Pharmacokinetic Drug-Drug Interaction With Coadministration of Cannabidiol and Everolimus in a Phase 1 Healthy Volunteer Trial

When highly purified cannabidiol (CBD; Epidiolex) and the mammalian target of rapamycin inhibitor everolimus are used concomitantly in the treatment of tuberous sclerosis complex, there is evidence of a pharmacokinetic (PK) interaction, leading to increased everolimus systemic exposure. We evaluated the effect of steady-state CBD exposure following multiple clinically relevant CBD doses on everolimus PK in healthy adult participants in a single-center, fixed-sequence, open-label, phase 1 study. All participants received oral everolimus 5 mg on day 1, followed by a 7-day washout. On days 9-17, participants received CBD (100 mg/mL oral solution) at 12.5 mg/kg in the morning and evening. On the morning of day 13, participants also received a single dose of oral everolimus 5 mg. Medications were taken 30 or 45 minutes (morning or evening dose) after starting a standardized meal. Maximum concentration and area under the concentration-time curve (AUC) from time of dosing to the last measurable concentration and extrapolated to infinity, of everolimus in whole blood were estimated using noncompartmental analysis, with geometric mean ratios and 90% confidence intervals for the ratios of everolimus dosed with CBD to everolimus dosed alone. A single dose of everolimus 5 mg was well tolerated when administered with multiple doses of CBD. Log-transformed everolimus maximum concentration, AUC from time of dosing to the last measurable concentration, and AUC extrapolated to infinity values increased by ≈2.5-fold, and everolimus half-life remained largely unchanged in the presence of steady-state CBD relative to everolimus dosed alone. Everolimus blood concentration monitoring should be strongly advised with appropriate dose reduction when coadministered with CBD.

Cannabidiol Does Not Convert to Δ9-Tetrahydrocannabinol in an In Vivo Animal Model

Introduction: Cannabidiol (CBD) can convert to Δ⁹-tetrahydrocannabinol (THC) in vitro with prolonged exposure to simulated gastric fluid; however, in vitro conditions may not be representative of the in vivo gut environment. Using the minipig, we investigated whether enteral CBD converts to THC in vivo.

Materials and Methods: Synthetic CBD (100 mg/mL) was administered orally in a sesame oil formulation twice daily to minipigs (N=3) in 15 mg/kg doses for 5 consecutive days. Blood samples were taken before and 1, 2, 4, and 6 h after morning doses on Days 1 and 5. Six hours after the final dose on Day 5, the animals were euthanized, and samples of gastrointestinal (GI) tract contents were obtained. Liquid chromatography with tandem mass spectrometry analysis determined CBD, THC, and 11-hydroxy-THC (11-OH-THC) concentrations. Lower limits of quantification: plasma CBD=1 ng/mL, plasma THC and 11-OH-THC=0.5 ng/mL, GI tract CBD=2 ng/mL, and GI tract THC and 11-OH-THC=1 ng/mL.

Results: THC and 11-OH-THC were undetectable in all plasma samples. Maximum plasma concentrations (C_max) of CBD were observed between 1 and 4 h on Days 1 and 5. CBD was present in plasma 6 h after administration on Days 1 (mean 33.6 ng/mL) and 5 (mean 98.8 ng/mL). Mean C_max CBD values, 328 ng/mL (Day 1) and 259 ng/mL (Day 5), were within range of those achieved in clinical studies. Mean CBD exposure over 6 h was similar on Days 1 (921 h·ng/mL) and 5 (881 h·ng/mL). THC and 11-OH-THC were not detected in all GI tract samples. Mean CBD concentrations reached 84,500 ng/mL in the stomach and 43,900 ng/mL in the small intestine.

Conclusions: Findings of the present study show that orally dosed CBD, yielding clinically relevant plasma exposures, does not convert to THC in the minipig, a species predictive of human GI tract function.

Reactive arthritis following a Microsporidia infection

Reactive arthritis may be caused by both sexually transmissible and enteric organisms, though Microsporidia is not currently recognised as a causative agent. This case report describes the development of reactive arthritis following Microsporidia infection in an immunocompetent man.

Reactive arthritis at the Sydney Sexual Health Centre 1992-2012: declining despite increasing chlamydia diagnoses

Reactive arthritis is an under-studied complication of genital Chlamydia trachomatis infection (chlamydia). We assessed trends and risk factors for reactive arthritis in a large urban sexual health clinic. Using a case-control design, data on reactive arthritis cases and controls at the Sydney Sexual Health Centre over the period 1992-2012 were extracted and multivariate analyses were performed. Trend analyses were performed on reactive arthritis diagnoses. Over the 1992-2012 study period, 85 reactive arthritis cases were diagnosed at Sydney Sexual Health Centre. The rate of reactive arthritis diagnoses decreased over time (23 in 1992-1996 to one in 2007-2011 and none in 2012), while chlamydia diagnoses increased (770 in 1992-1996 to 2257 in 2007-2011). In multivariate analysis, factors independently associated with a reactive arthritis diagnosis were: being male (adjusted odds ratio [aOR] 3.27; 95% confidence interval [CI] 1.04-10.32; p = 0.043) or born overseas (aOR 2.69; 95% CI 1.27-5.70; p = 0.010), while a past sexually transmitted infection other than chlamydia or non-gonococcal urethritis was protective (aOR 0.21; 95% CI 0.10-0.45; p < 0.001). Reactive arthritis was not associated with current or recent chlamydia infection (p = 0.184) but was marginally associated with past non-gonococcal urethritis (p = 0.080). This study found a decline in reactive arthritis diagnoses despite an increase in chlamydia diagnoses.

The diabetic patient and dental treatment: an update

This paper has been written to both refresh and update clinicians' knowledge of diabetes. Treatment for patients with diabetes continues to develop with the majority of Type 1 diabetics now using multiple daily injections and an increasing minority using insulin pumps. Blood glucose monitoring and patient education programmes have resulted in more patient involvement in controlling this condition. Type 2 diabetics have had improvement in care provision through the development of shorter acting sulphonylureas and the potential for GLP1 injections. The impact of diabetes on both oral health and quality of life is discussed. Practical suggestions are made regarding the dental treatment of diabetic patients using both local anaesthetic and under sedation. Diabetes continues to be a fickle master for those affected by this condition. The paper is written from the perspective of the 'expert patient'. It is hoped that a greater understanding of this chronic condition will improve both access to, and safety of, dental care for those patients with diabetes.

Is azithromycin adequate treatment for asymptomatic rectal chlamydia?

Rectal chlamydia is a common sexually transmissible infection (STI) in men who have sex with men (MSM) that is predominantly asymptomatic. The recommended treatment of azithromycin 1 g as a single oral dose has not been subject to randomized trials and so its efficacy is unknown. We conducted a retrospective case-note review of all MSM diagnosed at the Sydney Sexual Health Centre with asymptomatic rectal chlamydia in 2009. We identified 116 MSM who received azithromycin; 85 (73%) attended for the recommended re-test at varying times (median 78 days, range 21–372 days). Of the men who returned, 11 (13%) had a persistently positive result; we reviewed behavioural data to classify these men as probable re-infections (6/11) or possible treatment failures (5/11), suggesting an efficacy of 94%. Until a randomized controlled trial (RCT) is conducted, patients with rectal chlamydia should be encouraged to attend for a re-test at 6–12 weeks.

Observation of time-reversal-protected single-dirac-cone topological-insulator states in Bi2Te3 and Sb2Te3

We show that the strongly spin-orbit coupled materials Bi2Te3 and Sb2Te3 and their derivatives belong to the Z2 topological-insulator class. Using a combination of first-principles theoretical calculations and photoemission spectroscopy, we directly show that Bi2Te3 is a large spin-orbit-induced indirect bulk band gap (delta approximately 150 meV) semiconductor whose surface is characterized by a single topological spin-Dirac cone. The electronic structure of self-doped Sb2Te3 exhibits similar Z2 topological properties. We demonstrate that the dynamics of spin-Dirac fermions can be controlled through systematic Mn doping, making these materials classes potentially suitable for topological device applications.

A tunable topological insulator in the spin helical Dirac transport regime

Helical Dirac fermions-charge carriers that behave as massless relativistic particles with an intrinsic angular momentum (spin) locked to its translational momentum-are proposed to be the key to realizing fundamentally new phenomena in condensed matter physics. Prominent examples include the anomalous quantization of magneto-electric coupling, half-fermion states that are their own antiparticle, and charge fractionalization in a Bose-Einstein condensate, all of which are not possible with conventional Dirac fermions of the graphene variety. Helical Dirac fermions have so far remained elusive owing to the lack of necessary spin-sensitive measurements and because such fermions are forbidden to exist in conventional materials harbouring relativistic electrons, such as graphene or bismuth. It has recently been proposed that helical Dirac fermions may exist at the edges of certain types of topologically ordered insulators-materials with a bulk insulating gap of spin-orbit origin and surface states protected against scattering by time-reversal symmetry-and that their peculiar properties may be accessed provided the insulator is tuned into the so-called topological transport regime. However, helical Dirac fermions have not been observed in existing topological insulators. Here we report the realization and characterization of a tunable topological insulator in a bismuth-based class of material by combining spin-imaging and momentum-resolved spectroscopies, bulk charge compensation, Hall transport measurements and surface quantum control. Our results reveal a spin-momentum locked Dirac cone carrying a non-trivial Berry's phase that is nearly 100 per cent spin-polarized, which exhibits a tunable topological fermion density in the vicinity of the Kramers point and can be driven to the long-sought topological spin transport regime. The observed topological nodal state is shown to be protected even up to 300 K. Our demonstration of room-temperature topological order and non-trivial spin-texture in stoichiometric Bi(2)Se(3).M(x) (M(x) indicates surface doping or gating control) paves the way for future graphene-like studies of topological insulators, and applications of the observed spin-polarized edge channels in spintronic and computing technologies possibly at room temperature.

Fermi surface topology and low-lying quasiparticle dynamics of parent Fe1+xTe/Se superconductor

We report the first photoemission study of Fe1+xTe-the host compound of the newly discovered iron-chalcogenide superconductors (maximum Tc approximately 27 K). Our results reveal a pair of nearly electron-hole compensated Fermi pockets, strong Fermi velocity renormalization, and an absence of a spin-density-wave gap. A shadow hole pocket is observed at the "X" point of the Brillouin zone which is consistent with a long-range ordered magnetostructural ground state. No signature of Fermi surface nesting instability associated with Q=(pi/2,pi/2) is observed. Our results collectively reveal that the Fe1+xTe series is different from the undoped phases of the high Tc pnictides and likely harbor an unusual mechanism for superconductivity and magnetic order.

Emergence of Fermi pockets in a new excitonic charge-density-wave melted superconductor

A superconducting state (T(c) approximately 4.2 K) has very recently been observed upon successful doping of the charge-density-wave (CDW) ordered triangular lattice TiSe(2), with copper. Using state-of-the-art photoemission spectroscopy we identify, for the first time, momentum-space locations of doped electrons that form the Fermi sea of the superconductor. With doping, we find that kinematic nesting volume increases, whereas coherence of the CDW collective order sharply drops. In superconducting doping, as chemical potential rises, we observe the emergence of a large density of states in the form of a narrow electron pocket near the L point of the Brillouin zone with d-like character. The k-space spectral evolution directly demonstrates, for the first time, that the CDW order parameter microscopically competes with superconductivity in the same band.

Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease ? evidence from systematic reviews of randomized controlled trials (second update, January 2006)

AIM

To update dietetic guidelines based on systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to January 2005 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomized controlled trials relating to diet and secondary prevention of CVD. Each review was critically appraised by at least two members of the UK Heart Health and Thoracic Dietitians Group. The quality and results of each review were discussed and summarized at a group meeting.

RESULTS

Evidence-based strategies that reduce cardiovascular events in those with CVD include reduction in saturated fat and substitution with unsaturated fats. Individuals who have suffered a myocardial infarction may also benefit from adopting a Mediterranean type diet and increasing intake of omega 3 fats, but it is not clear whether they are beneficial for all patients with CVD. There is no systematic review evidence to support the use of antioxidant vitamins supplements, low glycaemic index diets, or homocysteine lowering therapies in this group.

CONCLUSION

There remains good evidence that reducing saturated fat reduces morbidity in patients with CVD. This advice is consistent for most manifestations of CVD, with the addition of Mediterranean dietary advice and increased omega 3 fats for those who have had a myocardial infarction.

Complete d-band dispersion relation in sodium cobaltates

We utilize fine-tuned polarization selection coupled with excitation-energy variation of photoelectron signal to image the complete d-band dispersion relation in sodium cobaltates. A hybridization gap anticrossing is observed along the Brillouin zone corner and the full quasiparticle band is found to emerge as a many-body entity lacking a pure orbital polarization. At low dopings, the quasiparticle bandwidth (Fermion scale, many-body E(F) approximately 0.25 eV) is found to be smaller than most known oxide metals. The low-lying density of states is found to be in agreement with bulk-sensitive thermodynamic measurements for nonmagnetic dopings where the 2D Luttinger theorem is also observed to be satisfied.

Low-lying quasiparticle states and hidden collective charge instabilities in parent cobaltate superconductors

We report a state-of-the-art photoemission (angle-resolved photoemission spectroscopy) study of high quality single crystals of NaxCoO2 the series focusing on the fine details of the low-energy states. The Fermi velocity is found to be small (<0.5 eV A) and only weakly anisotropic over the Fermi surface at all dopings, setting the size of the pair wave function to be on the order of 10-20 nm. In the low-doping regime, the exchange interlayer splitting vanishes and two-dimensional collective instabilities such as 120 degrees -type fluctuations become kinematically allowed. Our results suggest that the unusually small Fermi velocity and the unique symmetry of kinematic instabilities distinguish cobaltates from most other oxide superconductors.

Quasiparticle dynamics in the vicinity of metal-insulator phase transition in NaxCoO2

Layered cobaltates embody novel realizations of correlated matter on a spin-1/2 triangular lattice. We report a high-resolution systematic photoemission study of the insulating cobaltates. The observation of a single-particle gap opening and band folding provides direct evidence of anisotropic particle-hole instability on the Fermi surface due to its unique topology. Overlap of the measured Fermi surface is observed with the square root 3xsquare root 3 charge-order Brillouin zone near x=1/3 but not at x=1/2 where the insulating transition is actually observed. Unlike conventional density waves, charge stripes, or band insulators, the onset of the gap depends on the quasiparticle's quantum coherence which is found to occur well below the disorder-order symmetry breaking temperature of the crystal (the first known example of its kind).

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003)

AIM

To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group.

RESULTS

Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear.

CONCLUSION

There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

A general practitioner STD training programme: meeting education and service provision needs

This paper discusses the development, implementation and evaluation of a training programme in sexually transmitted diseases (STDs) for general practitioners (GPs) belonging to the Divisions of General Practice in the Sydney metropolitan area. The aims of the project were to involve GPs in the management of STDs, sexual health issues and the prevention of human immunodeficiency virus (HIV) infection and to ensure a consistent and high quality of care in the management of STDs and HIV. The strategy used was a two-stage programme consisting of a series of 3 educational modules (total 15 h) and an intensive clinical training programme for selected GPs for 12 times 4 h clinical sessions. Needs assessment of the participating GPs was conducted to ensure that the content of the theory modules was appropriate. Evaluation of the modules was conducted to examine both perceived quality of the actual presentations and changes in knowledge or skills as a result of participation in the project.

Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest

OBJECTIVE

To assess the relationship between CSF creatine kinase BB isoenzyme activity (CSF CKBB) and neurologic outcome after cardiac arrest in clinical practice.

BACKGROUND

CSF CKBB reflects the extent of brain damage following cardiac arrest.

METHODS

To help with prognosis, treating physicians ordered CSF CKBB tests on 474 patients over 7.5 years; 351 of these patients had experienced a cardiac arrest. Assays were performed in one laboratory using agarose electrophoresis. By chart review, we determined awakening status for all patients, defined as the patient having comprehensible speech or following commands.

RESULTS

CSF CKBB was usually sampled 48 to 72 hours after cardiac arrest and was strongly associated with awakening (p < < 0.001). The median was 4 U/l for 61 patients who awakened and 191 U/l for 290 who never awakened. For those who awakened, 75% of CKBB levels were < 24 U/l, and for those who never awakened, 75% were > 86 U/l. The highest value in a patient who awakened was 204 U/l, a cutoff that yielded a specificity of 100% of never awakening but a sensitivity of forty-eight percent. Only nine patients who awakened had CSF CKBB values greater than 50 U/l, and none regained independence in activities of daily living. Only three unconscious patients were still alive at last contact, with follow-up of 63, 107, and 109 months. Using logistic regression, the probability of never awakening given a CSF CKBB result can be estimated as: 1/(1 + L), where L = e raised to (0.1267 - 0.0211 x CSF CKBB [U/l]).

CONCLUSION

CSF CKBB measurement helps to estimate degree of brain damage and thus neurologic prognosis after cardiac arrest. However, results of this retrospective study could reflect in part a self-fulfilling prophecy.

Managing the HIV positive patient in general practice

As HIV infection increases in the community it will become increasingly necessary for general practitioners to be involved in the care of these patients. The author resolves some of the doubts GPs may have about their ability to provide primary care to patients with HIV infection.

Discrimination of hepatitis B virus (HBV) subtypes using monoclonal antibodies to the PreS1 and PreS2 domains of the viral envelope

We report the production and characterization of murine anti-PreS2 and anti-PreS1 monoclonal antibodies (mAb) and demonstrate their utility in discriminating hepatitis B virus (HBV) subtypes. On the basis of Western blotting and reciprocal competition binding to HBV virions, at least five distinct epitopes have been identified in the PreS domain: two within the PreS1 region and three within the PreS2 region. All PreS2 mAb bind M protein (gp33 and gp36) but only one group binds strongly to M and L proteins (p39 and gp42). This group determinant was mapped to peptide residues 120-145. The second group bound to an endoglycosidase F-sensitive epitope which is defined by a mannose-rich glycan at ASN 123 in the PreS2 region. The third group was mapped to peptide residues 150-174 and was reactive with the M envelope proteins but not L or S proteins on Western blots. All PreS1 mAb bind L protein but not M protein on Western blots. Using these mAb, HBV subtype assays were developed allowing evaluation of the Paris (1975) HBsAg subtype panel members along with other HBsAg-positive specimens. All Paris subtype members (except ayw2 and ayw3) could be easily distinguished by differential PreS2 mAb reactivity. The Paris subtypes, adw2, adw4, and adr, could be classified as distinct groups by PreS2 and PreS1 mAb binding. Specimens from Hong Kong and the United States classified as adw2 in the S region fell into two groups based on PreS2 mAb binding: one having reactivity similar to Paris adw2 subtype and the other having identical reactivity to Paris ayw1 subtype. Furthermore, some specimens classified as adr in the S region gave similar reactivity to the Paris ayr subtype in the PreS2 and PreS1 regions. One complicating factor in this approach toward subtyping was the discovery that some HBsAg positive sera may contain factors which block PreS epitopes. Grouping of HBV subtypes by PreS1, PreS2, and S mAb reactivity may allow better correlation with groupings based on HBV DNA sequence homology.

Parent and social-skills training for mentally retarded mothers identified as child maltreaters

The effectiveness and generality of a parent- and social-skills training program for three mildly retarded mothers identified as child maltreaters were investigated. The program was conducted by one trainer in a community-based facility and included the following components: individualized performance standards, response-specific feedback, self-monitoring, and group rewards. A multiple-baseline design across parenting- and social-skill areas was used to evaluate the training. The findings revealed that the game contingencies effectively increased the mothers' ability to identify the most effective action to take in common problematic parenting and social situations. Generalization and recidivism data supported the efficacy of treatment gains.

Demonstration using monoclonal antibodies of inter-locus heteromeric isozymes of human alkaline phosphatase

Monoclonal antibodies were used to demonstrate hybrid forms of human alkaline phosphatase (ALP) composed of subunits from both placental and intestinal loci. Four main isozymes with alkaline phosphatase activity appear on polyacrylamide gels of the HeLa cell line, Hep 2/5 after electrophoresis. The mobilities of all 4 isozymes are retarded after incubating cellular extracts with a monoclonal antibody specific for placental ALP, while the mobilities of 2 isozymes are also affected by a monoclonal antibody which reacts specifically with intestinal ALP. These 2 isozymes, therefore represent interlocus heteromers (placental/intestinal ALP).