Comparative Analyses of Bioequivalence Assessment Methods for In Vitro Permeation Test Data.

For topical, dermatological drug products, an in vitro option to determine bioequivalence (BE) between test and reference products is recommended. In particular, in vitro permeation test (IVPT) data analysis uses a reference-scaled approach for two primary endpoints, cumulative penetration amount (AMT) and maximum flux (Jmax), which takes the within donor variability into consideration. In 2022, the Food and Drug Administration (FDA) published a draft IVPT guidance that includes statistical analysis methods for both balanced and unbalanced cases of IVPT study data. This work presents a comprehensive evaluation of various methodologies used to estimate critical parameters essential in assessing BE. Specifically, we investigate the performance of the FDA draft IVPT guidance approach alongside alternative empirical and model-based methods utilizing mixed-effects models. Our analyses include both simulated scenarios and real-world studies. In simulated scenarios, empirical formulas consistently demonstrate robustness in approximating the true model, particularly in effectively addressing treatment-donor interactions. Conversely, the effectiveness of model-based approaches heavily relies on precise model selection, which significantly influences their results. The research emphasizes the importance of accurate model selection in model-based BE assessment methodologies. It sheds light on the advantages of empirical formulas, highlighting their reliability compared to model-based approaches and offers valuable implications for BE assessments. Our findings underscore the significance of robust methodologies and provide essential insights to advance their understanding and application in the assessment of BE, employed in IVPT data analysis.

Adaptive designs for IVPT data with mixed scaled average bioequivalence.

In vitro permeation tests (IVPT) offer accurate and cost-effective development pathways for locally acting drugs, such as topical dermatological products. For assessment of bioequivalence, the FDA draft guidance on generic acyclovir 5% cream introduces a new experimental design, namely the single-dose, multiple-replicate per treatment group design, as IVPT pivotal study design. We examine the statistical properties of its hypothesis testing method-namely the mixed scaled average bioequivalence (MSABE). Meanwhile, some adaptive design features in clinical trials can help researchers make a decision earlier with fewer subjects or boost power, saving resources, while controlling the impact on family-wise error rate. Therefore, we incorporate MSABE in an adaptive design combining the group sequential design and sample size re-estimation. Simulation studies are conducted to study the passing rates of the proposed methods-both within and outside the average bioequivalence limits. We further consider modifications to the adaptive designs applied for IVPT BE trials, such as Bonferroni's adjustment and conditional power function. Finally, a case study with real data demonstrates the advantages of such adaptive methods.

Association Between Generic-to-Generic Levothyroxine Switching and Thyrotropin Levels Among US Adults.

IMPORTANCE: Switching among generic levothyroxine sodium products made by different manufacturers typically occurs at the pharmacy and may affect serum thyrotropin (TSH) levels. OBJECTIVE: To compare TSH levels between patients who continued taking the same sourced generic levothyroxine product and those who switched. DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness research study with 1:1 propensity matching used data from OptumLabs Data Warehouse, a national administrative claims database linked to laboratory test results. Adults aged 18 years or older were included if they filled a generic levothyroxine prescription between January 1, 2008, and June 30, 2019, and had a stable drug dose, the same drug manufacturer, and a normal TSH level (0.3-4.4 mIU/L) for at least 3 months before either continuing to take the same product or switching among generic levothyroxine products (index date). Patients were excluded if they were pregnant, had diagnosed hypopituitarism or hyperthyroidism, or had a medical condition or used medications that could affect thyrotropin levels. They were also excluded if they filled a prescription for other forms of thyroid replacement therapy between 6 months before the index date and when the first TSH level was obtained 6 weeks to 12 months after the index date. Data were analyzed from December 1, 2019, to November 24, 2021. MAIN OUTCOMES AND MEASURES: Proportion of individuals with a normal (0.3-4.4 mIU/L) or markedly abnormal (<0.1 or >10.0 mIU/L) TSH level using the first available laboratory result 6 weeks to 12 months after the index date. A propensity score model was developed to minimize confounding using logistic regression with the binary outcome of continuing the same sourced levothyroxine product vs switching generic levothyroxine. Covariates were demographics, comorbidities, and baseline TSH level. The balance among the treatment groups was evaluated by comparing standardized mean differences of baseline covariates between the groups. RESULTS: A total of 15 829 patients filled generic levothyroxine (mean [SD] age, 58.9 [14.6] years; 73.4% [11 624] were women; 4.5% [705] were Asian, 10.2% [1617] were Black, 11.4% [1801] were Hispanic, and 71.4% [11 295] were White individuals); of these patients, 56.3% [8905] received a daily levothyroxine dose of 50 µg or less. A total of 13 049 patients (82.4%) continued taking the same sourced preparation, and 2780 (17.6%) switched among generic levothyroxine preparations. Among 2780 propensity-matched patient pairs, the proportion of patients with a normal TSH level after the index date was 82.7% (2298) among nonswitchers and 84.5% (2348) among switchers (risk difference, -0.018; 95% CI, -0.038 to 0.002; P = .07). The proportion of patients with a markedly abnormal TSH level after the index date was 3.1% (87) among nonswitchers and 2.5% (69) among switchers (risk difference, 0.007; 95% CI, -0.002 to 0.015; P = .14). The mean (SD) TSH levels after the index date were 2.7 (2.3) mIU/L among nonswitchers and 2.7 (3.3) mIU/L among switchers (P = .94). CONCLUSIONS AND RELEVANCE: Results of this comparative effectiveness research study suggest that switching among different generic levothyroxine products was not associated with clinically significant changes in TSH level. These findings conflict with the current guideline recommendation that warns clinicians about potential changes in TSH level associated with switching among levothyroxine products sourced from different manufacturers.

Rates of, and factors associated with, switching among generic levothyroxine preparations in commercially insured American adults.

IMPORTANCE: Some practice guidelines warn against generic L-thyroxine preparation switching. OBJECTIVE: To examine the rates of generic L-thyroxine preparation switching within one year of initiating L-thyroxine, and to examine factors associated with switching. DESIGN AND SETTING: Retrospective study using national data from a large administrative claims database from January 2008 through November 2018. PATIENTS: Medicare or commercially insured adults (≥18 years) who filled a generic L-thyroxine preparation. MAIN OUTCOME MEASURES: At least one switch from one generic L-thyroxine preparation to another within 1 year of L-thyroxine initiation defined by prescription fills. RESULTS: From January 2008 to November 2018, we included 483,390 patients who initiated generic L-thyroxine: mean (SD) age was 61.4 years (15.2), 75.2% were female, 72.6% were white. Within 1 year of initiating therapy, 98,013 (20%) switched to another L-thyroxine generic preparation at least once. In a multivariate logistic regression analysis, factors associated with switching included the number of pharmacies visited to fill L-thyroxine (>2 vs 1 adjusted OR [aOR] 7.15, 95% confidence interval [CI] 6.97-7.34), age ≥75 vs. <45 years (aOR 1.29, 95% CI 1.26-1.33), history of thyroid surgery (aOR 1.22, 95% CI 1.13-1.31), and first L-thyroxine fill date in 2018 vs. 2008 (aOR 3.32, 95% CI 3.14-3.51). CONCLUSIONS AND RELEVANCE: One in five patients switched among generic L-thyroxine manufacturers within one year of treatment initiation. Generic L-thyroxine switching occurred more often when more pharmacies were used to fill L-thyroxine. Given existing guideline recommendations, additional studies should clarify the impact of generic L-thyroxine switching on thyroid hormone values.

Antifungal activity of sterols and dipsacus saponins isolated from Dipsacus asper roots against phytopathogenic fungi.

The in vivo antifungal activity of crude extracts of Dipsacus asper roots was evaluated against the phytopathogenic fungi Botrytis cinerea, Colletotrichum coccodes, Blumeria graminis f. sp. hordei, Magnaporthe grisea, Phytophthora infestans, Puccinia recondita and Rhizoctonia solani using a whole-plant assay method. Ethyl acetate and acetone extracts, at 1000µg/mL, suppressed the development of tomato gray mold (TGM) and tomato late blight (TLB) by 90%. Through bioassay-guided isolation, five antifungal substances were isolated from the D. asper roots and identified as ß-sitosterol (1), campesterol (2), stigmasterol (3), cauloside A (4) and a novel dipsacus saponin, named colchiside (3-O-ß-d-xylopyranosyl-23-O-ß-d-glucopyranosyl-28-O-ß-d-(6-O-acetyl)-glucopyranosyl hederagenin) (5). Of those, cauloside A (4) displayed the greatest antifungal efficacy against rice blast, TGM and TLB. Colchiside (5) moderately suppressed the development of TLB, but exhibited little effect against the other diseases. The synergistic effects of the isolated compounds against TLB were also assessed. Synergistic and additive interactions were observed between several of the sterol compounds. This study indicated that the crude extracts of, and bioactive substances from, the roots of D. asper suppress TGM and TLB. In addition, cauloside A (4) and colchiside (5) could be used as antifungal lead compounds.

Different clinical courses of children exposed to a single incident of psychological trauma: a 30-month prospective follow-up study.

BACKGROUND: We investigated the distinct longitudinal trajectories of posttraumatic stress symptoms in a sample of 167 children, who witnessed death of two mothers of their schoolmates. METHODS: The cohort was followed-up at 2 days (T1), 2 months (T2), 6 months (T3), and 30 months (T4) after the traumatic event. The children's posttraumatic stress symptoms (T1-T4), depression (T1, T3 and T4), state anxiety (T1, T3 and T4), and quality of life (T4) were assessed, along with parental stress related to child rearing (T4). Different trajectory patterns of the children's posttraumatic stress symptoms were identified using growth mixture modeling (GMM). RESULTS: Four different patterns of symptom change were identified, which were consistent with the prototypical model, and were named Recovery (19.9%), Resilience (72.7%), Chronic Dysfunction (1.8%), and Delayed Reactions (5.6%). Significant differences were found in depression and anxiety scores, children's quality of life, and parental rearing stress according to the distinct longitudinal trajectories of posttraumatic stress symptoms. CONCLUSIONS: The present study suggests that individual differences should be taken into account in the clinical course and outcome of children exposed to psychological trauma. The two most common trajectories were the Resilience and the Recovery types, together suggesting that over 90% of children were evidenced with a favorable 30-month outcome. The latent classes were associated with significant mean differences in depression and anxiety scores, supporting the clinical validity of the distinct trajectories.

The effect of persistent posttraumatic stress disorder symptoms on executive functions in preadolescent children witnessing a single incident of death.

We compared executive functions (EFs) of traumatized preadolescent children with and without marked posttraumatic stress disorder (PTSD) symptoms to the performance of a nontraumatized control group, and examined the relationships between EF deficits and functional status in traumatized preadolescent children. Fifty-one preadolescent children who had witnessed a death at school 30 months prior (26 with marked PTSD symptoms and 25 without) and 30 healthy controls who had not been traumatized participated. EFs were examined using the Comprehensive Attention Test (CAT). The functional state of traumatized children was measured by the Parent Report Form-Children's Health and Illness Profile-Children's Edition (PRF-CHIP-CE). The traumatized children, regardless of status of PTSD symptomatology, showed poorer working memory performance than nontraumatized healthy controls. The traumatized children with marked PTSD symptoms performed more poorly on measures of interference control compared to those children without marked PTSD symptoms. Lower levels of EFs were associated with lower risk avoidance and diminished academic achievement in traumatized children. These results indicate that an inhibitory control deficit is specifically associated with the current PTSD symptoms but not with trauma exposure per se.

A 30-month prospective follow-up study of psychological symptoms, psychiatric diagnoses, and their effects on quality of life in children witnessing a single incident of death at school.

OBJECTIVE: We explored the course of trauma-related psychological symptoms and psychiatric diagnoses in 167 children who, as fourth graders, witnessed death at school and assessed the long-term effects of their symptoms on quality of life and their parents' rearing stress. METHOD: 167 children were evaluated using diverse self-rating symptom scales at 2 days (T1: May 19, 2007), 2 months (T2: July 16, 2007), 6 months (T3: November 12-17, 2007), and 30 months (T4: November 16-21, 2009) after the accident. All children were interviewed with the Diagnostic Interview Schedule for Children-Version IV (DISC-IV) at T1. High-risk children were assessed with the DISC-IV at T3 and T4. Children's quality of life and parental stress were assessed in all children and parents using the Parenting Stress Index and the Child Health and Illness Profile at T4. RESULTS: The mean scores and prevalence of severe posttraumatic stress disorder (PTSD) and anxiety symptoms decreased significantly over time (P < .001), but depressive symptoms did not. Although the prevalence of DISC-IV-based diverse anxiety disorders decreased significantly over time, 45% of high-risk subjects evaluated with the DISC-IV met criteria for an anxiety or depressive disorder at T4. Linear and logistic regression analyses showed that depressive symptoms at 6 months predicted more severe parental stress (ß = 0.51; odds ratio [OR] = 2.88), less satisfaction (ß = -0.25; OR = 2.66), and lower achievement (ß = -0.41; OR = 1.50) at 30 months. PTSD symptoms were not associated with parental stress or quality of life at T4. CONCLUSIONS: This study provides new evidence regarding the long-term course of trauma-related symptoms and diagnostic changes in children exposed to a single trauma. Children's depressive symptoms predicted lower children's quality of life and higher parental rearing stress after 2 years. Careful assessment and management of depressive symptoms can potentially reduce parental stress and improve quality of life of children.

HemoHIM ameliorates the persistent down-regulation of Th1-like immune responses in fractionated γ-irradiated mice by modulating the IL-12p70-STAT4 signaling pathway.

Whole body irradiated mice appear to experience a down-regulation of the helper T (Th)1-like immune response, and maintain a persistent immunological imbalance. In the current study, we evaluated the effect of HemoHIM (an herbal product made from Angelica Radix, Cnidium officinale , and Paeonia japonica cultivated in Korea) to ameliorate the immunological imbalance induce in fractionated γ-irradiated mice. The mice were exposed to γ rays twice a week (0.5 Gy fractions) for a total dose of 5 Gy, and HemoHIM was administrated orally from 1 week before the first irradiation to 1 week before the final analysis. All experiments were performed 4 and 6 months after their first exposure. HemoHIM ameliorated the Th1- and Th2-related immune responses normally occur in irradiated mice with or without dinitrophenylated keyhole limpet hemocyanin immunization. HemoHIM also restored the natural killer cell activities without changing the percentage of natural killer cells in irradiated mice. Furthermore, the administration of HemoHIM prevented the reduction in levels of interleukin-12p70 in irradiated mice. Finally, we found that HemoHIM enhanced the phosphorylation of signal transducer and activator of transcription (STAT) 4 that was reduced in irradiated mice. Our findings suggest that HemoHIM ameliorates the persistent down-regulation of Th1-like immune responses by modulating the IL-12p70/pSTAT4 signaling pathway.

Potent in vivo antifungal activity against powdery mildews of pregnane glycosides from the roots of Cynanchum wilfordii.

Two new pregnane glycosides, kidjoranine 3-O-ß-D-glucopyranosyl-(1 → 4)-ß-D-glucopyranosyl-(1 → 4)-α-L-cymaropyranosyl-(1 → 4)-ß-D-cymaropyranosyl-(1→4)-α-L-diginopyranosyl-(1 → 4)-ß-D-cymaropyranoside (5) and caudatin 3-O-ß-D-glucopyranosyl-(1 → 4)-ß-D-glucopyranosyl-(1 → 4)-α-L-cymaropyranosyl-(1 → 4)-ß-D-cymaropyranosyl-(1 → 4)-α-L-diginopyranosyl-(1 → 4)-ß-D-cymaropyranoside (6), were isolated from the roots of Cynanchum wilfordii along with four known compounds (1-4). The antifungal activities of the six compounds against barley powdery mildew caused by Blumeria graminis f. sp. hordei were compared to the antifungal activity of polyoxin B. The caudatin glycosides (1, 4, and 6) showed stronger antifungal activities than polyoxin B, whereas kidjoranine glycosides (2, 3, and 5) had weaker activities than polyoxin B. A wettable powder-type formulation (C. wilfordii-WP20) of the ethyl acetate extract from C. wilfordii roots prohibited the development of barley powdery mildew much more effectively than the commercial fungicide polyoxin B-WP10. In addition, C. wilfordii-WP20 effectively controlled strawberry powdery mildew caused by Sphaerotheca humuli under greenhouse conditions. Thus, the crude extract containing the pregnane glycosides can be used as a botanical fungicide for the environmentally benign control of powdery mildews.

Identification of correlated genetic variants jointly associated with rheumatoid arthritis using ridge regression.

Using the North American Rheumatoid Arthritis Consortium genome-wide association dataset, we applied ridged, multiple least-squares regression to identify genetic variants with apparent unique contributions to variation of anti-cyclic citrullinated peptide (anti-CCP), a newly identified clinical risk factor for development of rheumatoid arthritis. Within a 2.7-Mbp region on chromosome 6 around the well studied HLA-DRB1 locus, ridge regression identified a single-nucleotide polymorphism that was associated with anti-CCP variation when including the additive effects of other single-nucleotide polymorphisms in a multivariable analysis, but that showed only a weak direct association with anti-CCP. This suggests that multivariable methods can be used to identify potentially relevant genetic variants in regions of interest that would be difficult to detect based on direct associations.

A 6-month follow-up study of posttraumatic stress and anxiety/depressive symptoms in Korean children after direct or indirect exposure to a single incident of trauma.

OBJECTIVES: The aims of this study were to examine the symptoms of posttraumatic stress and anxiety/depression in Korean children after direct or indirect exposure to a single incident of trauma during a fire-escape drill and to assess the incidence of psychiatric disorders in this population. METHOD: A total of 1,394 students who attended the elementary school at which the traumatic event took place were evaluated using self-administered questionnaires (the Child Posttraumatic Stress Disorder-Reaction Index [CPTSD-RI], State Anxiety Scale of the State-Trait Anxiety Inventory for Children [STAIC], and Children's Depression Inventory [CDI]), as well as structured diagnostic interviews (Diagnostic Interview Schedule for Children, Version-IV [DISC-IV]) at 2 days (time point 1), 2 months (time point 2), and 6 months (time point 3) after the incident. The 335 students who witnessed the accident were defined as the direct-exposure group, and the remaining students (n = 1,059) were defined as the indirect-exposure group. The study was conducted from May to November 2007. RESULTS: At time point 1, the prevalence of severe posttraumatic stress disorder (PTSD), anxiety, and depressive symptoms was 18.2%, 5.5%, and 3.4%, respectively. The prevalence of severe PTSD symptoms, as measured by the CPTSD-RI, was significantly higher in the direct-exposure group than in the indirect-exposure group (36.6% vs 12.7%, respectively; P < .001). At time point 2, the prevalence of severe PTSD symptoms was 7.4% (14.0% in the direct-exposure group and 4.9% in the indirect-exposure group, P < .001). The mean total CPTSD-RI score was significantly higher (P < .001) in the direct-exposure group than in the indirect-exposure group. At time point 3, thirty-eight of the 58 subjects (65.5%) evaluated with the DISC-IV in the direct-exposure group had 1 or more of the 7 anxiety/depressive disorders assessed, including subthreshold diagnoses. Among the diagnoses meeting full DSM-IV criteria for each disorder, agoraphobia was the most prevalent (22.4%), followed by generalized anxiety disorder (13.8%), separation anxiety disorder (6.9%), PTSD (5.2%), and social phobia (5.2%). When the subthreshold diagnoses were considered along with the full syndrome diagnoses, separation anxiety disorder was the most common diagnosis (41.4%), followed by agoraphobia (34.5%), obsessive-compulsive disorder (22.4%), PTSD (20.7%), and social phobia (20.7%). CONCLUSIONS: The results of this study provide important evidence that various anxiety/depressive disorders, in addition to PTSD, might follow after direct or indirect exposure to trauma. Our findings highlight the importance of comprehensive screening for psychiatric problems in children exposed to trauma of any scale.