Single-agent ibrutinib versus chemoimmunotherapy regimens for treatment-naïve patients with chronic lymphocytic leukemia: A cross-trial comparison of phase 3 studies

Chemoimmunotherapy (CIT) and targeted therapy with single‐agent ibrutinib are both recommended first‐line treatments for chronic lymphocytic leukemia (CLL), although their outcomes have not been directly compared. Using ibrutinib data from the RESONATE‐2 (PCYC‐1115/1116) study conducted in patients ≥65 years without del(17p), we performed a cross‐trial comparison with CIT data from published phase 3 studies in first‐line treatment of CLL. Progression‐free survival (PFS), overall survival (OS), and safety data for ibrutinib (median follow‐up 35.7 months) were evaluated alongside available CIT data. CIT regimens included: fludarabine + cyclophosphamide + rituximab (CLL8, CLL10), bendamustine + rituximab (CLL10), obinutuzumab + chlorambucil and rituximab + chlorambucil (CLL11), and ofatumumab + chlorambucil (COMPLEMENT‐1). Median age across studies was 61‐74 years, with older populations receiving ibrutinib, obinutuzumab + chlorambucil, or rituximab + chlorambucil. Median follow‐up varied across studies/regimens (range 14.5‐37.4 months). Among all patients, PFS appeared longer with ibrutinib relative to CIT and OS appeared comparable. Relative to CIT studies that similarly excluded patients with del(17p) (CLL10) or enrolled older/less‐fit patients (CLL11), PFS appeared favorable for ibrutinib in high‐risk subgroups, including advanced disease, bulky lymph nodes, unmutated IGHV status, and presence of del(11q). Grade ≥ 3 infections ranged from 9% (ofatumumab + chlorambucil) to 40% (fludarabine + cyclophosphamide + rituximab), and was 25% with ibrutinib. Grade ≥ 3 neutropenia was 12% for ibrutinib and 26%‐84% for CIT. Although definitive conclusions cannot be made due to inherent limitations of cross‐trial comparisons, this report suggests that ibrutinib has a favorable benefit/risk profile and may potentially eliminate the need for chemotherapy in some patients. Randomized, comparative studies are needed to support these findings.

The quality of orthodontic practice websites

OBJECTIVE

To evaluate orthodontic practice websites for the reliability of information presented, accessibility, usability for patients and compliance to General Dental Council (GDC) regulations on ethical advertising.

SETTING

World Wide Web.

MATERIALS AND METHODS

The term 'orthodontic practice' was entered into three separate search engines. The 30 websites from the UK were selected and graded according to the LIDA tool (a validated method of evaluating healthcare websites) for accessibility, usability of the website and reliability of information on orthodontic treatment. The websites were then evaluated against the GDC's Principles for ethical advertising in nine different criteria.

RESULTS

On average, each website fulfilled six out of nine points of the GDC's criteria, with inclusion of a complaints policy being the most poorly fulfilled criteria. The mean LIDA score (a combination of usability, reliability and accessibility) was 102/144 (standard deviation 8.38). The websites scored most poorly on reliability (average 43% SD 11.7), with no single website reporting a clear, reliable method of content production. Average accessibility was 81% and usability 73%.

CONCLUSIONS

In general, websites did not comply with GDC guidelines on ethical advertising. Furthermore, practitioners should consider reporting their method of information production, particularly when making claims about efficiency and speed of treatment in order to improve reliability.

Cessation of immunosuppression during chemotherapy for post-transplant lymphoproliferative disorders in renal transplant patients

BACKGROUND

The optimal reduction of immunosuppressive therapy (IST) in renal transplant patients with post-transplant lymphoproliferative disorders (PTLDs) is uncertain. As chemotherapy is immunosuppressive, IST may be stopped during this time without compromising graft function. Subsequent long-term reduction of IST reduces relapse risk, but may increase risk of graft rejection.

METHODS

We performed a retrospective, matched cohort study of adult renal transplant patients in whom IST was ceased during chemotherapy and resumed at lower dose (calcineurin inhibitor at 50%, prednisolone ≤10 mg daily, no third agent) approximately 6 weeks after chemotherapy. Outcomes were compared with those of renal transplant patients without PTLD, matched for creatinine at equivalent time post-transplant that PTLD was diagnosed in cases, as well as for age, gender and year of transplant.

RESULTS

Twenty-four cases of PTLD occurring at a median of 9.2 years post-transplant were compared with 83 matched controls. PTLD cases were followed for a median of 11.9 years. Using competing risks analysis, time to 25% increase in serum creatinine was not significantly different between the two groups [adjusted hazard ratio (HR) 1.8, 95% confidence interval (CI) 0.89-3.6]. Similar results were obtained using multivariable Cox regression analysis (HR 1.19, 95% CI 0.44-3.23). Only one PTLD case experienced a ≥25% increase in creatinine <6 months after IST cessation in the setting of progressive PTLD and death. Three cases recommenced dialysis, compared with three controls (HR 2.5, 95% CI 0.47-13.00). Five-year patient survival rates for cases and controls were 70 and 94%, respectively (P = 0.01).

CONCLUSIONS

IST can be safely ceased during chemotherapy for PTLD in renal transplant patients. Furthermore, long-term reduction in IST is not associated with a significant difference in renal function deterioration. Prospective trials are needed to address the optimal reduction of IST in PTLDs.

High dose methotrexate and extended hours high-flux hemodialysis for the treatment of primary central nervous system lymphoma in a patient with end stage renal disease

This report discusses the case of a 52 year old female with post-transplant lymphoproliferative disorder, confined to the central nervous system, which was managed with high dose methotrexate (HDMTX) in the context of end stage renal disease. The patient received two doses of HDMTX followed by extended hours high-flux hemodialysis, plasma methotrexate concentration monitoring and leucovorin rescue. The hemodialysis technique used was effective in clearing plasma methotrexate and allowed delivery of HDMTX to achieve complete remission with limited and reversible direct methotrexate-related toxicity. Dialysis-dependent renal failure does not preclude the use of HDMTX when required for curative therapy of malignancy.

CHOP-like chemotherapy with or without rituximab in young patients with good-prognosis diffuse large-B-cell lymphoma: 6-year results of an open-label randomised study of the MabThera International Trial (MInT) Group

BACKGROUND

The MInT study was the first to show improved 3-year outcomes with the addition of rituximab to a CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone)-like regimen in young patients with good-prognosis diffuse large-B-cell lymphoma. Extended follow-up was needed to establish long-term effects.

METHODS

In the randomised open-label MInT study, patients from 18 countries (aged 18-60 years with none or one risk factor according to the age-adjusted International Prognostic Index [IPI], stage II-IV disease or stage I disease with bulk) were randomly assigned to receive six cycles of a CHOP-like chemotherapy with or without rituximab. Bulky and extranodal sites received additional radiotherapy. Randomisation was done centrally with a computer-based tool and was stratified by centre, bulky disease, age-adjusted IPI, and chemotherapy regimen by use of a modified minimisation algorithm that incorporated a stochastic component. Patients and investigators were not masked to treatment allocation. The primary endpoint was event-free survival. Analyses were by intention to treat. This observational study is a follow-up of the MInT trial, which was stopped in 2003, and is registered at ClinicalTrials.gov, number NCT00400907.

FINDINGS

The intention-to-treat population included 410 patients assigned to chemotherapy alone and 413 assigned to chemotherapy plus rituximab. After a median follow-up of 72 months (range 0·03-119), 6-year event-free survival was 55·8% (95% CI 50·4-60·9; 166 events) for patients assigned to chemotherapy alone and 74·3% (69·3-78·6; 98 events) for those assigned to chemotherapy plus rituximab (difference between groups 18·5%, 11·5-25·4, log-rank p<0·0001). Multivariable analyses showed that event-free survival was affected by treatment group, presence of bulky disease, and age-adjusted IPI and that overall survival was affected by treatment group and presence of bulky disease only. After chemotherapy and rituximab, a favourable subgroup (IPI=0, no bulk) could be defined from a less favourable subgroup (IPI=1 or bulk, or both; event-free survival 84·3% [95% CI 74·2-90·7] vs 71·0% [65·1-76·1], log-rank p=0·005). 18 (4·4%, 95% CI 2·6-6·9) second malignancies occurred in the chemotherapy-alone group and 16 (3·9%, 2·2-6·2) in the chemotherapy and rituximab group (Fisher's exact p=0·730).

INTERPRETATION

Rituximab added to six cycles of CHOP-like chemotherapy improved long-term outcomes for young patients with good-prognosis diffuse large-B-cell lymphoma. The definition of two prognostic subgroups allows a more refined therapeutic approach to these patients than does assessment by IPI alone.

FUNDING

Hoffmann-La Roche.

The pattern of ankle fractures sustained by outdoor activities at the Snowdonia National Park, North Wales, United Kingdom

OBJECTIVE

The aim of this study was to review the pattern of ankle fractures sustained by patients brought to the Emergency Department at Ysbyty Gwynedd from The Snowdonia National Park.

MATERIALS AND METHODS

The study group included all patients with ankle fractures on the mountain medicine database between March 2004 and December 2006. The presence of talar shift and comminution of the medial malleolus was noted. The pattern of fractures were analysed and compared with the literature. Radiographs were obtained for 20 casualties.

RESULTS

70% of these were injured whilst hill walking. Open fractures represented 12% of injuries. 75% of fractures required operative fixation. Weber B injuries were the commonest followed by Weber C and A. Talar shift was seen in 80% of the cases and 45% showed comminution of the medial malleolus.

CONCLUSIONS

In our case series we observed a high proportion of open and unstable ankle fractures, with the majority treated by operative fixation. The high rate of comminution of the medial malleolus has previously not been reported in the literature and has the potential of making operative fixation technically difficult. Encouraging the use of walking poles particularly at the time of descending may help to reduce the incidence of ankle fractures in hill walkers.

Consolidation Therapy With Low-Dose Thalidomide and Prednisolone Prolongs the Survival of Multiple Myeloma Patients Undergoing a Single Autologous Stem-Cell Transplantation Procedure

Purpose

Thalidomide is effective in the treatment of newly diagnosed and relapsed/refractory multiple myeloma (MM). However, the role of thalidomide in the post-autologous stem cell transplantation (ASCT) context remains unclear. This study assessed whether the addition of thalidomide consolidation following ASCT would improve the durability of responses achieved and overall survival.

Patients and Methods

Between January 2002 and March 2005, 269 patients with newly diagnosed MM who achieved disease stabilization or better with conventional induction chemotherapy received a single high-dose melphalan conditioned ASCT. Post-ASCT, 129 patients were randomly assigned to receive indefinite prednisolone maintenance therapy (control group) and 114 to receive the same in addition to 12 months of thalidomide consolidation (thalidomide group). The primary study end points were progression-free survival (PFS) and overall survival (OS). The secondary end point was tolerability.

Results

After a median follow-up of 3 years, the postrandomization 3-year PFS rates were 42% and 23% (P < .001; hazard ratio [HR], 0.5; 95% CI, 0.35 to 0.71) and the OS rates were 86% and 75% (P = .004; HR, 0.41; 95% CI, 0.22 to 0.76) in the thalidomide and control groups, respectively. There was no difference in survival between groups 12 months after disease progression (79% v 77%; P = .237). Neurological toxicities were more common in the thalidomide arm but there were no differences between arms for thromboembolic events.

Conclusion

Consolidation therapy with 12 months of thalidomide combined with prednisolone prolongs survival when used after a single high-dose therapy supported ASCT in patients with newly diagnosed MM. Furthermore, thalidomide consolidation therapy did not adversely impact on survival in the subsequent salvage setting.

Viral RNA synthesis by a particulate fraction from cucumber seedlings infected with cucumber mosaic virus

Particulate preparations from cucumber mosaic virus (CMV)-infected cucumber cotyledons incorporated [alpha-32P]GTP into products which, after phenol extraction, appeared to be double-stranded forms of the four CMV RNAs. In preparations isolated 3 to 5 days after inoculation, the label was incorporated mostly into plus RNA as shown by dot-blot hybridization using single-strand recombinant DNA clones of CMV RNA. After a short pulse the labeled material consisted mostly of small heterogeneous products, but part of the label could be chased into full-length RNAs, demonstrating that the synthetic process was continuous strand elongation rather than terminal addition. CMV RNAs added to the particulate fraction did not give rise to high molecular weight transcripts. In addition to the high molecular weight defined products which remained in the particulate fraction, small heterogeneous products, complementary to plant RNA and to viral RNA of both plus and minus polarity, were released into the incubation medium. They appeared to be products of the virus-induced Mr 100,000 (100K) protein which is solubilized from the particulate fraction during incubation. However, when the particulate fraction was first subjected to an extensive solubilization and washing treatment in order to remove the M(r) 100K protein [D. S. Gill, R. Kumarasamy, and R. H. Symons (1981) Virology 113, 1-8], and then used for product synthesis, a large amount of the product was still of small size, suggesting that the synthesis of high and low molecular weight RNA was intrinsically connected, and that the M(r) 100K protein was not merely contaminating the particulate fraction.

Effects of phenytoin sodium on doubling time, deoxyuridine suppression, 3H-methotrexate uptake and 57Co-cyanocobalamin uptake in HL60 cells

Phenytoin sodium (5-50 micrograms/ml) caused a dose-dependent prolongation of the doubling time of the human promyelocytic leukaemia cell line, HL60. This effect was unassociated with any alteration in cell viability. HL60 cells which were pre-incubated with 15 micrograms/ml phenytoin sodium for 1 or 48 h and then incubated with the same concentration of the drug plus either 3H-methotrexate (3H-MTX) or 57Co-cyanocobalamin for 90 min, showed an altered accumulation of both radioactive compounds when compared with control cells. Control cells were not pre-incubated with the drug and were subsequently studied in the absence of the drug. Pre-incubation with the drug for 1 h resulted in a 34% increase, and pre-incubation for 48 h in a 19% reduction in the accumulation of 3H-MTX. Pre-incubation for 1 or 48 h caused a 29% reduction in the accumulation of 57Co-cyanocobalamin. Cells cultured in the presence of 15 micrograms/ml phenytoin sodium for 48 h also gave a slightly increased deoxyuridine-suppressed value; this abnormality was partially corrected by the addition of 50 micrograms/ml folinic acid to the test system but was unaffected by the addition of 1 microgram/ml cyanocobalamin. The data indicate that the effects of phenytoin sodium on the proliferation of HL60 cells may have been slightly mediated via a reduced uptake of folate and possibly also of vitamin B12. They also suggest that one of the mechanisms underlying some of the undesirable effects of long-term therapy with phenytoin may be a drug-related impairment of both folate and vitamin B12 uptake by certain cells, including haemopoietic and neural cells.

Smile aesthetics

The aim of this article is to outline some of the factors practitioners should take into consideration when planning optimal smile aesthetics. The components of the smile that will be discussed include the smile are, incisor/gingival display, smile width, gingival aesthetics, tooth proportionality/symmetry, contacts/connectors/embrasures and the dental midlines.

Post-transplant hepatosplenic T-cell lymphoma successfully treated with HyperCVAD regimen

Hepatosplenic T-cell lymphoma (HSTL) is an aggressive lymphoma. In post-transplant immunosuppressed patients, HSTL is usually rapidly fatal. We report successful treatment of post-transplant HSTL in a 50-year-old renal allograft recipient by reducing immunosuppression and using intensive chemotherapy consisting of alternating cycles of HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) and MTX/HiDAC (methotrexate, Ara-C). Remission is ongoing at 8+ years. Literature review identified another 20 cases of HSTL in solid organ transplant recipients: median survival was 4 months; no other patients survived beyond 12 months. Bone marrow involvement was universal, but changes were often subtle: 6 of 12 cases had nondiagnostic examinations earlier on. High index of suspicion may lead to more timely diagnosis of this uncommon form of post-transplant lymphoproliferative disorder, and treatment with intensive chemotherapy such as HyperCVAD may be curative.

The influence of varying maxillary lateral incisor dimensions on perceived smile aesthetics

OBJECTIVE

The aim of this study was to determine the influence of varying the dimensions of the maxillary lateral incisors on perceived smile aesthetics.

DESIGN

Clinical study.

SETTING

Postgraduate dental teaching hospital.

METHODS

A photograph of a female smile displaying only the lips and teeth was digitally altered. First, the width of the maxillary lateral incisors, in proportion to the central incisor, was altered at 5% intervals to produce six images (52%, 57%, 62% [the 'golden proportion'], 67%, 72% and 77%). In a second group, the length of the lateral incisor was altered at 0.5 mm increments to produce five images with the lateral incisor 0.5 mm, 1 mm, 1.5 mm, 2 mm and 2.5 mm shorter than the adjacent central incisor. The photos were ranked from 'most attractive' to 'least attractive' by 41 hypodontia patients, 46 non-hypodontia 'control' patients and 30 dentists.

RESULTS

The 67% followed by the 72% lateral-to-central width proportions were the 'most preferred' by all groups. A maxillary lateral incisor that is 1-1.5 mm shorter than the central incisor was the 'most popular' maxillary lateral incisor length. The very short and very long maxillary lateral incisor was consistently perceived as 'least attractive'.

CONCLUSION

There is no evidence to suggest that the golden proportion should be considered the ideal aesthetic standard when creating space for the replacement of missing lateral incisors.

Radial pressure waveform dP/dt max is a poor indicator of left ventricular systolic function

BACKGROUND

The first derivative of left ventricular (LV) pressure over time (dP/dt max) is a marker of LV systolic function that can be assessed during cardiac catheterization and echocardiography. Radial artery dP/dt max has been proposed as a possible marker of LV systolic function and we sought to test this hypothesis.

MATERIALS AND METHODS

We compared simultaneously recorded radial dP/dt max (by high-fidelity tonometry) with LV dP/dt max (by high-fidelity catheter and echocardiography parameters analogous to LV dP/dt max). In study 1, beat-to-beat radial dP/dt max and LV dP/dt max were recorded at rest and during supine exercise in 12 males (aged 61 +/- 12 years) undergoing cardiac catheterization. In study 2, 2D-echocardiography and radial dP/dt max were recorded in 54 patients (separate to study 1; 39 men; aged 64 +/- 10 years) at baseline and peak dobutamine-induced stress. Three basal septum measures were taken as being analogous to LV dP/dt max: 1. Peak systolic strain rate; 2. Strain rate (SR-dP/dt max) during isovolumic contraction (IVCT) and; 3. Tissue velocity during IVCT.

RESULTS

In study 1 there was a significant difference between resting LV dP/dt max (1461 +/- 383 mmHg s(-1)) and radial dP/dt max (1182 +/- 319 mmHg s(-1); P < 0.001), and a poor, but statistically significant, correlation between the variables (R(2) = 0.006; P < 0.05). Similar results were observed during exercise. In study 2 there were weak (R(2) = -0.12; P = 0.01) to non-significant associations between radial dP/dt max and all echocardiographic measures analogous to LV dP/dt max at rest or peak stress.

CONCLUSION

Radial pressure waveform dP/dt max is not a reliable marker of LV systolic function.

Adult and paediatric basic life support: an update for the dental team

The aim of this paper is to review the current Resuscitation Council (UK) basic life support guidelines. The main changes made to the guidelines published in 2000 are that for adult basic life support no initial rescue breaths should be delivered before commencing chest compressions and that the compression to ventilation ratio should be 30:2 irrespective of the number of rescuers. For children over the age of one year, two rescuers should provide life support with a compression to ventilation ratio of 15:2. There is still a need to deliver rescue breaths before starting compressions in the child patient.

Pharmaceutical impurities: regulatory perspective for Abbreviated New Drug Applications

Impurities in drug substances and drug products have been important regulatory issues in the Office of Generic Drugs by having significant impact on the approvability of Abbreviated New Drug Application (ANDAs). This review begins with a discussion of ANDAs and its similarity/differences with NDAs, highlighting the importance of control of pharmaceutical impurities in generic drug product development and regulatory assessment. An overview of the FDA draft guidance documents "ANDAs: Impurities in Drug Substances" and "ANDAs: Impurities in Drug Products" are provided. This introduces the identification and qualification procedures for ANDAs and approaches to the establishment of acceptance criteria for both drug substance and drug product. Case studies included in this review illustrate the proposed pathway for determination of impurities and their acceptance criteria, based upon the general principles of these guidances.

Alternating hemiplegia of childhood: no mutations in the glutamate transporter EAAT1

Alternating hemiplegia of childhood (AHC) is a severe brain disorder, mainly characterised by episodes of hemiplegia, progressive mental retardation, and other severe paroxysmal and permanent neurological symptoms. Clinically and genetically, there is some overlap with sporadic (SHM) and familial (FHM) hemiplegic migraine, a severe monogenic subtype of migraine. Although no mutations were detected in the FHM1 CACNA1A and FHM2 ATP1A2 genes in sporadic AHC patients, a mutation was found in the FHM2 ATP1A2 gene in a family with AHC. Recently, a missense mutation was found in the SLC1A3 gene that encodes the glutamate transporter EAAT1, in a patient with alternating hemiplegia, episodic ataxia, seizures, and headache. Because of the remarkable clinical similarities and the potential role of glutamate in AHC, we analysed six sporadic patients with AHC for mutations in the SLC1A3 gene. No mutations were found. The SLC1A3 EAAT1 glutamate transporter gene does not seem to be involved in the pathogenesis of AHC.

Twenty-year remission of rheumatoid arthritis in 2 patients after allogeneic bone marrow transplant

We describe 21 and 19 year followup of 2 patients with severe rheumatoid arthritis (RA) who in 1984 and 1986 underwent allogeneic bone marrow transplantation (BMT) after full myeloablative conditioning, for therapy-induced aplastic anemia. Regarding the arthritis, both patients are well, taking no medications, and free of signs or symptoms of active RA. One patient is in excellent health overall, while the other has coronary artery disease and chronic obstructive pulmonary disease attributable to smoking. We suggest that allogeneic BMT may be a curative treatment for severe RA.

Alternating hemiplegia of childhood: no mutations in the second familial hemiplegic migraine gene ATP1A2

Alternating hemiplegia of childhood (AHC) is a rare disorder mainly characterised by attacks of hemiplegia and mental retardation. AHC has often been associated with migraine. Previously, we have excluded the involvement of the familial hemiplegic migraine (FHM) CACNA1A gene in four patients with AHC. A second gene for FHM was discovered recently: the ATP1A2 gene on chromosome 1q23, coding for the alpha 2 subunit of Na+,K+-ATPase. We performed a mutation analysis of the ATP1A2 gene in six patients, using direct sequencing, but found no mutations in any of the 23 exons. Other cerebral ion channel genes remain candidate genes for AHC.

A rapid RT-PCR screening assay incorporating multiplexed validated control genes for CBF rearrangements at diagnosis in AML

AIMS

Our objective was to establish a multiplexed assay using the Biomed 1 primers to detect AML1-ETO transcripts and 10 different CBFB-MYH11 transcripts, using BCR and ABL transcripts as controls.

METHODS

Control genes were systematically tested for characteristics of optimal controls. The final assay was validated on 50 AML patient samples.

RESULTS

Testing confirmed that the designated control gene criteria were fulfilled. Of 50 patient samples tested, four RT-PCR results were discordant with the cytogenetic result. In three cytogenetically negative cases, RT-PCR detected cryptic CBF rearrangements (one AML1-ETO and two CBFB-MYH11). The fourth case was inv(16) positive but negative by RT-PCR; however, the control gene result revealed suboptimal RNA quality.

CONCLUSIONS

We have described a robust multiplex RT-PCR assay that incorporates experimentally validated control genes that are important for accurate interpretation. The assay is more sensitive than cytogenetics in the detection of CBF AML. Application to large patient cohorts will determine the prognostic significance of cryptic CBF rearrangements compared with their cytogenetic counterparts.

Massive pulmonary haemorrhage complicating the treatment of acute coronary syndrome

Antiplatelet medications such as clopidogrel and tirofiban (glycoprotien IIb/IIIa inhibitors) are associated with a reduction in mortality and morbidity and are therefore recommended in the treatment of acute coronary syndromes. Massive pulmonary haemorrhage is a rare complication of both clopidogrel and tirofiban. Pulmonary haemorrhage may easily be mistaken for acute pulmonary oedema, a condition commonly seen in patients with acute coronary syndrome. Physicians need to be aware of this diagnostic dilemma because early treatment increases the chances of patient survival.

Regulatory considerations of pharmaceutical solid polymorphism in Abbreviated New Drug Applications (ANDAs)

A sponsor of an Abbreviated New Drug Application (ANDA) must have information to show that the proposed generic product and the innovator product are both pharmaceutically equivalent and bioequivalent, and therefore, therapeutically equivalent. Many pharmaceutical solids exist in several crystalline forms and thus exhibit polymorphism. Polymorphism may result in differences in the physico-chemical properties of the active ingredient and variations in these properties may render a generic drug product to be bioinequivalent to the innovator brand. For this reason, in ANDAs, careful attention is paid to the effect of polymorphism in the context of generic drug product equivalency. This review discusses the impact of polymorphism on drug product manufacturability, quality, and performance. Conclusions from this analysis demonstrate that pharmaceutical solid polymorphism has no relevance to the determination of drug substance "sameness" in ANDAs. Three decision trees for solid oral dosage forms or liquid suspensions are provided for evaluating when and how polymorphs of drug substances should be monitored and controlled in ANDA submissions. Case studies from ANDAs are provided which demonstrate the irrelevance of polymorphism to the determination of drug substance "sameness". These case studies also illustrate the conceptual framework from these decision trees and illustrate how their general principles are sufficient to assure both the quality and the therapeutic equivalence of marketed generic drug products.

Guinea-pig heart acetylcholinesterase after continuous physostigmine administration

G1 and G4 acetylcholinesterase (AChE) molecular forms were separated in different regions of guinea-pig heart. The activities of both were highest in the left side of the left ventricle (LV(L)). The reversible anticholinesterase physostigmine, or saline, was administered continuously for six days. In saline-treated animals the activity of both molecular forms was markedly increased in both atria, G1 activity was increased on the left side of the right ventricle (LV(R)), and G4 activity was increased on both sides of the right ventricle compared to untreated animals. However, G1 activity was significantly decreased on the left side of the left ventricle. Physostigmine administration caused a significant reduction in G4 activity in the left atrium (LA), the left side of the right ventricle, and the left side of the left ventricle, and a significant increase in G1 activity on the right side of the right ventricle compared to saline-treated animals. The distribution of AChE indicates a role for parasympathetic nerves in the control of both ventricles and atria. The changes in AChE in saline-treated animals could have been due to the anaesthesia or stress of the surgical procedures. Physostigmine caused delayed changes in the enzyme in some regions, consistent with an effect on its expression.

Natural history of cognitive deficits and their relationship to MRI T2-hyperintensities in NF1

BACKGROUND

Cognitive impairment is the most common complication of neurofibromatosis type 1 (NF1) in childhood. Current research suggests a strong relationship between cognitive deficits and brain T2-hyperintensities. The majority of these lesions disappear as the child ages. Cross-sectional data suggest that there also are improvements in intellect.

OBJECTIVE

To determine the natural history of cognitive functioning and MRI T2-hyperintensities from childhood into adulthood, and whether changes in MRI T2-hyperintensities over time are predictive of changes in cognitive functioning.

METHODS

The authors conducted a prospective longitudinal study of a cohort of 32 patients with NF1 and 11 unaffected sibling controls. All patients underwent neuropsychological assessments and 27 children underwent MRI examinations. The patients were then reassessed after an 8-year period.

RESULTS

and

CONCLUSIONS

There was no improvement in cognitive ability as the children with NF1 developed into adulthood compared with controls. Despite significant decreases in the number, size, and intensity of the T2-hyperintensities over the 8-year period, these changes were not associated with changes in cognitive ability. T2-hyperintensities in the cortex or subcortical or deep white matter are more frequent with age and these lesions are likely to have a different pathology than basal ganglia lesions. The best predictor of cognitive dysfunction in adulthood was the presence of T2-hyperintensities in childhood, rather than current lesion status. There is a limited time window (<18 years) in which the presence of T2-hyperintensities can be used as biologic markers of cognitive dysfunction.

The transmissible spongiform encephalopathies (prion diseases): a review for dental surgeons

The transmissible spongiform encephalopathies (prion diseases) are a fatal group of neurological diseases characterised by the accumulation of an abnormal form of prion protein in the brain. In humans, these disorders occur in sporadic, acquired and familial forms. Outbreaks of bovine spongiform encephalopathy, predominantly in the United Kingdom, and the emergence of a clinically and pathologically distinct human prion disease, variant CJD, has generated much interest in the transmissible spongiform encephalopathies. As the agent is detectable in lymphoid and neural tissue in variant CJD, clinicians should be aware of the possibility of cross infection of the causative agent. This is particularly important because the abnormal prion protein is resistant to routine sterilisation procedures. This article reviews the transmissible spongiform encephalopathies, and summarises guidelines concerning prevention of crossinfection when treating patients with or at risk of developing prion disease.

Treatment planning for the loss of first permanent molars

During the mixed-dentition stage of dental development, dentists may encounter patients with first permanent molars considered to have a poor long-term prognosis. In this situation, extraction of the tooth and space closure or use of the extraction space for future orthodontic treatment should be considered. The aim of this article is to give guidelines about treatment planning for patients who have first molars with a poor prognosis during the mixed-dentition stage.

Optical multibead arrays for simple and complex odor discrimination

A fiber optic bead-based sensor array platform has been employed to discriminate between six different odors and air carrier gas. Six different bead sensor types, with over 250 replicates of each, were monitored before, during, and after odor exposure to produce time-dependent fluorescence response patterns that were unique for each sensor-analyte combination. A total of 2,683 sensors were analyzed with respect to changes in their fluorescence, and signals from identical sensor beads were averaged to improve signal-to-noise ratios. Analyte classification rates of 100% were achieved for three complex (coffee bean) odors and three pure (simple) odors (toluene, acetone, 1,3-dinitrotoluene) measured at their highest relative concentrations. When lower odor concentrations were employed, the system exhibited better than 85% classification rates for analyte discrimination. Sensor response repeatability to these odor stimuli has also been quantified statistically, which is vital in defining the detection limit of the overall system. These results demonstrate, for the first time, the utility of our bead array technology for discriminating between different odor types at various dilution levels.

Alternating hemiplegia of childhood: no mutations in the familial hemiplegic migraine CACNA1A gene

INTRODUCTION

Alternating hemiplegia of childhood (AHC) is a rare disorder mainly characterized by attacks of hemiplegia and mental retardation. It has been often associated with migraine. The CACNA1A gene on chromosome 19 is involved in familial hemiplegic migraine and other episodic cerebral disorders, but also with progressive neuronal damage.

METHODS

We performed mutation analysis in this gene in four AHC patients, using single strand conformation polymorphism analysis.

RESULTS

We found nine polymorphisms, but no mutations in any of the 47 exons.

CONCLUSIONS

Other cerebral ion channel genes remain candidate genes for AHC.

Malignant lymphoma of the maxillary sinus masquerading as an odontogenic infection: report of a case

The dental surgeon can play an important role in the early referral of malignancy of the maxillary sinus, and should be familiar with the signs and symptoms of disease of the paranasal sinuses. Here we report a case of a 71-year-old male patient diagnosed with high-grade B-cell lymphoma of the maxillary sinus that was initially thought to be an odontogenic infection. We discuss the signs and symptoms of lymphomas and malignancy of the maxillary sinus.

Metastasis of thyroid carcinoma to the mandible. Case report

Metastatic tumours to the jaw bones are uncommon. The incidence of jaw bone metastasis is difficult to assess accurately since the usual method to determine the distribution of a metastatic tumour has been by a radiographic skeletal survey in which the jaws are rarely included. At times, metastatic lesions of the orofacial region may be the first evidence of dissemination of a known tumour from its primary site. A case of metastatic follicular carcinoma of the thyroid to the mandible is presented. The present case emphasizes the importance of considering metastasis in the differential diagnosis of a radiolucent lesion in the mandible in a patient with a history of any malignant disease.

Emergency drugs in dental practice

An increase in the life expectancy of medically compromised patients has resulted in greater numbers of these individuals within our ageing population. As dental surgeons are increasingly expected to provide care for such patients, the likelihood of a medical emergency occurring within the dental surgery may increase. This article reviews the more common emergency drugs that a dentist may have to administer in the event of a medical emergency. The indications, mode of action, method of administration and dose of each agent are discussed.

A new allele of interferon-alpha17 gene encoding IFN-alpha17b is the major variant in human population

Thirteen interferon (IFN)-alpha functional genes have been reported. Among these, a number of genes have allelic members (variants). In the case of IFN-alpha17, five variants, IFN-alpha17a, IFN-alpha17b, IFN-alpha17c, IFN-alpha17d, and IFN-alphaT, are known. The variants differ from each other by base changes in the coding region, leading to differences in amino acid sequences. We have developed oligonucleotide primers for amplification of IFN-alpha17 gene(s) using polymerase chain reaction (PCR). Genomic DNA, obtained from over 28,000 normal healthy individuals and from four cell lines, were used as templates in PCR to amplify the IFN-alpha17 gene sequences. The resulting PCR products were analyzed by restriction endonuclease digestion and DNA sequencing to identify the presence of variant sequences. The results show that a new variant of IFN-alpha17 is abundantly present (approximately 70%) along with another variant, possibly IFN-alpha17c (approximately 30%), in the genomic DNA of the population examined. This new variant, the protein product of which is identical to IFN-alpha17b, differs from the gene for IFN-alpha17b by a point mutation. We have named it IFN-alpha17b', which is the only variant found in U-937, KG-1, and EB-3 cell lines. Namalwa cells have IFN-alpha17b' and, possibly, IFN-alpha17c in equal proportions.

Structural requirements for a specificity switch and for maintenance of affinity using mutational analysis of a phage-displayed anti-arsonate antibody of Fab heavy chain first complementarity-determining region

We previously showed that a single mutation at heavy (H) position 35 of Abs specific for p-azophenylarsonate (Ars) resulted in acquisition of binding to the structurally related hapten p-azophenylsulfonate (Sulf). To explore the sequence and structural diversity of the H chain first complementarity-determining region (HCDR1) in modulating affinity and specificity, positions 30-36 in Ab 36-65 were randomly mutated and expressed as Fab in a bacteriophage display vector. Ab 36-65 is germline encoded, lacking somatic mutations. Following affinity selection on Sulf resins, 55 mutant Fab were isolated, revealing seven unique HCDR1 sequences containing different amino acids at position H:35. All Fab bound Sulf, but not Ars. Site-directed mutagenesis in a variety of HCDR1 sequence contexts indicates that H:35 is critical for hapten specificity, independent of the sequence of the remainder of HCDR1. At H:35, Asn is required for Ars specificity, consistent with the x-ray crystal structure of the somatically mutated anti-Ars Ab 36-71, while Sulf binding occurs with at least seven different H:35 residues. All Sulf-binding clones selected following phage display contained H:Gly33, observed previously for Ars-binding Abs that use the same germline V(H) sequence. Site-directed mutagenesis at H:33 indicates that Gly plays an essential structural role in HCDR1 for both Sulf- and Ars-specific Abs.

Ti:sapphire planar waveguide laser grown by pulsed laser deposition

We document the lasing performance of a waveguiding layer of Ti:sapphire, of ~12-mum thickness, grown by pulsed laser deposition from a 0.12-wt.% Ti(2)O(3) Ti:sapphire single-crystal target onto an undoped z-cut sapphire substrate. Lasing around 800 nm is observed when the waveguide layer is pumped by an argon-ion laser running on all-blue-green lines, with an absorbed power threshold of 0.56 W, with high-reflectivity (R>98%) mirrors. With a 5% pump duty cycle and a T=35% output coupler, a slope efficiency of 26% with respect to absorbed power is obtained, giving quasi-cw output powers in excess of 350 mW.

Differences in sequence-specific expression of two anti-arsonate Fabs in E. coli

Monoclonal antibodies are potentially useful therapeutic agents and can now be produced in hosts such as bacteria. However, it has been found that bacterial expression of some antibody-combining site fragments is greatly diminished. We compared two homologous anti-arsonate antibodies, 36-65 and 36-71, to address the question of why the former but not the latter expresses well as Fab in E. coli. These antibodies are both derived from the same variable region germline genes but differ in affinity due to somatic mutations present in 36-71. To investigate the poor expression of 36-71 Fab, we examined several factors, such as cellular toxicity, induction with isopropylthio-beta-D-galactoside, and growth of transformed bacteria at lower temperatures (30 degrees C), as well as the possibility of E. coli strain-related expression of Fab. However, none of these factors made a significant difference to Fab expression. We next localized a significant portion of the defect in Fab expression to the heavy chain by swapping the heavy and light chains from the two antibodies to construct hybrid Fabs. We used site-directed mutagenesis to engineer amino acids into the variable regions of antibody 36-71, to reproduce those found in 36-65 which is expressed well in E. coli. The defect in expression is due to residues located in the complementarity-determining regions, as mutations of heavy chain framework residues to those present in 36-65 do not enhance expression of 36-71 Fab in E. coli.

Both variant forms of interferon-alpha4 gene (IFNA4a and IFNA4b) are present in the human population

Alpha interferons (IFN-alpha) are a class of cytokines with various activities that are used as therapeutic agents for treatment of cancer and viral and immune disorder diseases. At least 13 IFN-alpha genes and 1 IFN-alpha pseudogene have been identified, which are clustered on human chromosome 9. Among the known IFN-alpha species, a number of allelic variants have been reported. Two variants of IFN-alpha4 (IFN-alpha4a and IFN-alpha4b) are known, which differ from each other by changes in their coding regions at nucleotide positions 220 and 410 and can be distinguished by selective restriction enzyme analysis. We have developed oligonucleotide primers for specific amplification of IFN-alpha4 gene fragments using the polymerase chain reaction (PCR). Genomic DNA obtained from over 28,000 normal healthy individuals and six human cell lines were used in this study. The resulting PCR products were analyzed by restriction endonuclease digestion and DNA sequencing to identify the presence of variant sequences. The results show that the DNA sequences for both variants of IFN-alpha4 are found in the population in nearly equal proportion. Individuals with either homozygous (e.g., alpha4a/alpha4a or alpha4b/alpha4b) or heterozygous (i.e., alpha4a/alpha4b) IFN-alpha4 genes were detected. Among the cell lines, KG-1, EB-3, and HTB-10 cells contain the genes for IFN-alpha4a only, whereas U-937, Namalwa, and Daudi cells contain the genes for both IFN-alpha4a and IFN-alpha4b.

Performance of a low-loss pulsed-laser-deposited Nd:Gd(3) Ga(5)O(12) waveguide laser at 1.06 and 0.94 mum

We report the laser performance of a low-propagation-loss neodymium-doped Gd(3)Ga(5)O(12) (Nd:GGG) waveguide fabricated by pulsed-laser deposition. An 8- mum -thick crystalline Nd:GGG film grown upon an undoped Y(3)Al(5)O(12) substrate lases at 1.060 and 1.062 microm when pumped by a Ti:sapphire laser operating at 740 or 808nm.Using a 2.2% output coupler, we observed a 1060-nm laser threshold of 4mW and a slope efficiency of 20%. Laser action was also achieved, for what we believe is the first time in Nd:GGG, on the quasi-three-level 937-nm transition. With a 2% output coupler at this wavelength a laser threshold of 17mW and a 20% slope efficiency were obtained. This demonstration of low propagation loss combined with the fact that these waveguides have a very high numerical aperture (0.75) makes pulsed-laser-deposited thin films attractive for high-power diode-pumped devices.

Identification of interferon-alpha 7, -alpha 14, and -alpha 21 variants in the genome of a large human population

The genes for type I interferon (IFN), which include 14 IFN-alpha genes, 1 IFN-beta gene, 1 IFN-omega gene, and a number of IFN-omega pseudogenes, are clustered on human chromosome 9. Among IFN-alpha genes, a number of variants have been reported. Three variants of IFN-alpha 7 (IFN-alpha 7a, IFN-alpha 7b, and IFN-alpha 7c) and IFN-alpha 14 (IFN-alpha 14a, IFN-alpha 14b, and IFN-alpha 14c) and two variants of IFN-alpha 21 (IFN-alpha 21a and IFN-alpha 21b) are identified. The variants differ from each other by base changes in the coding region and can be distinguished by selective restriction enzyme analysis and DNA sequencing. We have used polymerase chain reaction (PCR) with IFN species-specific oligonucleotide primers for amplification of IFN-alpha 7, IFN-alpha 14, and IFN-alpha 21 gene sequences. Genomic DNA obtained from over 28,000 normal healthy individuals were collected in six pools for PCR amplification. To identify the presence of variant sequences, the resulting PCR products of specific IFN-alpha genes were analyzed by restriction endonuclease digestion and DNA sequencing, with a limit of detection of minor components to 1% and 10%, respectively. The results show that only one variant form for each of IFN-alpha 7, IFN-alpha 14, and IFN-alpha 21, namely, IFN-alpha 7a, IFN-alpha 14c, and IFN-alpha 21b, is detectable in the genomic DNA of the population examined. Similar results were obtained from the analysis of a human myeloblastoid cell line, KG-1.

Interferon-alpha 8b is the only variant of interferon-alpha 8 identified in a large human population

Three variants of human interferon (IFN)-alpha 8a gene, that is, IFN-alpha 8b, and IFN-alpha 8c, have been reported previously. They differ from each other by changes in their coding region at nucleotide positions 359-360, 372, and 550. Human genomic DNA obtained from over 28,000 healthy blood donors and from 4 human cell lines was used in the polymerase chain reaction (PCR) designed for specific amplification of the IFN-alpha 8 gene fragments. The resulting PCR product was analyzed by (1) restriction endonuclease digestion, (2) DNA sequencing, and (3) allele-specific secondary PCR amplification. Only one sequence for IFN-alpha 8 was identified, and that was for IFN-alpha 8b. The sequences for IFN-alpha 8a and IFN-alpha 8c were not detected after PCR amplification either in the pooled leukocytes obtained from > 28,000 individuals or in cell lines tested. These data suggest that the naturally occurring variant or allele for IFN-alpha 8 in the population is IFN-alpha 8b. IFN-alpha 8a and IFN-alpha 8c variants were consistently below the level of detection of the assays and, if present at all in the population, are very rare.