Solution Oligonucleotide APIs: Regulatory Considerations.

Manufacture of oligonucleotide active pharmaceutical ingredients (APIs) typically consists of solid-phase synthesis, deprotection and cleavage, purification and filtration, and isolation from aqueous solutions through lyophilization. In the first step of drug product manufacture, the API is dissolved in water again and excipients are added. While isolation of oligonucleotide APIs can be meaningful in many cases, there may be cases where keeping the API in solution provides benefit, and multiple technical aspects must be taken into account and balanced when determining the appropriate API form. A significant factor is whether an API in solution will contain additional components. While APIs in solution containing additional components (so-called formulated APIs) are well established for biological products, there are regulatory guidelines in place that represent hurdles for industry to using a formulated API approach for oligonucleotide drugs. The present communication outlines conditions where a formulated API approach can be chosen in compliance with existing guidelines. Relevant aspects pertaining to risk management, GMP standards, facility design, control strategies, and regulatory submission content are discussed. In addition, the authors propose that existing guidelines be modernized to enable the use of a formulated API approach for additional reasons than the ones described in the existing regulatory framework. The manuscript aims to promote a dialog with regulators in this field.

Preliminary data demonstrate the Geriatric Surgery Verification program reduces postoperative length of stay.

OBJECTIVES/BACKGROUND: The Geriatric Surgery Verification (GSV) Program promotes clinical standards aimed to optimize the quality of surgical care delivered to older adults. The purpose of this study was to determine if preliminary implementation of the GSV Program standards improves surgical outcomes. DESIGN: Prospective study with cohort matching. SETTING: Data from a single institution compared with a national data set cohort. PARTICIPANTS: All patients aged ≥75 years undergoing inpatient operations between January 2018 and December 2019 were included. Cohort matching by age and procedure code was performed using a national data set. MEASUREMENTS: Baseline pre- and intraoperative characteristics prospectively recorded using Veterans Affairs Surgical Quality Improvement Program (VASQIP) variable definitions. Postoperative outcomes were recorded including complications as defined by VASQIP, 30-day mortality, and length of stay. RESULTS: A total of 162 patients participated in the GSV program, and 308 patients comprised the matched comparison group. There was no difference in postoperative occurrence of one or more complications (p = 0.81) or 30-day mortality (p = 0.61). Patients cared for by the GSV Program had a reduced postoperative length of stay (median 4 days [range 1,31] vs. 5 days [range 1,86]; p < 0.01; and mean 5.4 ± 4.8 vs. 8.8 ± 11.8 days; p < 0.01) compared with the matched cohort. In a multivariable regression model, the GSV Program's reduced length of stay was independent of other associated covariates including age, operative time, and comorbidities (p < 0.01). CONCLUSION: Preliminary implementation of the GSV Program standards reduces length of stay in older adults undergoing inpatient operations. This finding demonstrates both the clinical and financial value of the GSV Program.

Evaluation of a Presurgical Pregnancy Testing Protocol at an Ambulatory Surgery Center.

PURPOSE: A presurgical pregnancy testing protocol is recommended to prevent the administration of surgery and anesthesia to women of childbearing years who present for surgery with an undetected pregnancy. It is important to determine the compliance, cost analysis, time required, and barriers to complete a presurgical pregnancy testing protocol. DESIGN: Postimplementation qualitative and quantitative evaluation of a presurgical pregnancy protocol. METHODS: A review of the patient's electronic medical record, survey of the nursing staff, and an administrative interview was conducted 1 year after implementation of the presurgical pregnancy protocol. FINDINGS: Overall presurgical pregnancy protocol compliance was 0.7%. The total labor and equipment costs were $19,033 to $30,202 per year. Nurses reported significant time- and patient-related barriers to execute the protocol. CONCLUSIONS: A pregnancy testing protocol is a valuable safety measure that faces barriers, which can impede compliance. Through the use of simplified protocols, educational interventions for patients and providers, protocol compliance can be increased.

The evaluation of the implementation of the vascular preventative bundle and development of suggested interventions for improvement and sustainability.

Postoperative infections can complicate patient care and increase health care costs. A vascular preventative bundle was implemented at a large teaching/research intensive hospital to decrease surgical site infections (SSIs) with vascular surgery patients. The aim of this study was to measure fidelity to the bundle and determine if implementation of the vascular SSI bundle reduced the rate of SSIs. Three periods of data were collected, and they are identified as preimplementation (period 1), early implementation (period 2), and postimplementation (period 3). There were 711 patients for all three periods, approximately equally distributed in the periods. The use of preoperative hair clippings, chlorhexidine (CHG) wipes, and appropriate antibiotics showed the greatest improvement from preimplementation to early implementation. All three measures showed significant improvements in fidelity. For appropriate antibiotics, the fidelity was the highest and showed the largest improvement compared to the other measures. The performance of clippings preoperatively and using CHG wipes improved significantly. Evidence-based interventions have been recommended to support the implementation and sustainability of the bundle. The infection rate between preop and postperiod was not statistically different.

Fast accrual of C and N in soil organic matter fractions following post-mining reclamation across the USA.

Reclamation of post-mining sites commonly results in rapid accrual of carbon (C) and nitrogen (N) contents due to increasing plant inputs over time. However, little information is available on the distribution of C and N contents with respect to differently stabilized soil organic matter (SOM) fractions during succession or as a result of different reclamation practice. Hence, it remains widely unknown how stable or labile these newly formed C and N pools are. Gaining a deeper understanding of the state of these pools may provide important implications for reclamation practices with respect to C sequestration. We thus investigated C, N, and plant-derived compounds in bulk soil and SOM fractions during succession in post-mining chronosequences (reclaimed with overburden or salvaged topsoil) located along a northwest to southeast transect across the USA. Our results indicate that current reclamation practices perform well with respect to rapid recovery of soil aggregates and the partitioning of C and N to different SOM fractions, these measures being similar to those of natural climax vegetation sites already 2-5 years after reclamation. A general applicability of our results to other post-mining sites with similar reclamation practices may be inferred from the fact that the observed patterns were consistent along the investigated transect, covering different climates and vegetation across the USA. However, regarding SOM stability, the use of salvaged topsoil may be beneficial as compared to that of overburden material because C and N in the fraction regarded as most stable was by 26 and 35% lower at sites restored with overburden as compared to those restored with salvaged topsoil. Plant-derived compounds appeared to be mainly related to bio-available particulate organic matter and particulate organic matter partly stabilized within aggregates, challenging the long-term persistence of plant input C in post-mining soils.

Improving Preoperative Throughput.

Preoperative throughput is an important piece in achieving the perioperative goal for first case on time starts. An inefficient preoperative (preop) department can delay surgery starts and impact the patient flow throughout the day. Research is abundant in applying lean six sigma principles in the operating room, however there are minimal studies that specifically apply these tools in the preop. The perioperative process includes the preop, operating room, and the postoperative departments. All areas have to run like a well-oiled machine to improve performance and achieve positive outcomes. This article will discuss the implementation of new practices in preop along with the benefits and obstacles identified during the pilot study.

Use of Baby Isao Simulator and Standardized Parents in Hearing Screening and Parent Counseling Education.

PURPOSE: The primary purpose of this study was to test the effect of the combined use of trained standardized parents and a baby simulator on students' hearing screening and parental counseling knowledge and skills. METHOD: A one-group pretest-posttest quasi-experimental study design was used to assess self-ratings of confidence in knowledge and skills and satisfaction of the educational experience with standardized parents and a baby simulator. The mean age of the 14 audiology students participating in this study was 24.79 years (SD = 1.58). Participants completed a pre- and postevent questionnaire in which they rated their level of confidence for specific knowledge and skills. Six students (2 students in each scenario) volunteered to participate in the infant hearing screening and counseling scenarios, whereas others participated as observers. All participants participated in the briefing and debriefing sessions immediately before and after each of 3 scenarios. After the last scenario, participants were asked to complete a satisfaction survey of their learning experience using simulation and standardized parents. RESULTS: Overall, the pre- and post-simulation event questionnaire revealed a significant improvement in the participants' self-rated confidence levels regarding knowledge and skills. The mean difference between pre- and postevent scores was 0.52 (p < .01). The mean satisfaction level was 4.71 (range = 3.91-5.00; SD = 0.30) based on a Likert scale, where 1 = not satisfied and 5 = very satisfied. CONCLUSIONS: The results of this novel educational activity demonstrate the value of using infant hearing screening and parental counseling simulation sessions to enhance student learning. In addition, this study demonstrates the use of simulation and standardized parents as an important pedagogical tool for audiology students. Students experienced a high level of satisfaction with the learning experience.

Computer Simulation Shows the Effect of Communication on Day of Surgery Patient Flow.

To improve patient flow in a surgical environment, practitioners and academicians often use process mapping and simulation as tools to evaluate and recommend changes. We used simulations to help staff visualize the effect of communication and coordination delays that occur on the day of surgery. Perioperative services staff participated in tabletop exercises in which they chose the delays that were most important to eliminate. Using a day-of-surgery computer simulation model, the elimination of delays was tested and the results were shared with the group. This exercise, repeated for multiple groups of staff, provided an understanding of not only the dynamic events taking place, but also how small communication delays can contribute to a significant loss in efficiency and the ability to provide timely care. Survey results confirmed these understandings.

Using scattering theory to compute invariant manifolds and numerical results for the laser-driven Hénon-Heiles system.

Scattering theory is a convenient way to describe systems that are subject to time-dependent perturbations which are localized in time. Using scattering theory, one can compute time-dependent invariant objects for the perturbed system knowing the invariant objects of the unperturbed system. In this paper, we use scattering theory to give numerical computations of invariant manifolds appearing in laser-driven reactions. In this setting, invariant manifolds separate regions of phase space that lead to different outcomes of the reaction and can be used to compute reaction rates.

The effect of mercury on trees and their mycorrhizal fungi.

The Oak Ridge Reservation, established in 1942, was the designated site for the construction of the atomic bomb. During a 20-year period from 1944 to 1963 radioactive and toxic chemical pollutants, especially mercury compounds were released into the surrounding waterways. Tree diversity and mycorrhizal presence and abundance were analyzed in the mercury-contaminated floodplains of East Fork Poplar Creek Oak Ridge (EFPC) (Tennessee). A subsequent greenhouse study was conducted to assess the phytotoxic effects of different mercuric solutions on Platanus occidentalis (American Sycamore), inoculated with soils from EFPC. Total soil mercury in the field had no effect on tree diversity. Organic species of mercury proved to be more toxic than inorganic species of mercury and soil inoculants from EFPC had no protective effects against Hg toxicity in our greenhouse study. Comparison of the effects of mercury contamination in our field and greenhouse studies was difficult due to uncontrolled factors.

Restoring forests and associated ecosystem services on appalachian coal surface mines.

Surface coal mining in Appalachia has caused extensive replacement of forest with non-forested land cover, much of which is unmanaged and unproductive. Although forested ecosystems are valued by society for both marketable products and ecosystem services, forests have not been restored on most Appalachian mined lands because traditional reclamation practices, encouraged by regulatory policies, created conditions poorly suited for reforestation. Reclamation scientists have studied productive forests growing on older mine sites, established forest vegetation experimentally on recent mines, and identified mine reclamation practices that encourage forest vegetation re-establishment. Based on these findings, they developed a Forestry Reclamation Approach (FRA) that can be employed by coal mining firms to restore forest vegetation. Scientists and mine regulators, working collaboratively, have communicated the FRA to the coal industry and to regulatory enforcement personnel. Today, the FRA is used routinely by many coal mining firms, and thousands of mined hectares have been reclaimed to restore productive mine soils and planted with native forest trees. Reclamation of coal mines using the FRA is expected to restore these lands' capabilities to provide forest-based ecosystem services, such as wood production, atmospheric carbon sequestration, wildlife habitat, watershed protection, and water quality protection to a greater extent than conventional reclamation practices.

Comparing pure-, pulsed, and warbled tone thresholds in adults at 3000 and 6000 Hz.

PURPOSE: Pulsed and warbled tones are suitable substitutions for pure tones in hearing threshold measurement according to the 2005 American Speech-Language-Hearing Association guidelines. These guidelines also recommend measuring thresholds at 3000 and 6000 Hz. To date, there is no research directly supporting substitution of pulsed or warbled tones for pure tones at 3000 and 6000 Hz for listeners with normal hearing or with hearing loss. This study compared pure-, pulsed, and warbled tone thresholds at 3000 and 6000 Hz. METHOD: Forty-seven adults with normal hearing and 16 adults with sensorineural hearing loss participated in this study. Air-conduction thresholds were elicited with pure tones at octave intervals from 250 to 8000 Hz and with pure-, pulsed, and warbled tone stimuli at 3000 and 6000 Hz. RESULTS: Small mean differences in thresholds were obtained using each of the 3 stimulus types for both listeners with normal hearing and hearing loss. Some of the mean differences tested were found to be statistically significant. The differences were nevertheless small and in all cases within the clinically accepted 5-dB step size. CONCLUSION: Although substitutions did not violate the 5-dB step size, the slope of a listener's hearing loss may be a factor in the inaccuracy of measurement during the substitution of warbled tones for pure tones.

Collaborative genome-wide association analysis supports a role for ANK3 and CACNA1C in bipolar disorder.

To identify susceptibility loci for bipolar disorder, we tested 1.8 million variants in 4,387 cases and 6,209 controls and identified a region of strong association (rs10994336, P = 9.1 x 10(-9)) in ANK3 (ankyrin G). We also found further support for the previously reported CACNA1C (alpha 1C subunit of the L-type voltage-gated calcium channel; combined P = 7.0 x 10(-8), rs1006737). Our results suggest that ion channelopathies may be involved in the pathogenesis of bipolar disorder.

Follow-up of alcohol septal ablation for symptomatic hypertrophic obstructive cardiomyopathy the Baylor and Medical University of South Carolina experience 1996 to 2007.

OBJECTIVES: This study sought to determine the long-term outcome of alcohol septal ablation (ASA). BACKGROUND: There are inadequate data on the long-term outcome of ASA for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). METHODS: Six hundred and twenty-nine patients were enrolled consecutively (1996 to 2007) and 98.4% (n = 619) underwent ASA with 92% follow-up in 2007. Evaluation included deaths, procedural complications, pacemaker requirement, repeat ASA, and myectomy/valve surgery. Follow-up parameters included angina (Canadian Cardiovascular Society score), dyspnea (New York Heart Association functional class), exercise time, and echocardiographic indices (septal thickness, ejection fraction, resting and provoked gradients). RESULTS: Ethanol (2.6 +/- 1.0 ml) was injected into 1.3 +/- 0.5 septal arteries, inducing a septal infarct. Complications included death 1% (n = 6), permanent pacemaker requirement 8.2% (n = 52), coronary dissection 1.3% (n = 8), and worsening mitral regurgitation 0.3% (n = 2). The mean follow-up was 4.6 +/- 2.5 years (range: 3 months to 10.2 years). During follow-up, New York Heart Association functional class decreased from 2.8 +/- 0.6 to 1.2 +/- 0.5 (p < 0.001); Canadian Cardiovascular Society angina score decreased from 2.1 +/- 0.9 to 1.0 +/- 0 (p < 0.001); and exercise time increased from 4.8 +/- 3.3 to 8.2 +/- 1.0 (p < 0.001) min. The resting and provoked left ventricular outflow tract gradients decreased progressively (p < 0.001) and remained low during follow-up. The septal thickness decreased from 2.1 +/- 0.5 cm to 1.0 +/- 0.1 cm (p < 0.001) and the ejection fraction decreased from 68 +/- 9% to 62 +/- 3% (p < 0.001). The survival estimates at 1, 5, and 8 years were 97%, 92%, and 89%, respectively. CONCLUSIONS: The initial benefits of ASA were maintained during follow-up.

Initial experience with alcohol septal ablation using a novel magnetic navigation system.

OBJECTIVES: We compared the use of magnetically assisted intervention (MAI) with conventional guidewire techniques to perform alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Treatment of symptomatic patients with HOCM using ASA has been established as an effective therapy. However, in many cases cannulaton of the septal artery can be technically challenging. Recently, a magnetically directed guidewire system has been developed to assist in navigation in difficult percutaneous interventions. By directing the guidewire to the septal branch, this system has potential to shorten the procedure time and increase success and safety of ASA in patients with HOCM. METHODS: From October 2004 through October 2006, 44 consecutive patients underwent ASA using MAI with the Niobe system (Stereotaxis, Inc., St. Louis, MO). We compared these patients to 29 age- and gradient-matched cases using conventional techniques performed by an operator with >100 prior cases. RESULTS: All procedures were successful. Both the MAI and conventional groups had improved symptoms, exercise times, and reduced gradients compared with baseline. One dissection occurred in the conventional group. Although there were no aggregate differences in acute or 3-month clinical outcomes, the time required for guidewire cannulation of the septal branch decreased progressively with increasing experience (third tertile vs first tertile (3 [1.25-4.75 vs 10.5 [6-17] minutes, P = 0.004) compared with the conventional group (6 [2-10.25] minutes, P = 0.075 vs third tertile), suggesting a learning curve for MAI. CONCLUSIONS: MAI has the potential to improve wiring time and outcomes of HOCM patients undergoing ASA.

Effectiveness of percutaneous intervention for patients with obstructive hypertrophic cardiomyopathy and coronary artery disease.

Seven patients with obstructive hypertrophic cardiomyopathy and single-vessel coronary artery disease underwent percutaneous revascularization of the coronary lesion in addition to alcohol septal ablation therapy for dynamic outflow tract obstruction. One year later, there was a significant reduction of dynamic left ventricular outflow tract obstruction and no clinical evidence of restenosis.

AGML Central: web based gel proteomic infrastructure.

SUMMARY: AGML Central is a web-based open-source public infrastructure for dissemination of two-dimensional Gel Electrophoresis (2-DE) proteomics data in AGML format (Annotated Gel Markup Language). It includes a growing collection of converters from proprietary formats such as those produced by PDQUEST (BioRad), PHORETIX 2-D (Nonlinear Dynamics) and Melanie (GenBio SA). The resulting unifying AGML formatted entry, with or without the raw gel images, is optionally stored in a database for future reference. AGML Central was developed to provide a common platform for data dissemination and development of 2-DE data analysis tools. This resource responds to an increasing use of AGML for 2-DE public source data representation which requires automated tools for conversion from proprietary formats. Conversion and short-term storage is made publicly available, permanent storage requires prior registering. A JAVA applet visualizer was developed to visualize the AGML data with cross-reference links. In order to facilitate automated access a SOAP web service is also included in the AGML Central infrastructure. AVAILABILITY: http://bioinformatics.musc.edu/agmlcentral.

Ion uptake in Pinus banksiana treated with sodium chloride and sodium sulphate.

Within its wide range across Canada, jack pine is exposed to salinity from both natural and anthropogenic sources. To compare the effects of Cl and SO(4) on salt injury, sand and solution-culture grown jack pine (Pinus banksiana Lamb.) seedlings were treated with nutrient solutions containing 60 or 120 mM NaCl, 60 mM Na(2)SO(4), or a mixture of 60 mM NaCl and 30 mM Na(2)SO(4). After 5 weeks of salt treatments, concentrations of Cl, K, Na, and SO(4) were determined in roots, stem and needles of the current and previous years growth, and in necrotic needles. To determine the role of water uptake in the absorption and translocation of salts in plants, total transpiration was measured as the loss of water from a sealed system and related to total plant uptake of Cl, Na, and SO(4). Sodium uptake and root-to-shoot transport rates were greater in treatments containing Cl. A delay in root-to-shoot transport of both Na and Cl indicates retention of these ions in the roots. Electrolyte leakage of needles was more closely related to treatment Cl concentrations than treatment Na concentrations. The transport of Na ions to the shoot was related to the presence of Cl, but was not related to transpiration rate.

Predictors of outcome after alcohol septal ablation therapy in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND: Alcohol septal ablation (ASA) therapy results in clinical and hemodynamic improvement in patients with hypertrophic obstructive cardiomyopathy. However, a subset remains symptomatic afterward, requiring additional procedures. We sought to examine the determinants of an unsatisfactory outcome, defined as unchanged symptoms with <50% reduction of baseline left ventricular outflow tract (LVOT) gradient. METHODS AND RESULTS: Of 173 consecutive hypertrophic obstructive cardiomyopathy patients who underwent ASA, 39 had an unsatisfactory outcome after the first procedure. Patients with an unsatisfactory outcome had a higher baseline LVOT gradient, fewer septal arteries injected with ethanol, lower peak creatine kinase (CK), smaller septal area opacified by contrast echocardiography, and higher residual gradient in the catheterization laboratory after ASA (all P<0.05). Symptoms, septal thickness, mitral regurgitation severity, and ventricular function were not determinants of outcome. On multiple logistic regression, LVOT gradient reduction after ASA in the catheterization laboratory to > or =25 mm Hg (OR, 5.5; P=0.01) and peak CK <1300 U/L (OR, 2.5; P=0.04) were the independent predictors of an unsatisfactory outcome. CONCLUSIONS: The residual LVOT gradient in the catheterization laboratory and peak CK leak after ASA are the independent predictors of ASA outcome.