Grass pollen allergoids conjugated with mannan for subcutaneous and sublingual immunotherapy: a dose-finding study.

Background: Polymerized allergoids conjugated with mannan represent a novel approach of allergen immunotherapy targeting dendritic cells. In this study, we aimed to determine the optimal dose of mannan-allergoid conjugates derived from grass pollen (Phleum pratense and Dactylis glomerata) administered via either the subcutaneous or sublingual route. Methods: A randomized, double-blind, placebo-controlled trial with a double-dummy design was conducted, involving 162 participants across 12 centers in Spain. Subjects were randomly allocated to one of nine different treatment groups, each receiving either placebo or active treatment at doses of 500, 1,000, 3,000, or 5,000 mTU/mL over four months. Each participant received five subcutaneous (SC) doses of 0.5 mL each, every 30 days, and a daily sublingual (SL) dose of 0.2 mL. Participants who received active treatment through SC, received placebo through SL. Participants who received active treatment through SL, received placebo SC. One Group, as control, received bot SC and SL placebo. The primary efficacy outcome was the improvement in titrated nasal provocation tests (NPT) at the end of the study compared to baseline. Secondary outcomes included specific antibody (IgG4, IgE) and cellular (IL-10 producing and regulatory T cell) responses. All adverse events and side reactions were recorded and assessed. Results: Post-treatment, the active groups showed improvements in NPT ranging from 33% to 53%, with the highest doses showing the greatest improvements regardless of the administration route. In comparison, the placebo group showed a 12% improvement. Significant differences over placebo were observed at doses of 3,000 mTU/mL (p=0.049 for SL, p=0.015 for SC) and 5,000 mTU/mL (p=0.011 for SL, p=0.015 for SC). A dose-dependent increase in IgG4 was observed following SC administration, and an increase in IL-10 producing cells for both routes of administration. No serious systemic or local adverse reactions were recorded, and no adrenaline was required. Conclusion: Grass pollen immunotherapy with mannan-allergoid conjugates was found to be safe and efficacious in achieving the primary outcome, whether administered via the subcutaneous or sublingual routes, at doses of 3,000 and 5,000 mTU/mL. Clinical trial registration: https://www.clinicaltrialsregister.eu/ctr-search (EudraCT), identifier 2014-005471-88; https://www.clinicaltrials.gov, identifier NCT02654223.

The Causes and Consequences of DNA Damage and Chromosomal Instability Induced by Human Papillomavirus.

High-risk human papillomaviruses (HPVs) are the main cause of cervical, oropharyngeal, and anogenital cancers, which are all treated with definitive chemoradiation therapy when locally advanced. HPV proteins are known to exploit the host DNA damage response to enable viral replication and the epithelial differentiation protocol. This has far-reaching consequences for the host genome, as the DNA damage response is critical for the maintenance of genomic stability. HPV+ cells therefore have increased DNA damage, leading to widespread genomic instability, a hallmark of cancer, which can contribute to tumorigenesis. Following transformation, high-risk HPV oncoproteins induce chromosomal instability, or chromosome missegregation during mitosis, which is associated with a further increase in DNA damage, particularly due to micronuclei and double-strand break formation. Thus, HPV induces significant DNA damage and activation of the DNA damage response in multiple contexts, which likely affects radiation sensitivity and efficacy. Here, we review how HPV activates the DNA damage response, how it induces chromosome missegregation and micronuclei formation, and discuss how these factors may affect radiation response. Understanding how HPV affects the DNA damage response in the context of radiation therapy may help determine potential mechanisms to improve therapeutic response.

Protocolization of Analgesia and Sedation Through Smart Technology in Intensive Care: Improving Patient Safety.

BACKGROUND: The risk of medication errors in intensive care units is high, primarily in the drug administration phase. LOCAL PROBLEM: Management of high-alert medications within intensive care units in the study institution varied widely. The aim of this quality improvement project was to protocolize and centralize the management of high-alert medications in acute care settings and to implement smart intravenous infusion pump technology in intensive care units. METHODS: The project was conducted in 4 phases: (1) protocolization and standardization of intravenous mixtures, (2) centralization of intravenous mixture preparation in the Pharmacy Department, (3) programming of the smart pumps, and (4) dissemination and staged implementation of intravenous mixture protocols. Smart pumps (Alaris, CareFusion) were used to deliver the medicines, and the manufacturer's software (Alaris Guardrails, CareFusion) was used to analyze data regarding adherence to the drug library and the number of programming errors detected. RESULTS: Morphine, remifentanil, fentanyl, midazolam, dexmedetomidine, and propofol were included. After implementation of the smart pumps, 3283 infusions were started; of these, 2198 were programmed through the drug library, indicating 67% compliance with the safety software. The pumps intercepted 398 infusion-related programming errors that led to cancellation or reprogramming of drug infusions. CONCLUSIONS: Protocolization and centralization of the preparation of high-alert sedative and analgesic medications for critically ill patients and the administration of these drugs using smart pump technology decrease variability of clinical practice and intercept potentially serious medication errors.

Evaluation of interactions between the hepatitis C virus NS3/4A and sulfonamidobenzamide based molecules using molecular docking, molecular dynamics simulations and binding free energy calculations.

The Hepatitis C Virus (HCV) NS3/4A is an attractive target for the treatment of Hepatitis C infection. Herein, we present an investigation of HCV NS3/4A inhibitors based on a sulfonamidobenzamide scaffold. Inhibitor interactions with HCV NS3/4A were explored by molecular docking, molecular dynamics simulations, and MM/PBSA binding free energy calculations. All of the inhibitors adopt similar molecular docking poses in the catalytic site of the protease that are stabilized by hydrogen bond interactions with G137 and the catalytic S139, which are known to be important for potency and binding stability. The quantitative assessments of binding free energies from MM/PBSA correlate well with the experimental results, with a high coefficient of determination, R2 of 0.92. Binding free energy decomposition analyses elucidate the different contributions of Q41, F43, H57, R109, K136, G137, S138, S139, A156, M485, and Q526 in binding different inhibitors. The importance of these sidechain contributions was further confirmed by computational alanine scanning mutagenesis. In addition, the sidechains of K136 and S139 show crucial but distinct contributions to inhibitor binding with HCV NS3/4A. The structural basis of the potency has been elucidated, demonstrating the importance of the R155 sidechain conformation. This extensive exploration of binding energies and interactions between these compounds and HCV NS3/4A at the atomic level should benefit future antiviral drug design.

[Analysis of patient safety in the process of drug prescription in research.] / Análisis de la seguridad del paciente en el proceso de prescripción de medicamentos en investigación.

OBJECTIVE: The increasing complexity of clinical trial protocols and the very nature of investigational drugs increase the likelihood of prescribing errors and require comprehensive control and monitoring of treatments. The aim of this study was to measure and analyze the potential risks of prescribing errors in investigational drugs. METHODS: A prospective, descriptive, and observational study was carried out in a third-level hospital in Madrid, for one month in 2017. Manual prescribing errors (EP) in investigational drugs and potential risks of harm to the patient were analyzed. A descriptive statistical analysis was performed, including the absolute and relative frequency for the variables. RESULTS: A total of 254 medical orders corresponding to 327 lines of treatment and 274 different drugs were reviewed, of which 83% were categorized as "high-risk". Results showed 217 (85.4%) EP within the identification of the medical order and 1,045 (319,6%) in the treatment. The risk level of harm to the patient was high for all EP in patient identification and moderate for all EP in the clinical trial identification. The lines of treatment showed an especially high-risk potential for EP in dosage (25%) and frequency (41%). CONCLUSIONS: The high rate of EP found, along with the high-risk potential these entail, reflects the need for improving the security process when prescribing investigational drugs in our field.

OBJETIVO: La creciente complejidad de los protocolos de ensayo clínico y la propia naturaleza de los medicamentos en investigación aumentan la probabilidad de errores de medicación, a la par que exigen un control y seguimiento exhaustivo de los tratamientos. El objetivo de este artículo fue medir y analizar el riesgo potencial de los errores de prescripción de los medicamentos en investigación. METODOS: Se realizó un estudio prospectivo, descriptivo y observacional en un hospital de tercer nivel de Madrid, durante un mes en 2017. Se analizaron los errores de prescripción (EP) manual de medicamentos en investigación y el riesgo potencial de causar daño al paciente. Se realizó un análisis estadístico descriptivo, incluyendo la frecuencia absoluta y relativa para las variables. RESULTADOS: Se revisaron 254 órdenes médicas correspondientes a 327 líneas de tratamiento y 274 medicamentos distintos, de los cuales el 83% se categorizaron de riesgo alto. Se encontraron 217 (85,4%) EP en la identificación de la orden médica y 1.045 (319,6%) en el tratamiento. El nivel de riesgo de causar daño al paciente fue alto para todos los EP de identificación del paciente y moderado para todos los EP de identificación del ensayo clínico. En las líneas de tratamiento, el riesgo potencial fue alto, principalmente en los EP de dosis (25%) y frecuencia (41%). CONCLUSIONES: El elevado número de EP encontrados, junto con el alto riesgo potencial que supone la mayoría de ellos, refleja la necesidad de mejorar la seguridad del proceso de prescripción de medicamentos en investigación en nuestro entorno.

Identification of Small Molecules Exhibiting Oxacillin Synergy through a Novel Assay for Inhibition of vraTSR Expression in Methicillin-Resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) strains that are resistant to all forms of penicillin have become an increasingly common and urgent problem threatening human health. They are responsible for a wide variety of infectious diseases ranging from minor skin abscesses to life-threatening severe infections. The vra operon that is conserved among S. aureus strains encodes a three-component signal transduction system (vraTSR) that is responsible for sensing and responding to cell wall stress. We developed a novel and multifaceted assay to identify compounds that potentiate the activity of oxacillin, essentially restoring efficacy of oxacillin against MRSA, and performed high-throughput screening (HTS) to identify oxacillin potentiators. HTS of 13,840 small-molecule compounds from an antimicrobial-focused Life Chemicals library, using the MRSA cell-based assay, identified three different inhibitor scaffolds. Checkerboard assays for synergy with oxacillin, reverse transcriptase PCR (RT-PCR) assays against vraR expression, and direct confirmation of interaction with VraS by surface plasmon resonance (SPR) further verified them to be viable hit compounds. A subsequent structure-activity relationship (SAR) study of the best scaffold with diverse analogs was utilized to improve potency and provides a strong foundation for further development.

Exploring small molecules with pan-genotypic inhibitory activities against hepatitis C virus NS3/4A serine protease.

Among the many Hepatitis C virus (HCV) genotypes and subtypes, genotypes 1b and 3a are most prevalent in United States and Asia, respectively. A total of 132 commercially available analogs of a previous lead compound were initially investigated against wild-type HCV genotype 1b NS3/4A protease. Ten compounds showed inhibitory activities (IC50 values) below 10 µM with comparable direct binding affinities (KD values) determined by surface plasmon resonance (SPR). To identify pan-genotypic inhibitors, these ten selected compounds were tested against four additional genotypes (1a, 2a, 3a, and 4) and three drug-resistant mutants (A156S, R155K, and V36M). Four new analogs have been identified with better activities against all five tested genotypes than the prior lead compound. Further, the original lead compound did not show activity against genotype 3a NS3/4A, whereas four newly identified compounds exhibited IC50 values below 33 µM against genotype 3a NS3/4A. Encouragingly, the best new compound F1813-0710 possessed promising activity toward genotype 3a, which is a huge improvement over the previous lead compound that had no effect on genotype 3a. This intriguing observation was further analyzed by molecular docking and molecular dynamics (MD) simulations to understand their different binding interactions, which should benefit future pan-genotypic inhibitor design and drug discovery.

Identification and design of novel small molecule inhibitors against MERS-CoV papain-like protease via high-throughput screening and molecular modeling.

The development of new therapeutic agents against the coronavirus causing Middle East Respiratory Syndrome (MERS) is a continuing imperative. The initial MERS-CoV epidemic was contained entirely through public health measures, but episodic cases continue, as there are currently no therapeutic agents effective in the treatment of MERS-CoV, although multiple strategies have been proposed. In this study, we screened 30,000 compounds from three different compound libraries against one of the essential proteases, the papain-like protease (PLpro), using a fluorescence-based enzymatic assay followed by surface plasmon resonance (SPR) direct binding analysis for hit confirmation. Mode of inhibition assays and competition SPR studies revealed two compounds to be competitive inhibitors. To improve upon the inhibitory activity of the best hit compounds, a small fragment library consisting of 352 fragments was screened in the presence of each hit compound, resulting in one fragment that enhanced the IC50 value of the best hit compound by 3-fold. Molecular docking and MM/PBSA binding energy calculations were used to predict potential binding sites, providing insight for design and synthesis of next-generation compounds.

Failure mode and effects analysis applied to the administration of liquid medication by oral syringes.

OBJECTIVE: To carry out a Failure Mode and Effects Analysis (FMEA) to the use of oral syringes. METHODS: A multidisciplinary team was assembled within the Safety Committee.  The stages of oral administration process of liquid  medication were analysed, identifying the most critical and establishing the  potential modes of failure that can cause errors. The impact associated with  each mode of failure was calculated using the Risk Priority Number (RPN).  Preventive actions were proposed. RESULTS: Five failure modes were identified, all classified as high risk (RPN>  100). Seven of the eight preventive actions were implemented. CONCLUSIONS: The FMEA methodology was a useful tool. It has allowed to know  the risks, analyse the causes that cause them, their effects on patient safety and  the measures to reduce them.

Objetivo: Realizar un análisis modal de fallos y efectos (AMFE) aplicado a la utilización de jeringas orales.Métodos: Un grupo multidisciplinar dentro del Comité de Seguridad analizó las etapas en la administración oral de los medicamentos líquidos, identificándose las más críticas y estableciendo modos potenciales de fallo que podrían producir un error. El riesgo asociado a cada modo de fallo se calculó  utilizando el número de prioridad de riesgo (NPR). Se sugirieron acciones preventivas.Resultados: Se identificaron cinco modos de fallo, todos clasificados de alto  riesgo (NPR>100). Siete de las ocho recomendaciones fueron implementadas.Conclusiones: La aplicación de la metodología AMFE ha sido una herramienta muy útil que ha permitido conocer los riesgos, analizar las causas que los pueden provocar y saber los efectos que tienen en la seguridad del paciente; todo ello con el fin de implantar acciones para  reducirlos.

Identification of novel small molecule inhibitors against NS2B/NS3 serine protease from Zika virus.

Zika flavivirus infection during pregnancy appears to produce higher risk of microcephaly, and also causes multiple neurological problems such as Guillain-Barré syndrome. The Zika virus is now widespread in Central and South America, and is anticipated to become an increasing risk in the southern United States. With continuing global travel and the spread of the mosquito vector, the exposure is expected to accelerate, but there are no currently approved treatments against the Zika virus. The Zika NS2B/NS3 protease is an attractive drug target due to its essential role in viral replication. Our studies have identified several compounds with inhibitory activity (IC50) and binding affinity (KD) of ∼5-10 µM against the Zika NS2B-NS3 protease from testing 71 HCV NS3/NS4A inhibitors that were initially discovered by high-throughput screening of 40,967 compounds. Competition surface plasmon resonance studies and mechanism of inhibition analyses by enzyme kinetics subsequently determined the best compound to be a competitive inhibitor with a Ki value of 9.5 µM. We also determined the X-ray structure of the Zika NS2B-NS3 protease in a "pre-open conformation", a conformation never observed before for any flavivirus proteases. This provides the foundation for new structure-based inhibitor design.

Inhibitor recognition specificity of MERS-CoV papain-like protease may differ from that of SARS-CoV.

The Middle East Respiratory Syndrome coronavirus (MERS-CoV) papain-like protease (PLpro) blocking loop 2 (BL2) structure differs significantly from that of SARS-CoV PLpro, where it has been proven to play a crucial role in SARS-CoV PLpro inhibitor binding. Four SARS-CoV PLpro lead inhibitors were tested against MERS-CoV PLpro, none of which were effective against MERS-CoV PLpro. Structure and sequence alignments revealed that two residues, Y269 and Q270, responsible for inhibitor binding to SARS-CoV PLpro, were replaced by T274 and A275 in MERS-CoV PLpro, making critical binding interactions difficult to form for similar types of inhibitors. High-throughput screening (HTS) of 25 000 compounds against both PLpro enzymes identified a small fragment-like noncovalent dual inhibitor. Mode of inhibition studies by enzyme kinetics and competition surface plasmon resonance (SPR) analyses suggested that this compound acts as a competitive inhibitor with an IC50 of 6 µM against MERS-CoV PLpro, indicating that it binds to the active site, whereas it acts as an allosteric inhibitor against SARS-CoV PLpro with an IC50 of 11 µM. These results raised the possibility that inhibitor recognition specificity of MERS-CoV PLpro may differ from that of SARS-CoV PLpro. In addition, inhibitory activity of this compound was selective for SARS-CoV and MERS-CoV PLpro enzymes over two human homologues, the ubiquitin C-terminal hydrolases 1 and 3 (hUCH-L1 and hUCH-L3).

Home-based oral immunotherapy protocol with pasteurized egg for children allergic to hen's egg.

BACKGROUND: In the last decade the use of different types of oral immunotherapy for food-allergic patients has increased with generally satisfactory outcomes. Cow's milk and hen's egg, a common element in the daily diet, have received the main interest. Most of these immunotherapy regimens are performed in the hospital, causing inconvenience for both children and their parents. OBJECTIVES: To assess the efficacy and safety of a home-based oral immunotherapy regimen with raw pasteurized egg. METHODS: The study group comprised children aged 6 years and older with allergy to hen's egg proteins, proven by positive skin prick-tests (SPT) and/orspecific immunoglobulin E (sIgE) and positive open oral food challenge (OOFC) with boiled or raw egg. Patients who met the inclusion criteria and signed the informed consent form underwent egg immunotherapy according to an established schedule. RESULTS: The treatment was given to 31 of the 36 recruited patients: 80.6% of the intention-to-treat population achieved complete tolerance to the maximum dose equivalent to one raw hen's egg, 3.2% achieved incomplete tolerance, and 16.2% did not achieve an acceptable tolerance dose. Most of the latter patients had a positive baseline OOFC with low doses of boiled egg. The average number of reactions per treated patient was 5.8, most of them grades 1 and 2; there were no grade 4 reactions. CONCLUSIONS: This home-based oral immunotherapy protocol proved to effectively induce tolerance to hen's egg in most of the egg-allergic children and its safety profile was acceptable.