Preclinical characterization of a non-peptidomimetic HIV protease inhibitor with improved metabolic stability.

Protease inhibitors (PIs) remain an important component of antiretroviral therapy for the treatment of HIV-1 infection due to their high genetic barrier to resistance development. Nevertheless, the two most commonly prescribed HIV PIs, atazanavir and darunavir, still require co-administration with a pharmacokinetic boosting agent to maintain sufficient drug plasma levels which can lead to undesirable drug-drug interactions. Herein, we describe GS-9770, a novel investigational non-peptidomimetic HIV PI with unboosted once-daily oral dosing potential due to improvements in its metabolic stability and its pharmacokinetic properties in preclinical animal species. This compound demonstrates potent inhibitory activity and high on-target selectivity for recombinant HIV-1 protease versus other aspartic proteases tested. In cell culture, GS-9770 inhibits Gag polyprotein cleavage and shows nanomolar anti-HIV-1 potency in primary human cells permissive to HIV-1 infection and against a broad range of HIV subtypes. GS-9770 demonstrates an improved resistance profile against a panel of patient-derived HIV-1 isolates with resistance to atazanavir and darunavir. In resistance selection experiments, GS-9770 prevented the emergence of breakthrough HIV-1 variants at all fixed drug concentrations tested and required multiple protease substitutions to enable outgrowth of virus exposed to escalating concentrations of GS-9770. This compound also remained fully active against viruses resistant to drugs from other antiviral classes and showed no in vitro antagonism when combined pairwise with drugs from other antiretroviral classes. Collectively, these preclinical data identify GS-9770 as a potent, non-peptidomimetic once-daily oral HIV PI with potential to overcome the persistent requirement for pharmacological boosting with this class of antiretroviral agents.

Discovery of triazolopyridine GS-458967, a late sodium current inhibitor (Late INai) of the cardiac NaV 1.5 channel with improved efficacy and potency relative to ranolazine.

We started with a medium throughput screen of heterocyclic compounds without basic amine groups to avoid hERG and ß-blocker activity and identified [1,2,4]triazolo[4,3-a]pyridine as an early lead. Optimization of substituents for Late INa current inhibition and lack of Peak INa inhibition led to the discovery of 4h (GS-458967) with improved anti-arrhythmic activity relative to ranolazine. Unfortunately, 4h demonstrated use dependent block across the sodium isoforms including the central and peripheral nervous system isoforms that is consistent with its low therapeutic index (approximately 5-fold in rat, 3-fold in dog). Compound 4h represents our initial foray into a 2nd generation Late INa inhibitor program and is an important proof-of-concept compound. We will provide additional reports on addressing the CNS challenge in a follow-up communication.

Discovery of triazolopyridinone GS-462808, a late sodium current inhibitor (Late INai) of the cardiac Nav1.5 channel with improved efficacy and potency relative to ranolazine.

Previously we disclosed the discovery of potent Late INa current inhibitor 2 (GS-458967, IC50 of 333nM) that has a good separation of late versus peak Nav1.5 current, but did not have a favorable CNS safety window due to high brain penetration (3-fold higher partitioning into brain vs plasma) coupled with potent inhibition of brain sodium channel isoforms (Nav1.1, 1.2, 1.3). We increased the polar surface area from 50 to 84Å(2) by adding a carbonyl to the core and an oxadiazole ring resulting in 3 GS-462808 that had lower brain penetration and serendipitously lower activity at the brain isoforms. Compound 3 has an improved CNS window (>20 rat and dog) relative to 2, and improved anti-ischemic potency relative to ranolazine. The development of 3 was not pursued due to liver lesions in 7day rat toxicology studies.

Intermittent abdominal pain in a 6-year-old child: the psycho-social-cultural evaluation.

The dramatic surge in diversity in the western world requires a commitment by pediatric providers to understand unique psychosocial presentations of distress, as well as to have an understanding of normative cultural values and health-seeking behaviors. We report a case of apparent recurrent abdominal pain that evolved into a unique culturally salient presentation of obsessive compulsive disorder in a 6-year-old young girl. Access to integrated mental health professionals assisted in the identification of this disorder, if not success in referral and treatment.

Forensic issues in infant mental health: Challenging systems, clinical risk, future collaborations.

Much clinical work in infant mental health includes working with families of young children involved in the complex arenas of the legal and child protection systems. These systems have their own distinctive languages, cultures, and values, but they share a concern with clinicians about the best interest of the child. This special issue explores selected topics in this area, calling attention to research, policy, and clinical issues in forensic infant mental health. The purpose of the issue is to stimulate additional thinking and additional scholarly attention to these vital issues that have such importance for families around the world.

Psychopharmacological treatment for very young children: contexts and guidelines.

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Three-dimensional CT image analysis of the digging system in the aardvark.

We examined the bone movement in the forepaw and hind paw in the aardvark (Orycteropus afer) by using three-dimensional (3D)-computed tomography (CT) techniques and osteometrical methods to confirm the functional adaptation of the extremities as a digging system. The four metacarpal bones could be strongly bent from the distal carpal bones. The distal end of the second and third metacarpal bones possessed enlarged smooth articulation surfaces that allowed the proximal phalanx to bend at a sharp angle. However, the articulation surface was not well-developed in the distal end of the fourth and fifth metacarpal bones and the proximal phalanx could bend at smaller angle in these two lateral digits. The proximal phalanges sharply crook from the metatarsal in the first, second, third and fourth digits in the hind paw. We suggest that the medial two digits in the forepaw directly contribute to the crushing, when these proximal phalanges crook in the phase of power stroke. In contrast the lateral third and fourth digits may act as sweeper of the crushed soil. These suggestions regarding the different functional adaptation between medial two digits and lateral two digits are consistent with the anatomical data of the forearm musculature. In the hind paw, we suggest that the second, third and fourth digits are functionally similar and that the hind paw may not act as a crushing apparatus but as a running motor or soil-sweeper similarly using these main three digits.

Geographical variation of the skull of the lesser mouse deer.

We examined the geographical variation of the skull size and shape of the lesser mouse deer (Tragulus javanicus) from Laos, Thailand, Peninsular Malaysia, Sumatra, Java, Borneo, Langkawi and some Islands of Tenasserim in Myanmar. Although the influence of the climatic condition on skull size was not confirmed in the mainland populations, the skull became rostro-caudally longer in the populations of Tenasserim and Sumatra because of island isolation effect. The skull size was classified into the following three clusters of localities from the matrix of Q-mode correlation coefficients: 1) Langkawi and Tenasserim, 2) Laos and Thailand, 3) Sumatra and Borneo. The skulls in the population of Java belong to the cluster of Langkawi and Tenasserim in male, however were morphologically similar to those in the cluster of Borneo and Sumatra. The canonical discriminant analysis pointed out that the Laos and Tenasserim populations were separated from the other ones and that the populations of Sumatra, Java and Borneo were intermingled each other.

Proportion and cluster analyses of the skull in various species of the tree shrews.

The skull adaptation was functional-morphologically examined in 14 species of the tree shrews. From the data of the proportion indices, the similarities were confirmed between T. minor and T. gracilis, T. tana and T. dorsalis, and T. longipes and T. glis. We demonstrated that the splanchnocranium was elongated in terrestrial T. tana and T. dorsalis and shortened in arboreal T. minor and T. gracilis from the proportion data. In both dendrogram from the matrix of the Q-mode correlation coefficients and scattergram from the canonical discriminant analysis, the morphological similarities in the skull shape suggested the terrestrial-insectivorous adaptation of T. tana and T. dorsalis, and the arboreal adaptation of T. minor and T. gracilis. Since the osteometrical skull similarities were indicated among the three species of Tupaia by cluster and canonical discriminant analyses, the arbo-terrestrial behavior and its functional-morphological adaptation may be commonly established in T. montana, T. longipes and T. glis.

Macroscopic study of the functional significance of the forearm muscles in the giant panda.

The extensor and flexor group muscles and their related muscles were functional-morphologically observed in the dead body of the giant panda to clarify the action of the forearm and the palm in the manipulation of the species. The Musculus flexor carpi ulnaris had two developed heads, however, we can conclude that the contraction of this muscle slightly changes the angle of the accessory carpal bone to the ulna. The data pointed out that the accessory carpal bone acts as a supporting post, when the giant panda seizes the object. The M. abductor digiti I longus possessed the well-developed origin in both ulna and radius. These findings suggest that this muscle may function as a supinator of the forearm. We also suggest that the well-developed M. pronator quadratus and M. pronator teres, and the proximal part of the M. abductor digiti I longus and the M. supinator may efficiently contribute to the pronator-spinator action of the forearm, when the giant panda brings the food to its mouth using the manipulation system equipped in the palm region.

Morphological adaptation of the skull for various behaviors in the tree shrews.

Skull size and shape were examined among 14 species of the tree shrews (Tupaia montana, T. picta, T. splendidula, T. mulleri, T. longipes, T. glis, T. javanica, T. minor, T. gracilis, T. dorsalis, T. tana, Dendrogale melanura, D. murina, and Ptilocercus lowii). The bones of face were rostro-caudally longer in T. tana and T. dorsalis, contrasting with T. minor and T. gracilis, D. melanura, D. murina and P. lowii which have smaller facial length ratios. The arbo-terrestrial species (T. longipes and T. glis) were similar to terrestrial species in length ratios of bones of face unlike the other arbo-terrestrial species (T. montana, T. picta, T. splendidula, and T. mulleri). We propose that T. longipes and T. glis have adapted to foraging for termites and ants as have T. tana and T. dorsalis. Additionally small body size in T. javanica may be the result of being isolated in Java. We separated the species into 5 groups from the measurment values of skulls: 1) Terrestrial species; T. tana and T. dorsalis, 2) Arboreal species; T. minor and T. gracilis, 3) Arbo-terrestrial species group 1: T. montana, T. splendidula, T. picta and T. mulleri, and T. javanica, 4) Arbo-terrestrial species group 2: T. glis and T. longipes, 5) Arboreal species of Dendrogale and Ptilocercus. Principal component analysis separated species into 8 clusters as follows: 1) T. tana, 2) T. dorsalis, 3) T. montana, T. splendidula, T. picta and T. mulleri, 4) T. glis and T. longipes, 5) T. javanica, 6) T. minor and T. gracilis, 7) D. melanura and D. murina, and 8) P. lowii. We suggest that these clusters correspond to behavioral strategies and peculiarities observed in foraging, feeding and locomotion in each species.

Geographical variation of skull size and shape in various populations in the black giant squirrel.

We osteometrically examined the skulls of the black giant squirrel (Ratufa bicolor) from three mainland populations (M. Malayan Peninsula, V. South Vietnam, and B. Burma, India and North Thailand) and from two island populations (T. Tioman, and S. Sumatra Islands). The skull in the Malayan peninsula population was significantly smaller than that of the two other mainland populations. It is consistent with Bergmann's rule as shown in the gray-bellied squirrel. The two island populations did not show obvious differences in comparison with the Malayan population in many measurements. In the proportion analysis eliminating the size factor, the differences among populations were not easily confirmed and we concluded that the osteological characters peculiar to each population could not be shown in this species. The first and second principal component scores of M, S, and T populations were intermingled, whereas the V and B populations of V and B were not separated in the chart. We pointed out that the morphological differences were demonstrated between northern and southern groups of the Isthmus of Kra in the mainland populations, and that the two island populations did not show the island-isolation effect in comparison with the M population. The adaptational variation related to feeding and locomotion could not be confirmed among populations of the black giant squirrel as shown in the proportion analysis.

Geographical variation of skull morphology and its functional significances in the red-cheeked squirrel.

Skulls of the red-cheeked squirrel (Dremomys rufigenis) from various geographical locations: Malaysia (peninsular area), Vietnam (south district)-Laos, and Thailand (north district) were osteometrically examined. The skull size of the squirrels in the southern (Malaysia) population was fundamentally larger than that in the northern (Vietnam, Laos and Thailand) populations. The proportion indices indicated that the splanchnocranium was relatively longer in the Malaysia population, and that the interorbital space was narrower in Vietnam-Laos, and Thailand populations. We suggest that the long nose and laterally-oriented orbits in the skull may be better adapted for terrestrial-insectivorous life in the Malaysia population and the binocular sense facilitated by rostrally-oriented eyes contributes to the arboreal-fruit eating behavior in the two northern populations. The Malaysia population was clearly distinguished from the other populations by the principal component analysis. We suggest that the geographical barrier of the Isthmus of Kra influences the morphological variation of the skull among the squirrel populations.

Geographical and functional-morphological variations of the skull in the gray-bellied squirrel.

The geographical variations of the skulls were osteometrically examined in the gray-bellied squirrel (Callosciurus caniceps) from the populations of Korat, Ranong, southernmost Thailand, and Terutau Island. The skull size was larger in northern population than in the southern population in the continental mainland. The zoogeographical influences of the Isthmus of Kra remained unclear, since the plots from Korat population were intermingled with those from southernmost Thailand population in the principal component charts. Although Korat population has been thought to belong to north group, we suggest that Ranong and southernmost Thailand populations may contain individuals from both north and south groups separated by the ancient Kra barrier. Terutau Island population was similar to southernmost Thailand population in skull size, although Terutau population has been isolated in the island and separated from the south group of the Isthmus of Kra. In the proportional analysis the interorbital space was narrower and the binocular sense has been well-developed in Terutau population. It suggests that this population has been highly adapted to arboreal behavior. In contrast, the skull with larger interorbital space was more adaptive for terrestrial life in Korat population. The canonical discriminant analysis could clearly separate the four populations in the scattergrams of discriminant scores.

Integrating mental health services in primary care continuity clinics: a national CORNET study.

OBJECTIVE: To determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider. METHODS: Pediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM_PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites. RESULTS: Seventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006). CONCLUSIONS: Directors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites.

Immune dysregulation and glucocorticoid resistance in minority and low income pregnant women.

Chronic prenatal stress contributes to poor birth outcomes for women and infants. Importantly, poor birth outcomes are most common among minority and low income women. To investigate underlying mechanisms, we tested the hypothesis that chronic stress related to minority or low income status is associated with glucocorticoid resistance as indicated by disruption in the cytokine-glucocorticoid feedback circuit. Home visits were conducted during which 3rd trimester pregnant women completed stress and depression surveys and provided blood for pro- and anti-inflammatory cytokines. Saliva was collected 5 times the preceding day for diurnal cortisol levels. For statistical analyses, women were grouped 3 ways, by race, income, and the presence or absence of either of those risk factors; this last group was labeled high or low general risk. Immune regulation was evaluated by evidence of a functioning negative feedback relationship between cytokines and cortisol. Of 96 participants, 18 were minority, 22 of low income, and 29 either minority or low income (high general risk). Pearson partial correlation identified a significant negative relationship between cortisol area under the curve (AUC) and pro- to anti-inflammatory cytokine ratios in the low general risk women (i.e., Caucasian, higher income) including IFNγ/IL10 (r=-0.73, p<0.0001), IL6/IL10 (r=-0.38, p=0.01), IL1ß/IL10 (r=-0.44, p=0.004) and TNFα/IL10 (r=-0.41; p=0.005); no such correlations existed in the high general risk women (i.e., minority, low income) for (IFNγ/IL10: r=-0.25, p=0.43; IL6/IL10: r=0.12, p=0.70; IL1 ß/IL10: r=0.05, p=0.87; TNFα/IL10: r=0.10; p=0.75), suggestive of glucocorticoid resistance. Cortisol levels throughout the day also were higher in minority and high general risk groups (p<0.05). Without cytokine glucocorticoid feedback, a pregnant woman's ability to regulate inflammation is limited, potentially contributing to adverse maternal and infant outcomes.

The heritability of postpartum depression.

Postpartum depression (PPD) is a serious mood disorder that may carry life-long consequences for a woman and her family. Multiple risk factors for PPD have been identified, including psychosocial, situational, and biological stimuli, several of which are experienced by most, if not all, postpartum women. Given the commonality of these risk factors, it is unclear why fewer than 20% of postpartum women actually develop PPD. In this review, we suggest that different susceptibility to PPD among postpartum women may be explained by the presence or absence of genetic variants that confer increased risk. We review three categories of genes known to code for proteins associated with depression in the general population or proteins known to be affected by childbirth for their possible association with PPD, including genes related to central nervous system monoamine availability, proinflammatory cytokines, and brain neuropeptides. Only two studies are available in the literature to date specifically looking at polymorphisms in postpartum women as related to PPD; both are concerned with monoamine availability. These are discussed in further depth. Conclusions regarding the contribution of genetic polymorphisms to the development of PPD are mixed. Ultimately, the complexity of the disorder and the interrelationships among different genes thought to contribute to depression suggest that much more research is required to understand the heritability of PPD. The complexity of the disorder also suggests that epigenetic influences must be considered as well when discussing susceptibility.

Screening for postpartum depression at well-child visits: is once enough during the first 6 months of life?

OBJECTIVE: Screening for maternal depression is gaining acceptance as a standard component of well-child care. We tested the feasibility of this policy and determined the prevalence and incidence of maternal depression at well-child visits during the first 6 months of life. METHODS: Providers in an adolescent-oriented maternity program were cued electronically, when they opened the electronic medical records of 0- to 6-month-old infants to conduct well-child visits, to ask the mothers to complete the Edinburgh Postpartum Depression Scale. Incident cases represented mothers who crossed the referral threshold (score of > or =10) after the first screening. RESULTS: Mothers usually brought their infants to the clinic, and none refused screening. Providers could act on 99% of the 418 screening cues; they administered the Edinburgh Postpartum Depression Scale 98% of the time and always referred mothers with scores of > or =10. Overall, 20% of the mothers scored > or =10. Scores were unstable at < or =3 postpartum weeks (kappa = 0.2). Thereafter, the prevalence and incidence of scores of > or =10 decreased from 16.5% at 2 months to 10.3% and 5.7%, respectively, at 4 months. Prevalence increased to 18.5% at the 6-month visit, and incidence decreased to 1.9%. Repeat screening detected only 2 mothers (5.7%) with scores of > or =10. CONCLUSIONS: Electronic cueing improved compliance with the detection and referral phases of screening for maternal depression at well-child visits. Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months, and screening at the 6-month well-child visit is preferable to screening at the 4-month visit.