brief overview of Good Manufacturing Practice (GMP) and the consistency approach is discussed below and an overview of how manufacturers can use the consistency approach and GMP controls along with statistical analysis of processes at each stage of the production process (starting materials, antigen and finished product) to build in quality and reduce the need for in vivo finished product tests. A final summary and outline of some challenges we will face in moving this approach forward is covered in conclusion.

Severe statin-induced rhabdomyolysis mimicking Guillain-Barré syndrome in four patients with diabetes mellitus treated with fusidic acid

BACKGROUND

An interaction between fusidic acid and HMG coenzyme A reductase inhibitors (statins), resulting in rhabdomyolysis, has been described. Pain and mild weakness are common presenting symptoms.

CASE REPORT

We report four patients with Type 2 diabetes prescribed long-term statin treatment who, following treatment with fusidic acid, presented atypically with painless, severe flaccid paralysis suggestive of Guillain-Barré syndrome. This, together with nerve conduction studies consistent with Guillain-Barré syndrome, resulted in the delayed recognition of rhabdomyolysis in these cases.

CONCLUSIONS

The addition of fusidic acid can precipitate rhabdomyolysis in patients with diabetes already taking a statin. This can present with rapidly progressive weakness resembling Guillain-Barré syndrome. We recommend that creatine kinase is checked in patients with diabetes on statin therapy who present with profound weakness and routinely in those commenced on prolonged courses of fusidic acid.

Anaemia is common and predicts mortality in diabetic nephropathy

BACKGROUND

Diabetes is the single largest cause of chronic renal failure, accounting for 18% of patients on renal replacement therapy in the UK.

AIM

To investigate the chronic kidney disease stage at which patients with diabetic nephropathy are referred to renal services, determine the prevalence of anaemia in patients with diabetic nephropathy, examine patient outcome and identity prognostic factors.

DESIGN

Retrospective review.

METHODS

Patients with diabetic nephropathy referred to our renal services between 1989 and 2004 were identified from electronic records. Estimated glomerular filtration rate (calculated using the MDRD formula) and haemoglobin at referral were collected. Times to renal replacement therapy and death were noted.

RESULTS

We identified 508 patients. At referral, mean eGFR was 34 ml/min/1.73 m(2) and 48% of patients were at CKD stages 4 and 5. Mean haemoglobin was 11.7 g/dl; 21% had a haemoglobin <10 g/dl at referral. Median survival was 37.9 months (95%CI 33.2-42.6); median survival independent of renal replacement therapy (RRT) was 21 months (95%CI 17.8-24.6). Of patients starting RRT, 38% did so within 1 year of referral. Older age (RR 1.02, 95%CI 1.01-1.04) and lower haemoglobin (RR 0.9, 95%CI 0.85-0.99) at referral predicted death on multivariate analysis.

DISCUSSION

At referral to renal services, almost 50% of patients with diabetic nephropathy were at CKD stages 4 and 5. Anaemia was common and predicted mortality. All diabetic patients from CKD stage 3 should be screened for anaemia. We believe that patients with diabetic nephropathy should be discussed with renal services when they reach CKD stage 3 with evidence of progression of renal disease.

Efficacy of particle-based DNA delivery for vaccination of sheep against FMDV

As an alternative strategy to classical inactivated viral vaccine against FMDV, naked DNA vaccine is attractive because of safety, flexibility and low cost. However DNA vaccination is usually poorly efficient in target species. Indeed we found that naked DNA plasmids encoding for P1-2A3C3D and GM-CSF proteins did not induce any detectable immunity against FMDV in sheep. Interestingly, we demonstrate herein that formulations of DNA on poly(D,L-lactide-co-glycolide) (PLG) or in lipofectin triggered divergent types of immune responses: PLG stimulated a T cell response and could elicit significant neutralising antibody titers, whereas lipofectin generated even higher antibody titers but no significant T cell response. The DNA/PLG regimen used in five sheep protected against clinical symptoms and viraemia and prevented the carrier state in four of them. Thus formulated DNA can be remarkably efficient against FMDV in a ruminant species that is usually refractory to DNA vaccination.

Porcine γδ T cells: Possible roles on the innate and adaptive immune responses following virus infection

gammadelta T cells recognise different types of antigen in alternative ways to alphabeta T cells, and thus appear to play a complementary role in the immune response. However, unlike alphabeta T cells, the role or function of gammadelta T cells is still unclear. As pigs possess a high proportion of circulating gammadelta T cells, they are suitable large animal model to study gammadelta T cell functions. This as yet has not been fully exploited, leaving porcine gammadelta T cell biology and its role in immunity in its infancy. Foot-and-mouth disease (FMD) high potency "emergency" vaccines are able to induce early protection from challenge and it has been suggested that, in part, there is some involvement of innate immune responses. The antigen component of the vaccine is able to stimulate purified naive pig gammadelta T cells and induce the mRNA of various cytokines and chemokines. This observation suggests that gammadelta T cells probably contribute to the early phase of the immune responses to FMD vaccination, and perhaps infection. A subset of these circulating gammadelta T cells display a phenotype similar to professional antigen presenting cells and are able to take up and present soluble antigen to CD4(+) T cells in a direct cell-cell interaction via MHC class II. This direct interaction between gammadelta T cells and CD4(+) T cells is likely to have a significant influence on the out come of the adaptive immune response.

The effect of high dose atorvastatin therapy on lipids and lipoprotein subfractions in overweight patients with type 2 diabetes

Few data are available on the effects of high dose statin therapy on lipoprotein subfractions in type 2 diabetes. In a double blind randomised placebo-controlled trial we have studied the effects of 80 mg atorvastatin over 8 weeks on LDL, VLDL and HDL subfractions in 40 overweight type 2 diabetes patients. VLDL and LDL subfractions were prepared by density gradient ultracentrifugation. Triglycerides, cholesterol, total protein and phospholipids were measured and mass of subfractions calculated. HDL subfractions were prepared by precipitation. Atorvastatin 80 mg produced significant falls in LDL subfractions (LDL(1) 66.2 mg/dl:36.6 mg/dl, LDL(2) 118:56.6 mg/dl, LDL(3) 36.9:19.9 mg/dl all P < 0.01 relative to placebo) and VLDL subfractions (VLDL(1) 55:22.1 mg/dl, VLDL(2) 40.1:19.1 mg/dl, VLDL(3) 52.6:30 mg/dl all P < 0.01 relative to placebo). There was no change in the proportion of LDL present as LDL(3). There was a reduction in the proportion of VLDL as VLDL(1) and a reciprocal increase in the proportion as VLDL(3). Changes in VLDL subfractions were associated with changes in lipid composition, particularly a reduction in cholesterol ester and a reduction in the cholesterol ester/triglyceride ratio. Effects on HDL subfractions were largely neutral. High dose atorvastatin produces favourable effects on lipoprotein subfractions in type 2 diabetes which may enhance antiatherogenic potential.

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure

The occurrence of severe acute renal failure in 3 patients who developed diarrhoea while taking angiotensin converting enzyme (ACE) inhibitors led us to undertake a retrospective cohort survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking this class of drug. Serum creatinine was measured as part of the diagnostic workup of 2398 consecutive admissions to an acute medical receiving unit in a district general hospital. Outcome measures were the presence of diarrhoea and/or vomiting, and whether taking an ACE inhibitor, NSAID or diuretic at the time of admission, also previous, initial and follow up serum creatinine concentrations. Peak serum creatinine in the 3 cases was 1159, 989 and 765 micromol/l. None of the 3 required dialysis and all recovered renal function completely after receiving large volumes of intravenous fluid. In the cohort study, 89 of 2398(3.7%) admissions had serum creatinine >/=200 micromol/l. Nine were regular dialysis patients. Of the remaining patients, 30 (37.5%) were taking an ACE inhibitor. Six of 30 (20%) gave a history of diarrhoea and/or vomiting. Median creatinine concentration in this group was 135 (range 111-209) micromol/l before admission, 292 (216-724) micromol/l when first seen in hospital, and 134 (94-219) micromol/l following the withdrawal of drug therapy and fluid replacement. In conclusion, volume depletion causing acute renal failure in patients taking ACE inhibitors is not uncommon. Such patients and their general practitioners should be aware that reversible renal impairment may occur during intercurrent illnesses, particularly if characterised by diarrhoea and/or vomiting.

Reactions in the oral mucous membrane after exposure to Carisolv--combined results from a clinical screening test in humans and an experimental study in rats

OBJECTIVE

To evaluate reactions in the oral mucosa after direct contact with Carisolv.

SETTING

The Faculty of Odontology in Göteborg, Sweden.

SUBJECTS

34 healthy persons for a clinical screening test and 35 Sprague Dawley rats for a histological study.

DESIGN

Mixed Carisolv or 0.5 % NaOCl were soaked in paper and applied to either side of the medial frenula of the lower lip of 34 persons. The solutions were left on the oral mucosa for three minutes. Inspection was made and photographs were taken immediately after exposure and also after 1 hour, 24 hours, and 72 hours. Mixed Carisolv was applied in a similar manner as described above to 35 adult Sprague Dawley rats. The animals were killed and biopsies were taken immediately after Carisolv exposure and also after 1 hour, 24 hours, and 48 hours. The biopsies were sectioned and prepared for histomorphometrical evaluation in light microscopy where cells were counted on regions from the epithelium layer deeper into the mucous membrane.

RESULTS

Some adverse reactions were detected on the oral mucosa of humans up to 24 hours after Carisolv exposure for 3 minutes. The detected inflammatory reactions were slight and no patient felt any discomfort. The results of the histological study on rat did not show any statistically significant increase of the number of cells at any time after Carisolv exposure.

CONCLUSIONS

If the oral mucosa gets in direct contact with Carisolv for 3 minutes no or only a weak inflammatory response may be expected.

Developing a non-aversive intervention strategy in the management of aggression and violence for people with learning disabilities using natural therapeutic holding

This paper builds upon a previous piece of research regarding the development of 'natural therapeutic holding' as a non-aversive alternative to control and restraint (C and R) in managing aggression and violence in people with learning disabilities. This paper represents aspects of an ongoing programme of research and explains the aims and values which underpin natural therapeutic holding by describing the theory, aims, values and practical application. The concepts of individual risk management and pro-active intervention strategies are discussed with illustrations of practical application given by means of a case study. The case study shows that over a relatively short period of time, an individual with severe learning disabilities who is aggressive and violent, learns alternative coping strategies to aggression and violence through the application of natural therapeutic holding. The article concludes that natural therapeutic holding is a very effective intervention strategy in the management of violence in people with learning disabilities from two perspectives: (a) it provides staff with safe, professional and ethical skills with which they can manage aggressive and violent clients and (b) as a therapy, natural therapeutic holding gives clients the opportunity to learn coping strategies which are more effective than violence.

Natural therapeutic holding: a non-aversive alternative to the use of control and restraint in the management of violence for people with learning disabilities

For at least the last 10 years, control and restraint (C&R) has gained increased popularity amongst nurses as a safe, professional and legal means to manage violence in health care settings. However, during this period there has been an increased momentum to find non-aversive management strategies for people with learning disabilities and there has been frequent debate on the abolition of practices which do not achieve this. More recently, the main criticisms of C&R have been the professional and ethical objections that the techniques used inflict some degree of pain or discomfort to the client, and the fact that it remains a reactive strategy with no theoretical framework for professional practice. On this basis, alternatives should be sought which seek to address these issues. This paper outlines the development of natural therapeutic holding, an approach which is non-aversive and which provides a theoretical structure for professionals to base their practice on in order to develop clear therapeutic goals for the client. Initial findings within a small community residential service for people with learning disabilities indicate that natural therapeutic holding was a preferred method of intervention strategy by staff, proving as effective as C&R in the management of violent incidents, with interventions being much shorter in duration and non-aversive in nature.

Intracellular particle dissolution in macrophages isolated from the lung of the Fischer (F-344) rat

Alveolar macrophages were removed from male F-344 rats by bronchoalveolar lavage and maintained in vitro for 14 days. Over this period the macrophages remained viable as judged by propidium iodide exclusion, lysosomal uptake of acridine orange, and phagocytosis of 1.75-microns latex beads. After 7 and 14 days of culture the cells contained lipid droplets. The macrophages were shown to ingest and dissolve monodisperse 57Co3O4 particles, which were relatively insoluble in extracellular medium. The fraction of 57Co3O4 dissolved intracellularly was determined at intervals during the culture period. The mean dissolution rate (+/- SEM) was 0.36 +/- 0.02% per day for the F-344 rat. This was lower than 1.4 +/- 0.05% per day estimated by Kreyling in macrophages from the beagle dog. The significance of this difference is discussed.

Transport of particles of colloidal gold within and from rat lung after local deposition by alveolar microinjection

Because inhalation and intratracheal instillation deposit particles throughout the respiratory tract, these methods of administration give little information on the movement of particles within the lung and no direct information on the clearance kinetics from locally defined sites within alveolar tissue. Approximately 0.05 microL of 195Au-labeled gold colloid was administered to 32 rats by microinjection into a small volume of subpleural alveoli. Its fate was studied by whole-body counting and serial sacrifice over 15 months. The kinetics of clearance from the subpleural deposition site showed that there was no rapid removal of particles, and the main clearance process was defined by an exponential term with a half-time averaging 583 days. There was a wide variation between individual animals. The distribution of 195Au at sacrifice showed that the gold colloid was nearly all retained within the respiratory tract. The particles were not appreciably redistributed throughout the lung volume, so most of the material not cleared from the lung remained close to the deposition site. At the later times after microinjection, much of the gold colloid was associated with thickened pleura and adjoining septae.

Effects of pravastatin and cholestyramine on gonadal and adrenal steroid production in familial hypercholesterolaemia

1. Adrenal and gonadal steroids are derived from cholesterol, which may be derived from plasma lipoproteins or de novo synthesis. 2. Inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, the rate limiting enzyme in cholesterol synthesis, may therefore affect steroidogenesis when used as lipid-lowering agents in hypercholesterolaemia. 3. We have assessed gonadal and adrenal function in subjects with heterozygous familial hypercholesterolaemia (FH) before and after 12 weeks treatment with pravastatin, an HMG CoA reductase inhibitor, or cholestyramine as a control in maximal recommended doses. 4. No changes in measured plasma cortisol responses to tetracosactrin injection were seen in 11 patients on cholestyramine or 12 on pravastatin. 5. No changes were seen in testosterone, sex hormone binding globulin, androstenedione, dehydroepiandrosterone sulphate, oestradiol or 17 alpha-hydroxyprogesterone. 6. Gonadotrophin levels were unaffected in 10 male subjects on cholestyramine and 7 on pravastatin. 7. Measurements on a subset of subjects continuing to 24 weeks treatment also showed no changes. 8. No adverse effect on adrenal or gonadal function could be demonstrated in patients with familial hypercholesterolaemia on maximal recommended doses of pravastatin.

Paradoxical platelet behaviour in diabetic ketoacidosis

Thrombotic events may occur in patients who present with severe uncontrolled diabetes or with diabetic coma. As a possible explanation for this, platelet function was investigated at presentation with diabetic ketoacidosis and during treatment in 10 patients. Concentrations of the platelet-specific proteins, platelet factor 4 (PF4) and beta-thromboglobulin (beta TG) were elevated and fell towards normal with treatment. Despite evidence of increased aggregation in vivo, platelets from subjects with ketoacidosis were insensitive to adenosine 5'-diphosphate (ADP), sensitivity increasing with correction of ketoacidosis. Platelets from ketoacidotic diabetics were initially insensitive to the anti-aggregatory action of prostacyclin (PGI2) and became normal with treatment. Initial blood glucose concentrations correlated with log10 ADP concentrations (r = 0.72, p less than 0.01) and with log10 PGI2 ID50 (the PGI2 concentration required to half-inhibit ADP-induced aggregation) (r = 0.66, p less than 0.025). Glucose concentrations throughout the 2-week study period correlated with all log10 ADP concentrations (r = 0.32, p less than 0.005) and all log10 PGI2 ID50 concentrations (r = 0.51, p less than 0.001). The decrease in ADP sensitivity in ketoacidosis, paradoxical in view of the evidence of increased in vivo platelet aggregation, may result from an acquired platelet storage pool deficiency.

Acipimox in the treatment of patients with hyperlipidaemia: a double blind trial

Fifty-two patients with Fredrickson Type IIb or Type IV hyperlipidaemia, in whom diet had not achieved satisfactory lipid levels, completed a double blind randomised study of acipimox versus placebo. The patients were given acipimox, 250 mg three times daily or placebo for a three month period, and plasma lipids and glucose were monitored. The patients receiving acipimox showed a fall in the mean concentration of plasma triglyceride compared to placebo (0.74 mmol/l) and this was most marked in patients whose initial plasma triglyceride levels were greater than 3 mmol/l (1.0 mmol/l, confidence limits 0.18, 1.82). Acipimox was well tolerated, and could be a useful addition to the drugs available for the treatment of patients with hypertriglyceridaemia.

A method for microinjection into subpleural alveoli of rat lung in situ

A new technique is described for the micropuncture of rat lung in the intact thorax. Under pentobarbital sodium anesthesia a glass micropipette is passed through a small area of the parietal pleura, which has been cleared of overlying intercostal muscle. The micropipette is passed into the lung parenchyma and withdrawn again without collapsing the lung. The current application of this technique is in the microinjection of fluid into subpleural alveoli, which is illustrated using a suspension of colloidal gold. The gold particles are immediately dispersed over the surface of many alveoli, a small proportion spreading laterally as far as 4-6 mm. There is no evidence of alveolar flooding.

Effects of acipimox, a nicotinic acid derivative, on lipolysis in human adipose tissue and on cholesterol synthesis in human jejunal mucosa

The mode of action of acipimox (5-methyl-pyrazine carboxylic acid 4-oxide), an hypotriglyceridaemic agent, was examined in human adipose tissue and intestinal mucosa. The rates of release of fatty acids and glycerol from human adipose tissue were measured in vitro. The release of fatty acids and glycerol from adipose tissue maximally stimulated by isoprenaline (10(-5) mol/l) fell by 40 and 25% respectively (P less than 0.025 and P less than 0.025) in the presence of acipimox (10(-5) mol/l). In submaximally stimulated adipose tissue (isoprenaline 10(-7) mol/l) acipimox (10(-4) mol/l) fully inhibited release of fatty acids (P less than 0.05) and glycerol (P less than 0.025) to basal rates. In unstimulated adipose tissue acipimox (10(-3) mol/l) reduced the rate of glycerol release (P less than 0.05), but not the rate of fatty acid release. Cholesterol synthesis in jejunal mucosa was measured in vitro by the incorporation of [2-14C]-acetate into sterols. Addition of cholesterol to the incubation reduced [2-14C]acetate incorporation into sterols from 8.7 +/- 2.1 (mean +/- standard error) to 3.7 +/- 1.0 pmol h-1 mg-1 of tissue (P less than 0.01). Acipimox at 10(-4)-10(-2) mmol/l had no consistent effect on cholesterol synthesis. Acipimox appears to exert its main hypolipidaemic effect by reducing lipolysis and free fatty acid flux to the liver, thereby reducing the precursor pool size of very low density lipoprotein (VLDL)-triglyceride and VLDL synthesis.

The localisation of particles retained in the trachea of the rat

Particles of 133BaSO4 were deposited on the surface of rat trachea by intra-tracheal injection. Aggregates of particles were located in the trachea by autoradiography and electron microscopy. Following deposition, particles not rapidly removed by muco-ciliary clearance remained on the epithelium for some time. After 2 hr most had been ingested by macrophages on the surface, though some were still free in the mucus. By 24 hr, 74 per cent. of the aggregates remaining were beneath the epithelium in the lamina propria, and after 7 days almost all of them were in or beneath the epithelium. All the buried particles identified by EM were within macrophages. After 24 hr the particles in the tracheal wall were beneath epithelium which was not ciliated columnar, but cuboidal or flatter, with fewer or no ciliated cells and infiltrated with lymphocytes. It is suggested that particle retention in airways is accomplished by ingestion by macrophages which then migrate through this type of epithelium.

Ouabain binding to renal tubules of the rabbit

It is well known that ouabain, a specific inhibitor of Na-K ATPase-dependent transport, interferes with renal tubular salt reabsorption. In this study, we employed radiochemical methods to measure the kinetics of [3H]ouabain binding to slices of rabbit renal medulla and high resolution quantitative autoradiography to determine the location and number of cellular binding sites. The kinetics obeyed a simple bimolecular reaction with an association constant of 2.86 +/- 0.63 SD x 10(3) M-1 min-1 and a dissociation constant of 1.46 x 10(-3) min-1, yielding an equilibrium binding constant of 0.51 x 10(-6) M. Binding was highly dependent upon temperature. At a concentration of 10(-6) M, the rate of accumulation between 25 degrees C and 35 degrees C exhibited a Q10 of 1.8. At 0 degree C the rate of ouabain dissociation was negligible. The specificity of binding was demonstrated with increasing potassium concentrations. At a concentration of 1 microM, 6 mM, and 50 mM K+ produced a 2.5- and 7-fold decrease, respectively, in the rate of ouabain accumulation observed at zero K+. Binding was completely inhibited by 1 mM strophanthin K. The major site of ouabain binding was the thick ascending limb; little or no binding was observed in thin limbs and collecting ducts. Moreover, binding was confined to the basolateral membranes. From autoradiographic grain density measurements, it was estimated that each cell contains over 4 x 10(6) ouabain binding sites or Na-K ATPase molecules. These results taken together with physiological and biochemical observations suggest that Na-K ATPase plays a key role in salt reabsorption by this segment.

The retention of particles in large airways of the respiratory tract

After the intra-tracheal injection in the conscious rat of 133 BaSO 4 particles suspended in 2.5 μI isotonic mannitol, only approximately 80% were rapidly removed from the distal trachea by mucociliary clearance. Some 20% were cleared with a mean half-time of 16 h, and approximately 1% remained in the tracheal tissue for at least 30 d. Such retention could be a basis for effects of inhaled toxic particles on the large airways. Mucus was collected from the trachea of the conscious rat and shown to exhibit shear-thinning. When BaSO 4 particles suspended in the mucus were injected into another rat, clearance kinetics over 2 d were similar to those for particles suspended in mannitol.

Measurement of mucociliary clearance from the trachea of conscious and anesthetized rats

A technique is described whereby particles are injected as a suspension into the trachea of conscious rats. Tracheostomy and cannulation are performed under halothane, but the particles are injected 10 min after recovery. Clearance of BaSO4 particles labeled with 133Ba was determined with a collimated slit gamma-counter, either aligned with the region of particle deposition or used to scan along the animal. Compared with clearance up the trachea in conscous rats, the effect of halothane, thiopental and pentobarbital was to inhibit clearance. With halothane, clearance was resumed at the control rate 0-3 min after anesthesia lasting 7-9 min.