A phase 1/2 clinical trial of enzyme replacement in fabry disease: pharmacokinetic, substrate clearance, and safety studies

Fabry disease results from deficient alpha-galactosidase A (alpha-Gal A) activity and the pathologic accumulation of the globotriaosylceramide (GL-3) and related glycosphingolipids, primarily in vascular endothelial lysosomes. Treatment is currently palliative, and affected patients generally die in their 40s or 50s. Preclinical studies of recombinant human alpha-Gal A (r-halphaGalA) infusions in knockout mice demonstrated reduction of GL-3 in tissues and plasma, providing rationale for a phase 1/2 clinical trial. Here, we report a single-center, open-label, dose-ranging study of r-halphaGalA treatment in 15 patients, each of whom received five infusions at one of five dose regimens. Intravenously administered r-halphaGalA was cleared from the circulation in a dose-dependent manner, via both saturable and non-saturable pathways. Rapid and marked reductions in plasma and tissue GL-3 were observed biochemically, histologically, and/or ultrastructurally. Clearance of plasma GL-3 was dose-dependent. In patients with pre- and posttreatment biopsies, mean GL-3 content decreased 84% in liver (n=13), was markedly reduced in kidney in four of five patients, and after five doses was modestly lowered in the endomyocardium of four of seven patients. GL-3 deposits were cleared to near normal or were markedly reduced in the vascular endothelium of liver, skin, heart, and kidney, on the basis of light- and electron-microscopic evaluation. In addition, patients reported less pain, increased ability to sweat, and improved quality-of-life measures. Infusions were well tolerated; four patients experienced mild-to-moderate reactions, suggestive of hypersensitivity, that were managed conservatively. Of 15 patients, 8 (53%) developed IgG antibodies to r-halphaGalA; however, the antibodies were not neutralizing, as indicated by unchanged pharmacokinetic values for infusions 1 and 5. This study provides the basis for a phase 3 trial of enzyme-replacement therapy for Fabry disease.

Evidence for secular trends in children's physical activity behaviour

It is not clear whether the global increase in weight problems in children is the result of excessive energy intake or decreasing energy expenditure. Methodological limitations have made it difficult to analyse. There is evidence that at least part of the problem may lie with increasing energy consumption, but it is important to examine the other side of the energy equation also. However, it is not possible to conclusively describe physical activity trends because of the absence of suitable baseline data. One solution is to summate all available evidence in as many areas of daily activities as possible and then draw tentative conclusions. This review summarises available trend data on direct representations of physical activity in a range of contexts, together with indirect measures such as sedentariness, fitness, and attitudes. The conclusions drawn are: physical activity in clearly defined contexts such as active transport, school physical education, and organised sports is declining in many countries; young people would like to be active but are often constrained by external factors such as school policy or curricula, parental rules in relation to safety and convenience, and physical environmental factors.

A controlled study of the effect of therapies aimed at adolescent and family psychopathology in anorexia nervosa

Ninety patients with severe anorexia nervosa fulfilling DSM-III-R criteria were assessed in depth in terms of their family developmental psychopathology and then randomly allocated to either one of three treatment groups or to no treatment. In three treatment regimes, a behavioural approach to diet and weight gain was coupled with individual and family psychotherapy directed at the adolescent maturational problems. All three treatment regimes were highly significantly effective at one year in terms of weight gain, return of menstruation, and aspects of social and sexual adjustment. Body weights above those at pubertal onset were achieved for the group mean maximum and one-year follow-up weights for all three treatment groups but not the control group.

The prevention of thymic lymphomas in transgenic mice by human O6-alkylguanine-DNA alkyltransferase

Nitrosoureas form O6-alkylguanine-DNA adducts that are converted to G to A transitions, the mutation found in the activated ras oncogenes of nitrosourea-induced mouse lymphomas and rat mammary tumors. These adducts are removed by the DNA repair protein O6-alkylguanine-DNA alkyltransferase. Transgenic mice that express the human homolog of this protein in the thymus were found to be protected from developing thymic lymphomas after exposure to N-methyl-N-nitrosourea. Thus, transgenic expression of a single human DNA repair gene is sufficient to block chemical carcinogenesis. The transduction of DNA repair genes in vivo may unravel mechanisms of carcinogenesis and provide therapeutic protection from known carcinogens.

Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa

Ninety subjects with DSM-III-R anorexia nervosa were randomly allocated to four treatment options, one inpatient, two outpatient, and one comprising an assessment interview only. Twenty were thus offered a package of outpatient individual and family psychotherapy. At 2-year follow-up, 12 of the 20 were classed as well, or very nearly well, according to operationally defined criteria. Statistically significant improvements over time were obtained for weight, mean body mass index (BMI), and also for psychological, sexual, and socioeconomic adjustments. Weight and BMI changes were significantly better than for the assessment only group, some of whom had received extensive treatment elsewhere. The style of the outpatient therapy and compliance with it are described in some detail and prognostic indicators for the treated and untreated groups presented. Lower weights at presentation and vomiting were associated with poorer outcome, although age and length of history were not.

The 'price' of Olympic Gold

In 1981 the Commonwealth Government established the Australian Institute of Sport (AIS). The Australian Sports Commission (ASC) which administers the AIS has 2 objectives: (1) excellence in sports performances; and (2) increased participation in sports and sports activities. State-based institutes of sport have also been established with the same or very similar objectives. Federal policy directs the bulk of the ASC budget to elite athlete programs. A smaller proportion goes towards community participation. The official reason is based on the notion of the 'trickle-down' or 'demonstration' effect. That is, a flow-on of benefits to the broader community in the form of increased participation as a direct result of elite sports success. The aims of this study were to determine the (1) spending pattern to elite sports programs for the 5 Olympics 1976/77 to 1995/96, (2) evidence for the two ASC objectives having been met, and (3) expected medal tally at the 2000 Olympic Games. Results show funding (in 1998 dollars), has accelerated from about $1.2 million (1976/77) to $106 million in (1997/98), particularly since the Games were awarded to Sydney. The total amount spent on elite athletes was $0.918 billion. In the period 1980-96 Australia won 25 gold and 115 total Olympic medals. This equates to approximately $37 million per gold and $8 million per medal in general. There was a significant linear relationship between money spent and total medals won. This was also found when all medal types were analysed independently. The predicted medal tally in 2000 (based on the cost per medal and the expenditure towards Sydney) indicates the medal count will be about 14+/-1 gold, 15+/-2 silver and 33+/-4 bronze. Based on our nation's record of international sporting achievement, there is little doubt we have fulfilled the ASC's first objective. Current data on physical activity patterns of Australians suggest the second objective has not been met. Focusing attention on and achieving the first objective does not appear to have any bearing on the second objective. It is time to revisit the notion that elite sporting success leads to greater mass participation as a result of the so-called 'trickle-down' effect.

Morphological evolution of athletes over the 20th century: causes and consequences

Over the course of the past century it has become increasingly difficult to find athletes of the size and shape required to compete successfully at the highest level. Sport is Darwinian in that only the 'fittest' reach the highest level of participation. Not every physical characteristic could be expected to play a role in this selection process, but two that are important and for which substantial data assemblies exist, are height and mass. Measurements of elite athlete sizes were obtained from a variety of sources as far back as records allowed. We charted the shift in these anthropometric characteristics of elite sportspeople over time, against a backdrop of secular changes in the general population. Athletes in many sports have been getting taller and more massive over time; the rates of rise outstripping those of the secular trend. In open-ended sports, more massive players have an advantage. Larger players average longer careers and obtain greater financial rewards. In some sports it is equally difficult to find athletes small enough to compete. In contrast, there are sports that demand a narrow range of morphological characteristics. In these sports the size of the most successful athletes over the century has remained constant, despite the drift in the population characteristics from which they are drawn. A number of social factors both drive and are driven by the search for athletes of increasingly rare morphology. These include globalisation and international recruitment, greater financial and social incentives, and the use of special training methods and artificial growth stimuli. In many sports the demand for a specific range in body size reinforces the need to adopt questionable and illegal behaviours to reach the required size and shape to compete at the top level. Future scenarios also include 'gene-farming' through assortative mating and athlete gamete banks.

New approach to the management of airway obstruction in "high risk" neonates

Epignathus is a rare tumor of newborns that is associated with a high mortality secondary to airway obstruction in the neonatal period. Due to recent advances in prenatal ultrasound and magnetic resonance imaging techniques, accurate in utero diagnosis of this rare teratoma will enable the health care team to prepare for "emergency" management of a difficult airway. We present a case of a newborn with a large epignathus diagnosed prenatally who underwent tracheotomy with intact maternal-fetal circulation. After airway stabilization, maternal-fetal circulation was interrupted and the epignathus was successfully removed. To our knowledge, this is the first extrauterine surgical procedure successfully performed using this technique. A new approach to airway management in "high risk" neonates involving the cooperative efforts of pediatricians, neonatologists, anesthesiologists, and otolaryngologists is presented.

Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

(1) Describe the self-care, productivity and leisure problems identified by individuals with a spinal cord injury (SCI) during rehabilitation, (2) describe the perceived level of satisfaction and performance with self-care, productivity and leisure activities following an SCI, (3) quantify the relationship between the Canadian occupational performance measure (COPM), a client-centred, individualized measure of function, and the functional independence measure (FIM).

SETTING

Tertiary rehabilitation centre, spinal cord injury unit, GF Strong Rehabilitation Centre, Vancouver, Canada.

METHODS

Health records from 41 individuals with an SCI admitted between 2000 and 2002 were reviewed. Information was obtained from assessments performed on admission and discharge. Self-care, productivity and leisure problems identified by individuals with an SCI were described and their perceived level of performance and satisfaction was calculated. The relationship between the COPM and the FIM was measured by the Pearson product correlation.

RESULTS

Self-care goals were identified most frequently (79%) followed by productivity (12%) and leisure (9%) goals. The top three problems identified by individuals with an SCI were functional mobility (including transfers and wheelchair use), dressing and grooming. A fair relationship was found between the COPM and the FIM (r between 0.351 and 0.514, P<0.05).

CONCLUSIONS

The results highlight the importance of including a client-centred outcome measure in the assessment of individuals with an SCI. Initial support is provided for use of the COPM in individuals with an SCI.

Multiple axis-II diagnoses of personality disorder

BACKGROUND

Simultaneous diagnosis of more than one personality disorder (PD) has been termed 'comorbidity' or 'co-occurrence' implying that single diagnoses are the norm and multiple diagnoses interesting exceptions. Surveys of PD subjects in fact show 1.5-5.6 diagnoses per subject. Our study explores the hypothesis that multiple PD diagnosis is common and increases with increasingly personality disordered populations.

METHOD

The PDQ-R questionnaire was administered to three UK samples: referrals for specialist PD in-patient treatment (n = 275); high tariff offenders attending a probation centre (n = 57); and undergraduate students (n = 274).

RESULTS

Means of 6.0 (95% CI 5.7-6.3), 4.0 (3.1-5.0) and 3.4 (3.0-3.8) PDQ-R diagnoses per subject were found respectively. High rates of PD diagnosis in individual subjects suggest that multiple diagnosis is the norm rather than the exception.

CONCLUSIONS

Multiple diagnosis of PD is better construed as 'breadth' of psychopathology rather than comorbidity and is a function of sampling frame. High rates of multiple diagnoses question the interpretation of studies of any single PD. The graded construct of 'breadth' of axis-II pathology may further our understanding of PD.

Evaluation and management of congenital cervical teratoma. Case report and review

Congenital cervical teratoma can be clinically dramatic, although essentially benign. Prognosis is good provided that the airway is quickly stabilized and resection is not delayed. We present a case of massive cervical teratoma diagnosed using antenatal magnetic resonance imaging. The child was maintained on maternal circulation after cesarean section until successfully intubated, with a second team ready for emergent bronchoscopy or tracheotomy. After delivery, the lesion grew rapidly with persistent bleeding; biopsy revealed a benign, immature teratoma. On computed tomography all anatomy ventral to the vertebrae was obliterated. At surgery, however, the tumor was easily resected. The literature is reviewed, with attention to malignancy in neonatal cervical teratoma. Surgery was delayed because of the aggressive imaging appearance and rapid growth. This case suggests that when evaluating neonatal tumors, the standard criteria for infiltration and resectability may require modification.

Synergistic efficacy of O6-benzylguanine and 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) in a human colon cancer xenograft completely resistant to BCNU alone

The DNA repair protein O6-alkylguanine-DNA alkyltransferase (alkyltransferase) repairs cytotoxic DNA damage formed by 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). High levels of this repair protein cause tumor drug resistance to nitrosoureas. To investigate the ability of a direct alkyltransferase inhibitor, O6-benzylguanine, to reverse the nitrosourea resistance of human colon cancer cells, we studied the VACO 6 cell line which has high alkyltransferase and is completely resistant to BCNU at maximal tolerated doses in the xenograft model. O6-Benzylguanine at 0.5 microgram/mL for 1 hr inactivated VACO 6 alkyltransferase by > 98% and reduced the IC50 of BCNU by 3- to 4-fold. Further analysis indicated that these two agents act in a highly synergistic fashion. In xenograft bearing athymic mice, dose-dependent depletion of hepatic and tumor alkyltransferase was noted. To maintain alkyltransferase depletion in the xenograft for at least 24 hr, two doses of 60 mg/kg O6-benzylguanine were given 1 hr prior and 7 hr after BCNU. Under these conditions, VACO 6 xenografts became responsive to BCNU with significant reductions (P < 0.001) in the tumor growth rate. The combination increased toxicity to the host, reducing the maximum tolerated dose of BCNU by approximately 50%. This study provides definitive evidence that high alkyltransferase activity is responsible for BCNU resistance in human colon cancer xenografts and that with careful drug scheduling, O6-benzylguanine can sensitize a tumor which is completely unresponsive to BCNU alone. Further studies which optimize the therapeutic index of BCNU and O6-benzylguanine in vivo will define the schedule to be used in broader preclinical studies.

Evidence for the aetiology of injuries in Australian football

OBJECTIVES

To determine in Australian football (a) the influence of ground hardness and playing grade (level) on game speed and structure, and (b) player movement patterns throughout the game and across levels.

METHODS

The design consisted of several studies. Seventeen games played on grounds of different hardness in 2000 were used to determine game speed and structure. Four first grade and four second grade grand final games (1994, 1996, 1997, 1999) were used to determine the game speed and structure on the same ground but at different levels. Fifty one players (44 first grade and seven second grade) were used to measure movement patterns within games and across levels during the 2000 season.

RESULTS

There was a significant relation between ground hardness and game speed, which could lead to higher injury rates when the ground is harder. There was a 6.7% difference in game speed between the first and second grade levels reflecting differences in injury incidence. The first grade games were also characterised by a greater number of shorter, high intensity play periods and longer stop periods than the second grade games. Midfield players in the first grade games covered about 24% greater distance than their second grade counterparts, and there was a significant difference in their playing speeds.

CONCLUSIONS

Over the past 40 years, the game speed in the top level of Australian football has approximately doubled. Over the same time, the number of collisions and the estimated injury incidence have also doubled. This study provides additional support to the suggestion that these variables are strongly linked. Factors such as ground hardness, playing level, and time during the game influence game speed and are therefore important in injury development in Australian football.

Cost-offset following specialist treatment of severe personality disorders

Service usage of 24 patients with a personality disorder was established for one year pre-treatment and one year post-treatment via a prospective survey of the patients, their original referrer and their general practitioner. The average annual cost of psychiatric and prison services (calculated from extra-contractual referrals (ECR) tariffs and Home Office data) was £13 966 pre-treatment compared to £1306 post-treatment, representing a cost-offset of £12 658 per patient per year. The average cost of the specialist admission was £25 641. Thus the cost to the Nation for treating these personality disordered patients in a tertiary treatment resource would be recouped within two years and represent a saving thereafter.

Young adults with hemophilia in the U.S.: demographics, comorbidities, and health status

Improvements in hemophilia care over the last several decades might lead to expectations of a near-normal quality of life for young adults with hemophilia. However, few published reports specifically examine health status indicators in this population. To remedy this knowledge gap, we examined the impact of hemophilia on physical and social functioning and quality of life among a national US cohort of 141 young men with hemophilia aged 18-34 years of age who received care at 10 geographically diverse, federally funded hemophilia treatment centers in 11 states between 2005 and 2013 and enrolled in the Hemophilia Utilization Group Studies. Indicators studied included educational achievement, employment status, insurance, health-related quality of life, and prevalence of the following comorbidities: pain, range of motion limitation, overweight/obesity, and viral status. The cohort was analyzed to compare those aged 18-24 to those aged 25-34 years. When compared to the general US adult population, this nationally representative cohort of young US adults with hemophilia experienced significant health and social burdens: more liver disease, joint damage, joint pain, and unemployment as well as lower high-school graduation rates. Nearly half were overweight or obese. Conversely, this cohort had higher levels of health insurance and equivalent mental health scores. While attention has typically focused on newborns, children, adolescents, and increasingly, on older persons with hemophilia, our findings suggest that a specific focus on young adults is warranted to determine the most effective interventions to improve health and functioning for this apparently vulnerable age group.

Severe personality disorders. Treatment issues and selection for in-patient psychotherapy

BACKGROUND

Severe personality disorder (SPD) is an imprecise but useful term referring to some notoriously difficult to treat psychiatric patients. Their long-term psychiatric treatment is often unsuccessful, in spite of hospitalisation. The specialist expertise of in-patient psychotherapy units (IPUs) can successfully meet some of SPD patients' needs.

METHOD

Relevant literature on the subject is summarised and integrated with the authors' specialist clinical experience.

RESULTS

Many clinical problems with SPD patients are interpersonal and prevent any effective therapeutic alliance, which is necessary for successful treatment. With in-patients, inconsistencies in treatment delivery and issues surrounding compulsory treatment reinforce patients' mistrust of professionals, compromising accurate diagnosis and an assessment of the need for specialist IPU referral.

CONCLUSIONS

General psychiatric teams are well-placed to plan long-term treatment for SPD patients which may include IPU treatment. Timely referral of selected SPD patients to an IPU maximises a successful outcome, especially if there is appropriate post-discharge collaboration with general psychiatric teams to consolidate gains made.

Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder

BACKGROUND

The view that severe personality disorder (SPD) is untreatable derives from poor-quality studies of treatment outcome which use indirect measures of SPD pathology. This study evaluates the impact of psychotherapeutic in-patient treatment on core personality disorder symptoms.

METHOD

137 SPD patients completed the Borderline Syndrome Index (BSI) on referral and one year post-treatment ('admitted', n = 70) or one year post-referral ('non-admitted', n = 67); 22 of the non-admitted group were refused extra-contractual referral funding for their treatment.

RESULTS

There was a significantly greater reduction in BSI scores in the treated than in the non-admitted group. Changes in BSI scores were significantly positively correlated with length of treatment. Assessment of the reliability and clinical significance of changes in individual subjects showed that the magnitude of this change was reliable and clinically significant in 42.9% of the admitted sample, compared with only 17.9% of the non-admitted sample (18.2% of the unfunded group).

CONCLUSIONS

Specialist in-patient treatment is effective in reducing core SPD psychopathology.

Assessment of the pharmacological effects of inotropic drugs on left ventricular pressure and contractility: an evaluation of the QA interval as an indirect indicator of cardiac inotropism

INTRODUCTION

The ICH S7A and S7B guidelines require that effects of test substances on the cardiovascular system be assessed with respect to blood pressure, heart rate and electrocardiogram intervals. Where adverse effects are identified additional supplemental studies, including ventricular contractility, should be conducted as deemed appropriate. However, there is an absence of definitive guidance regarding when to pursue supplementary studies, in part due to ill-defined criteria of what constitutes an adverse effect and to surgical/technical monitoring limitations of study designs. However with advances in technology it is now feasible to develop models for assessing LVP and contractility in conjunction with standard assessments. The objectives of this study were to 1) develop a model for chronic evaluation of LVP and contractility, 2) illustrate changes in LV contractility without concurrent proportional changes in heart rate and/or systemic blood pressure and 3) determine if the QA interval, the time between the Q on the ECG and the beginning of the upstroke on the arterial blood pressure, can be used as a indicator of altered LV contractility.

METHODS

Dogs (N=4) were implanted with a telemetry transmitter. LVP, contractility, ECG and BP were assessed prior to and up to 24 h following administration of Atenolol (10 mg/kg) and Pimobendan (0.45 mg/kg).

RESULTS

Atenolol caused an approximately 30% decrease in HR, followed by a sustained decrease in maximum left ventricular contractility (+dP/dt mmHg/s). No effects were noted on blood pressure. Pimobendan caused a 100% increase in contractility (+dP/dt mmHg/s) which remained elevated for approximately 4 h. No effects were noted on blood pressure. Heart rate was highly variable initial decreasing, followed by a highly variable increase until 4 h postdose. Following administration of both compounds changes in maximum left ventricular contractility correlated with reverse changes in QA interval duration.

DISCUSSION

This model demonstrates that evaluation of LV contractility complements measurements of heart rate and blood pressure as part of a more complete cardiovascular safety assessment strategy. Furthermore, we demonstrate an apparent correlation between dP/dt and QA interval and concluded that QA interval can be utilized as an indicator of a potential inotropic effect. However further confirmation should be assessed through additional in-vivo measurements of LVP and contractility.

Olympic lightweight and open-class rowers possess distinctive physical and proportionality characteristics

Rowers competing at the 2000 Olympic Games were measured for 38 anthropometric dimensions. The aim was to identify common physical characteristics that could provide a competitive advantage. The participants included 140 male open-class rowers, 69 female open-class rowers, 50 male lightweight rowers, and 14 female lightweight rowers. Body mass, stature, and sitting height were different (P < 0.01) between the open-class and lightweight rowers, as well as a comparison group of healthy young adults ("non-rowers", 42 males, 71 females), for both sexes. After scaling for stature, the open-class rowers remained proportionally heavier than the non-rowers, with greater proportional chest, waist, and thigh dimensions (P < 0.01). Rowers across all categories possessed a proportionally smaller hip girth than the non-rowers (P < 0.01), which suggested the equipment places some constraints on this dimension. Top-ranked male open-class rowers were significantly taller and heavier and had a greater sitting height (P < 0.01) than their lower-ranked counterparts. They were also more muscular in the upper body, as indicated by a larger relaxed arm girth and forearm girth (P < 0.01). For the male lightweight rowers, only proportional thigh length was greater in the best competitors (P < 0.01). In the female open-class rowers, skinfold thicknesses were lower in the more highly placed competitors (P < 0.01). In conclusion, the rowers in this sample demonstrated distinctive physical characteristics that distinguish them from non-rowers and other sports performers.

A decrease in the association between the physical activity patterns of Australian parents and their children; 1985-1997

The present study investigated the interactions between parents' and children's physical activity levels by examining whether or not parents who exercise have children who participate in sport. Of primary interest was an investigation of trends in these interactions over time. Information was collected from 10-13 y old children in 1985 (n = 2463) and then again in 1997-99 (n = 1469), about their sports participation and their perceptions of parents' exercise habits. Boys' participation in at least one sport declined from 87% in 1985 to 76% in 1997/1999 while, among girls, participation fell from 80% to 71%. According to their children's perceptions, mothers exercising regularly fell from 36% to 31% between surveys, while fathers exercising regularly fell from 39% to 32%. Interactions between parents' and children's exercise and sports behaviours were examined employing chi-square analysis techniques. Results showed gender-specific relationships for the 1985 sample, such that active fathers were associated with increased participation in sports by boys, and inactive mothers were associated with less participation in sports by girls. These interactions seemed to diminish over time. It is possible that changes in social structures during this time may be affecting familial behaviour relationships, such as the role modelling of active behaviours.

Are short term savings worth long term costs? Funding treatment for personality disorders

The new system of funding introduced by the National Health Service reforms has led to an increased awareness of financial concerns within the NHS. This was indeed one of the main aims of the reforms, with the expectation that a more efficient and better quality service would result. This may be a realistic aim, as long as clinicians' freedom to make appropriate secondary and tertiary referrals do not become totally dependent upon financial considerations. Yet it has become clear from findings within our own unit, Henderson Hospital, that, in at least 42% of cases, requests for ECR funding for treatment were refused on a purely financial basis (Dolan & Norton, 1992).