Analgesic efficacy, safety, and tolerability of a long-acting abuse-deterrent formulation of oxycodone for moderate-to-severe chronic low back pain in subjects successfully switched from immediate-release oxycodone

OBJECTIVES

This post hoc analysis of data from a randomized, double-blind, placebo-controlled, enriched-enrollment randomized-withdrawal Phase III study evaluated the safety, tolerability, and analgesic efficacy of Oxycodone DETERx extended-release (ER), abuse-deterrent capsules (Xtampza® ER) in subjects with chronic low back pain who were successfully transitioned from immediate-release (IR) oxycodone.

METHODS

Continuous outcomes were analyzed using a mixed-model repeated-measures approach; binomial outcomes were analyzed using chi-squared; and time-to-event outcomes using Kaplan-Meier analyses.

RESULTS

A total of 110 subjects previously prescribed IR oxycodone entered the Open-label Titration Phase. Forty-four subjects were randomized to Oxycodone DETERx (n=22) or placebo (n=22) in the 12-week Double-blind Maintenance Phase. Efficacy results in this subgroup showed a statistically significant difference between Oxycodone DETERx and placebo in average pain intensity scores from Randomization Baseline to Week 12 (least squares mean [± standard error], -1.88 [0.70]; P=0.0078). Additional efficacy results indicated that Oxycodone DETERx vs placebo was associated with a statistically significant benefit in durability of effect from Week 2 through Week 12 (P<0.01), numbers of subjects with a ≥30% (n [%] 10 [45.5%] vs 0 [0%]; P=0.0004) and ≥50% (10 [45.5%] vs 0 [0%]; P=0.0004) improvement in pain intensity, longer time-to-exit (P=0.0014), a greater number of subjects who completed the study (14 [63.6%] vs 4 [18.2%]), and less rescue medication use (acetaminophen; mean [SD], 163.5 [337.8] mg) vs 216.2 [377.3] mg). Adverse event profiles were consistent with opioid class effects and results from the original study; Oxycodone DETERx was well tolerated in subjects previously treated with short-acting oxycodone.

CONCLUSIONS

Oxycodone DETERx resulted in clinically meaningful and statistically significant efficacy in subjects with chronic low back pain who were previously prescribed IR oxycodone and were successfully switched to ER Oxycodone DETERx.

Induced Lactation in Nonpregnant Cows: Profitability and Response to Bovine Somatotropin

Significant culling of high-producing cows with low fertility reduces profitability of dairy farms as those cows are replaced with heifers. Induced lactation of nonpregnant cows may be a management alternative to reduce culling and increase profits. The objectives of this study were to evaluate the efficacy of bovine somatotropin (bST) to increase milk production in cows induced into lactation with estrogen plus progesterone, and to determine the profitability of inducing cows into lactation vs. using replacement heifers entering the herd as first-lactation cows. Parity 1 or greater, nonpregnant, healthy Holstein cows (n = 28) were induced into lactation by administration of estradiol-17beta (0.075 mg/kg of body weight [BW] per d) and progesterone (0.25 mg/kg of BW per d) for 7 d. Milking began on d 18. Cows were randomly assigned to control or bST treatment groups on d 37 +/- 20 of milking, and milk production was compared for 70 d. After the 70-d comparison, all cows received bST for the duration of lactation. Cows receiving bST produced more milk (28.4 kg/d) than controls (24.1 kg/d), with variable yields among cows. For the economic analysis, induced cows were compared to first-lactation cows in the same herd using fair market value for costs and multiple component pricing for milk. Net present value for an induced cow (1966 dollars) was significantly greater than that for a first-lactation cow (1446 dollars). Our data suggest that bST use in induced cows is profitable. If a reliable method were developed and approved by the FDA, inducing nonpregnant cows into lactation could be used by dairy producers to increase profitability.

Extreme serum elevations of aspartate aminotransferase

OBJECTIVE

To determine the frequency, etiology, and associated mortality of extreme elevations of serum AST.

METHODS

The medical records were reviewed of all patients with a serum AST over 3000 U/L during 1 full calendar year at a large, tertiary-care hospital. Serum AST, with an upper limit of normal at 35 U/L, is included in the automated, 18-test chemistry profile run on virtually all clinically ill patients admitted to this hospital.

RESULTS

Of 23,125 admissions, 56 patients had or developed serum AST concentrations greater than 3000 U/L, an occurrence rate of approximately two per 1000 admissions. Either liver or skeletal muscle was the origin of virtually all such AST elevations. Acute hypotension (ischemic or hypoxic hepatitis) accounted for the majority (29/56) of the cases; toxic (seven) or viral (four) hepatitis together accounted for 11/56 cases. Overall mortality, on this admission, was 31/56 (55%).

CONCLUSIONS

Extreme elevations of AST are most often attributable to hypoxic hepatitis. Patients with extreme AST due to hypoxic hepatitis had a 22/29 (75%) mortality compared with 9/27 (33%) for all other causes combined.

Occurrence, etiology, and clinical significance of extreme thrombocytosis: a study of 280 cases

PURPOSE

To determine the etiology and to evaluate the clinical consequences of an extremely elevated platelet count.

PATIENTS AND METHODS

A review of the medical records was performed on all patients encountered during a 5 1/2-year period who had at least one platelet count of 1,000 x 10(9)/L or greater.

RESULTS

Of the total of 280 patients with extreme thrombocytosis (EXT), 231 (82%) had reactive thrombocytosis (RT), 38 (14%) had a myeloproliferative disorder (MPD), and 11 (4%) had cases of uncertain etiology. RT was more common than MPD in all age groups except those in the eighth decade and older. Symptoms of bleeding and/or vaso-occlusive phenomena were noted in association with EXT in 21 (56%) of the MPD patients but in only 10 (4%) of the RT patients. Treatment to lower the platelet count and/or inhibit platelet function was employed in 36 MPD patients and 23 RT patients. Eight patients with MPD and 34 with RT are known to have died, but no patient in either group is known to have died of a thrombotic or bleeding event when the platelet count was greater than or equal to 1,000 x 10(9)/L.

CONCLUSIONS

Platelet counts greater than or equal to 1,000 x 10(9)/L should not be considered rare events in the general, acute-care hospital population, and usually represent a reactive phenomenon.

Immunoglobulin D benign monoclonal gammopathy. A case report

The authors report a case, perhaps the first, of immunoglobulin D (IgD) benign monoclonal gammopathy. The patient, a 48-year-old black woman, initially had a 500 mg/dl IgD-lambda M-spike, hypercalcemia, and anemia. There was no bone pain, lytic bone lesions, or evidence of renal failure. The bone marrow showed 2.8% plasma cells with a diffuse (not nodular) IgD plasmacytosis and strong lambda predominance. Only trace amounts of free lambda light chains could be demonstrated by immunoelectrophoresis in serum and concentrated urine. The anemia responded quickly to iron therapy. Chemotherapy was not initiated. Over the 6+ years of follow-up, the patient has had no progression of clinical disease attributable to her IgD monoclonal gammopathy. The IgD M-spike has steadily decreased.

Bone marrow and peripheral blood findings in patients with extreme thrombocytosis. A report of 63 cases

Sixty-three bone marrow (BM) and peripheral blood specimens from patients with platelet counts of 1000 x 10(9)/L or greater were examined in an attempt to determine if any BM or peripheral blood findings could be used reliably to distinguish primary thrombocythemia from other myeloproliferative disorders and extreme examples of reactive thrombocytosis. Our results indicated that the BM findings in primary thrombocythemia were quite similar to those in polycythemia vera and chronic granulocytic leukemia with associated extreme thrombocytosis. However, statistically significant differences between the BM findings in myeloproliferative disorders and extreme reactive thrombocytosis were found in the numbers of megakaryocytes, presence or absence of megakaryocyte clusters, stainable iron, cellularity, and reticulin content. We concluded that BM examination is a useful procedure as an aid in determining the cause of extreme thrombocytosis.

Albuminuria vs urinary total protein for detecting chronic renal disorders

A literature review and our own data are presented to demonstrate that urinary albumin (UA) excretion increases in many renal disorders and that it offers a far more sensitive indicator than the commonly used urinary total protein (UTP) for the early detection of renal involvement in many chronic diseases such as diabetes mellitus, hypertension, and systemic lupus erythematosus. In many individuals with these disorders, UA increases severalfold, even while UTP remains within the reference interval. UA is also more suited than UTP for following therapeutic responses in these slowly progressive renal disorders. Increases in UA are associated with increased mortality. UTP measurements are plagued with many analytical problems, whereas UA is much easier to standardize. We recommend that both UA and UTP be measured when quantitative urine protein assays are ordered, especially when the UTP is less than 300 mg/g of creatinine.

Albuminuria vs urinary total protein for detecting chronic renal disorders

A literature review and our own data are presented to demonstrate that urinary albumin (UA) excretion increases in many renal disorders and that it offers a far more sensitive indicator than the commonly used urinary total protein (UTP) for the early detection of renal involvement in many chronic diseases such as diabetes mellitus, hypertension, and systemic lupus erythematosus. In many individuals with these disorders, UA increases severalfold, even while UTP remains within the reference interval. UA is also more suited than UTP for following therapeutic responses in these slowly progressive renal disorders. Increases in UA are associated with increased mortality. UTP measurements are plagued with many analytical problems, whereas UA is much easier to standardize. We recommend that both UA and UTP be measured when quantitative urine protein assays are ordered, especially when the UTP is less than 300 mg/g of creatinine.

Altered regulation of platelet-derived growth factor A-chain and c-fos gene expression in senescent progeria fibroblasts

The study of human genetic disorders known as premature aging syndromes may provide insight into the mechanisms of cellular senescence. These diseases are clinically characterized by the premature onset and accelerated progression of numerous features normally associated with human aging. Previous studies have indicated that fibroblasts derived from premature aging syndrome patients have in vitro growth properties similar to senescent fibroblasts from normal individuals. As an initial approach to determine whether gene expression is altered in premature aging syndrome fibroblasts, RNA was prepared from various cell strains and used for gel blot hybridization experiments. Although normal fibroblasts only express platelet-derived growth factor (PDGF) A-chain mRNA for a brief period following mitogenic stimulation, one strain of Hutchinson-Gilford (progeria) syndrome fibroblasts, AG3513, constitutively expresses PDGF A-chain mRNA and PDGF-AA homodimers. The PDGF A-chain gene does not appear to be amplified or rearranged in these fibroblasts. AG3513 progeria fibroblasts have properties characteristic of senescent cells, including an altered morphology and a diminished mitogenic response to growth promoters. The diminished response of AG3513 progeria fibroblasts to PDGF stimulation was examined in some detail. Studies using 125I-PDGF-BB, which binds with high affinity to both A- and B-type PDGF receptors, indicate that normal and AG3513 progeria fibroblasts have a similar number of PDGF receptors. Although receptor autophosphorylation occurs normally in PDGF-stimulated AG3513 progeria fibroblasts, c-fos mRNA induction does not. The senescent phenotype of AG3513 fibroblasts is probably unrelated to their constitutive PDGF A-chain gene expression; further studies are necessary in order to directly address this issue. Also, additional analysis of this progeria fibroblast strain may provide information on the control of mitogen-inducible gene expression in normal cells.

The diagnosis of microcytic anemia by a rule-based expert system using VP-Expert

We describe our experience in creating a rule-based expert system for the interpretation of microcytic anemia using the expert system development tool, VP-Expert, running on an IBM personal computer. VP-Expert processes data (complete blood cell count results, age, and sex) according to a set of user-written logic rules (our program) to reach conclusions as to the following causes of microcytic anemia: alpha- and beta-thalassemia trait, iron deficiency, and anemia of chronic disease. Our expert system was tested using previously interpreted complete blood cell count data. In most instances, there was good agreement between the expert system and its pathologist-author, but many discrepancies were found in the interpretation of anemia of chronic disease. We conclude that VP-Expert has a useful level of power and flexibility, yet is simple enough that individuals with modest programming experience can create their own expert systems. Limitations of such expert systems are discussed.

Antibody-nucleic acid interactions. Antibodies to psoralen-modified RNA as probes of RNA structure

Antisera elicited by immunization of rabbits with 4'-aminomethyl-trioxsalen (AMT)-modified poly(A,U) complexed with methylated bovine serum albumin was characterized in competition radioimmunoassays (RIA) and enzyme-linked immunosorbent assays (ELISA). AMT-poly(A,U) was over 10,000-fold more reactive than unmodified poly(A,U) or AMT alone. The antiserum cross-reacted to varying extents with AMT-modified-RNA's and -DNA's. The presence of AMT-uridine usually assured strong reactivity. The amino group of AMT contributed to antibody binding to a small degree. Binding was not significantly affected by high ionic strength, suggesting that binding does not involve ion pair formation. Murine encephalomyocarditis virus replicative intermediates, as well as cellular RNA and DNA were modified by psoralen in intact cells, suggesting that EMCV RNA and cellular RNA's in intact cells possess detectable stretches of base pairs. The antibodies described here will be useful in studying the secondary and tertiary structure of RNA's in vitro and in intact cells.

Red blood cell antibody identification and confirmation using commercial panels. A computer program for the IBM personal computer

A menu-driven computer program that utilizes a data base of commercial panels was developed to assist in the identification and confirmation of red blood cell antibodies. A selected panel, along with the corresponding serum reactions, is displayed on the monitor and possible antibody patterns including dosage-dependent patterns are highlighted. A panel interpretation is then printed that includes a list of the possible (nonexcluded) antibodies, a probability level of identification for each possible antibody, and a table of antibody characteristics to aid in the differentiation among the possible antibodies. The panel data base can also be searched for additional red blood cells of specified phenotypes to confirm each suspected antibody. These additional red blood cells may be combined into a temporary panel for computer analysis. The program can also enter, print, edit, and delete any commercial panel from the data base. This computer program has proved to be faster and more accurate than the standard manual method for panel analysis, especially when multiple antibodies are present.

Rapid identification of Clostridium species by high-pressure liquid chromatography

High-pressure liquid chromatography was evaluated as a rapid means of identifying various species of clostridia. Isolates were inoculated into a defined medium and incubated aerobically for 1 h at 35 degrees C. The organisms were removed, and the supernatants were derivatized for 1 min at room temperature by the addition of o-phthalaldehyde. The total time required to run each chromatogram was approximately 50 min. Standardized peak heights for each medium component and any new peaks formed were calculated for each isolate and compared with those for uninoculated control medium. Multiple isolates of various Clostridium species gave consistent patterns of medium utilization that could be used for identification. This rapid method can easily be adapted for laboratory use and has the potential for automation.

A comparison of antibiotic susceptibility profiles using single and multiple isolates per patient

We compared the antibiogram statistics generated by including all clinical isolates to those obtained by tabulating no more than one isolate of a particular organism from a given patient. We found that 48.3% of the isolates presented multiple occurrences in individual patients but found no practical differences in the profiles obtained by the two methods. We also tabulated the occurrence of minimum inhibitory concentration (MIC)-distinct organisms among the sets of multiple isolates of E. coli and of S. aureus and found that only 20.9% of those isolates represented duplicate organisms by MIC profile. This heterogeneity of MIC sensitivity that occurs in multiple isolates from individual patients was not expected but provides an explanation for the lack of difference between the two methods of tabulating antibiotic susceptibility statistics.

Effect of adrenocorticotropic hormone and associated hormonal responses on semen quality and sperm output of bulls

The objective was to determine if semen quality and output could be affected by pharmacological doses of adrenocorticotropin. Three Holstein bulls, one 7 yr old and two yearlings, were treated with 200 IU adrenocorticotropic hormone every 8 h for 6 days. Effects of treatment on semen traits and peripheral concentrations of glucocorticoids, testosterone, and androstenedione were measured. Viability of spermatozoa (percentage motility and percentage intact acrosomes), ejaculate volume, sperm concentration, and weekly sperm output were unaffected by adrenocorticotropin treatment up to 8 wk posttreatment. The proportion of spermatozoa with cytoplasmic droplets and head abnormalities was elevated slightly from .8 +/- .1 and 4.2 +/- .3% to 1.3 +/- .2 and 5.8 +/- .4% during treatment. Total glucocorticoids increased from 11.9 +/- 2.7 ng/ml before treatment to 73.5 +/- 4.1 ng/ml during treatment. Testosterone decreased in the yearling bulls from 5.5 +/- .9 ng/ml plasma before treatment to .5 +/- .5 ng/ml afterward; the decrease began 8 h following the initial adrenocorticotropin injection and persisted until 24 h following last injection. The mature bull had normal testosterone concentrations for the first 4 days of injection, and decreased concentrations for the last 2 days of injection. Semen viability, concentration, and sperm output are unaffected by a pharmocological administration of adrenocorticotropin and subsequent marked increase of glucocorticoids and decrease of testosterone. Only a small increase of semen content of immature sperm or sperm with abnormal heads may be associated with these marked endocrine changes.

Radiographic evaluation of bovine artificial inseminating technique among professional and herdsman-inseminators using .5- and .25-ml French straws

Using radiography, inseminating syringe tip location and inseminate distribution in excised bovine reproductive tracts were described for 20 professional and 20 herdsman-inseminators using .5- and .25-ml French straws. Inseminations (20 by each participant) were performed in tracts placed on a device that stimulated the anatomical position of the reproductive organs in vivo. A computer-coupled graphics information digitizer was used to quantitate the precise location of the syringe tip and to estimate the distribution of radiopaque inseminate within the tract from each pair of radiographs. Neither category of inseminator (professional or herdsman) nor volume of inseminate (.5 vs .25 ml) influenced (P greater than .05) syringe tip placement or subsequent distribution of the radiopaque inseminate within the tract. The proportion of syringe tip placements in various anatomical locations (586 attempts) were: uterine body, 39%; cervix, 25%; left uterine lumen, 13% and right uterine lumen, 23%. The variability among inseminators was high, with the ability to position the syringe tip in the uterine body ranging from 0 to 85% of the 20 attempts. Among all inseminators, 82% were unable to place the syringe in the uterine body greater than 60% of the time. When averaged across all inseminations (n = 666), 40% of the inseminate was located in the uterine body and(or) equally distributed in the uterine lumina. The remainder of the inseminate was located in the cervix (17%) or disproportionately in one uterine lumen (43%). Syringe tip placement in the uterine body was correlated (r = .73; P less than .05) with the proportion of inseminate located in the uterine body and(or) equally distributed to the lumen of both uterine horns. Measurements of various anatomical components of the reproductive tract were made from the first radiograph. The means were: cervical diameter, 5.9 cm; length from internal cervical os to external uterine bifurcation, 16.4 cm; uterine body length, 1.7 cm and uterine body surface area, 3.6 cm2. There was no relationship between the palpable anatomical components and uterine body size.

Extension of the model concerning linkage of genes coding for C-1 related functions in Methylobacterium organophilum

Evidence is presented which suggests that Methylobacterium organophilum contains isoenzymes of phosphoenolpyruvate carboxylase activity. Methanol-grown cells contained an acetyl coenzyme A (CoA)-insensitive activity which precipitated in a 65 to 75% of saturation ammonium sulfate fraction. Succinate-grown cells contained an acetyl-CoA-stimulated activity which precipitated in a 55 to 65% of saturation ammonium sulfate fraction. Mutants unable to grow on methanol appeared to lack acetyl-CoA-insensitive activity. This acetyl-CoA-insensitive phosphoenolpyruvate carboxylase, along with malyl-CoA lyase, is proposed to be encoded by the C-1 operon. The gene for formate dehydrogenase appeared to reside outside the operon and was not inducible by methanol. M. organophilum was unable to grow on formate, and evidence is presented suggesting that formate is unable to induce the enzymes which comprise the serine pathway for formaldehyde fixation. An expanded model for the C-1 operon is presented.

Detection of HBsAg in coagulation Factor IX concentrates

HBsAg was detected in two commercial clotting factor concentrates: Proplex (Hyland) and Konyne (Cutter). HBsAg was positive by RIA in samples of Proplex but not Konyne. Immune-electron microscopy, however, demonstrated clumped small spheres of HBsAg in both preparations, and lamellar-type strands were seen in several preparations.

Hepatitis-B: a review

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.

Serine transhydroxymethylase isoenzymes from a facultative methylotroph

Two serine transhydroxymethylase activities have been purified from a facultative methylotrophic bacterium. One enzyme predominates when the organism is grown on methane or methanol as the sole carbon and energy source, whereas the second enzyme is the major isoenzyme found when succinate is used as the sole carbon and energy source. The enzyme from methanol-grown cells is activated by glyoxylate, is not stimulated by Mg2+, Mn2+, or Zn2+, and has four subunits of 50,000 molecular weight each. The enzyme from succinate-grown cells is not activated by glyoxylate and is stimulated by Mg2+, Mn2+, and Zn2+, and sodium dodecyl sulfate-acrylamide gel electrophoresis indicates that this enzyme has subunit molecular weight of 100,000, the same as the molecular weight obtained for the active enzyme. Cells grown in the presence of both methanol and succinate incorporate less methanol carbon per unit time than cells grown on methanol and have a lower specific activity of the glyoxylate-activated enzyme than methanol-grown cells. Adenine, glyoxylate, or trimethoprim in the growth medium causes an increased level of serine transhydroxymethylase in both methanol- and succinate-grown cells by stimulating the synthesis of the glyoxylate-activated enzyme.