Dissolution Profile Similarity Assessment-Best Practices, Decision Trees and Global Harmonization

During the write-up of the meeting summary reports from the 2019 dissolution similarity workshop held at the University of Maryland's Center of Excellence in Regulatory Science and Innovation (M-CERSI), several coauthors continued their discussions to develop a "best-practice" document defining the steps required to assess dissolution profiles in support of certain biowaivers and postapproval changes. In previous reports, current challenges related to dissolution profile studies were discussed such that the steps outlined in the two flow charts ("decision trees") presented here can be applied. These decision trees include both recommendations for the use of equivalence procedures between reference and test products as well as application of the dissolution safe space concept. Common approaches towards establishing dissolution safe spaces are described. This paper encourages the preparation of protocols clearly describing why and how testing is performed along with the expected pass/fail criteria prior to generating data on the materials to be evaluated. The target audience of this manuscript includes CMC regulatory scientists, laboratory analysts, as well as statisticians from industry and regulatory health agencies involved in the assessment of product quality via in vitro dissolution testing. Building upon previous publications, this manuscript provides a solution to the current ambiguity related to dissolution profile comparison. The principles outlined in this and previous manuscripts provide a basis for global regulatory alignment in the application of dissolution profile assessment to support manufacturing changes and biowaiver requests.

Through the back door: Unconventional protein secretion

Proteins are secreted from eukaryotic cells by several mechanisms besides the well-characterized classical secretory system. Proteins destined to enter the classical secretory system contain a signal peptide for translocation into the endoplasmic reticulum. However, many proteins lacking a signal peptide are secreted nonetheless. Contrary to conventional belief, these proteins are not just released as a result of membrane damage leading to cell leakage, but are actively packaged for secretion in alternative pathways. They are called unconventionally secreted proteins, and the best-characterized are from fungi and mammals. These proteins have extracellular functions including cell signaling, immune modulation, as well as moonlighting activities different from their well-described intracellular functions. Among the pathways for unconventional secretion are direct transfer across the plasma membrane, release within plasma membrane-derived microvesicles, use of elements of autophagy, or secretion from endosomal/multivesicular body-related components. We review the fungal and metazoan unconventional secretory pathways and their regulation, and propose experimental criteria to identify their mode of secretion.

Chemical gradients in human enamel crystallites

Dental enamel is a principal component of teeth1, and has evolved to bear large chewing forces, resist mechanical fatigue and withstand wear over decades2. Functional impairment and loss of dental enamel, caused by developmental defects or tooth decay (caries), affect health and quality of life, with associated costs to society3. Although the past decade has seen progress in our understanding of enamel formation (amelogenesis) and the functional properties of mature enamel, attempts to repair lesions in this material or to synthesize it in vitro have had limited success4-6. This is partly due to the highly hierarchical structure of enamel and additional complexities arising from chemical gradients7-9. Here we show, using atomic-scale quantitative imaging and correlative spectroscopies, that the nanoscale crystallites of hydroxylapatite (Ca5(PO4)3(OH)), which are the fundamental building blocks of enamel, comprise two nanometric layers enriched in magnesium flanking a core rich in sodium, fluoride and carbonate ions; this sandwich core is surrounded by a shell with lower concentration of substitutional defects. A mechanical model based on density functional theory calculations and X-ray diffraction data predicts that residual stresses arise because of the chemical gradients, in agreement with preferential dissolution of the crystallite core in acidic media. Furthermore, stresses may affect the mechanical resilience of enamel. The two additional layers of hierarchy suggest a possible new model for biological control over crystal growth during amelogenesis, and hint at implications for the preservation of biomarkers during tooth development.

Procalcitonin in hemodialysis patients presenting with fever or chills to the emergency department

We sought to assess the role of procalcitonin in discriminating severe bacterial infections requiring antibiotic treatment from non-bacterial causes of fever or chills in chronic dialysis patients. Chronic hemodialysis patients who were admitted to the emergency room due to fever and/or chills were recruited to the study. The presence or absence of bacterial infection was defined after recruitment conclusion by an infectious disease specialist who was blinded to procalcitonin results. Procalcitonin levels were compared between infected and non-infected patients. Out of 54 patients recruited, 22 (41%) patients eventually diagnosed with infection. Mean (± SD) procalcitonin values were 4.3 (± 5.5) ng/ml among cases, 1.0 (± 2.0) ng/ml among controls with no infection (p = 0.02). A cutoff PCT value of 1 ng/ml or higher had 77% sensitivity and 59% specificity for the diagnosis of severe infection. Procalcitonin cannot usefully identify hemodialysis patient with bacterial infection.

Limitations of Multicultural Supervision in Clinical Neuropsychology

Method

The authors reviewed the literature regarding general aspects of multicultural supervision in clinical psychology, supervision in clinical neuropsychology, and additionally highlighted the gaps related to supervision in multicultural neuropsychology. Finally, they introduced ideas to address some of the needs in the arena of supervision in multicultural neuropsychology.

Discussion

Available resources that explore, delineate, or evaluate competent multicultural supervision in clinical neuropsychology are absent. Partially, the limited understanding of - and research that focuses on - the influence of diversity in neuropsychological assessment and interventions might explain the lack of resources allotted to competent multicultural supervision in clinical neuropsychology. It is proposed that in clinical, neuropsychology supervisory process (as in therapy supervision) should include a culturally competent supervisor who can assist in the development of self-awareness, knowledge, and skills in order to provide interventions that understand, honor, and respect the clients’ multiple diversity dimensions.

Diagnosing Social Communication Disorder (SCD) in Multicultural Individuals: A Case Study

Objective

Explore the impact of culture, developmental stage, and cognitive functioning in a possible diagnosis of SCD.

Case Description

A 12-year-old South Asian, bilingual/bicultural adolescent male (X) presented with concerns regarding his executive and social functioning skills. His medical history was notable for craniosynostosis - successfully treated with craniofacial surgery at age 1 - and a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation.

Diagnostic Impressions and Outcomes

X demonstrated superior intellectual performance with some inefficiencies in cognitive processing. Challenges with social interaction were not observed over the course of testing but his mother reported difficulties understanding pragmatic aspects of communication (sexual innuendos in double entendres) and recognizing when conversation had moved to a different topic. He kept a small social circle and preferred the company of older children.

Discussion

In conceptualizing X’s difficulties with social pragmatics, we must keep in mind the socio-cultural context in which he is growing up. He is the son of immigrant parents with South Asian roots. He is at an adolescent developmental stage where he is beginning to explore his individual identity while navigating the differing mores between his South Asian home culture and his American host culture. Therefore, responding to sexual innuendos may be a decision that is fraught with cultural angst over what is appropriate in one context but not the other. His gifted abilities and ADHD may make it difficult for him to remain engaged in the classroom or with similar-aged peers who don’t challenge his intellectual proclivities. His ADHD may also explain his difficulty in recognizing when the topic of conversation has changed. In deciding whether to assign a diagnosis of SCD, it is important to remember these cultural and developmental factors which could explain his difficulties in a normalizing way. These factors should also inform potential therapeutic recommendations.

A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial

OBJECTIVES

Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate.

METHODS

From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865.

RESULTS

In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days.

CONCLUSIONS

We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.

A virtual learning collaborative to implement health promotion in routine mental health settings: Protocol for a cluster randomized trial

BACKGROUND

Despite widespread use of learning collaboratives in health care, few randomized trials have evaluated their effectiveness. The primary aim of this cluster randomized implementation trial is to evaluate the effectiveness of a virtual learning collaborative (VLC) in the implementation of a lifestyle intervention for persons with serious mental illness (SMI) in routine mental health settings, compared to standard individual technical assistance.

METHODS

Forty-eight mental health provider organizations from across the United States will be recruited to participate in the trial. The evidence-based practice to be implemented is the InSHAPE health promotion intervention for persons with SMI. Sites will be stratified by size and randomized to receive an 18-month intensive group-based VLC with monthly learning sessions or individual technical assistance with four scheduled conference calls over 18 months. Sites will be enrolled in three blocks of 16 sites each. The primary outcomes are InSHAPE program participation and fidelity, and participant weight loss; secondary outcomes are program operation, program uptake, participant health behaviors of physical activity and nutrition, organizational change, and program sustainment. Implementation outcomes are measured at 3, 6, 12, 18, and 24 months after the program start-up. Participant-level outcomes are measured at fixed intervals every 3 months after each participant enrolls in the study.

DISCUSSION

This study will determine whether VLCs are an effective implementation strategy among resource-limited providers when the new practice necessitates a shift in mission, scope of practice, type of services delivered, and new financing.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03891368 Registered 25 March 2019, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT03891368?term=NCT03891368&rank=1.

First-Principles and Empirical Approaches to Predicting In Vitro Dissolution for Pharmaceutical Formulation and Process Development and for Product Release Testing

This manuscript represents the perspective of the Dissolution Working Group of the International Consortium for Innovation and Quality in Pharmaceutical Development (IQ) and of two focus groups of the American Association of Pharmaceutical Scientists (AAPS): Process Analytical Technology (PAT) and In Vitro Release and Dissolution Testing (IVRDT). The intent of this manuscript is to show recent progress in the field of in vitro predictive dissolution modeling and to provide recommended general approaches to developing in vitro predictive dissolution models for both early- and late-stage formulation/process development and batch release. Different modeling approaches should be used at different stages of drug development based on product and process understanding available at those stages. Two industry case studies of current approaches used for modeling tablet dissolution are presented. These include examples of predictive model use for product development within the space explored during formulation and process optimization, as well as of dissolution models as surrogate tests in a regulatory filing. A review of an industry example of developing a dissolution model for real-time release testing (RTRt) and of academic case studies of enabling dissolution RTRt by near-infrared spectroscopy (NIRS) is also provided. These demonstrate multiple approaches for developing data-rich empirical models in the context of science- and risk-based process development to predict in vitro dissolution. Recommendations of modeling best practices are made, focused primarily on immediate-release (IR) oral delivery products for new drug applications. A general roadmap is presented for implementation of dissolution modeling for enhanced product understanding, robust control strategy, batch release testing, and flexibility toward post-approval changes.

Implementation of a Lifestyle Intervention for People With Serious Mental Illness in State-Funded Mental Health Centers

OBJECTIVE

The purpose of this study was to evaluate health outcomes of a state-supported implementation in community mental health settings of an evidence-based lifestyle intervention for overweight and obese adults with serious mental illness.

METHODS

Weight and fitness outcomes were evaluated for 122 overweight or obese adults with serious mental illness in four community mental health centers (CMHCs) that were participating in a phased statewide implementation of the In SHAPE lifestyle intervention. Six- and 12-month outcomes were compared between two CMHCs that implemented In SHAPE in the first 12 months and two CMHCs with similar characteristics that implemented In SHAPE in a subsequent phase in the statewide implementation 12 months later.

RESULTS

Participants in the two In SHAPE sites (N=63 participants) lost significantly more weight (p=.003) and showed greater improvement in fitness (p=.011) compared with participants at the two usual care control sites (N=59 participants). At six months, nearly half (49%) of In SHAPE participants and at 12 months more than half (60%) of In SHAPE participants showed clinically significant cardiovascular risk reduction defined as ≥5% weight loss or improved fitness (>50 m [164 feet] increase on the six-minute walk test). The difference between the In SHAPE and control groups was not statistically significant.

CONCLUSIONS

This natural experiment demonstrated promising public health benefits of a practical implementation of health promotion programming for overweight and obese adults with serious mental illness and offers a potential model for reducing risk of early mortality among individuals served by state-funded mental health centers nationwide.

Clinically applicable irreversible electroporation for eradication of micro-organisms

Irreversible electroporation (IRE) damages cell membranes and is used in medicine for nonthermal ablation of malignant tumours. Our aim was to evaluate the antimicrobial effect of IRE. The pathogenic micro-organisms, Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa and Candida albicans were subjected to IRE. Survival was measured as a function of voltage and the number of pulses applied. Combined use of IRE and oxacillin for eradication of Staph. aureus was also tested. Log10 reduction in micro-organisms positively correlated with the number of applied pulses. The colony count of Strep. pyogenes and E. coli declined by 3·38 and 3·05 orders of magnitude, respectively, using an electric field of 2000 V and 100 pulses. Killing of Staph. aureus and P. aeruginosa was achieved with a double cycle of IRE (2000, 1500 V and repeated 1250 V respectively) of 50-100 IRE pulses. The addition of subclinical inhibitory concentrations of oxacillin to the Staph. aureus suspension prior to IRE led to total bacterial death, demonstrating synergism between oxacillin and IRE. Our results demonstrate that using IRE with clinically established parameters has a marked in vitro effect on pathogenic micro-organisms and highlights the potential of IRE as a treatment modality for deep-seated infections, particularly when combined with low doses of antibiotics.

SIGNIFICANCE AND IMPACT OF THE STUDY

Irreversible electroporation (IRE) is utilized in interventional radiology to treat cancer patients. In this study we evaluated in vitro the antimicrobial effect of IRE. We demonstrated that using IRE with clinically established parameters has a marked effect on pathogenic micro-organisms and is synergistic to antimicrobials when both are combined. Our results point to the potential of IRE as a treatment modality for deep-seated infections.

Industry's View on Using Quality Control, Biorelevant, and Clinically Relevant Dissolution Tests for Pharmaceutical Development, Registration, and Commercialization

This article intends to summarize the current views of the IQ Consortium Dissolution Working Group, which comprises various industry companies, on the roles of dissolution testing throughout pharmaceutical product development, registration, commercialization, and beyond. Over the past 3 decades, dissolution testing has evolved from a routine and straightforward test as a component of end-product release into a comprehensive set of tools that the developer can deploy at various stages of the product life cycle. The definitions of commonly used dissolution approaches, how they relate to one another and how they may be applied in modern drug development, and life cycle management is described in this article. Specifically, this article discusses the purpose, advantages, and limitations of quality control, biorelevant, and clinically relevant dissolution methods.

Activation Peaking during the Acquisition of a Motor Task under High and Low Contextual-Interference Conditions

The purpose of this study was to assess the effect of high and low contextual-interference conditions on physiologic activation levels during the acquisition of a simple positioning task. 29 subjects, over 192 acquisition trials, learned to move to four positions in either a random (high interference) or blocked (low interference) sequence. Data on movement information, heart rate, and skin conductance were collected and analyzed. The movement data showed typical effects of contextual interference for acquisition that conformed to previously published findings. Heart rate was sensitive to the demands of movement extent. The high contextual-interference condition showed slower acquisition rates and higher activation levels as measured by skin conductance. It was concluded that changes in activation levels during practice may contribute or provide a sensitive index of contextual interference.

The adaptor protein DCAF7 mediates the interaction of the adenovirus E1A oncoprotein with the protein kinases DYRK1A and HIPK2

DYRK1A is a constitutively active protein kinase that has a critical role in growth and development which functions by regulating cell proliferation, differentiation and survival. DCAF7 (also termed WDR68 or HAN11) is a cellular binding partner of DYRK1A and also regulates signalling by the protein kinase HIPK2. DCAF7 is an evolutionarily conserved protein with a single WD40 repeat domain and has no catalytic activity. We have defined a DCAF7 binding motif of 12 amino acids in the N-terminal domain of class 1 DYRKs that is functionally conserved in DYRK1 orthologs from Xenopus, Danio rerio and the slime mold Dictyostelium discoideum. A similar sequence was essential for DCAF7 binding to HIPK2, whereas the closely related HIPK1 family member did not bind DCAF7. Immunoprecipitation and pulldown experiments identified DCAF7 as an adaptor for the association of the adenovirus E1A protein with DYRK1A and HIPK2. Furthermore, DCAF7 was required for the hyperphosphorylation of E1A in DYRK1A or HIPK2 overexpressing cells. Our results characterize DCAF7 as a substrate recruiting subunit of DYRK1A and HIPK2 and suggest that it is required for the negative effect of DYRK1A on E1A-induced oncogenic transformation.

Functional and Structural Mimicry of Cellular Protein Kinase A Anchoring Proteins by a Viral Oncoprotein

The oncoproteins of the small DNA tumor viruses interact with a plethora of cellular regulators to commandeer control of the infected cell. During infection, adenovirus E1A deregulates cAMP signalling and repurposes it for activation of viral gene expression. We show that E1A structurally and functionally mimics a cellular A-kinase anchoring protein (AKAP). E1A interacts with and relocalizes protein kinase A (PKA) to the nucleus, likely to virus replication centres, via an interaction with the regulatory subunits of PKA. Binding to PKA requires the N-terminus of E1A, which bears striking similarity to the amphipathic α-helical domain present in cellular AKAPs. E1A also targets the same docking-dimerization domain of PKA normally bound by cellular AKAPs. In addition, the AKAP like motif within E1A could restore PKA interaction to a cellular AKAP in which its normal interaction motif was deleted. During infection, E1A successfully competes with endogenous cellular AKAPs for PKA interaction. E1A's role as a viral AKAP contributes to viral transcription, protein expression and progeny production. These data establish HAdV E1A as the first known viral AKAP. This represents a unique example of viral subversion of a crucial cellular regulatory pathway via structural mimicry of the PKA interaction domain of cellular AKAPs.

Functional analysis of the C-terminal region of human adenovirus E1A reveals a misidentified nuclear localization signal

The immortalizing function of the human adenovirus 5 E1A oncoprotein requires efficient localization to the nucleus. In 1987, a consensus monopartite nuclear localization sequence (NLS) was identified at the C-terminus of E1A. Since that time, various experiments have suggested that other regions of E1A influence nuclear import. In addition, a novel bipartite NLS was recently predicted at the C-terminal region of E1A in silico. In this study, we used immunofluorescence microscopy and co-immunoprecipitation analysis with importin-α to verify that full nuclear localization of E1A requires the well characterized NLS spanning residues 285-289, as well as a second basic patch situated between residues 258 and 263 ((258)RVGGRRQAVECIEDLLNEPGQPLDLSCKRPRP(289)). Thus, the originally described NLS located at the C-terminus of E1A is actually a bipartite signal, which had been misidentified in the existing literature as a monopartite signal, altering our understanding of one of the oldest documented NLSs.

Selective formation of metastable ferrihydrite in the chiton tooth

Metastable precursors are thought to play a major role in the ability of organisms to create mineralized tissues. Of particular interest are the hard and abrasion-resistant teeth formed by chitons, a class of rock-grazing mollusks. The formation of chiton teeth relies on the precipitation of metastable ferrihydrite (Fh) in an organic scaffold as a precursor to magnetite. In vitro synthesis of Fh under physiological conditions has been challenging. Using a combination of X-ray absorption and electron paramagnetic resonance spectroscopy, we show that, prior to Fh formation in the chiton tooth, iron ions are complexed by the organic matrix. In vitro experiments demonstrate that such complexes facilitate the formation of Fh under physiological conditions. These results indicate that acidic molecules may be integral to controlling Fh formation in the chiton tooth. This biological approach to polymorph selection is not limited to specialized proteins and can be expropriated using simple chemistry.

Family advocacy for the IPS supported employment project: accomplishments and challenges

TOPIC

A majority of people with serious mental illnesses want to return to work as part of their recovery, but access to effective employment services is limited. This report highlights the role that families can take to advocate for access to high-quality services for their relatives with mental illnesses.

PURPOSE

This report summarizes major accomplishments of the family advocacy for the Individual Placement and Support (IPS) supported employment project, which is part of the Johnson & Johnson-Dartmouth Community Mental Health Program.

SOURCES USED

This description draws on published literature related to the role of families on behalf of individuals living with serious mental health conditions and supported employment services. The experiences of family members as advocates for change are also included.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Family teams can play a key role in changing public policy to increase access to evidence-based employment services and in promoting high-quality services at the local level in partnership with state mental health and vocational rehabilitation agency leaders responsible for employment services. In addition, family teams can educate their peers to better understand the role of work in recovery.

Dry self-cleaning properties of hard and soft fibrillar structures

Recently, gecko-inspired synthetic adhesives (GSAs) have been made using a variety of fabrication techniques and materials, with one made from a hard polymer having been reported to recover its shear adhesion after fouling by normal use, or "dry self-clean", a feature useful for applications in wall crawling robots, reusable adhesives, microfabrication and solar panel cleaning. This paper investigates the impact of two design parameters on the dry self-cleaning capability of GSAs by experimentally testing two GSAs after fouling with small (1 μm), medium (3-10 μm), and large (40-50 μm) particles. We found that a GSA made from a hard thermoplastic with nanoscopic fibers was able to recover 96-115% of its shear adhesion after fouling with small and large but not medium particles, while a GSA made from a soft polymer and microscopic fibers recovered 40-55% on medium and large particles, with SEM imaging revealing particles embedding within the polymer. An analysis of the contact strength between fibers, particles and substrates of various dimensions and elasticity reveals that dry self-cleaning will be more effective for GSAs fabricated with smaller fiber diameters and for GSAs fabricated from materials with smaller loss functions, such as hard thermoplastics. These results have important implications on the choice of materials and geometries used for GSAs when dry self-cleaning capability is a desired function in the material.

Viral retasking of hBre1/RNF20 to recruit hPaf1 for transcriptional activation

Upon infection, human adenovirus (HAdV) must activate the expression of its early genes to reprogram the cellular environment to support virus replication. This activation is orchestrated in large part by the first HAdV gene expressed during infection, early region 1A (E1A). E1A binds and appropriates components of the cellular transcriptional machinery to modulate cellular gene transcription and activate viral early genes transcription. Previously, we identified hBre1/RNF20 as a target for E1A. The interaction between E1A and hBre1 antagonizes the innate antiviral response by blocking H2B monoubiquitination, a chromatin modification necessary for the interferon (IFN) response. Here, we describe a second distinct role for the interaction of E1A with hBre1 in transcriptional activation of HAdV early genes. Furthermore, we show that E1A changes the function of hBre1 from a ubiquitin ligase involved in substrate selection to a scaffold which recruits hPaf1 as a means to stimulate transcription and transcription-coupled histone modifications. By using hBre1 to recruit hPaf1, E1A is able to optimally activate viral early transcription and begin the cycle of viral replication. The ability of E1A to target hBre1 to simultaneously repress cellular IFN dependent transcription while activating viral transcription, represents an elegant example of the incredible economy of action accomplished by a viral regulatory protein through a single protein interaction.

Effects of fetal antiepileptic drug exposure: outcomes at age 4.5 years

OBJECTIVE

To examine outcomes at age 4.5 years and compare to earlier ages in children with fetal antiepileptic drug (AED) exposure.

METHODS

The NEAD Study is an ongoing prospective observational multicenter study, which enrolled pregnant women with epilepsy on AED monotherapy (1999-2004) to determine if differential long-term neurodevelopmental effects exist across 4 commonly used AEDs (carbamazepine, lamotrigine, phenytoin, or valproate). The primary outcome is IQ at 6 years of age. Planned analyses were conducted using Bayley Scales of Infant Development (BSID at age 2) and Differential Ability Scale (IQ at ages 3 and 4.5).

RESULTS

Multivariate intent-to-treat (n = 310) and completer (n = 209) analyses of age 4.5 IQ revealed significant effects for AED group. IQ for children exposed to valproate was lower than each other AED. Adjusted means (95% confidence intervals) were carbamazepine 106 (102-109), lamotrigine 106 (102-109), phenytoin 105 (102-109), valproate 96 (91-100). IQ was negatively associated with valproate dose, but not other AEDs. Maternal IQ correlated with child IQ for children exposed to the other AEDs, but not valproate. Age 4.5 IQ correlated with age 2 BSID and age 3 IQ. Frequency of marked intellectual impairment diminished with age except for valproate (10% with IQ <70 at 4.5 years). Verbal abilities were impaired for all 4 AED groups compared to nonverbal skills.

CONCLUSIONS

Adverse cognitive effects of fetal valproate exposure persist to 4.5 years and are related to performances at earlier ages. Verbal abilities may be impaired by commonly used AEDs. Additional research is needed.

The C-terminal region of E1A: a molecular tool for cellular cartography

The adenovirus E1A proteins function via protein–protein interactions. By making many connections with the cellular protein network, individual modules of this virally encoded hub reprogram numerous aspects of cell function and behavior. Although many of these interactions have been thoroughly studied, those mediated by the C-terminal region of E1A are less well understood. This review focuses on how this region of E1A affects cell cycle progression, apoptosis, senescence, transformation, and conversion of cells to an epithelial state through interactions with CTBP1/2, DYRK1A/B, FOXK1/2, and importin-α. Furthermore, novel potential pathways that the C-terminus of E1A influences through these connections with the cellular interaction network are discussed.

Use of models in identification and prediction of physiology in critically ill surgical patients

BACKGROUND

With higher-throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review.

METHODS

A review of the literature and experience with models and physiological state representation and prediction after injury was undertaken.

RESULTS

A brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis.

CONCLUSION

Modelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician.

Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations

BACKGROUND

Acute traumatic coagulopathy (ATC) is an impairment of hemostasis that occurs early after injury and is associated with a 4-fold higher mortality, increased transfusion requirements and organ failure.

OBJECTIVES

The purpose of the present study was to develop a clinically relevant definition of ATC and understand the etiology of this endogenous coagulopathy.

PATIENTS/METHODS

We conducted a retrospective cohort study of trauma patients admitted to five international trauma centers and corroborated our findings in a novel rat model of ATC. Coagulation status on emergency department arrival was correlated with trauma and shock severity, mortality and transfusion requirements. 3646 complete records were available for analysis.

RESULTS

Patients arriving with a prothrombin time ratio (PTr) > 1.2 had significantly higher mortality and transfusion requirements than patients with a normal PTr (mortality: 22.7% vs. 7.0%; P < 0.001. Packed red blood cells: 3.5 vs. 1.2 units; P < 0.001. Fresh frozen plasma: 2.1 vs. 0.8 units; P < 0.001). The severity of ATC correlated strongly with the combined degree of injury and shock. The rat model controlled for exogenously induced coagulopathy and mirrored the clinical findings. Significant coagulopathy developed only in animals subjected to both trauma and hemorrhagic shock (PTr: 1.30. APTTr: 1.36; both P < 0.001 compared with sham controls).

CONCLUSIONS

ATC develops endogenously in response to a combination of tissue damage and shock. It is associated with increased mortality and transfusion requirements in a dose-dependent manner. When defined by standard clotting times, a PTr > 1.2 should be adopted as a clinically relevant definition of ATC.

Rhinocerebral mucormycosis in patients without predisposing medical conditions: a review of the literature

Rhinocerebral mucormycosis is a rare disease, affecting almost exclusively patients with known predisposing conditions such as diabetes mellitus, immunocompromised status, haemochromatosis or major trauma. Subsequent to a case of rhinocerebral mucormycosis in a 78-year-old woman without any known risk factor, we reviewed the published English-language literature and found an additional 72 cases. Reviewing all the published case series of mucormycosis involving any site, the proportion of apparently normal hosts among cases of rhinocerebral mucormycosis was found to be 9.06% (95% confidence interval 6.7-11.8). These findings suggest that rhinocerebral mucormycosis in patients without known predisposing factors is more prevalent than was previously believed.

Insoles for prevention and treatment of back pain

BACKGROUND

There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.

OBJECTIVES

To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

SEARCH STRATEGY

We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL) to March 2005, and MEDLINE, EMBASE, and CINAHL to February 2007; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.

SELECTION CRITERIA

We included randomized controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.

DATA COLLECTION AND ANALYSIS

One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.

MAIN RESULTS

Six randomized controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

LIMITATIONS

This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.

AUTHORS' CONCLUSIONS

There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.High quality trials are required for stronger conclusions.

Retinal nerve fibre layer imaging compared with histological measurements in a human eye

PURPOSE

A feasibility study comparing retinal nerve fibre layer (RNFL) thickness values obtained with imaging devices against RNFL thickness measurements obtained histologically in a human eye.

DESIGN

A single patient scheduled for orbital exenteration, who still possessed a healthy functioning eye.

METHODS

Before surgery, the eye was imaged using optical coherence tomography (OCT) and scanning laser polarimetry (SLP). After orbital exenteration, the globe was sectioned, and 100 equidistant RNFL thickness measurements were obtained for each of four concentric rings centred on the optic disc, with diameters of 3.0, 3.5, 4.0, and 4.5 mm.

RESULTS

RNFL thickness was found to be inversely related to the distance from the centre of the optic disc along each radial meridian. Peripapillary RNFL thickness was found comparable for histology, OCT, and SLP. RNFL thickness measured histologically confirmed a 'double hump' pattern, peaking at the superior and inferior poles. Histologically derived RNFL thickness (microm), at 3.0 and 3.5 mm diameter ring ranged between 30-135 and 25-115 respectively. In comparison, the 3.0 mm diameter GDx data ranged between 25 and 100, and the 3.4 mm diameter OCT data between 40 and 175.

CONCLUSIONS

Imaging data appear qualitatively similar when compared to the histologically derived data. Quantitative differences may be partly due to scaling differences and histological artefacts. The histological analysis approach demonstrated in this study can potentially serve to validate imaging-derived data, as well as help improve our understanding of RNFL loss in glaucoma.

Clinical characteristics of eyes demonstrating atypical patterns in scanning laser polarimetry

PURPOSE

To characterize which clinical features are associated with the occurrence of atypical birefringence patterns (ABP) occasionally seen with scanning laser polarimetry (SLP).

METHODS

Sixty-one subjects, including glaucoma patients, glaucoma suspects, and normal subjects, underwent a full clinical examination, standard visual field (VF) test, and a GDx-VCC SLP examination. One eye was selected from each patient. The magnitude of ABP was determined in two independent ways: using a support vector machine analysis (typical scan score (TSS)) and by a masked experienced observer. We assessed whether the magnitude of ABP was correlated with age, gender, the refractive state of the eye, corneal polarization axis and magnitude, GDx global parameters (TSNIT and NFI), and the VF status, as evident from glaucoma hemifield test (GHT), mean deviation (MD), and the pattern standard deviation (PSD).

RESULTS

Of the 61 study eyes, 27 (44%) showed an ABP, based on a TSS cutoff (<82.5). A very high correlation was found between the TSS score and the masked experienced observer score (r(2)=0.80; P<0.001). The following clinical parameters were found, on bivariate analysis, to be significantly correlated with the presence of an ABP: age (r(2)=0.086; P=0.02); corneal polarization magnitude (r(2)=0.069; P=0.04); TSNIT (r(2)=0.16; P<0.001).

CONCLUSION

The presence and magnitude of ABP did not seem to be closely correlated with most clinical parameters. A low, but statistically significant, correlation was found for age and corneal polarization magnitude (r(2)=0.086 and 0.069, respectively). A low-medium correlation was found for TSNIT (r(2)=0.16); however, we speculate that this might represent a confounding effect, rather than an underlying association. We conclude that none of the clinical parameters investigated in this study appears to be strongly correlated with the presence of an ABP on SLP scans performed using the commercially available GDx-VCC.

Just add water and the Colorado River still reaches the sea

A recent article in Environmental Management by All argued that flood flows in North America's Colorado River do not reach the Gulf of California because they are captured and evaporated in Laguna Salada, a below sea-level lakebed near the mouth of the river. We refute this hypothesis by showing that (1) due to its limited area, the Laguna Salada could have evaporated less than 10% of the flood flows that have occurred since 1989; (2) low flow volumes preferentially flow to the Gulf rather than Laguna Salada; (3) All's method for detecting water surface area in the Laguna Salada appears to be flawed because Landsat Thematic Mapper images of the lakebed show it to be dry when All's analyses said it was flooded; (4) direct measurements of salinity at the mouth of the river and in the Upper Gulf of California during flood flows in 1993 and 1998 confirm that flood waters reach the sea; and (5) stable oxygen isotope signatures in clam shells and fish otoliths recorded the dilution of seawater with fresh water during the 1993 and 1998 flows. Furthermore, All's conclusion that freshwater flows do not benefit the ecology of the marine zone is incorrect because the peer-reviewed literature shows that postlarval larval shrimp populations increase during floods, and the subsequent year's shrimp harvest increases. Furthermore, freshwater flows increase the nursery area for Gulf corvina (Cynoscion othonopterus), an important commercial fish that requires estuarine habitats with salinities in the range of 26-38 per thousand during its natal stages. Although flood flows are now much diminished compared to the pre-dam era, they are still important to the remnant wetland and riparian habitats of the Colorado River delta and to organisms in the intertidal and marine zone. Only a small fraction of the flood flows are evaporated in Laguna Salada.

Carotid Angioplasty and Stenting is a Safe and Durable Procedure in a Community Hospital

Carotid angioplasty and stenting (CAS) has been touted as a reasonable alternative to carotid endarterectomy (CEA) for high-risk surgical candidates. Several published CAS series, primarily from academic centers, show immediate results approaching those of CEA. However, very little is known about long-term results with CAS, particularly in the community hospital setting. Therefore, we retrospectively reviewed our CAS experience. From February 1999 to July 2003, 44 consecutive patients underwent placement of 46 stents. The mean patient age was 73 years, and 57 per cent were men. Most patients were asymptomatic (74%). High-risk categories included prior CEA (71%), other anatomic risks (13%), and/or significant medical comorbidities (16%). Technical success was achieved in all 46 cases. At 30 days, there were no deaths and one stroke, giving a combined stroke/mortality of 2 per cent. Clinical follow-up was obtained on all 44 patients at a mean follow-up of 42 months. Duplex scans performed on 44 stents (96%), at a mean follow-up of 40 months, demonstrated four 60 per cent to 79 per cent recurrent stenoses. CAS in a community hospital can have a 30-day stroke/mortality equivalent to CEA. The procedure is durable, with no critical (80%–99%) carotid restenoses and no stroke or transient ischemic attacks referable to a stented carotid artery in long-term follow-up.

Carotid angioplasty and stenting is a safe and durable procedure in a community hospital

Carotid angioplasty and stenting (CAS) has been touted as a reasonable alternative to carotid endarterectomy (CEA) for high-risk surgical candidates. Several published CAS series, primarily from academic centers, show immediate results approaching those of CEA. However, very little is known about long-term results with CAS, particularly in the community hospital setting. Therefore, we retrospectively reviewed our CAS experience. From February 1999 to July 2003, 44 consecutive patients underwent placement of 46 stents. The mean patient age was 73 years, and 57 per cent were men. Most patients were asymptomatic (74%). High-risk categories included prior CEA (71%), other anatomic risks (13%), and/or significant medical comorbidities (16%). Technical success was achieved in all 46 cases. At 30 days, there were no deaths and one stroke, giving a combined stroke/mortality of 2 per cent. Clinical follow-up was obtained on all 44 patients at a mean follow-up of 42 months. Duplex scans performed on 44 stents (96%), at a mean follow-up of 40 months, demonstrated four 60 per cent to 79 per cent recurrent stenoses. CAS in a community hospital can have a 30-day stroke/mortality equivalent to CEA. The procedure is durable, with no critical (80%-99%) carotid restenoses and no stroke or transient ischemic attacks referable to a stented carotid artery in long-term follow-up.

Intraoperative Neuromonitoring Detects Thrombotic Occlusion of the Left Common Iliac Arterial Bifurcation After Anterior Lumbar Interbody Fusion

Prompt recognition of acute or delayed vascular insults during anterior spinal reconstructive surgery of the lower lumbar levels is paramount for successful intervention and prevention of sequelae. Although surgical exposure of the lower lumbar levels requires mindful dissection and cautious retraction of abdominal vessels, ischemic insult due to partial or complete occlusion of the iliac arteries may go undetected without adequate surgical monitoring. We present a case of progressive thrombotic occlusion of the left common iliac artery detected by intraoperative spinal cord monitoring using somatosenory evoked potentials (SSEPs) at the peripheral and central levels. Surgical monitoring using palpation of vessels and pulse oximetry of the great toe were initially proposed as simple and relatively inexpensive modalities for routine surgical monitoring. Subsequently, monitoring cortical SSEPs were combined with great toe pulse oximetry to advance continuous routine surgical monitoring. However, using only cortical SSEPs predisposes such protocols to an inherently higher risk of false positives. Neuromonitoring protocols should rely heavily on the replication of waveforms recorded at multiple sites along the neural pathway.

Effects of motor imagery training after chronic, complete spinal cord injury

Abnormalities in brain motor system function are present following spinal cord injury (SCI) and could reduce effectiveness of restorative interventions. Motor imagery training, which can improve motor behavior and modulate brain function, might address this concern but has not been examined in subjects with SCI. Ten subjects with SCI and complete tetra-/paraplegia plus ten healthy controls underwent assessment before and after 7 days of motor imagery training to tongue and to foot. Motor imagery training significantly improved the behavioral outcome measure, speed of movement, in non-paralyzed muscles. Training was also associated with increased fMRI activation in left putamen, an area associated with motor learning, during attempted right foot movement in both groups, despite foot movements being present in controls and absent in subjects with SCI. This fMRI change was absent in a second healthy control group serially imaged without training. In subjects with SCI, training exaggerated, rather than normalized, baseline derangement of left globus pallidus activation. The current study found that motor imagery training improves motor performance and alters brain function in subjects with complete SCI despite lack of voluntary motor control and peripheral feedback. These effects of motor imagery training on brain function have not been previously described in a neurologically impaired population, and were similar to those found in healthy controls. Motor imagery might be of value as one component of a restorative intervention.

Endovascular treatment of obliterative hepatocavopathy with inferior vena cava occlusion and renal vein thrombosis

We describe the endovascular treatment of an occlusion of the inferior vena cava (IVC) due to obliterative hepatocavopathy with renal and iliac vein thrombosis. A 34-year-old man with nephrotic syndrome and hepatic dysfunction presented to the hospital after a 3-month history of lower extremity swelling with an acute deterioration in his condition. Magnetic resonance venography diagnosed a massive IVC occlusion with thrombosis of the entire IVC, iliac veins, and renal vein. He was treated with thrombolysis, and a chronic occlusion of the infrahepatic IVC was discovered. After venous stenting of the IVC and iliac veins, he dramatically improved. After 24 months, he remains symptom-free with a patent IVC and iliac veins.

Evaluating ecological condition using soil biogeochemical parameters and near infrared reflectance spectra

Rapid, repeatable assessment of ecological condition is critical for quantitative ecosystem monitoring. Soils provide a sensitive, integrative indicator for which sampling and analysis techniques are well defined. We evaluated soil properties as indicators of ecological condition (subjectively classified into minimally/moderately/severely degraded based on vegetative, hydrologic and edaphic cues) at 526 sites within Ft. Benning military installation (Georgia, USA). For each sample, we measured 17 biogeochemical parameters, and collected high-resolution diffuse reflectance spectra using visible/near infrared reflectance spectroscopy (VNIRS). VNIR spectra have been related to numerous soil attributes - we examine them here for diagnosing integrated response (i.e., ecological condition). We used ordinal logistic regression (OLR) and classification trees (CT) to discriminate between condition categories using both sets of predictors (biogeochemistry and spectra). Sixteen biogeochemical parameters were significantly different across condition categories; however, multivariate models greatly improved discrimination ([calibration, validation] accuracy of [69%, 66%] and [96%, 73%] for OLT and CT models, respectively). Important predictors included total C, total P, and Mehlich K/Ca/Mg. VNIR spectra further improved discrimination ([calibration, validation] accuracy of [74%, 70%] and [96%, 75%] for OLR and CT models, respectively). While spectra were comparably effective at discriminating minimally degraded sites, they were significantly more effective at discriminating severely degraded sites. Error rates across confounding factors suggest that watershed of origin and landscape position were the only important confounders, likely due to imbalanced sampling. We conclude that multivariate diagnosis improves accuracy, and that VNIR spectroscopy, which yields substantial cost and logistical improvements over conventional analyses, provides an effective tool for rapid condition diagnosis.