Assessing Physicochemical Stability of Monoclonal Antibodies in a Simulated Subcutaneous Environment.

Monoclonal antibodies (mAbs) are being increasingly administered by the subcutaneous (SC) route compared to the traditional intravenous route. Despite the growing popularity of the subcutaneous route, our current knowledge regarding the intricate mechanistic changes happening in the formulation after injection in the subcutaneous space, as well as the in vivo stability of administered mAbs, remains quite limited. Changes in the protein environment as it transitions from a stabilized, formulated drug product in an appropriate container closure to the SC tissue environment can drastically impact the structural stability and integrity of the injected protein. Interactions of the protein with components of the extracellular matrix can lead to changes in its structure, potentially impacting both safety and efficacy. Investigating protein stability in the SC space can enable early assessment of risk and performance of subcutaneously administered proteins influencing clinical decisions and formulation development strategies. The Subcutaneous Injection Site Simulator (SCISSOR) is a novel in vitro system that mimics the subcutaneous injection site and models the events that a protein goes through as it transitions from a stabilized formulation environment to the dynamic physiological space. In this paper, we utilize the SCISSOR to probe for biophysical and chemical changes in seven mAbs post SC injection using a variety of analytical techniques. After 24 h, all mAbs demonstrated a relative decrease in conformational stability, an increase in fragmentation, and elevated acidic species. Higher order structure analysis revealed a deviation in the secondary structure from the standard and an increase in the number of unordered species. Our findings suggest an overall reduced stability of mAbs after subcutaneous administration. This reduced stability could have a potential impact on safety and efficacy. In vitro systems such as the SCISSOR combined with downstream analyses have potential to provide valuable information for assessing the suitability of lead molecules and aid in formulation design optimized for administration in the intended body compartment, thus improving chances of clinical success.

The minimum effective dose (ED90) of prophylactic oxytocin infusion during cesarean delivery in patients with and without obesity: an up-down sequential allocation dose-response study.

BACKGROUND: Obesity is associated with greater oxytocin requirement during labor induction or augmentation. There are scant data exploring the intra-operative requirement during cesarean delivery in patients with obesity, and none comparing it with those without obesity. We evaluated the minimum effective dose (ED90) of an oxytocin infusion to achieve adequate uterine tone during cesarean delivery in patients with and without obesity. METHODS: Patients (body mass index ≥30 kg/m2 represented patients with obesity) undergoing cesarean delivery using subarachnoid block were included. This prospective dual-arm dose-finding study used a 9:1 biased sequential allocation design. Oxytocin infusion was initiated at 13 IU/h at cord clamping in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician four minutes after initiation of the infusion. The dose of oxytocin infusion for subsequent patients was determined according to the response of the previous patient in the group. Oxytocin-associated side effects were evaluated. Dose-response data for the groups was evaluated using log-logistic function and ED90 estimates derived from fitted equations using the delta method. RESULTS: The ED90 of oxytocin was significantly higher for patients with obesity (n = 40) compared with those without obesity (n = 40) [25.7 IU/h, 95% CI 18.6 to 32.9) vs. 16.6 IU/h, 95% CI 14.9 to 18.3)]; relative ratio 1.55 [95% CI 1.09 to 2.01] (P = 0.019). CONCLUSIONS: Patients with obesity require a higher intra-operative oxytocin infusion dose rate to achieve a satisfactorily contracted uterus after fetal delivery when compared with patients without obesity.

Dosimetric correlation of bone marrow irradiation with acute hematological toxicity in concurrent chemoradiation of cervical carcinoma patients.

Background: Many acute toxicities are associated with concurrent chemoradiation in cervical carcinoma, which includes burning micturition, burning defecation, pain lower abdomen, increased frequency of stools along with Acute Hematological Toxicity (AHT). AHT is often an expected adverse effect, which can lead to treatment interruptions and decreased response rates. The purpose of this study is to analyze if there are any dosimetric constraints on the volume of bone marrow irradiated with AHT in cervical carcinoma patients treated with concurrent chemoradiation. Material and Methods: In this retrospective study of 215 patients, a total of 180 patients were eligible for analysis. Multiple parameters of bone marrow volumes (whole pelvis bone marrow and its sub-volumes--ilium, lower pelvis, and lumbosacral spine) which were contoured individually for all patients were assessed to have any statistically significant association with AHT. Results: The median age of the cohort was 57 years and majority of cases were locally advanced (stage IIB-IVA: 88.3%). Grade I, II, III leukopenia was seen in 44, 25, and 6 patients, respectively. A statistically significant correlation between grade 2+ and 3+ leukopenia was seen if bone marrow V10, V20, V30, and V40 were more than 95%, 82%, 62%, and 38%, respectively. In subvolume analysis, volumes of lumbosacral spine V20, V30, and V40 more than 95%, 90%, and 65%, respectively, were statistically significant for AHT. Conclusion: Bone marrow volumes should also be given a constraint and should be tried to be achieved so that it leads to minimal treatment breaks due to AHT.

Practices of Procedural Pain Management in Neonates through Continuous Quality Improvement Measures.

OBJECTIVE: Although the benefits of pain control measures in neonates are well known, the actual usage was not optimal in our unit. Therefore, we implemented a quality improvement project to improve pain management practices through multiple Plan-Do-Study-Act (PDSA) cycles. METHOD: Our project included hemodynamically stable newborns weighing ≥1300 g. We identified four common procedures: intravenous cannulation, venous sampling, heel prick, and nasogastric tube insertion. The selected pain control measures were skin-to-skin contact, breastfeeding, expressed breast milk orally, and oral sucrose. Between April 2019 and September 2019, we intervened multiple times and reassessed shortcomings. We encouraged evidence-based practices and gave solutions for shortcomings. Data were interpreted weekly to assess the compliance to pain control interventions. RESULTS: Minimal pain control measures (3-4%) were utilized for identified procedures before the project began. We could improve the use of pain control measures steadily and achieve the target of 80% of procedures after seven different interventions over five months. There was a retention of the effect on reassessing twice at second and fourth months of stopping further intervention once the target got achieved. CONCLUSION: Quality Improvement science can identify the shortcomings and help to improve the compliance for pain control practices in neonates, as demonstrated in this neonatal unit.

Utility of High Resolution 2D NMR Fingerprinting in Assessing Viscosity of Therapeutic Monoclonal Antibodies.

PURPOSE: The viscosity of highly concentrated therapeutic monoclonal antibody (mAb) formulations at concentrations ≥ 100 mg/mL can significantly affect the stability, processing, and drug product development for subcutaneous delivery. An early identification of a viscosity prone mAb during candidate selection stages are often beneficial for downstream processes. Higher order structure of mAbs may often dictate their viscosity behavior at high concentration. Thus it is beneficial to gauge or rank-order their viscosity behavior using noninvasive structural fingerprinting methods and to potentially screen for suitable viscosity lowering excipients. METHODS: In this study, Dynamic Light Scattering (DLS) and 2D NMR based methyl fingerprinting were used to correlate viscosity behavior of a set of Pfizer mAbs. The viscosities of mAbs were determined. Respective Fab and Fc domains were generated for studies. RESULT: Methyl fingerprinting of intact mAbs allows for differentiation of viscosity prone mAbs from well behaved ones even at 30-40 mg/ml, where bulk viscosity of the solutions are near identical. For viscosity prone mAbs, peak broadening and or distinct chemical shift changes were noted in intact and fragment fingerprints, unlike the well-behaved mAbs, indicative of protein protein interactions (PPI). CONCLUSION: Fab-Fab or Fab-Fc interactions may lead to formation of protein networks at high concentration. The early transients to these network formation may be manifested through peak broadening or peak shift in the 2D NMR spectrum of mAb/mAb fragments. Such insights go beyond rank ordering mAbs based on viscosity behavior, which can be obtained by other methods as well..

Correction to "Water-Soluble Blue Fluorescent Nonconjugated Polymer Dots from Hyaluronic Acid and Hydrophobic Amino Acids".

[This corrects the article DOI: 10.1021/acsomega.1c01343.].

Impact of sarcopenia in locally advanced head and neck cancer treated with chemoradiation: An Indian tertiary care hospital experience.

BACKGROUND: Sarcopenia is emerging as a poor prognostic factor in terms of treatment outcome as well as complications in cancer patients. This study aims to determine the prevalence of sarcopenia and its impact on outcome and toxicity in head and neck squamous cell carcinoma (HNSCC) patients treated with definitive chemo radiotherapy. MATERIAL AND METHODS: Three hundred patients of locally advanced HNSCC were included. All patients were treated with radical radiotherapy dose of 70 Gy/35# over 7 weeks along with concurrent chemotherapy. Sarcopenia was assessed from radiation planning computed tomography (CT) scans using skeletal muscle mass at level C3. The impact of sarcopenia on treatment outcome, Disease Free Survival (DFS) and toxicity was evaluated. Association between patient factors and outcome was calculated in univariate and multivariate analyses. RESULTS: Sarcopenic patients were more likely to be elderly, female gender and hypopharyngeal primary. The average SMI of the entire patient cohort was 31.9 cm2/m2 and for males and females were 32.78 cm2/m2 and 26.19 cm2/m2 respectively. As per cut of criteria used nearly 91% of the patient cohort were sarcopenic. Sarcopenic patients had a worse treatment outcome namely poorer disease free survival, more toxicities and more treatment gaps. As per ROC curve patients with SMI of >32 cm2/m2 fared better than those with SMI < 32 cm2/m2. CONCLUSION: Sarcopenia in HNSCC patients receiving definitive chemo radiotherapy is an independent prognostic factor and is associated with a worse treatment outcome and more toxicities.

Water-Soluble Blue Fluorescent Nonconjugated Polymer Dots from Hyaluronic Acid and Hydrophobic Amino Acids.

Fluorescent polymers have been increasingly investigated to improve their water solubility and biocompatibility to enhance their performance in drug delivery and theranostic applications. However, the environmentally friendly synthesis and dual functionality of such systems remain a challenge due to the complicated synthesis of conventional fluorescent materials. Herein, we generated a novel blue fluorescent polymer dot through chemical conjugation of hydrophobic amino acids to hyaluronic acid (HA) under one-pot green chemistry conditions. These nonconjugated fluorescent polymer dots (NCPDs) are water soluble, nontoxic to cells, have high fluorescence quantum yield, and can be used for in vitro bioimaging. HA-derived NCPDs exhibit excitation wavelength-dependent fluorescent properties. In addition, the NCPDs also show enhanced doxorubicin loading and delivery in naive and drug-resistant breast cancer cells in 2D and 3D tumor cellular systems. These results demonstrate the potential for successful synthetic scale-up and applications for HA-derived NCPDs.

Sulfation modulates the targeting properties of hyaluronic acid to P-selectin and CD44.

Many targeting strategies can be employed to direct nanoparticles to tumors for imaging and therapy. However, tumors display a dynamic, heterogeneous microenvironment that undergoes spatiotemporal changes, including the expression of targetable cell-surface biomarkers. Here, we develop a nanoparticle system to effectively target two receptors overexpressed in the microenvironment of aggressive tumors. Hyaluronic acid (HA) was regioselectivity modified using a multi-step synthetic approach to alter binding specificities for CD44 and P-selectin to tumor cell interaction. The dual-targeting strategy utilizes sulfate modifications on HA that targets P-selectin, in addition to native targeting of CD44, which exploits spatiotemporal alterations in the expression patterns of these two receptors in cancer sites. Using biophysical characterization and in vitro studies, we demonstrate that modified HA nanoparticles effectively targets both P-selectin+ and CD44+ cells, which lays the groundwork for future in vivo biomedical applications.

In-vivo anterior segment OCT imaging provides unique insight into cerulean blue-dot opacities and cataracts in Down syndrome.

Down syndrome (DS) is frequently associated with cataract, but there remains scant information about DS cataract morphology. Supra-nuclear cataracts in DS have been proposed as indicative of beta-amyloid (Aß) aggregation and thus potential biomarkers for Alzheimer's (AD). This study employed anterior segment OCT (AS-OCT) and slit-lamp (SL) photography to image the crystalline lens in DS, compared with adult controls. Lens images were obtained post-dilation. Using MATLAB, AS-OCT images were analysed and lens opacities calculated as pixel intensity and area ratios. SL images were classified using LOCS III. Subjects were n = 28 DS (mean ± SD 24.1 ± 14.3years), and n = 36 controls (54.0 ± 3.4years). For the DS group, AS-OCT imaging revealed the frequent presence of small dot opacities (27 eyes, 50%) in the cortex and nucleus of the lens, covering an area ranging from 0.2-14%. There was no relation with age or visual acuity and these dot opacities (p > 0.5) and they were not present in any control lenses. However, their location and morphology does not coincide with previous reports linking these opacities with Aß accumulation and AD. Four participants (14%) in the DS group had clinically significant age-related cataracts, but there was no evidence of early onset of age-related cataracts in DS.

Vascular reactivity to mental stress is associated with poor cardiovascular disease outcomes in females following acute coronary syndrome.

BACKGROUND: We aimed to test the hypothesis that peripheral endothelial dysfunction induced by mental stress may predict cardiovascular events after acute coronary syndrome beyond traditional cardiovascular disease risk factors. METHODS: This was a prospective study in which 417 patients who had acute coronary syndrome were enrolled in two sites at the US and Qatar. Cardiovascular disease risk factors such as past medical history, blood pressure, heart rate, peripheral endothelial dysfunction, and response to three different mental stress examinations (Stroop Color Word, Arithmetic, and Spiral Omnibus) as assessed by ratio of reactive hyperemia tonometry (EndoPAT) with stress over EndoPAT at rest were obtained at baseline. Major adverse cardiac events were then recorded at 1 year after the index event. RESULTS: There were no differences in baseline peripheral endothelial dysfunction or vascular response to mental stress between the US vs. Qatar patients. Women were more likely to experience major adverse cardiac events in the year following acute coronary syndrome (relative risk 2.42, 95% confidence interval 1.53-3.84, P = 0.044), and had a significantly lower mental stress ratio compared to women who did not (1.0 ± 0.17 vs. 1.20 ± 0.17, P = 0.04). In multivariate analyses stratified by sex, baseline peripheral endothelial dysfunction (EndoPAT < 1.7) (χ = 8.0, P = 0.005) and mental stress ratio (χ = 7.7, P = 0.006), were independently predictive of major adverse cardiac events in women, but not men. CONCLUSION: The current study demonstrates that in women both baseline endothelial function and vascular function in response to mental stress ratio are predictive of worse cardiovascular disease outcomes 1 year after acute coronary syndrome. The study may suggest an important mechanism for adverse clinical outcomes in women following acute coronary syndrome.

ω-Hydroxy isoprenoid bisphosphonates as linkable GGDPS inhibitors.

The enzyme geranylgeranyl diphosphate synthase (GGDPS) is a potential therapeutic target for multiple myeloma. Malignant plasma cells produce and secrete large amounts of monoclonal protein, and inhibition of GGDPS results in disruption of protein geranylgeranylation which in turn impairs intracellular protein trafficking. Our previous work has demonstrated that some isoprenoid triazole bisphosphonates are potent and selective inhibitors of GGDPS. To explore the possibility of selective delivery of such compounds to plasma cells, new analogues with an ω-hydroxy group have been synthesized and examined for their enzymatic and cellular activity. These studies demonstrate that incorporation of the ω-hydroxy group minimally impairs GGDPS inhibitory activity. Furthermore conjugation of one of the novel ω-hydroxy GGDPS inhibitors to hyaluronic acid resulted in enhanced cellular activity. These results will allow future studies to focus on the in vivo biodistribution of HA-conjugated GGDPS inhibitors.

A prospective study of evaluation of operative duration as a predictor of mortality in pediatric emergency surgery: Concept of 100 minutes laparotomy in resource-limited setting.

INTRODUCTION: Operative duration is an important but under-studied predictor of mortality in emergency laparotomies. AIMS AND OBJECTIVES: The primary objective of this study was to quantify the effect of duration of emergency laparotomy in children on mortality; and to identify a rough cut-off duration of laparotomy to serve as a guide so that a laparotomy can be planned to optimize pediatric surgical patient outcome. MATERIALS AND METHODS: This is a prospective study conducted in a government tertiary teaching institution over a period of 24 months. All children in the age group of 5-10 years presenting in the emergency department with Pediatric Risk of Mortality III score ≤8, undergoing emergency laparotomy in emergency operation theater, were included. OBSERVATIONS AND RESULTS: In all, 213 children were included in the study. The mean time from presentation to shifting to the operating room was 3.7 h. The mean operative duration was 108 min. The mean operative time in survived patients was 102 min as compared to 135 min in expired patients (P < 0.05). The 30-day in-hospital mortality rate was 17.4%. After application of binary logistic regression analysis, it was found that time to laparotomy and operative duration were significant risk factors (<0.05) predicting post-operative mortality. Kaplan-Meier survival curve showed a decrease at a mean weighted operative duration of approximately 100 min. Receiver operating characteristic curve analysis yielded operative duration of 123.5 min at which Youden's index maximized. CONCLUSION: This 100-min duration of laparotomy might appear a long duration but in casualty setup of a government hospital with limited resources, there are so many hurdles for optimal working that completion of an emergency laparotomy in children in 100 min can be considered a realistic target for improving post-operative outcome. At an operative duration of <123.50 min, mortality rates within acceptable limits can be achieved.

Pneumohernios due to perforated cecum in left Amyand's hernia.

We report a case of incarcerated left indirect inguinal hernia in a male child which on exploration revealed the presence of free air and fecal matter containing fluid in the hernial sac. This is the second reported case of the presence of cecal perforation in left Amyand's hernia in pediatric age group and unique in the sense of the form of abnormal anatomy encountered per-operatively.

Efficacy and Stability studies of microbial folate fortified fruit juices prepared using probiotic microorganism.

Folate, natural form of water soluble vitamin folic acid, is significant for humans as involved in most important metabolic reactions i.e. nucleotide synthesis and amino acid inter conversions. Thus its deficiency causes neural tube defects in newborns and cardiovascular diseases, and cancers. Humans cannot synthesize folate de novo so consumption through diet is essential. Natural food sources, supplements and fortified food products are the choices available to complete the Daily recommended intake. However microbial fortification using probiotics recently gained wide attention due to dual advantage of natural food matrix with enhanced folate content along with the probiotics benefits. Current study was focused on the microbial fortification of fruit juices and their efficacy and stability studies. Freshly filtered orange and tomato juice was prepared and inoculated with Streptococcus thermophilus NCIM 2904. Incubation was done at 40°C and samples were collected at different time interval. Folate extraction was done using human plasma and content was measured by microbiological assay using Lactobacillus casei NCIM No. 2364. Efficacy and stability studies were carried out to ensure the quality of juices to be consumed in terms of folate content, viable cell count and pH after 4 weeks of storage at low temperature. Positive results were observed as folate content was quite stable whereas viable cell count was also found to be significant till some time without adding any preservatives. The results indicated that fortified fruit juices could be used as probiotic beverages with enhanced folate content.

Plant derived antimicrobial peptide Ib-AMP1 as a potential alternative drug candidate for Staphylococcus aureus toxins.

Due to an increase in the occurrence of multi drug resistant microorganisms a need for the development of alternative drugs comes in light. This alternative drug should be such that the microorganisms should not be able to develop resistance against them easily. Antimicrobial peptides are the most potential candidates to be developed as alternative drug. In the present study the three toxins ETA, ETB and PVL of Staphylococcus aureus were docked with four antimicrobial peptides, Ib-AMP1, JCPep7, Snakin2, Sesquin, derived from plants. The docking studies predict that Ib-AMP1 shows significant interactions with all these three toxins. Hence, further studies can be carried out for developing Ib-AMP1 as an alternative drug against the toxins of Staphylococcus aureus.

In vitro evaluation of shear bond strength and microleakage of different pit and fissure sealants.

AIM AND OBJECTIVES: Fissure caries is most common in children due to deep pit and fissures. Pit and fissure areas on the occlusal surface of the teeth make them susceptible to dental caries, which need to be prevented or restored. Fissures sealant reduces the risk of occlusal caries. The present study was done to evaluate microleakage and shear bond strength of various fissure sealants. MATERIALS AND METHODS: Thirty-six extracted molars were randomly allocated equally (n = 12) into three groups with three different sealants to evaluate shear bond strength and microleakage at sealant space. The shear bond strengths was evaluated with one-way analysis of variance and microleakage by Kruskal-Wallis nonparametric test using the Statistical Package for the Social Sciences version 18.0 (Chicago: SPSS Inc, 2009). RESULTS: Tetric flow (16.8 MPa) recorded the highest shear bond strength and the difference was statistically significant with enamel loc (12.8 MPa). There was no statistically significant difference in relation to microleakage (P > 0.05) in the tested groups. CONCLUSIONS: Tetric flow recorded the highest shear bond strength and the difference was statistically significant with enamel loc. However, there was no statistically significant difference among the groups regarding microleakage.

Anatomical Study of Chiari Network and the Remnant of Left Venous Valve in the Interior of Right Atrium.

Chiari network occurs due to incomplete resorption of right valve of sinus venosus. It is often noticed as fenestrated membranous structure or reticular network like structure in the valve of inferior vena cava and coronary sinus. The remnant of left venous valve is observed as trabeculae over the fossa ovalis. The incidence of Chiari network and the remnant of left venous valve were studied in 80 cadaveric hearts utilized for teaching the undergraduates. The right atrium was opened anterior to sulcus terminalis and the interior was examined for the presence of these embryological remnants. The incidence of Chiari network and left venous valve in the present study is 3.75% and 7.5%, respectively. Chiari network was observed as a fenestrated membranous structure in 2 specimens and a reticular network in 1 specimen, with variable extension to coronary sinus opening and right atrial wall. The remnant of left venous valve was observed as multiple fine strands in 3 specimens and trabecular structure in 3 specimens. These structures may create diagnostic confusion, difficulty in interventional procedures, and complications like thromboembolic events. Hence, the knowledge about the incidence, morphology, and clinical manifestations of these rare embryological remnants is mandatory.

Spasticity and the use of intrathecal baclofen in patients with spinal cord injury.

Muscle spasms and spasticity constitute a significant problem in patients with spinal cord injury, interfering with rehabilitation and leading to impairments in quality of life in addition to medical complications. Administration of intrathecal baclofen (ITB) is indicated when spasticity continues to produce a clinical disability despite trials of oral treatments and other alternatives in patients who have functional goals and/or pain without contractures. Severe spasticity of spinal origin has been shown to respond dramatically to long-term ITB when used in appropriate patients with spasticity.

Bilateral TMJ Involvement in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a systemic inflammatory, slowly progressive disease that results in cartilage and bone destruction. Temporomandibular joint (TMJ) involvement is not uncommon in RA, and it is present in about more than 50% of patients; however, TMJ is usually among the last joints to be involved and is associated with many varied clinical signs and symptoms. Hence, RA of TMJ presents to the dentist with great diagnostic challenges. This report presents a case of RA with bilateral TMJ involvement with its classical radiographic findings and review literature.