Pharmacokinetics of genistein distribution in blood and retinas of diabetic and non-diabetic rats

Genistein, a natural tyrosine kinase inhibitor, may act as an intraocular antiangiogenic agent. Its therapeutical use, however, is limited by its nonlinear pharmacokinetics. We aimed to determine genistein's kinetics and retinal tissue distributions in normal and diabetic rats. We developed an isocratic, reverse-phase C18 HPLC system to measure genistein concentration in blood and retinas of streptozotocin (65 mg/kg IV)-diabetic and non-diabetic rats receiving two types of genistein-rich diet (150 and 300 mg/kg) for ten days. Genistein's decay exhibited a two-compartmental open model. Half-lives of distribution and elimination were 2.09 and 71.79 min, with no difference between groups. Genistein steady-state concentration in blood for 150 and 300 mg/kg diet did not differ between diabetic (0.259 ± 0.07 and 0.26 ± 0.06 μg/ml) and non-diabetic rats (0.192 ± 0.05 and 0.183 ± 0.09 μg/ml). In retina, genistein concentration was significantly higher in diabetic rats (1.05 ± 0.47 and 0.997 ± 0.47 μg/gm wt. vs. 0.087 ± 0.11 and 0.314 ± 0.18 μg/gm wt., p < 0.05). The study determined that increasing genistein dose did not change its bioavailability, perhaps due to the poor aqueous solubility. The retina's increased genistein could be due to increased permeability of blood-retinal barrier that occurs early in diabetes.

Role of observational studies in supporting extrapolation of efficacy data from adults to children with epilepsy - A systematic review of the literature using lacosamide as an example

Extrapolation of efficacy data from adults to children is accepted for focal epilepsy - the antiepileptic drug, lacosamide, has been approved for the treatment of children ≥4 years of age on this basis. Since many small-scale, open-label studies are reported in the literature before approval, a systematic review was conducted to ascertain whether results of these could be used to support extrapolation in epilepsy in the future. In the absence of randomised trials, a second analysis was conducted for reports on lacosamide use in adults with generalized epilepsies. Twenty-seven articles were included in the paediatric qualitative synthesis, and 14 in the adult. Paediatric studies were analysed separately based on seizure type: focal, generalised and mixed. In focal epilepsy, safety and seizure-related findings mirrored those observed in the adult Phase II/III trials, supporting the feasibility of data extrapolation. Few studies reported outcomes in children with epilepsies associated with generalised seizures, and those that included children with different seizure types, mostly did not provide results separately. Lacosamide treatment appeared beneficial for children and adults experiencing tonic-clonic and myoclonic seizures. Reports of seizure aggravation were inconsistent and, in many cases, could not be clearly attributed to lacosamide. Given the absence of sufficient data, evidence for the feasibility of extrapolation was not as clear-cut as it was in focal epilepsy. These results highlight the complexities of conducting trials in the generalised epilepsy setting, and the importance of studies in the real-life setting and of analysing efficacy data per generalized seizure type and syndrome.

Pregnancy Outcomes After Exposure to Certolizumab Pegol: Updated Results From a Pharmacovigilance Safety Database

Objective

Anti–tumor necrosis factor (anti‐TNF) medications are effective in controlling chronic inflammatory diseases, but information about their use and safety in pregnancy is limited. Consequently, anti‐TNF agents are often discontinued early in gestation. Certolizumab pegol (CZP), a PEGylated, Fc‐free anti‐TNF agent approved for the treatment of rheumatic diseases and/or Crohn's disease, has minimal to no active placental transfer. This analysis was undertaken to evaluate pregnancy outcomes in women receiving CZP, especially those exposed during early pregnancy.

Methods

Prospective and retrospective data on maternal CZP exposure were extracted from the UCB Pharma safety database through March 6, 2017. Analysis was limited to prospective reports to avoid potential bias associated with retrospective submissions. The numbers of live births, miscarriages, elective abortions, stillbirths, and major congenital malformations were ascertained.

Results

Of 1,137 prospectively reported pregnancies with maternal exposure to CZP, 528 (including 10 twin pregnancies) had 538 known outcomes: 459 live births (85.3%), 47 miscarriages (8.7%), 27 elective abortions (5.0%), and 5 stillbirths (0.9%). There were 8 major congenital malformations (1.7%) among the 459 infants. First trimester exposure occurred in 367 (81.2%) of 452 pregnancies resulting in 459 live births. Exposure during all 3 trimesters occurred in 201 (44.5%) of 452 pregnancies.

Conclusion

This analysis represents the largest cohort of pregnant women exposed to an anti‐TNF agent for management of chronic inflammatory diseases. Analysis of pregnancy outcomes does not indicate a teratogenic effect of CZP, compared to the general population, nor an increased risk of fetal death. The data are reassuring for women of childbearing age considering treatment with CZP.

Incidence and prevalence of axial spondyloarthritis: methodologic challenges and gaps in the literature

OBJECTIVES

The incidence and prevalence of axial spondyloarthritis (axSpA), including ankylosing spondylitis (AS) and non-radiographic (nr-)axSpA, have been investigated in multiple populations, though there is a paucity of population-level data. Here, we identify population-based studies in AS and nr-axSpA, and describe the methodologic challenges in conducting these, outlining potential reasons for disparate incidence and prevalence estimates.

METHODS

PubMed and Embase were searched for population-based studies providing incidence and prevalence rates, published in English from 1 Jan 2000-30 Jun 2015. Extracted information included incidence/prevalence rates, geographical population, study design, data source, case definition, age/gender, and classification criteria used.

RESULTS

Of 2,148 articles identified, 19, from 15 countries, fulfilled eligibility criteria. Incidence rates per 100,000 patient-years were reported in 4 AS studies and varied from 0.4 (Iceland) to 15.0 (Canada). Reported AS prevalence rates per 100,000 persons also showed considerable variation (16 studies: 6.5 [Japan] to 540.0 [Turkey]). Only 3 axSpA and no nr-axSpA prevalence rates were reported. Considerable variation was seen in the methodology used to estimate incidence and prevalence rates, e.g. screening method, study design, and classification criteria. Although the prevalence of AS is known to vary by HLA-B27 status, only 4 studies reported this genetic marker.

CONCLUSIONS

There is an unmet need for future studies to use consistent methodology, capture all relevant information (including HLA-B27 positivity), and investigate under-reported populations (e.g. nr-axSpA; southern hemisphere countries) to estimate the population burden of axSpA. Future studies should aim to address data gaps to provide accurate incidence/prevalence estimates for the global axSpA population.

Treatment of ulcerative compared to non-ulcerative interstitial cystitis with hyperbaric oxygen: a pilot study

Background

The etiology of interstitial cystitis (IC) is often idiopathic but can be due to Hunner's ulcers. Hyperbaric oxygen (HBO) is used to treat ulcerative disease of the superficial skin. We hypothesized that HBO can treat ulcerative IC (UIC) but would be less efficacious for non-ulcerative IC (NIC).

Methods

Patients with NIC and UIC enrolled in this study. Following informed consent, demographic information was collected. A visual analog pain scale and validated questionnaires were collected; each patient underwent cystoscopy prior to treatment. Each subject met with a hyperbaric specialist and after clearance underwent 30 treatments over 6 weeks. Adverse events were monitored. Patients repeated questionnaires, visual analog pain scale and global response assessment (GRA) immediately, 2 weeks, 3, 6 and 12 months after treatment. Patients also underwent cystoscopy 6 months after treatment. Differences before and after treatment were compared.

Results

Nine patients were recruited to this study. One was unable to participate, leaving two subjects with NIC and six with UIC. All patients completed HBO without adverse events. Three patients completed HBO but pursued other therapies 7, 8.5 and 11 months after treatment. On GRA, 83% of patients with UIC were improved. This treatment effect persisted, as 66% of UIC patients remained better at 6 months. In contrast, only one patient in the NIC group improved. Questionnaire scores improved in both groups. Pain scores improved by 2 points in the UIC group but worsened by 1.5 points in the NIC group. Two patients with ulcers resolved at 6-month cystoscopy.

Conclusion

HBO appeared beneficial for both UIC and NIC. Data shows slightly better benefit in patients with UIC compared to NIC; both groups showed improvement. Given the small sample size, it is difficult to draw definitive conclusions from these data. Larger studies with randomization would be beneficial to show treatment effect.

Harmonisation of ethics committees' practice in 10 European countries

BACKGROUND

The Directive 2001/20/EC was an important first step towards consistency in the requirements and processes for clinical trials across Europe. However, by applying the same rules to all types of drug trials and transposing the Directive's principles into pre-existing national legislations, the Directive somewhat failed to meet its facilitation and harmonization targets. In the field of ethics, the Directive 2001/20/EC conditioned the way of understanding and transposing the "single opinion" process in each country. This led to a situation in which two models of research ethics committees organisation systems exist, being the model in which the "single opinion" is considered to be the decision made by a single ethics committee more effective and simpler in terms of administrative and logistic workload.

METHOD

A survey was conducted in 10 European countries. Members of the European Clinical Research Infrastructures Network working party number 1, with expertise in the field of ethics, responded.

RESULTS

There is a major heterogeneity in the composition of ethics committees among the surveyed countries based on the number of members, proportion of experts versus lay members and expertise of the scientific members. A harmonized education of the ethics committees' membership based in common curricula is recommended by the majority of countries.

CONCLUSIONS

Despite the efforts for harmonization of the European Clinical Trial Directive, from an ethical point of view, there remains a plurality of ethics committees' systems in Europe. It is important to comprehend the individual national systems to understand the problems they are facing.

Phase I trial of combination becatecarin and oxaliplatin in patients with advanced solid tumors

2561

Background: Becatecarin (rebeccamycin analogue-RA) is an anti-tumor antibiotic with inhibitory activity against both topoisomerase II and I as well as DNA intercalating properties. We performed a phase I trial to a) determine the maximum tolerated dose (MTD) of RA in combination with oxaliplatin; b) determine the dose limiting toxicities (DLT) (c) obtain data on pharmacokinetics and (d) observe for any antitumor activity. Methods: Eligibility criteria included patients with advanced solid tumors refractory to standard therapy; performance status 0–2; adequate hematologic, renal and liver function. Patients were treated with RA as a 1 hour infusion daily x 5 and oxaliplatin on day 5 only, after RA infusion. Treatment was repeated q 21 days. The following dose levels were evaluated: Dose level 1: RA 80 mg/m2/d and oxaliplatin 90 mg/m2; Dose level 2: RA 80 mg/m2/d and oxaliplatin 130 mg/m2; Dose level 3: RA 110 mg/m2/d and oxaliplatin 130 mg/m2. Results: A total of 15 evaluable patients were enrolled. Median age was 56 (8 male, 7 female). A variety of tumor types were enrolled. A total of 56 cycles were administered. DLT occurred at a dose of RA at 110 mg/m2/d x 5 days and oxaliplatin at 130 mg/m2 and consisted of grade 3 hypophosphatemia and grade 4 atrial fibrillation. At this dose level 2 of 3 enrolled patients also developed grade 3 neutropenia. The MTD and recommended phase II dose was RA at 80 mg/m2/daily x 5 along with oxaliplatin 130 mg/m2 day 5 q 21 days. Three confirmed partial responses were observed in patients with hepatocellular, gallbladder and esophageal cancers. Six patients experienced stable disease. Conclusions: At the MTD combination RA and oxaliplatin is well tolerated and given the response rate and stable diseases observed, phase II studies are recommended. Supported by Grants U01 CA62502, MO1-RR-00080, K23 CA109348–01 from the National Institutes of Health.

No significant financial relationships to disclose.

Clinical results of a phase II study of sorafenib in patients (pts) with non-GIST sarcomas (CTEP study #7060)

10001

Background: Sorafenib, an oral multi-targeted tyrosine kinase inhibitor, approved for the treatment of renal carcinoma, inhibits tumor cell proliferation and angiogenesis. We performed a multi-institutional phase II trial of sorafenib in sarcoma. Methods: Six different histological categories were examined, each as a separate Simon two-stage trial. The starting dose of sorafenib was 400 mg PO BID. If ≥1 RECIST partial response (PR) was observed in the first 12 pts, 25 more were accrued to that arm. Results: 120 pts (40 M, 80 F) received 553 28-day cycles of therapy as of 1/07. Two RECIST PR were observed in 37 (6%) leiomyosarcoma (LMS) pts and at least 3 PR in 23 (13%) angiosarcomas (AS) pts. No PR were seen in pts with MFH, synovial sarcoma, malignant peripheral nerve sheath tumor (MPNST) or other sarcomas. Median time to progression (mTTP) is 10 ( ± 2), 15 ( ± 3), and 23 ( ± 4) weeks for non-AS, LMS and AS pts, respectively (Kaplan-Meier estimate,  ± SE). mTTP for AS is >2 fold longer than for other histologies (p=0.039, log rank), and compares favorably with single institution mTTP data for angiosarcoma (paclitaxel 17.3 wk, doxorubicin 16 wk, Fury et al. Cancer J. 2005; 11:241). 64/120 (53%) pts required dose reductions, mostly for dermatological toxicity (see abstract by Keohan, this meeting). Other grade 3, 4 and 5 toxicities included asthenia, hypertension, cardiomyopathy and hemorrhage. Two fatalities, from hemorrhage and intestinal perforation, were deemed possibly related to treatment. Correlative sorafenib pharmacokinetics, MAPK pathway activation and soluble markers of angiogenesis will be presented. Conclusions: Sorafenib has significant activity against angiosarcoma, although the RECIST response rate is low. Sorafenib is associated with disease control in other sarcoma subtypes (e.g. LMS). Accrual continues in AS and MPNST. Further study of sorafenib in sarcomas appears warranted, either in combination with cytotoxic chemotherapy or in a randomized setting. Supported in part by P01-CA47179 Sarcoma Program Project grant and N01 phase II grant.

[Table: see text]

Phase II trial of pemetrexed disodium and gemcitabine in advanced carcinoma of the urothelium (E4802): A trial of the Eastern Cooperative Oncology Group

5079

Background: Advanced urothelial carcinoma is a moderately chemosensitive disease. Although the gemcitabine/cisplatin regimen has essentially replaced M-VAC as front-line therapy, both regimens are moderately toxic and produce similar response rates and median survival. Pemetrexed is a novel multi-targeted antifolate with single agent activity in advanced urothelial cancer. We evaluated pemetrexed in combination with gemcitabine in untreated pts with advanced urothelial cancer. Methods: Patients with TCC or mixed histologies received pemetrexed 500 mg/m2 IV over 10 minutes followed by gemcitabine 1,000 mg/ m2 IV over 30 minutes on day 1, with gemcitabine repeated on day 8 of a 21-day cycle. Dose reductions were mandated for grade 3/4 toxicities. Patients remained on treatment until disease progression or unacceptable toxicity or a maximum of 6 cycles of therapy. Standard RECIST criteria were used to assess response. Results: Total accrual was 46 pts. Two pts never started therapy and were excluded, leaving 44 pts included in the analysis. The pt cohort was 36 (82%) male and 42 (95%) Caucasian. Twenty-two pts (50%), 21 (48%) and 1 (2%) had 0, 1 and 2 MSKCC risk factors respectively. Seventy-five percent of pts had distant metastatic disease at study entry including 7 (16%) with liver, 3 (7%) bone and 14 (32%) lung metastases. A median of 4 cycles were administered (range, 1–6). The most common reasons for discontinuing treatment were progressive disease (27%) and toxicity (20%). Eighteen pts experienced grade 4 toxicities, including leukocytes (n=5), neutrophils (n=18), cardiac arrest, fatigue, infection with grade 3 or 4 neutropenia (n=1 pt each). Two pts died from grade 5 toxicities while receiving treatment: one death was from neutropenia and the other pt died from infection without neutropenia following sepsis and subsequent cardiac arrest. Response information is available for 39 pts. There has been 1 complete response and 10 partial responses with an overall response rate of 28% (90% CI: [17%, 42%]). Eleven pts had stable disease for at least 6 weeks. Conclusions: Pemetrexed/gemcitabine has modest activity in patients with previously untreated advanced TCC of the urothelium, but at the cost of significant toxicity.

[Table: see text]

Phase I trial of daily lenalidomide and docetaxel given every three weeks in patients with advanced solid tumors

3570

Background: Lenalidomide is a potent anti-angiogenic and immune modulating agent. This phase I trial of docetaxel and lenalidomide was undertaken to evaluate the maximal tolerated dose (MTD), dose-limiting toxicity (DLT), and secondarily, any tumor response for this novel combination. Methods: Patients with advanced solid tumors with adequate organ function were eligible. Lenalidomide was given orally days 1–14, and docetaxel was administered intravenously on day 1 of each 21-day cycle. DLT was defined as grade 3 or higher non-hematologic toxicity, grade 4 neutropenia with fever, and grade 4 anemia or thrombocytopenia. Results: Nineteen patients, 14 male and 5 female, with tumor types including prostate (7), sarcoma (3), head and neck (2), pancreatic, colon, melanoma, adenocarcinoma of unknown primary, gastric, bladder, and GIST have been enrolled. ECOG performance status was zero (10 patients) or one (9 patients). The median age was 59 years (range 35 to 86). Fourteen patients had zero or one prior treatment regimens (range 0 to 6). A total of 64 cycles have been administered (range 1 to 12). In the first nine evaluable patients, eight (89%) had grade 3 or 4 neutropenia. Docetaxel 75 mg/m2 given every 3 weeks with lenalidomide 5 mg on days 1–14 exceeded the MTD due to one grade 3 nausea/vomiting and one grade 4 neutropenia with fever. After the addition of pegfilgrastim on day 2, there has not been any neutropenia in the subsequent seven evaluable patients. Other grade 3 and 4 toxicities included leukopenia (31%), lymphopenia (19%), as well as nausea, vomiting, fatigue, anemia, infection, hyponatremia, and hypokalemia (6% each). Seven patients (44%) have had stable disease (range 3 to 12 cycles). One prostate cancer patient experienced a >95% reduction of PSA. Enrollment is ongoing and the current dose level is docetaxel 75 mg/m2, lenalidomide 10 mg days 1–14, and pegfilgrastim on day 2. Conclusions: The toxicity evaluation is ongoing. This trial will provide the MTD of docetaxel 75 mg/m2 given every 3 weeks with lenalidomide on days 1–14 in combination with pegfilgrastim support to avoid neutropenia.

No significant financial relationships to disclose.

An evaluation of the taxi service available to wheelchair users

Adverse accounts of wheelchair user's experience of the taxi service have been reported. It is not clear whether these experiences are "once off" or reflect those of the user group. Wheelchair users living in cities throughout Ireland were surveyed. Of 306 questionnaires a response rate of 40.3% was achieved. Nearly 50% felt they had been refused a taxi because of their condition. Fifty one percent felt inadequately secured in a taxi with 35% rating driver's knowledge of handling as poor or very poor. Eight people (7%) had been injured as a result of unsafe handling by the taxi driver. Thirty percent said the modifications to the vehicles were inadequate and 45% said further modifications were needed. The results suggest that wheelchair users do not have access to a reliable, safe taxi service. The most important finding of the study was that that taxi driver's lack knowledge of how to handle and secure wheelchairs and people are being injured as a result. This study illustrates two things; the need to educate taxi drivers and the need to revisit the specifications for wheelchair accessible taxis to ensure modifications are adequate for users needs.

A phase I pharmacokinetic (PK) and pharmacodynamic (PD) study of MN-029, a novel vascular disrupting agent (VDA), in patients (pts) with advanced solid tumors

3096

Background: MN-029 is a novel VDA that binds reversibly to the colchicine-binding site on tubulin and inhibits microtubule assembly, resulting in disruption of the cytoskeleton of tumor endothelial cells (EC). Disruption of the tumor EC cytoskeleton ultimately leads to a temporary reduction in tumor blood flow. Methods: MN-029 is administered IV as a 10–20 min infusion, at 3-wk intervals in pts with advanced cancer. The study has followed an accelerated titration design, with intrapatient dose escalation. PD effects on tumor blood flow are evaluated using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Results: 28 pts were enrolled (13M/15F), median age 56 (range 35 - 76) and tumor types: colorectal (5), renal (5), hepatocellular (3), ovarian (2), melanoma (2), soft tissue sarcoma (2), carcinoid (2) and others (7). A total of 110 cycles of MN-029 were given, median 3/pt (range 1–20), over 9 dose levels (4, 8, 16, 24, 36, 54, 80, 120 and 180 mg/m2). Escalation proceeded until an initial dose-limiting toxicity (DLT) was observed in 1 pt in the 180 mg/m2 cohort, consisting of a reversible episode (3 hours post dose) of acute coronary ischemia (without sequelae and with preservation of myocardial function) probably due to coronary vasospasm. Therefore, this cohort was expanded to 6 pts, with no further DLTs observed. Common mild to moderate toxicities included nausea, vomiting (which appears dose-related), hypotension, fatigue and diarrhea. There was no significant myelotoxicity, stomatitis or alopecia. Seven pts had stable disease after 3 cycles, including 2 pts with carcinoid tumor (+21 cycles and +17 cycles). PK data generally indicated dose-related increases in Cmax and AUC values, although substantial inter-patient variability was observed. Tumor blood flow reduction assessed by DCE-MRI was recorded at 120 and 180 mg/m2, but not at 80 mg/m2. Conclusions: MN-029 produced reductions in tumor blood flow at doses that were well tolerated. Accrual continues at 225 mg/m2. [Supported in part by grants from MediciNova, Inc. and M01 RR-000080]

[Table: see text]

Phase I study of the EGFR tyrosine kinase inhibitor erlotinib in combination with docetaxel and radiation in locally advanced squamous cell cancer of the head and neck (SCCHN)

5545

Background: EGFR is highly expressed in SCCHN, representing a promising therapeutic target. Erlotinib (E) is an EGFR tyrosine kinase inhibitor that may potentiate the efficacy of concurrent radiation (RT) and docetaxel (D). We sought to establish the MTD, toxicities and preliminary efficacy of the combination of RT, D and E in patients (pts) with SCCHN. Methods: Patients with previously untreated stage III-IVB SCCHN were enrolled in a phase I dose-escalating study with standard once-daily RT (70.2 Gy, 1.8 Gy/day), weekly D for the duration of RT and daily E for two weeks prior, during and up to two years following RT. 4 dose levels (DL) were evaluated [D (mg/m2)/E (mg): 15/50, 15/100, 20/100, 20/150]. A 3+3 escalation design was followed. Pharmacokinetic studies (PK) were performed. Results: A total of 23 patients were enrolled (6 pts at each DL 1–3, 5 pts at DL4). Primary site: oral cavity (n = 1), pharynx (n = 15) and larynx (n = 7). 20 patients (87%) had stage IV disease. Three dose-limiting toxicities were observed, 1 at each DL (1–3), including a death within 30 days from last treatment (DL1), grade 3 mucositis resulting in holding RT (>5 days) (DL2) and grade 4 mucositis (DL3). No DLT to date on DL4 with 3/5 pts evaluable. In patients enrolled at DL 1–3 (n = 18), post concurrent chemoRT, best response was CR (n = 15), not evaluable (n = 2), death on study (n = 1). 3/3 pts who underwent planned neck dissection had a pathologic CR. 9 patients are currently receiving adjuvant E and 1 has completed the 2-year course. 3 patients have relapsed. Interpatient variability of E peak plasma concentrations measured after the first dose was observed at all dose levels: 458 ± 173 ng/mL (DL1), 686 ± 364 (DL2), 1017 ± 241 (DL3), 833 ± 222 (DL4) (mean ± s.d., n = 6, 6, 6, 2 at DL1–4 respectively). Adjuvant erlotinib plasma concentration data will be presented separately. No significant PK interaction of erlotinib with docetaxel was noted. Conclusions: The combination of daily erlotinib with weekly docetaxel and RT for pts with stage III-IVB SCCHN is feasible and active. A phase II trial is planned. Supported in part by NIH grants nos. CA62502 and M01 RR-000080.

No significant financial relationships to disclose.

68 GENE EXPRESSION COMPARISONS BETWEEN BOVINE IN VIVO AND CLONED EMBRYOS PRODUCED BY THREE DIFFERENT METHODS

Developmental pathways in the mammalian embryo are profoundly influenced by the epigenetic interaction of the environment and the genome. Loss of epigenetic control has been implicated in aberrant gene expression and altered imprinting patterns with consequence to the physiology and viability of the conceptus. Bovine somatic cell nuclear transfer (SCNT) is contingent on in vitro culture, and both SCNT and culture conditions are known to induce changes in embryonic gene expression patterns. Using these experimental models, this study compared gene expression of Day 7 cloned blastocysts created from three different SCNT protocols using the same cell line, with Day 7 in vivo blastocysts to elucidate mechanisms responsible for variations in phenotypic outcomes. SCNT methods included: (1) traditional SCNT by subzonal injection (SI); (2) handmade cloning (HMC); and (3) modified serial nuclear transfer (SNT), developed within the group. Four imprinted genes (Grb10, Ndn, Nnat, and Ube3a), four chromatin remodeling genes (Cbx1, Cbx3, Smarca4, and Smarcb1) and two genes implicated in polycystic liver disease (Prkcsh and Sec63) were analyzed in single blastocysts from each treatment (n = 5). All blastocysts expressed Actin, Oct-4 and Ifn-tau. All genes were sequence verified. Several genes were expressed ubiquitously across all groups, including Ndn, Ube3a, Cbx1, Cbx3, and Smarcb1. Interestingly, Grb10 was not expressed in two HMCs and one SNT blastocyst. Nnat was weakly expressed in one in vivo blastocyst and in the majority of cloned blastocysts in all groups. Prkcsh and Sec63 were expressed in all but one HMC blastocyst. While gene expression patterns were mostly maintained following SCNT, the imprinted genes Nnat and Grb10 showed instances of differential or abnormal expression in SCNT embryos. The chromatin remodeling genes were maintained in all SCNT treatments. Prkcsh and Sec63 were both absent in one HMC blastocyst, with implications for liver dysfunction, a condition previously reported in abnormal cloned offspring. The variable mRNA expression following SCNT provides an insight into genetic and environmental factors controlling implantation, placentation, organ formation, and fetal growth.

220 AN EXPRESSION PROFILE OF GENES CRUCIAL FOR PLACENTAL DEVELOPMENT IN SINGLE IN VIVO, IN VITRO AND CLONED BOVINE BLASTOCYSTS

Abnormalities of the placenta are a major factor contributing to early death in cloned bovine conceptuses. This is primarily due to incomplete chromatin remodeling and reprogramming of the donor nucleus. It is unknown whether genetic aberrations of genes crucial for placental development can be detected in pre-implantation cloned bovine embryos. This study looked at the expression profile of four genes in single bovine blastocysts derived from in vivo, in vitro produced (IVP), or cloning techniques, including handmade cloning (HMC) and serial HMC (SHMC). The genes studied included acrogranin, caudal type homeobox 2 (cdx2), estrogen-receptor-related receptor beta (essrb), and the mammalian relative of DnaJ (MRJ). These genes play a role in trophoblast regulation and placental development. Messenger RNA expression was analyzed by using PCR following cDNA amplification by means of SMART cDNA synthesis (Clontech, Palo alto, CA, USA). Primers were designed from homologous human and mouse sequence. PCR products were sequenced for verification. Five single blastocysts were analyzed from each of the following treatments: in vivo, IVP, HMC, and SHMC. Pooled (n = 10) IVP blastocyst cDNA produced by standard RT was used as a positive control. Grade 1 Day 7 blastocysts were selected for all treatments. Amplified cDNA was tested using control genes polyA, IFN-τ and GDF9. In vitro-produced embryos were matured, fertilized and cultured as published by Ruddock et al. (2004 Biol. Reprod. 70, 1131). Cloned HMC embryos were produced as described by Tecirlioglu et al. (2003 Reprod. Fertil. Dev. 15, 361). Serial HMC embryos were produced as per the HMC embryos, followed by a second round of nuclear transfer at the pronuclear stage. The pooled IVP, in vivo, and IVP blastocysts expressed all four genes of interest. In the HMC-cloned embryos, all four genes were expressed. However, in the SHMC cloned embryos, although MRJ was found to be expressed in all blastocysts, three of the five blastocysts did not express acrogranin. Similarly, two SHMC embryos did not express cdx2, and essrb was weakly expressed in three of the five embryos analyzed. Initial pregnancy rates of HMC and SHMC embryo transfers are similar. Further pregnancy results are pending. These results indicate that aberrations of genes crucial for placental development can be detected in single cloned blastocysts. It also suggests that failed implantation and/or placental defects may stem from patterned genetic defects in the pre-implantation embryo. An increase in the number of embryos analyzed would further strengthen results. These genes could act as markers to identify cloning techniques that produce more embryos with normal genetic profiles. The benefits of developing a screening tool to assess abnormalities in single pre-implantation embryos would be significant.

119 THE LOCALIZATION OF A METHYL BINDING DOMAIN PROTEIN (MBD4) IN MURINE AND BOVINE OOCYTES AND PRE-IMPLANTATION EMBRYOS

The presence of MBD4, a member of the methyl binding domain family, was investigated in both murine and bovine oocytes and pre-implantation embryos. MBD4 is the only MBD family member that is involved in DNA repair but not active in transcriptional repression or in the formation of complexes with histone deacetylase complexes (HDACs). It contains a mismatch-specific glycosylase domain that acts to repair G:T mismatches within a CpG context. Bovine cumulus oocyte complexes were collected from abattoir-derived ovaries, matured in vitro and used for IVF as described previously (Ruddock et al. 2004 Biol. Reprod. 70, 1131–1135). Samples were analyzed at all steps in this process. Murine oocytes were collected from superovulated mice (C57BL6 × CBA) and subjected to conventional IVF. A polyclonal antibody derived in the rabbit against human peptides from specific regions of MBD4 (Imgenex, San Diego, CA, USA) was used to localize MBD4 protein. This antibody was tested at a variety of concentrations against both human HL60 leukemia cells and bovine embryos. Staining of HL60 cells was optimum at 32–64 μg/mL and embryos at 64 μg/mL. Briefly, the staining protocol consisted of fixing cells and zona-free oocytes or embryos in 4% paraformaldehyde for 15 min, followed by 15 min in 0.1% Triton X-100. Primary antibody incubation was performed overnight at 4°C. Embryos were then washed in blocking buffer for 1 hr prior to incubation at 4°C in mouse anti-rabbit IgG conjugated to FITC in blocking buffer for 30 min in the dark. Lastly, embryos were incubated in 10 μg/L Hoescht 33342 for 15 min, and then washed and mounted with Vectashield (Vector Labs, Burlingame, CA, USA). Negative controls contained no primary antibody. Mounted cells/embryos were viewed by epifluorescence microscopy. MBD4 was found to be expressed in both murine and bovine oocytes and pre-implantation embryos. In the cow, faint nuclear expression was detected at the 2-cell stage, followed by exclusion of the protein from the nucleus until the blastocyst stage of development. At this stage, staining was primarily nuclear and quite intense. In the mouse, staining was cytoplasmic at the 2 pronuclear stage, but was then concentrated in the nucleus from the 2-cell stage onward. It will be interesting to determine if this is due to the different timing of embryonic genome activation between the two species, hence implying a role for MBD4 in this important biological process. Further investigations are underway to compare the subcellular localization of the other MBD proteins in both species during preimplantation development and to identify a role for MBD4 in embryonic genome activation.

235 THE INVESTIGATION OF mRNA EXPRESSION OF SEVERAL CHROMATIN REMODELLING GENES DURING BOVINE PREIMPLANTATION DEVELOPMENT

The efficiency of obtaining live calves from somatic cell nuclear transfer remains quite low. One factor implicated in this failure is inadequate chromatin remodelling of the donor nucleus. Five Polycomb group (PcG) genes were investigated as potential remodelling factors in bovine oocytes and preimplantation embryos. These genes (Cbx6, Eed, Edr1, Yy1, and Zfp144) are involved in transcriptional activation and cell cycle regulation. We hypothesize that inadequate expression may cause the developmental abnormalities seen following cloning. This study is aimed at characterizing normal expression, prior to comparative studies with cloned embryos. Three single abattoir-derived in vitro-matured (IVM) oocytes or in vitro-produced (IVP) embryos from each of the following stages: 2-cell, 4-cell, 8-cell, 16–32 cell, morula, Day 7 blastocyst, and Day 8 hatched blastocyst, were studied. Messenger RNA was isolated from individual samples with Dynabeads (Dynal, Inc., Lake Success, NY, USA) and then cDNA was created and amplified with a SMART cDNA synthesis kit (BD Biosciences Clontech, Palo Alto, CA, USA). Products were diluted 1:10 and used to amplify target genes by PCR. PCR products were sequenced for confirmation of identity. All amplified embryo samples expressed the housekeeping genes Poly(A) polymerase and actin. Similarly, all embryos up to the 8-cell stage expressed GDF9, an oocyte-specific gene, while IFN-tau, involved in maternal recognition of pregnancy, was expressed in one morula and all blastocyst samples. Cbx6 was not expressed at any stage. The other four genes were all expressed fairly consistently throughout the pre-implantation period. Eed transcript was detected in all samples, with the exception of one oocyte, one 4-cell embryo, and one 8-cell embryo. Edr1 transcript was detected in all samples except for two oocytes, one 16–32-cell embryo, and one Day 7 blastocyst. Yy1 was expressed in all but one oocyte, one 2-cell embryo, two 4-cell embryos, and one Day 7 blastocyst. Finally, Zfp144 transcript was detected in one oocyte and in all embryos until the 16–32 stage, and then was not detected until seen in one Day 7 and all Day 8 blastocysts. Cbx6, yet to be fully characterized in any species, is also known as the neuronal pentraxin receptor, and is involved in transport and clearance of synaptic debris. It is known to have the characteristic chromobox domain of the Cbx family, of which several family members play a role during pre-implantation development. Eed, Edr1, Yy1, and Zfp144 are expressed throughout the pre-implantation period, although levels of Zfp144 mRNA appear to drop during the embryonic genome activation and then reappear by the late blastocyst stage. This consistent expression may suggest a role for the proteins in chromatin remodelling or modulating patterns of gene expression in early development. Further studies are required to determine if these factors are expressed incorrectly in cloned embryos, potentially providing a link to the abnormalities observed post nuclear transfer.

Dual-test monitoring of hyperglycemia using daily glucose and weekly fructosamine values

The purpose of this study was to assess the impact of using a dual-test blood glucose/fructosamine home monitoring system to assist individuals identified as having the potential for poor glycemic control to achieve values closer to normal. Forty-eight subjects found to have a fasting blood glucose value of > or = 126 mg/dL, casual blood glucose value of > or = 140 mg/dL, and/or blood fructosamine value of > or = 310 micromol/L, agreed to perform daily self testing for 90 days and were provided a dual-test blood glucose/fructosamine home monitoring system and testing supplies at no charge to them. Medication changes/compliance along with dietary and exercise habits were compared to testing results by the principle investigator at approximate 30-day intervals. The desired goal of this project was to achieve and/or maintain a fasting blood glucose value of < or = 110 mg/dL, a casual blood glucose value of < or = 140 mg/dL and a blood fructosamine value of < or = 310 micromol/L by encouraging each individual to realize the effect of dietary intake and exercise habits, and understand the importance of medication compliance, if appropriate, in achieving better overall glycemic control. Four subjects withdrew from the study prior to completion, 11 of the remaining 44 completed 60 days of testing and 33 of 44 completed 90 days of testing. Regular monitoring and counseling achieved an average reduction in blood glucose of 27.5% and a 16.6% reduction in average blood fructosamine when compared to original screening results of these 44 individuals. This study indicates that the addition of weekly fructosamine values to daily blood glucose values provides both the patient and clinician valuable information to evaluate the impact of dietary, exercise, and medication therapy changes on glycemic control by bridging the existing gap between daily blood glucose values and quarterly HbA1c confirmation of intervention results.

A study of the knowledge that school rugby coaches have in the management and prevention of serious neck injury

The following study is an analysis of the knowledge school rugby coaches responsible for Senior Cup Team in Leinster, have in the area of neck injury prevention and management. When serious neck injuries affect schoolboys it is particularly tragic and deserves special attention. The study targeted all the coaches of Senior Cup Teams in Leinster. Results showed that coaches lack vital knowledge in the area of neck injury prevention, recognition and management. Only 50% (n = 18) of coaches have a first aid qualification and only 47% (n = 17) carry first aid equipment to deal with neck injuries to matches. More than half of the schools in the study sample do not have neck collars available and a staggering 83% (n = 30) of schools do not have a stretcher available to SCT players. The study highlights the need to provide better first aid facilities in schools and demonstrates the need for further education of school rugby coaches.

Dual test diabetes screening project: screening for poor glycemic control in a large workplace population

The objective of this study was to assess the efficacy of a dual test blood glucose/fructosamine home monitoring system to screen individuals in the workplace for poor glycemic control. Screening values qualifying individuals for 90 days of additional monitoring were as follows: fasting blood glucose > or =126 mg/dL, casual blood glucose > or =140 mg/dL, and/or fructosamine <310 micromol/L. Subjects with positive values were provided access to classroom instruction by a Certified Diabetes Educator. The population consisted of 100 males and 177 females, ages 22-71 years, mean 49.7 years, with 12 males and 22 females reporting diabetes. Their ethnic backgrounds were 17.7% African American, 0.4% Asian, 1.8% Hispanic, 0.4% mixed, and 79.8% Caucasian reflecting the general United States population. A total of 26 males and 27 females had results indicating poor glycemic control. Of the known individuals with diabetes, seven of 12 males and 15 of 22 females had positive results. More males than females were unaware of their potential for diabetes but of those previously diagnosed with diabetes more females than males had poor glycemic control. A total of 31 subjects tested positive for blood glucose, 39 tested positive for fructosamine, indicating a 15.1% (p < 0.005) improvement in detection chances with fructosamine. Cost per subject including equipment, supplies, and labor was $18.13. Study results indicate that the addition of a fructosamine test improves screening accuracy for large groups of people while retaining ease of use and affordability.

Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri

PURPOSE

To describe three children with acute fourth cranial nerve palsy secondary to pseudotumor cerebri.

METHODS

We reviewed the medical records of children younger than 18 years who were diagnosed with pseudotumor cerebri between 1977 and 1997. Pseudotumor cerebri was defined by normal neuro-imaging, elevated intracranial pressure measured by lumbar puncture, and normal cerebrospinal fluid composition.

RESULTS

Three children with pseudotumor cerebri presented with vertical diplopia and clinical signs of fourth cranial nerve palsy including a hypertropia of the affected eye, which increased with adduction and ipsilateral head tilt. The fourth cranial nerve palsy resolved after reduction of the intracranial pressure in all three children.

CONCLUSIONS

Fourth cranial nerve palsy may occur in children with pseudotumor cerebri and may be a nonspecific sign of elevated intracranial pressure.

Residential care in hospital and in the community--quality of care and quality of life

BACKGROUND

The reduction of beds in long-stay hospitals has led to concerns over the quality of care offered to the remaining residents as well as that provided in the community. This study seeks to compare the quality of care and quality of life (reported satisfaction) from residents in both types of setting.

METHOD

A cross-sectional comparison was made of community residential homes and hospital wards drawn randomly from lists provided by local authorities in the outer London area. Samples were drawn from all the main provider types (local authority, housing association, private and joint NHS/voluntary sector). Measures were taken of the quality of the physical environment, staff and resident characteristics, external management arrangements and internal management regimes, resident satisfaction and staff stress. Direct observations were also made of the amount and quality of staff-resident interactions.

RESULTS

In general, the most disabled residents were found to be still living in hospital in the Worst conditions and receiving the poorest quality of care. Although there were some problems with missing data, hospital residents also seemed most dissatisfied with their living situation. There were few differences between community providers regarding either the quality of care provided or the levels of reported satisfaction. Quality of care in the community homes seemed to be much more determined by the personality and orientation of project leaders.

CONCLUSIONS

Purchasers and providers still need to give attention to the problems of selectively discharging the most able residents to the community, leaving the most disabled being looked after in progressively deteriorating conditions. All residential providers need to review their internal management practices and try to ensure that residents are offered, as far as possible, the opportunity to make basic choices about where and how they will live. Staff training and quality assurance practices need to be reviewed in order to improve the direct quality of care offered to the most disabled individuals.

Mental health. Refocusing long-term care

How to provide care in the community for clients who are suffering from a long-term mental health problem is a dilemma for mental health service planners and providers. Community psychiatric nurses (CPNs) are the ideally placed profession to provide care for these people according to recent reports and are a part of the multidisciplinary teams. This paper outlines how four CPNs worked in a unidisciplinary team titled the community support teams (CST) in Greenwich, taking secondary referrals exclusively from the psychiatric service and each carrying a small caseload of severely ill clients. The client input of the CST is compared to the generic CPNs' input who provided a standard CPN service to a wide client mix including long-term clients.

Community psychiatric nurse teams: intensive support versus generic care

BACKGROUND

This study evaluated whether a community psychiatric nurse (CPN) team providing a comprehensive aftercare service, using a case management approach, improves psychopathology and social functioning of the long-term mentally ill, and reduces hospital use compared with a generic CPN team.

METHOD

Patients suffering from severe and persistent mental health problems were randomised to intensive aftercare or generic care after referral to the CPN manager. Each group contained 41 patients who were assessed at baseline and at 6, 12 and 18 months by an independent research psychologist. Outcome measures included the GAS, PSE, SAS, patient and relatives' satisfaction, number of admissions, and length of stay.

RESULTS

No difference between the groups was found on any of the outcome measures, despite the much higher number of contacts of the intensive (n = 52) versus generic CPNs (n = 13) and the much greater range of interventions.

CONCLUSIONS

Intensive aftercare for people with persistent mental health problems was not found to be of greater benefit than generic CPN care. Many factors need to be considered for aftercare to be effective, including community resources, process of care, and staff training.

Isoniazid resistant tuberculosis in a school outbreak: the protective effect of BCG

An outbreak of isoniazid resistant tuberculosis occurred in a large second level school. A total of 1,160 teenage pupils were at risk. Nineteen cases of tuberculosis were diagnosed, 15 were students, 9 of whom were among 251 non-vaccinated students and 6 among 909 vaccinated students. Two cases of miliary tuberculosis, one of whom also had tuberculous (TB) meningitis, occurred in the non-vaccinated group. The number of children with Heaf grade +3 or +4 was significantly greater among children who had been given Bacille Calmette-Guérin (BCG) vaccination (8 vs 4.4%). This suggests a boosting effect on the response in vaccinated children. The protective effect of neonatal BCG vaccination in this school outbreak suggests that it provides significant protection against tuberculosis lasting into adolescence.

Isoniazid resistant tuberculosis in a school outbreak: the protective effect of BCG

An outbreak of isoniazid resistant tuberculosis occurred in a large second level school. A total of 1,160 teenage pupils were at risk. Nineteen cases of tuberculosis were diagnosed, 15 were students, 9 of whom were among 251 non-vaccinated students and 6 among 909 vaccinated students. Two cases of miliary tuberculosis, one of whom also had tuberculous (TB) meningitis, occurred in the non-vaccinated group. The number of children with Heaf grade +3 or +4 was significantly greater among children who had been given Bacille Calmette-Guerin (BCG) vaccination (8 vs 4.4%). This suggests a boosting effect on the response in vaccinated children. The protective effect of neonatal BCG vaccination in this school outbreak suggests that it provides significant protection against tuberculosis lasting into adolescence.

Personality as a vulnerability factor to depression

One hundred and forty non-depressed primiparous women in a stable relationship completed two personality measures (the EPI and the IPSM) antenatally, and were then assessed for depression at several times post-natally. The risk of depression at six months was increased up to tenfold by high interpersonal sensitivity and threefold by high neuroticism. When previously depressed women were excluded from analyses, high interpersonal sensitivity and, to a lesser extent, high neuroticism were still associated with an increased risk of being depressed. Interpersonal sensitivity, as measured, is suggested as a refined personality risk factor to both the onset and recurrence of depression.

Improved pulmonary function in chronic quadriplegics after pulmonary therapy and arm ergometry

Quadriplegics suffer from restrictive lung disease due to neural damage, spasticity, and prolonged immobilisation. These studies were undertaken to see whether respiratory therapy can improve expiratory capacity in quadriplegics. Fifteen patients with chronic quadriplegia participated in a programme of pulmonary therapy and resistance exercise for 7 to 12 weeks. Pulmonary therapy consisted of incentive spirometry for 15 minutes a day 3 to 5 days per week. Resistance exercise consisted of pedalling an arm ergometer up to 30 minutes three times a week. Forced vital capacity was measured with the subject in a wheelchair wearing a nose clip. The volume of expired air (max Ve) was as determined with a paramagnetic analyser during arm ergometry. The volume of expired air was divided by the number of breaths, giving the volume of expired air per breath (Ve). The results indicated that a combination of incentive spirometry and arm ergometry improves vital capacity and increased the maximum volume of expired air during exercise. These methods are non-invasive, and such modalities should constitute part of the rehabilitation of patients with neuromuscular disease.

Community- and hospital-acquired pneumonia associated with Chlamydia TWAR infection demonstrated serologically

Serum specimens from 198 patients with pneumonia hospitalized in Seattle between October 1980 and April 1981 were retrospectively tested for antibody against a recently described Chlamydia organism called TWAR. They had been previously tested for antibody for some viruses and Mycoplasma. Twenty (10%) had serologic evidence of recent TWAR infection. The hospital records of the patients with acute TWAR antibody and an equal number of matched controls were examined for clinical characteristics, laboratory tests, treatment, and course during the hospital stay. It was not possible clinically or roentgenographically to distinguish pneumonia associated with TWAR antibody from pneumonia in the controls. Nine of 20 patients with TWAR antibody acquired pneumonia during their hospital stay. The mode of transmission in the hospital was not determined. All the patients with hospital-acquired pneumonia had been intubated, and all had had some surgical procedure. Ten of 20 control patients had onset of their pneumonia in the hospital. Fifteen (11%) of 142 of the patients with pneumonia had evidence of influenza A virus infection. The clinical characteristics of their pneumonias were similar to those of the patients with acute TWAR antibody.

Cost-efficiency of a long-acting cephalosporin agent

In a prospective longitudinal study of patients in a general surgical ward, the relative cost-efficiencies of a long-acting third generation cephalosporin (ceftriaxone--mean plasma elimination t 1/2 390 min) and a short-acting second generation cephalosporin (cephamandole: mean plasma elimination t 1/2 32 min) were determined. The total cost of therapy for 24 h was +32.88 for cephamandole and +22.78 for ceftriaxone, that is, a reduction of 31%. Considerable cost containment can be achieved by using third generation cephalosporin agents that only require the administration of one intravenous injection per day.