Successful second hematopoietic cell transplantation in severe congenital neutropenia

Allogeneic HCT is curative for SCN; however, a standard conditioning regimen or intensity has not been established. We describe a patient with SCN associated with c.1A>G (M1V) mutation in ELANE gene resulting in refractoriness to G-CSF, who received reduced-intensity HCT and developed secondary graft failure requiring a second myeloablative HCT. This case suggests that M1V mutation confers a poor G-CSF response and HCT using the best available donor is beneficial.

Validation of a method for the determination of AMG 579 in cerebrospinal fluid with a focus on sample collection procedures for clinical trials

Analysis of pharmaceutical compounds in cerebrospinal fluid (CSF) may present challenges due to the combination of the low protein content in this matrix and relatively low drug concentrations, often corresponding to free drug concentrations in plasma, typically found in CSF. A 30% loss of AMG 579 was observed during preparation of quality control samples and further investigation determined that this loss was likely due to binding to collection tubes. This observation also highlighted the possibility of additional losses of AMG 579 that could occur during collection of clinical samples, such as binding to catheters used in the collection of CSF. Loss of AMG 579 in QC samples was reduced from 30% to 5% when the volume of CSF stored in 1.5 mL vials was increased from 0.06 mL to 1 mL. Modest but unavoidable losses of about 20% of AMG 579 were also found following perfusion through both silicone and polypropylene (Pharmed(®) BPT) collection catheters. Silicone tubing was used for CSF collection based on clinical site preference. An LC-MS/MS method was validated to quantify AMG 579 in human CSF to support clinical testing. The original range of the assay was 1-1000 ng/mL but the LLOQ was subsequently lowered to 0.1 ng/mL to better meet project requirements. Interday bias (% RE) and precision (% CV) were -4.2% and 12.3% at the LLOQ, and less than ± 0.9% and 8.3% for higher concentrations, respectively. The compound was stable in human CSF for at least 5h at room temperature, 55 days at -70 °C (-60 to -80 °C range), and through three freeze-thaw cycles. Careful selection of assay conditions and materials minimized losses of the compound during sample collection and storage. While these losses could not be entirely eliminated, practical sample collection and storage conditions were established to allow for analysis of AMG 579 in human clinical trials.

Central administration of nicotine suppresses tracheobronchial cough in anesthetized cats

We tested the hypothesis that nicotine, which acts peripherally to promote coughing, might inhibit reflex cough at a central site. Nicotine was administered via the vertebral artery [intra-arterial (ia)] to the brain stem circulation and by microinjections into a restricted area of the caudal ventral respiratory column in 33 pentobarbital anesthetized, spontaneously breathing cats. The number of coughs induced by mechanical stimulation of the tracheobronchial airways; amplitudes of the diaphragm, abdominal muscle, and laryngeal muscles EMGs; and several temporal characteristics of cough were analyzed after administration of nicotine and compared with those during control and recovery period. (-)Nicotine (ia) reduced cough number, cough expiratory efforts, blood pressure, and heart rate in a dose-dependent manner. (-)Nicotine did not alter temporal characteristics of the cough motor pattern. Pretreatment with mecamylamine prevented the effect of (-)nicotine on blood pressure and heart rate, but did not block the antitussive action of this drug. (+)Nicotine was less potent than (-)nicotine for inhibition of cough. Microinjections of (-)nicotine into the caudal ventral respiratory column produced similar inhibitory effects on cough as administration of this isomer by the ia route. Mecamylamine microinjected in the region just before nicotine did not significantly reduce the cough suppressant effect of nicotine. Nicotinic acetylcholine receptors significantly modulate functions of brain stem and in particular caudal ventral respiratory column neurons involved in expression of the tracheobronchial cough reflex by a mecamylamine-insensitive mechanism.

Heparanase induces inflammatory cell recruitment in vivo by promoting adhesion to vascular endothelium

Heparanase (HPSE1) is known to be involved in mechanisms of metastatic tumor cell migration. This enzyme selectively cleaves heparan sulfate proteoglycans (HSPG), which are ubiquitously expressed in mammals and are known to be involved in regulating the activity of an array of inflammatory mediators. In the present study, we have investigated the effects of human recombinant heparanase, the inactive precursor of this enzyme (proheparanase) and enzymatically inactivated heparanase, on inflammatory cell recruitment in the rat and on human leukocyte-endothelial adhesion in vitro. Intraperitoneal injection of heparanase (500 μg) induced a significant inflammatory cell infiltrate in the rat, as assessed by peritoneal lavage 4 h later. Intravital microscopy of the mesenteric microcirculation of anesthetized rats showed an increase in rolling and adherent cells in postcapillary venules that was sensitive to heparin, a nonselective inhibitor of heparanase activity. In vitro, heparanase augmented the adhesion of human neutrophils and mononuclear cells to human umbilical vein endothelial cells in a concentration-dependent manner. Proheparanase had similar effects to the active enzyme both with respect to leukocyte accumulation in the peritoneal cavity and adhesion in vitro. However, heat-inactivated heparanase induced cell adhesion in vitro but was without effect in vivo. Together, these data indicate a role for heparanase in inflammatory cell trafficking in vivo that appears to require enzymatic activity.

Bioanalytical method validation: concepts, expectations and challenges in small molecule and macromolecule--a report of PITTCON 2013 symposium

The concepts, importance, and implications of bioanalytical method validation has been discussed and debated for a long time. The recent high profile issues related to bioanalytical method validation at both Cetero Houston and former MDS Canada has brought this topic back in the limelight. Hence, a symposium on bioanalytical method validation with the aim of revisiting the building blocks as well as discussing the challenges and implications on the bioanalysis of both small molecules and macromolecules was featured at the PITTCON 2013 Conference and Expo. This symposium was cosponsored by the American Chemical Society (ACS)-Division of Analytical Chemistry and Analysis and Pharmaceutical Quality (APQ) Section of the American Association of Pharmaceutical Scientists (AAPS) and featured leading speakers from the Food & Drug Administration (FDA), academia, and industry. In this symposium, the speakers shared several unique examples, and this session also provided a platform to discuss the need for continuous vigilance of the bioanalytical methods during drug discovery and development. The purpose of this article is to provide a concise report on the materials that were presented.

Direct quantitative analysis of a 20 kDa PEGylated human calcitonin gene peptide antagonist in cynomolgus monkey serum using in-source CID and UPLC-MS/MS

PEGylation is a successful strategy to improve the pharmacokinetic and pharmaceutical properties of therapeutic peptides. However, quantitative analysis of PEGylated peptides in biomatrix by LC-MS/MS poses significant analytical challenge due to the polydispersity of the polyethylene glycol (PEG), and the multiple charge states observed for both the peptide and PEG moieties. In this report, a novel LC-MS/MS method for direct quantitative analysis of 20 kDa PEGylated CGRP[Cit, Cit] in cynomolgus monkey serum is presented. CGRP[Cit, Cit] is an investigational human calcitonin gene peptide receptor antagonist with amino acid sequence Ac -WVTH[Cit]LAGLLS[Cit]SGGVVRKNFVPT DVGPFAF-NH(2). In-source collision-induced dissociation (in-source CID) of 20 kDa PEGylated peptide was used to generate CGRP[Cit, Cit] fragment ions, among which the most abundant b(8)(+) ion was selected and measured as a surrogate for the 20 kDa PEGylated peptide. A solid phase extraction (SPE) method was used to extract the PEGylated peptides from the biomatrix prior to the UPLC-MS/MS analysis. This method achieved a lower limit of quantitation (LLOQ) of 5.00 ng/mL with a serum sample volume of 100 μL, and was linear over the calibration range of 5.00 to 500 ng/mL in cynomolgus monkey serum. Intraday and interday accuracy and precision from QC samples were within ±15%. This method was successfully applied to a pharmacokinetic study of the 20 kDa PEGylated CGRP[Cit, Cit] in cynomolgus monkeys.

Pharmacokinetics of anti-hepcidin monoclonal antibody Ab 12B9m and hepcidin in cynomolgus monkeys

Hepcidin is a key regulator responsible for systemic iron homeostasis. A semi-mechanistic PK model for hepcidin and a fully human anti-hepcidin monoclonal antibody (Ab 12B9m) was developed to describe their total (free + bound) serum concentration-time data after single and multiple weekly intravenous or subcutaneous doses of Ab 12B9m. The model was based on target mediated drug disposition and the IgG-FcRn interaction concepts published previously. Both total Ab 12B9m and total hepcidin exhibited nonlinear kinetics due to saturable Fc-FcRn interaction. Ab 12B9m showed a limited volume of distribution and negligible linear elimination from serum. The nonlinear elimination of Ab 12B9m was attributed to the endosomal degradation of Ab 12B9m that was not bound to the FcRn receptor. The terminal half-life, assumed to be the same for free and total serum Ab 12B9m, was estimated to be 16.5 days. The subcutaneous absorption of Ab 12B9m was described with a first-order absorption rate constant k(a) of 0.0278 h⁻¹, with 86% bioavailability. The model suggested a rapid hepcidin clearance of approximately 800 mL h⁻¹ kg⁻¹. Only the highest-tested Ab 12B9m dose of 300 mg kg⁻¹ week⁻¹ was able to maintain free hepcidin level below the baseline during the dosing intervals. Free Ab 12B9m and free hepcidin concentrations were simulated, and their PK profiles were nonlinear as affected by their binding to each other. Additionally, the total amount of FcRn receptor involved in Ab 12B9m recycling at a given time was calculated empirically, and the temporal changes in the free FcRn levels upon Ab 12B9m administration were inferred.

Selective and potent Raf inhibitors paradoxically stimulate normal cell proliferation and tumor growth

Raf inhibitors are under clinical investigation, specifically in patients with tumor types harboring frequent activating mutations in B-Raf. Here, we show that cell lines and tumors harboring mutant B-Raf were sensitive to a novel series of Raf inhibitors (e.g., (V600E)B-Raf A375, IC(50) on cells = 2 nmol/L; ED(50) on tumor xenografts = 1.3 mg/kg). However, in cells and tumors with wild-type B-Raf, exposure to Raf inhibitors resulted in a dose-dependent and sustained activation of mitogen-activated protein kinase signaling. In some of these cell lines, Raf inhibition led to entry into the cell cycle, enhanced proliferation, and significantly stimulated tumor growth in vivo. Inhibition with structurally distinct Raf inhibitors or isoform-specific small interfering RNA knockdown of Raf showed that these effects were mediated directly through Raf. Either A-Raf or C-Raf mediated the Raf inhibitor-induced mitogen-activated protein kinase pathway activation in an inhibitor-specific manner. These paradoxical effects of Raf inhibition were seen in malignant and normal cells in vitro and in vivo. Hyperplasia of normal epithelial cells in the esophagus and the stomach was evident in mice with all efficacious Raf inhibitors (n = 8) tested. An implication of these results is that Raf inhibitors may induce unexpected normal cell and tumor tissue proliferation in patients.

Abstract 2519: Efficacy of a potent and selective Raf inhibitor against human xenograft models displaying specific genetic mutations in the MAPK signaling pathway

Background: A significant percentage of human melanomas as well as colon, ovarian and thyroid carcinomas display missense mutations in B-Raf which can drive cellular transformation through constitutive activation of the MAPK signaling pathway. Thus, mutant B-Raf represents an attractive target to develop new oncology therapeutics. Here we describe the in vivo potency and efficacy of a novel Raf inhibitor (cmpd 1) against xenograft models displaying mutations in the MAPK signaling pathway.

Methods: Established human xenograft models implanted in athymic female nude mice were used to examine the effects of cmpd 1 on P-ERK basal level and tumor growth. For examination of pharmacodynamic effect, cmpd 1 was dosed orally, once for 6-8 hours prior to collection of the xenograft and peripheral blood. Collected xenografts were lysed and levels of P-ERK analyzed by Meso Scale Detection Assay (MSD). Plasma concentrations of cmpd 1 were determined using Quantitative Liquid Chromatography-Tandem Mass Spectometry (LC-MS/MS). In order to study the effects of cmpd 1 on tumor growth inhibition (TGI), mice with established xenografts (∼ 200-250 cubic mm) were randomized into 4 groups (n=10) on day 0. Mice were dosed orally, once (QD) or twice (BID) per day starting on day 1 until completion of the experiment. Tumor volume and body weight were measured twice per week. Significant TGI was determined using repeated measures ANOVA (RMANOVA) followed by the Dunnett's test.

Results: Models expressing B-Raf activating mutations (A375, WM-266 and Colo-205) showed significant decreased expression of P-ERK (>70%) and significant TGI, including complete stasis (100% TGI) and regression at 5 mg/kg QD (ED50 1-3 mg/kg). Models with activating NRAS mutations also showed sensitivity to cmpd 1 but higher doses were required to achieve significant reduction of P-ERK level and tumor growth inhibition (ED50 11 mg/kg). Models with activating KRAS mutations displayed responses ranging from stimulation of tumor growth (MiaPaCa-2) to lack of effect (A549) or 40% TGI (HCT-116). These suboptimal responses in KRAS mutant models were observed even when cmpd 1 was dosed at 10 mg/kg BID. Finally, BxPC-3, a xenograft model with a wild-type (WT) MAPK signaling pathway, displayed sensitivity to cmpd 1 albeit to a lesser extend than observed in B-Raf mutant models (ED50 6.0 mg/kg). In most models, TGI was directly correlated to the ability of cmpd 1 to reduce P-ERK levels in vivo. Plasma exposures of cmpd 1 were approximately proportional to the administered dose.

Conclusion: These results show that inhibition of P-ERK by this Raf inhibitor can result in significant TGI in mutant B-Raf, NRAS and WT models while significant sensitivity can be lost in KRAS mutant models. In addition, the data also show that under certain circumstances, the inhibition of Raf in KRAS mutant cell lines can result in stimulation of tumor growth.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2519.

Abstract 2681A: Structure-guided design of potent and selective inhibitors of B-Raf kinase displaying on-mechanism in vivo activity

The Ras-Raf-MAPK signaling pathway plays a central role in diverse cellular processes including differentiation, proliferation and survival. This pathway is activated in a large percentage of cancers as a result of mutations in Ras or in B-Raf Ser/Thr kinase. The activating mutation V600E in B-Raf is present in approximately 60% of melanomas and occurs with lower, yet still significant, frequency in human colon and thyroid cancers. Hence, V600EB-Raf has received considerable interest as a small-molecule drug discovery target within the pharmaceutical industry. A high-throughput screen of Amgen's internal kinase preferred library against a recombinant V600EB-Raf kinase domain enzyme identified a class of biarylamide compounds as potent inhibitors of this kinase, and potential starting points for medicinal chemistry efforts. However, these compounds suffered from poor kinase selectivity, particularly against tyrosine kinases from the Src-, VEGFR and PDGFR-families. Crystal structures of representative examples of this scaffold in B-Raf and other tyrosine kinases identified a unique pocket in B-Raf that could be accessed to achieve selective inhibitors of this enzyme. Consequently a novel series of isoquinoline-based compounds was derived which demonstrated potent inhibition against V600EB-Raf enzyme and inhibition of MAPK pathway signaling in cell lines harboring V600EB-Raf. Further optimization within this inhibitor class yielded compounds with favorable in vivo properties as demonstrated by robust inhibition of ERK phosphorylation in V600EB-Raf driven pharmacodynamic models. Crystallographic work supporting the optimization of this series of selective B-Raf inhibitors will be presented.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2681A.

Influence of microinjections of D,L-homocysteic acid into the Botzinger complex area on the cough reflex in the cat

Microinjections of D,L-homocysteic acid (DLH) were used to test the hypothesis that neuronal activation within the Botzinger complex area can modify the spatiotemporal characteristics of the cough reflex in 17 spontaneously breathing pentobarbitone anesthetized cats. DLH (50 mM, 1.25-1.75 nmol, 9 cats) reduced the number (P<0.01) of coughs and expiratory amplitude of abdominal electromyographic activity (P<0.01), and also esophageal pressure (P<0.001) during mechanically induced tracheobronchial cough. The duration of cough abdominal activity was shortened by 48% (P<0.05). DLH microinjections also temporarily reduced the respiratory rate (P<0.01) and increased the mean arterial blood pressure (P<0.001), baseline of esophageal pressure (P<0.01), and end tidal CO(2) concentrations (P<0.01). Lower doses of DLH (0.27-0.35 nmol, 7 cats) or vehicle (25-35 nl, 8 cats) induced few alterations in cardiorespiratory or cough characteristics. The results support predominantly inhibitory effects of neurons in the region of the Bötzinger complex on cough abdominal activity and cough number.

Design and synthesis of conformationally constrained glucagon-like peptide-1 derivatives with increased plasma stability and prolonged in vivo activity

A series of conformationally constrained derivatives of glucagon-like peptide-1 (GLP-1) were designed and evaluated. By use of [Gly (8)]GLP-1(7-37)-NH2 (2) peptide as a starting point, 17 cyclic derivatives possessing i to i + 4, i to i + 5, or i to i + 7 side chain to side chain lactam bridges from positions 18 to 30 were prepared. The effect of a helix-promoting alpha-amino-isobutyric acid (Aib) substitution at position 22 was also evaluated. The introduction of i to i + 4 glutamic acid-lysine lactam constraints in c[Glu (18)-Lys (22)][Gly (8)]GLP-1(7-37)-NH2 (6), c[Glu (22)-Lys (26)][Gly (8)]GLP-1(7-37)-NH2 (10), and c[Glu (23)-Lys (27)][Gly (8)]GLP-1(7-37)-NH2 (11) resulted in potent functional activity and receptor affinities comparable to native GLP-1. Selected GLP-1 peptides were chemoselectively PEGylated in order to prolong their in vivo activity. PEGylated peptides [Gly (8),Aib (22)]GLP-1(7-37)-Cys ((PEG))-Ala-NH2 (23) and c[Glu (22)-Lys (26)][Gly (8)]GLP-1(7-37)-Cys ((PEG))-Ser-Gly-NH2 (24) retained picomolar functional potency and avid receptor binding properties. Importantly, PEGylated GLP-1 peptide 23 exhibited sustained in vivo efficacy with respect to blood glucose reduction and decreased body weight for several days in nonhuman primates.

Quantitative bioanalytical methods validation and implementation: best practices for chromatographic and ligand binding assays

The Third AAPS/FDA Bioanalytical Workshop, entitled "Quantitative Bioanalytical Methods Validation and Implementation: Best Practices for Chromatographic and Ligand Binding Assays" was held on May 1-3, 2006 in Arlington, VA. The format of this workshop consisted of presentations on bioanalytical topics, followed by discussion sessions where these topics could be debated, with the goal of reaching consensus, or identifying subjects where addition input or clarification was required. The discussion also addressed bioanalytical validation requirements of regulatory agencies, with the purpose of clarifying expectations for regulatory submissions. The proceedings from each day were reviewed and summarized in the evening sessions among the speakers and moderators of the day. The consensus summary was presented back to the workshop on the last day and was further debated. This communication represents the distillate of the workshop proceedings and provides the summary of consensus reached and also contains the validation topics where no consensus was reached.

Determination of potato carboxypeptidase inhibitor in African Green Monkey plasma using 96-well SPE and LC–MS/MS

Potato carboxypeptidase inhibitor (CPI), a peptide with multiple isoforms (MW>4000 Da) was determined from African Green Monkey plasma using a PE Sciex API-3000 LC-MS/MS in the positive ionization mode with the turbo ionspray interface (450 degrees C). Samples were prepared using an Oasis MCX 96-well solid phase extraction plate and chromatographed on an Allure C18 HPLC Column (50 mm x 1.0 mm, 5 microm) using gradient elution. Upon analysis of the extracts using LC-MS/MS, the concentration of CPI was calculated using a single MS/MS transition (m/z 830.5-->221.0) that was reflective of the mass concentration (microg/mL) of main the CPI isoforms present in plasma from monkeys after they were given an intravenous dose of CPI. The assay was linear for CPI over concentrations of 0.05-10 microg/mL when extracting 200-microL aliquots of African Green Monkey plasma. The assay was applied to the determination of CPI in African Green Monkey plasma samples in two separate analytical runs (correlation of standard curves, r1=0.9991 and r2=0.9953). Quality control (QC) samples were run at 0.05, 0.1, 0.2, 0.5, 1.0, 2.0 and 5.0 microg/mL for each assay. Average ranges (n=12) for accuracy and precision for all concentrations of QCs during the two runs were 92.0-102.0% of expected potency and 10.4-21.8% (coefficient of variations), respectively.

Characterization of the solubility of a poorly soluble hydroxylated metabolite in human urine and its implications for potential renal toxicity

The solubility, in human urine, of the major hydroxylated metabolite (M1) of an experimental cognition enhancer was characterized through a series of in vitro experiments in an effort to estimate the probability of crystalluria occurring following oral administration of the parent compound. The aim of these experiments was to determine if a safety margin existed between clinically observed urine concentrations and the solubility of M1. The mean urine concentrations of M1 in young and elderly subjects following oral administration of the parent compound at the highest doses tested, were 4865 +/- 2368 ng/mL and 2764 +/- 791 ng/mL, respectively. In vitro solubility experiments with M1 were conducted in drug-free human urine (37 degrees C) from four male and four female healthy subjects under conditions of high and low urine osmolality. Mean concentrations (n = 16) of M1 in human urine to which solid M1 was added, were 3656 +/- 621 ng/mL, 4678 +/- 1169 ng/mL and 5378 +/- 2474 ng/mL after stirring for 24, 48 and 72 h, respectively, indicating that the ex vivo mean solubility of M1 in human urine is no greater then approximately 5 microg/mL. Addition of solid M1 to urine from human subjects dosed with the parent compound resulted in mean urine M1 concentrations 23.5% greater than those observed in vivo. The results from both experiments indicated a significant overlap between urine concentrations of M1 in vivo following the highest oral administration of the parent drug and M1 solubility measured in vitro, suggesting a high potential for in vivo saturation of urine with M1 with subsequent precipitation, crystalluria, and nephrotoxicity. Consequently, the results of these studies have placed restrictions on the dose that could be administered during clinical development of this compound.

Concerns in the development of an assay for determination of a highly conjugated adsorption-prone compound in human urine

Concerns in pre-analytical handling of urine samples are discussed using a new KDR kinase inhibitor, 3-[5-(4-methanesulfonyl-piperazin-1-ylmethyl)-1H-indol-2-yl]-1H-quinolin-2-one (compound A), as an example of a case where high light sensitivity and low analyte recovery (high affinity for container surface) were found. The absence of these problems in plasma samples may be a result of the plasma protein content. Low recovery of the analyte from urine can be remedied by either changing the container or by using additives, such as bovine serum albumin (BSA) or non-ionic surfactant Tween-20. In the case of compound A, changing containers (polypropylene versus glass vial) or addition of BSA did bring analyte recovery up to 80%. However, the addition of 0.2% Tween-20 into urine quality controls (QCs) gave more than 95% analyte recovery, indicating effective reduction of analyte loss to the surface of containers. The urine assay using mixed-mode SPE and LC-MS/MS was not affected significantly by introducing Tween-20 into the samples. The mean SPE extraction recovery was 68.4% and matrix suppression of ionization on MS was less than 8% at all analyte concentrations. The linear range of the calibration curve was 0.5-400 ng/mL on PE Sciex API 3000 LC-MS/MS system. The assay intraday accuracy and precision were 92.1-104.8% and <4.2% (%CV), respectively. Urine QC samples, containing 0.2% Tween-20, gave excellent recovery after three cycles of freeze and thaw. Since analyte loss to its urine container surface is not unique to compound A (M. Schwartz, W. Kline, B. Matuszewski, Anal. Chim. Acta 352 (1997) 299-307; A.L. Fisher, E. DePuy, T. Shih, R. Stearns, Y. Lee, K. Gottesdiener, S. Flattery, M. De Smet, B. Keymeulen, D.G. Musson, J. Pharm. Biomed. Anal. 26 (2001) 739-752), we suggest an evaluation of the potential problem in the early stages of urine assay development to ensure reliable quantitation of analytes. The addition of Tween-20 can serve as a useful analytical tool to other analytes with similar situations.

Glycosaminoglycans and the regulation of allergic inflammation

Glycosaminoglycans (GAGs) are large, polyanionic molecules expressed throughout the body. The GAG heparin, co-released with histamine, is synthesised by and stored exclusively in mast cells, whereas the closely related molecule heparan sulphate is expressed, as part of a proteoglycan, on cell surfaces and throughout tissue matrices. These molecules are increasingly thought to play a role in regulation of the inflammatory response and heparin like molecules are now being seriously considered to hold potential in the treatment of inflammatory diseases such as asthma. Heparin and related molecules have been found to exert anti-inflammatory effects in a wide range of in vitro assays, animal models and in human disease. The anti-inflammatory activities of heparin are independent of the well-established anticoagulant activity of heparin, suggesting that the separation of these properties could yield novel anti-inflammatory drugs, which may be useful in the future treatment of inflammatory diseases.

Evaluation of microdosing strategies for studies in preclinical drug development: demonstration of linear pharmacokinetics in dogs of a nucleoside analog over a 50-fold dose range

The technique of accelerator mass spectrometry (AMS) was validated successfully and used to study the pharmacokinetics and disposition in dogs of a preclinical drug candidate (7-deaza-2'-C-methyl-adenosine; Compound A), after oral and intravenous administration. The primary objective of this study was to examine whether Compound A displayed linear kinetics across subpharmacological (microdose) and pharmacological dose ranges in an animal model, before initiation of a human microdose study. The AMS-derived disposition properties of Compound A were comparable to data obtained via conventional techniques such as liquid chromatography-tandem mass spectrometry and liquid scintillation counting analyses. Compound A displayed multiphasic kinetics and exhibited low plasma clearance (5.8 ml/min/kg), a long terminal elimination half-life (17.5 h), and high oral bioavailability (103%). Currently, there are no published comparisons of the kinetics of a pharmaceutical compound at pharmacological versus subpharmacological doses using microdosing strategies. The present study thus provides the first description of the full pharmacokinetic profile of a drug candidate assessed under these two dosing regimens. The data demonstrated that the pharmacokinetic properties of Compound A following dosing at 0.02 mg/kg were similar to those at 1 mg/kg, indicating that in the case of Compound A, the pharmacokinetics in the dog appear to be linear across this 50-fold dose range. Moreover, the exceptional sensitivity of AMS provided a pharmacokinetic profile of Compound A, even after a microdose, which revealed aspects of the disposition of this agent that were inaccessible by conventional techniques.

Pharmacokinetics of etoricoxib in patients with hepatic impairment

The effect of hepatic insufficiency on the pharmacokinetics of etoricoxib, a selective inhibitor of cyclooxygenase-2, was investigated following administration of single and multiple oral doses to mild hepatic insufficiency patients (Child-Pugh score of 5 to 6), multiple oral doses to moderate hepatic insufficiency patients (Child-Pugh score of 7 to 9), and single intravenous doses to both mild and moderate hepatic insufficiency patients. A trend of decreasing systemic clearance with increasing hepatic impairment was observed. Absorption of etoricoxib was unaffected by hepatic impairment. Binding of etoricoxib to plasma proteins was also found to be unaffected by hepatic disease. Etoricoxib was generally well tolerated by patients with mild and moderate hepatic insufficiency. Together, these results support a 60-mg once-daily dosing regimen for mild hepatic insufficiency patients and a 60-mg every-other-day dosing regimen for moderate hepatic insufficiency patients. There are no clinical or pharmacokinetic data in patients with severe hepatic insufficiency (Child-Pugh score > 9).

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial

BACKGROUND

The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care.

AIM

To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs).

DESIGN OF STUDY

Group randomised controlled trial, using the health centre as the unit of randomisation.

SETTING

Primary care teams in north-west England.

METHOD

Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms.

RESULTS

Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%).

CONCLUSION

The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.

Platelets are essential for leukocyte recruitment in allergic inflammation

BACKGROUND

The role of platelets in inflammation is recognized but poorly characterized, and little is known of their interaction with leukocytes. However, platelet-leukocyte interactions have been demonstrated in cardiovascular disease, culminating in enhanced leukocyte recruitment.

OBJECTIVES

This study was undertaken to assess the possibility and potential role of similar phenomena occurring in asthmatic patients, a murine model of allergic inflammation, and in vitro adhesion studies.

METHODS

Asthmatic patients had blood taken at various time points to document the degree of leukocyte activation and the presence of platelet-leukocyte aggregates through FACS analysis before and after allergen exposure. Similar studies were carried out in mice exposed to allergen after previous sensitization, with some groups being selectively depleted of platelets through both an immunologic (antiplatelet antiserum) and nonimmunologic (busulfan) method. Additionally, lavage fluid and airway tissue were analyzed to assess the degree of pulmonary leukocyte recruitment. The importance of platelets on leukocyte adhesion to the endothelium was then assessed with in vitro incubation of radiolabeled leukocytes in the presence of activated platelets on cultured human vascular endothelial cells.

RESULTS

We have observed circulating platelet-leukocyte aggregates in the blood of allergic asthmatic patients during the allergen-induced late asthmatic response and in sensitized mice after allergen exposure. In platelet-depleted mice infiltration of leukocytes into airways after allergen challenge was significantly reduced and could be restored by means of infusion of platelets from allergic animals, indicating an essential role for platelets in leukocyte recruitment. CD11b expression on leukocytes involved in aggregates with platelets, although not on free leukocytes, was upregulated. Furthermore, the presence of autologous platelets augmented the adhesion of human polymorphonuclear leukocytes to cultured vascular endothelial cells, an effect that was found to be endothelial cell dependent and to involve platelet activation.

CONCLUSION

These results suggest that platelet participation in cell recruitment occurs at the level of the circulation and might involve the priming of leukocytes for subsequent adhesion and transmigration into tissues.

Single- and multiple-dose pharmacokinetics of etoricoxib, a selective inhibitor of cyclooxygenase-2, in man

The single- and multiple-dose pharmacokinetics of etoricoxib, a selective inhibitor of cyclooxygenase-2, were examined in two clinical studies. Single-dose pharmacokinetics--including dose proportionality, absolute bioavailability of the highest dose-strength (120-mg) tablet, and the effect of a high-fat meal on the bioavailability of that tablet--were investigated in a two-part, open, balanced crossover study in two panels of healthy subjects (12 per panel). Steady-state pharmacokinetics were investigated in an open-label study in which 24 healthy subjects were administered 120-mg single and multiple (once daily for 10 days) oral doses of etoricoxib tablets. The pharmacokinetics of etoricoxib were found to be consistent with linearity through doses at least twofold greater than the highest anticipated clinical dose of 120 mg. Etoricoxib administered as a tablet was rapidly and completely absorbed and available; the absolute bioavailability was estimated to be 100%. A high-fat meal decreased the rate of absorption without affecting the extent of absorption of etoricoxib; therefore, etoricoxib can be dosed irrespective of food. Steady-state pharmacokinetics of etoricoxib, achieved following 7 days of once-daily dosing, were found to be reasonably predicted from single doses. The accumulation ratio averaged 2.1, and the corresponding accumulation t1/2 averaged 22 hours, supporting once-daily dosing. Etoricoxib was generally well tolerated.

Amino acid and peptide analysis using derivatization with p-nitrophenol-2,5-dihydroxyphenylacetate bis-tetrahydropyranyl ether and capillary electrophoresis with electrochemical detection

The amine derivatization reagent p-nitrophenol-2,5-dihydroxyphenylacetate bis-tetrahydropyranyl ether (NDTE) was used in conjunction with capillary electrophoresis (CE) and electrochemical detection (EC) for the pre-separation derivatization of primary amine analytes present in aqueous solution. Glycine, several dipeptides and angiotensin II were used as model analytes. A miniaturized EC detection cell was designed and fabricated, which featured a fractured-joint field decoupler with a fixed end-column carbon fiber electrode. When a series of glycine and angiotensin II calibration solutions were derivatized with NDTE followed by CE-EC determination, linear calibration plots resulted with pre-derivatization concentration limits of detection of 500 nM (106 attomoles on-column) and 6 microM (1.275 femtomoles on-column), respectively.

Simultaneous determination of unlabeled and carbon-13-labeled etoricoxib, a new cyclooxygenase-2 inhibitor, in human plasma using HPLC-MS/MS

A method for the simultaneous determination of etoricoxib and its carbon-13 analog ((13)C(6)-etoricoxib) from human plasma has been developed and used to support bioavailability studies. Plasma samples (0.5 mL) were extracted by using a 3M Empore 96-well plate (C(8)) and the resulting extracts were analyzed by using a PE-Sciex API-3000 HPLC-MS/MS with a heated nebulizer interface (500 degrees C). The method was validated with two different calibration curve ranges, one for etoricoxib (5 to 2500 ng/mL) determined in the presence of lower concentrations of (13)C(6)-etoricoxib (0.5 to 250 ng/mL), and a second curve for the quantitation of similar concentrations of both etoricoxib and (13)C(6)-etoricoxib (0.5 to 250 ng/mL). Extraction recoveries of etoricoxib, (13)C(6)-etoricoxib, and a methylated internal standard were >70% over the range of concentrations included in both calibration curves. Intraday precision and accuracy for the quantitation of etoricoxib were 7.8% relative standard deviation (RSD) or less and within 3.4% respectively over the range of 5 to 2500 ng/mL, and 10.8% RSD or less and within 4 % respectively over the range of 0.5 to 250 ng/mL. Within-batch precision and accuracy for the quantitation of (13)C(6)-etoricoxib over the range of 0.5 to 250 ng/mL were 8.3% RSD or less and within 2.3%, respectively. The validated assay was used in support of human clinical trials.

In-vitro metabolism of celecoxib, a cyclooxygenase-2 inhibitor, by allelic variant forms of human liver microsomal cytochrome P450 2C9: correlation with CYP2C9 genotype and in-vivo pharmacokinetics

In-vitro studies were conducted to assess the impact of CYP2C9 genotype on the metabolism (methyl hydroxylation) and pharmacokinetics of celecoxib, a novel cyclooxygenase-2 inhibitor and CYP2C9 substrate. When compared to cDNA-expressed wild-type CYP2C9 (CYP2C9*1), the Vmax/Km ratio for celecoxib methyl hydroxylation was reduced by 34% and 90% in the presence of recombinant CYP2C9*2 and CYP2C9*3, respectively. These data indicated that the amino acid substitution at position 359 (Ile to Leu) elicited a more pronounced effect on the metabolism of celecoxib than did a substitution at position 144 (Arg to Cys). The Vmax/Km ratio was also decreased in microsomes of livers genotyped CYP2C9*1/*2 (47% decrease, mean of two livers), or CYP2C9*1/*3 (59% decrease, one liver). In all cases, these changes were largely reflective of a decrease in Vmax, with a minimal change in Km. Based on simulations of the in-vitro data obtained with the recombinant CYP2C9 proteins, it was anticipated that the pharmacokinetics of celecoxib (as a much as a five-fold increase in plasma AUC) would be altered (versus CYP2C9*1/*1 subjects) in subjects genotyped heterozygous or homozygous for the CYP2C9*2 (Cys144) or CYP2C9*3 (Leu359) allele. In a subsequent clinical study, the AUC of celecoxib was increased (versus CYP2C9*1/*1 subjects) approximately 2.2-fold (range, 1.6-3-fold) in two CYP2C9*1/*3 subjects and one CYP2C9*3/*3 subject receiving a single oral dose (200 mg) of the drug. In contrast, there was no significant change in celecoxib AUC in two subjects genotyped CYP2C9*1/*2.

High-throughput simultaneous determination of the HIV protease inhibitors indinavir and L-756423 in human plasma using semi-automated 96-well solid phase extraction and LC-MS/MS

A method for the simultaneous determination of the HIV protease inhibitors indinavir and L-756423, in human plasma has been developed. Plasma samples (0.5 ml) were extracted using a 3M Empore 96-well plate in the mixed phase cation exchange (MPC) format. The extraction method was automated through the application of both the Packard 204DT and TOMTEC Quadra 96 work stations, and the resulting extracts were analyzed using a PE-Sciex API-3000 LC-MS/MS with a heated nebulizer interface (500 degrees C). The assay was linear in the concentration range 1-2500 ng/ml for indinavir and 5 2500 ng/ml for L-756423 when 0.5-ml aliquots of plasma were extracted. Recoveries of indinavir and L-756423 were greater than 76 and 80%, respectively, over the calibration curve range when using the described sample preparation method. Within-batch precision and accuracy for the quantitation of indinavir over the range 1-2500 ng/ml were 5.4% R.S.D. or less and within 4.0%, respectively. Within-batch precision and accuracy for the quantitation of L-756423 over the range 5-2500 ng/ml were 5.3% R.S.D. or less and within 3.4%, respectively. Interbatch variability for the analysis of indinavir QC samples at low (3 ng/ml), middle (250 ng/ml) and high (2250 ng/ml) were 3.2, 2.9, and 1.9%, respectively. Interbatch variability for the analysis of L-756423 QC samples at low (15 ng/ml), middle (250 ng/ml) and high (2250 ng/ml) concentration were 2.0, 2.5, and 3.3%, respectively. The validated assay was used in support of human clinical trials.

Dealing with doubt. How patients account for non-specific chronic low back pain

OBJECTIVE

To explore the ways that persons with long standing chronic low back pain respond to the problem of medical doubt about the presence of organic pathology.

METHOD

Qualitative analysis of accounts provided by 12 persons attending a back pain rehabilitation clinic in NW England.

RESULTS

Subjects rejected the notion that they were culpable for their pain. They were not culpable for the onset of their pain. They argued that despite their cooperation, no sensible explanation of their pain was forthcoming from health professionals. Finally, they asserted that medical scepticism had been damaging and dispiriting.

CONCLUSION

Patients dealt with clinical doubt by stressing their own expertise. They constituted their beliefs about the cause and trajectory of their pain and disability as accurate accounts of their disability. They resisted the suggestion that there might be psychological factors involved in their ill-health by locating culpability among clinicians, who were confused or uncertain about diagnosis and treatment.

Determination of celecoxib in human plasma by normal-phase high-performance liquid chromatography with column switching and ultraviolet absorbance detection

A method is described for the determination of celecoxib in human plasma. Samples were extracted using 3M Empore membrane extraction cartridges and separated under normal-phase HPLC conditions using a Nucleosil-NO2 (150x4.6 mm, 5 microm) column. Detection was accomplished using UV absorbance at 260 nm. The HPLC method included a column switching procedure, in which late eluting compounds were diverted to waste, to reduce run-time to 12 min. The assay was linear in the concentration range of 25-2000 ng/ml when 1-ml aliquots of plasma were extracted. Recoveries of celecoxib were greater than 91% over the calibration curve range. Intraday precision and accuracy for this assay were 5.7% C.V. or better and within 2.3% of nominal, respectively. The assay was used to analyze samples collected during human clinical studies.

Determination of L-756 423, a novel HIV protease inhibitor, in human plasma and urine using high-performance liquid chromatography with fluorescence detection

A method for the determination of L-756 423, a novel HIV protease inhibitor, in human plasma and urine is described. Plasma and urine samples were extracted using 3M Empore extraction disk cartridges in the C18 and MPC (mixed-phase cation-exchange) formats, respectively. The extract was analyzed using HPLC with fluorescence detection (ex 248 nm, em 300 nm), and included a column switching procedure to reduce run-time. The assay was linear in the concentration range 5 to 1000 ng/ml when 1-ml aliquots of plasma and urine were extracted. Recoveries of L-756 423 were greater than 84% over the calibration curve range using the described sample preparation procedures. Intra-day precision and accuracy for this assay was less than 9% RSD and within 7%, respectively. Inter-day variabilities for the plasma (n=17) and urine (n= 10) were less than 5% and 3% for low (15 ng/ml) and high (750 ng/ml) quality control samples. Bovine serum albumin (0.5%) was used as an additive to urine to prevent precipitation of L-756 423 during the storage of clinical samples. The assay was used in support of human clinical trials.

Hydroquinone-based derivatization reagents for the quantitation of amines using electrochemical detection

Two new reagents, NDTE (2,5-dihydroxyphenylacetic acid, 2,5-bis-tetrahydropyranyl ether p-nitrophenyl ester) and HLTE (homogentisic gamma-lactone tetrahydropyranyl ether), are described for the chemical derivatization of primary and/or secondary amines to form an electrochemically active product. These reagents undergo reaction with the aforementioned analytes to form a product possessing the hydroquinone moiety, thus allowing for reversible electrochemical detection at mild oxidation potentials. The reactivity of each reagent was demonstrated by using N-ethylbenzylamine (EBzA) and the dipeptide isoleucine leucine methyl ester as model analytes. The investigation included the isolation and identification of the intermediates and final products from derivatization of EBzA. These isolated standards were subsequently characterized with respect to electrochemical properties by means of cyclic voltammetry. In LC-EC experiments, the concentration limit of detection (CLOD) of the purified EBzA product was determined to be 5 nM (100 fmol) at a detection potential of +200 mV vs Ag/AgCl ([Cl-] = 3 M). The CLOD values obtained by LC-EC after derivatization of aqueous solutions of EBzA and Ile-Leu-OMe with NDTE were 25 nM (250 fmol) and 250 nM (2.5 pmol), respectively.

Chronic low back pain rehabilitation programs: a study of the optimum duration of treatment and a comparison of group and individual therapy

STUDY DESIGN

Eighty-four patients with chronic low back pain were treated using cognitive behavioral principles on a pain management program. Outcome data were collected at four points: 10 weeks before treatment, immediately before and immediately after treatment, and 6 months after treatment. In part 1 of the study, patients were assigned randomly to group or individual treatment contexts. In part 2 of the study, patients were assigned randomly to programs of 15, 30, or 60 hours duration.

OBJECTIVES

To identify the differences in outcome between programs that treated patients as part of a group and those that treated patients individually and the effects of duration of treatment on outcome.

SUMMARY OF BACKGROUND DATA

Cognitive behavioral programs have been shown to be an effective means of managing chronic low back pain. The literature is concerned with group programs, however, the duration of which vary widely.

METHOD

Psychological and functional variables were measured before and after treatment and at the 6-month follow-up visit. Changes in these variables were measured, and comparisons were made between group and individual programs and between 15-, 30-, and 60-hour programs.

RESULTS

Data analysis showed a significant, beneficial effect of intervention in terms of the majority of variables; however, these changes were generally independent of whether patients were treated as part of a group or individually and whether patients completed a 15-, 30-, or 60-hour program.

CONCLUSIONS

Cognitive behavioral rehabilitation programs have been demonstrated to be an effective means of reducing psychological distress, of changing cognition, and of improving the function of patients with chronic low back pain; however, the length of program and whether patients were treated individually or as part of a group did not affect outcome. This finding has clinical and economic implications.

Selective fluorogenic derivatization of a peptide nucleic acid trimer with naphthalene-2,3-dicarboxaldehyde

The reversed-phase high-performance liquid chromatography of a Peptide Nucleic Acid (PNA) trimer has been studied after its preseparation fluorogenic derivatization with naphthalene-2,3-dicarboxaldehyde in the presence of cyanide (NDA/CN). Trace levels of the PNA trimer were determined in cell homogenate samples containing the PNA trimer at prederivatization concentrations as low as 48.9 ng ml-1. The sample pretreatment operations included a deproteination step, achieved by ultra-filtration, followed by fluorogenic derivatization (NDA/CN). Subsequently, to achieve adequate selectivity, the fluorescently labeled PNA was subjected to high performance anion exchange chromatography prior to quantitation via fluorescence detection. The various problems encountered during sample pretreatment and separation of derivatized PNA trimer in biological samples are presented and discussed.

Sodium/proton antiporter in the euryhaline crab Carcinus maenas: molecular cloning, expression and tissue distribution

Gill epithelial cells of euryhaline crustaceans demonstrate net inward transport of sodium ions, possibly via apical Na+/H+ antiporters, Na+/K+/2Cl- cotransporters or Na+ channels working in series with the basolateral Na(+) + K(+)-ATPase. We have identified and sequenced the cDNA coding for a crustacean Na+/H+ antiporter, starting with mRNA isolated from gills of the euryhaline green shore crab Carcinus maenas. The complete 2595-base-pair cDNA includes an open reading frame coding for a 673-amino-acid protein. A search of GenBank revealed more than 20 high-scoring matches, all Na+/H+ antiporter sequences from mammalian, amphibian, teleost and nematode species. Injection of Xenopus laevis oocytes with cRNA transcribed from the cloned crab sequence substantially enhanced Na(+)-dependent H+ efflux from the oocytes. Analysis of crab tissue antiporter mRNA levels by semi-quantitative reverse transcription-polymerase chain reaction revealed that posterior and anterior gills of Carcinus maenas expressed this antiporter the most strongly, followed in decreasing order by skeletal muscle, hepatopancreas, hypodermis and heart. Hydropathy and transmembrane alpha-helix analysis suggested a 10-helix membrane-spanning topology of the antiporter protein. It is clear from this study that Carcinus maenas gills vigorously transcribe a gene coding for a Na+/H+ antiporter. Whether these gills also express a gene coding for an epithelial Na+ channel or Na+/K+/2Cl- cotransporter remains to be demonstrated.

The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting

STUDY DESIGN

Three hundred patients, attending their general practitioners with attacks of acute low back pain, formed the subject population for a study of fear avoidance and other variables in the prediction of chronicity. Follow-up was at 2 and 12 months.

OBJECTIVE

The hypothesis to be tested was that evidence of psychological morbidity, particularly fear-avoidance behavior, would be manifest from the outset of the presenting attack in susceptible subjects.

SUMMARY OF BACKGROUND DATA

While back pain is an almost universal human experience, only about 5% of sufferers seek medical advice. Most of these respond to conservative treatment. However, approximately 10% of those who experience an acute attack of low back pain go on to become chronic sufferers.

METHODS

Psychosocial and physiological data (including fear-avoidance measures) were collected from a sample of 300 acute low back pain patients within 1 week of presentation and at 2 months, to try to predict 12 month outcome.

RESULTS

Data analysis showed that subjects who had not recovered by 2 months were those who went on to become chronic low back pain patients (7.3%). Using multiple regression analyses, fear-avoidance variables were the most successful in predicting outcome. Using multiple discriminant function analyses, the results suggest that the outcome in terms of the future course of low back pain can be correctly classified in 66% from fear-avoidance variables alone and in 88% of patients from all variables.

CONCLUSIONS

The results suggest that, at the earliest stage of low back pain, fear of pain should be identified by clinicians and, where this is severe, pain confrontation should arguably form part of the approach to treatment.

Broiler Carcass Reprocessing, A Further Evaluation

The microbiological quality of 745 conventionally processed and 745 reprocessed broiler carcasses was determined. Carcasses were taken from the processing line prior to entering the chiller in five commercial processing plants. Each plant was sampled twice during the winter, spring, and summer. Analyses included aerobic bacteria, Enterobacteriaceae , and Escherichia coli counts plus qualitative Salmonella (SAL) prevalence. Differences between overall mean log₁₀ counts for aerobic bacteria, Enterobacteriaceae , and E. coli were not significant. The prevalence of SAL detected on conventionally processed and reprocessed carcasses also was not significantly different. Some variation was observed in microbiological quality of carcasses among processing plants. Although the SAL prevalence appeared to decline from winter to summer replications, no significant trend could be demonstrated. Continuation of the practice of reprocessing carcasses appears justified.

An application of the fear avoidance model to three chronic pain problems

The Fear Avoidance Model of Exaggerated Pain Perception was developed in an attempt to explain how, and why, some individuals develop a more substantial psychological overlay to their low back pain problem than do others. The present paper describes a study in which three chronic pain groups, consisting of Post-Herpetic neuralgia patients, Reflex Sympathetic Dystrophy patients and chronic low back pain patients were compared with three pain-free comparison groups using the Fear Avoidance Model of Exaggerated Pain Perception. The results show statistically significant differences between the chronic groups and the recovered comparison groups. These results demonstrate the usefulness of the Fear Avoidance Model as an explanation of psychological overlay in chronic pain conditions regardless of pathology.

Keyboard operating posture and actuation force: implications for muscle over-use

A substantial proportion of the problems in keyboard operator 'Over-use Syndromes' occur in the wrist and finger extensor muscle group. Biomechanical analysis shows these muscles to be subject to substantial sustained static (isometric) muscle contraction during the work task. This study measured the maximum relaxed finger press forces for 60 subjects in three arm support methods, in order to predict what the minimum keypress force should be to permit finger support sufficient to facilitate relaxation of finger extensor muscles. It was postulated that the minimum key activation force should accommodate the 95 percentile predicted population relaxed finger weights. The predicted force of 0.8 newton is within limits previously proposed for performance criteria, and which have been found practical commercially.

Physiotherapy exercises for low back pain: process and clinical outcome

This study was designed to assess whether physiotherapy exercises administered for low back pain have the physiological effects that they purport to have (increase spinal mobility and muscle strength) and whether these effects are of clinical relevance (related to changes in pain and function). Thirty-six patients were allocated to three treatment conditions, mobilizing exercises, isometric exercises or an attention-placebo control procedure. The results did not support the hypotheses concerning the effects of physiotherapy exercises, and hence challenge widely held views concerning the mechanism by which some patients suffering from low back pain improve whilst undergoing physiotherapy exercises.