A Phase I Study to Evaluate the Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Recombinant Human Hyaluronidase PH20 Administered Intravenously in Healthy Volunteers.

BACKGROUND: Recombinant human hyaluronidase PH20 (rHuPH20) is used in subcutaneous formulations (eg, RITUXAN HYCELA [rituximab and hyaluronidase human], HERCEPTIN HYLECTA [trastuzumab and hyaluronidase-oysk], PHESGO [pertuzumab/trastuzumab/hyaluronidase-zzxf], and Darzalex FASPRO [daratumumab and hyaluronidase-fihj]) to increase the dispersion and absorption of coadministered therapeutics. Although unlikely, subcutaneous products that include rHuPH20 could be mistaken for the intravenous formulation of the corresponding drugs (eg, RITUXAN [rituximab], HERCEPTIN [trastuzumab], and DARZALEX [daratumumab]). To understand the potential effects of inadvertent intravenous injection of rHuPH20, we investigated the safety profile, pharmacokinetics (PK), and pharmacodynamics (PD) of rHuPH20 administered intravenously. OBJECTIVES: This Phase I, open-label, single-center study in healthy volunteers was designed to assess the safety profile, tolerability, PK, and PD of rHuPH20 administered intravenously. METHODS: Healthy volunteers received 5 mL intravenous infusion of either 10,000 U (n = 12) or 30,000 U (n = 12) rHuPH20 over 5 minutes. Blood samples for PK and PD analysis were obtained at baseline and at various times after initiation of infusion. Adverse events and laboratory parameters were measured to assess the safety profile and tolerability of the intravenous infusion. The PK of rHuPH20 was assessed using both an enzymatic assay and a mass-based immunoassay, and plasma hyaluronan concentrations were measured as a PD marker using an HPLC-MS/MS disaccharide assay. RESULTS: All 24 volunteers (mean age = 36.5 years) completed the study, and no serious adverse events were reported in either treatment group. Overall, 2 adverse events (both Grade 1) were reported; catheter site pain in the 10,000 U group and hypotension in the 30,000 U group. Plasma concentrations of rHuPH20 increased during the 5-minute intravenous infusion (median tmax = 6 minutes from intravenous initiation) followed by a rapid plasma clearance (t1/2 ∼10 minutes from intravenous initiation). Plasma hyaluronan concentrations increased with dose and time (tmax range = 45‒120 minutes from intravenous initiation) and returned to baseline within 1 week of administration. Changes in both PK and PD measurements appeared proportional to dose. CONCLUSIONS: The study demonstrated that intravenous administration of up to 30,000 U rHuPH20 was well tolerated, rapidly cleared from the plasma, and did not appear to be associated with any serious adverse effects at doses used in subcutaneous therapeutic products. (Curr Ther Res Clin Exp. 2020; 81).

Referral Patterns and Sociodemographic Predictors of Adult and Pediatric Behavioral Health Referrals in a Federally Qualified Health Center.

Federally Qualified Health Centers (FQHCs) provide comprehensive care to medically underserved populations whose access to behavioral health services may be limited. The goal of the current study was to examine referral patterns to specialty mental health and subsequent treatment initiation in an FQHC. In a 13-month period from March 2017 to March 2018, 1201 patients received a specialty mental healthcare referral. Of these patients, 37% reported scheduling an appointment with this referral, 44% refused the referral, 4% reported improvement in symptoms and not needing a referral, and 5% were not able to be reached due to a contact number being out of service. Common referral reasons among adults were depression, anxiety, and stress, and the most prevalent pediatric referral reasons were behavioral problems, depression, attention deficit hyperactivity disorder (ADHD), and anxiety. These data suggest that of the patients who received a specialty mental health referral, only one-third scheduled an appointment. The study also suggested that anxiety problems may be underrecognized in both adult and pediatric patients. Although significant attention has been put on increasing access to behavioral health services, there is still an unmet need. Universal mental health screening and increased coordination with specialty mental health providers in the community may better address this need.

A systematic review of persons of color participation in first episode psychosis coordinated specialty care randomized controlled trials in North America.

The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.

The C-terminal domain of the Uup protein is a DNA-binding coiled coil motif.

The bacterial Uup protein belongs to the REG subfamily of soluble ATP-binding cassette (ABC) ATPases, and is implicated in precise excision of transposons. In Escherichia coli, the uup gene encodes a 72 kDa polypeptide that comprises two ABC domains, separated by a linker region, and a 12kDa C-terminal domain (CTD). Uup binds double-stranded DNA with no sequence specificity, and we previously demonstrated that the CTD domain is a crucial region that participates in DNA-binding activity. We report herein the NMR structure of Uup CTD, consisting of an intramolecular antiparallel two-stranded coiled coil motif. Structural comparison with analogous coiled coil domains reveals that Uup CTD contains an atypical 3(10)-helix in the α-hairpin region that contributes to the hydrophobic core. Using NMR titration experiments, we identified residues of the CTD domain involved in the binding to double-stranded DNA. These residues are located on two opposite surfaces at the base of the coiled coil, formed by the N- and C-terminal extremities, where a strictly conserved proline residue induces an overwinding of the coiled coil. Finally, preliminary analysis of NMR spectra recorded on distinct Uup constructs precludes a fully flexible positioning of the CTD domain in full-length Uup. These structural data are the first reported for a non-ATPase domain within ABC REG subfamily.

C-terminal domain of the Uup ATP-binding cassette ATPase is an essential folding domain that binds to DNA.

The Uup protein belongs to a subfamily of soluble ATP-binding cassette (ABC) ATPases that have been implicated in several processes different from transmembrane transport of molecules, such as transposon precise excision. We have demonstrated previously that Escherichia coli Uup is able to bind DNA. DNA binding capacity is lowered in a truncated Uup protein lacking its C-terminal domain (CTD), suggesting a contribution of CTD to DNA binding. In the present study, we characterize the role of CTD in the function of Uup, on its overall stability and in DNA binding. To this end, we expressed and purified isolated CTD and we investigated the structural and functional role of this domain. The results underline that CTD is essential for the function of Uup, is stable and able to fold up autonomously. We compared the DNA binding activities of three versions of the protein (Uup, UupDeltaCTD and CTD) by an electrophoretic mobility shift assay. CTD is able to bind DNA although less efficiently than intact Uup and UupDeltaCTD. These observations suggest that CTD is an essential domain that contributes directly to the DNA binding ability of Uup.

Examining Caretaker Attitudes Towards Primary Prevention of Pediatric Behavioral Health Problems in Integrated Care.

Understanding caretaker attitudes towards the prevention of pediatric behavioral disorders is important for the effective delivery of prevention services. Caretakers of children ages 0-18 (N = 385) read a description of pediatric prevention services in an integrated primary care setting. Attitudes towards these services were assessed. The majority of participants (80%) agreed that prevention is important, 87% reported interest in learning their child's risk for a behavioral disorder, 84% were interested in learning the results of a screen for behavioral disorders, and 88% were interested in learning parenting strategies. Participants endorsed similarly positive attitudes towards prevention in integrated care. Perceived risks outweighing perceived benefits, younger caregiver age, and identifying as non-Hispanic White predicted less favorable attitudes towards prevention. Other socio-demographic characteristics (e.g., caretaker education) were associated with disorder-specific beliefs about the importance of prevention, but not general attitudes. Findings suggest generally positive attitudes towards preventing behavioral disorders in an integrated care setting.

Dispersive effects and focused biodistribution of recombinant human hyaluronidase PH20: A locally acting and transiently active permeation enhancer.

BACKGROUND: Recombinant human hyaluronidase PH20 (rHuPH20) facilitates the dispersion and absorption of subcutaneously administered therapeutic agents. This study aimed to characterize the transient, local action of rHuPH20 in the subcutaneous (SC) space using focused biodistribution and dye dispersion studies conducted in mice. MATERIALS AND METHODS: To evaluate the biodistribution of rHuPH20, mice were intradermally administered rHuPH20 (80 U). The enzymatic activity of rHuPH20 was analyzed in the skin, lymph nodes, and plasma. Animal model sensitivity was determined by intravenous administration of rHuPH20 (80 U) to the tail vein. To evaluate local dispersion, mice received an intradermal injection of rHuPH20 followed by an intradermal injection of Trypan Blue dye at a contralateral site 45 minutes later. Dye dispersion was measured using a digital caliper. RESULTS: After intradermal rHuPH20 injection, enzymatic activity was detected within the skin near the injection site with levels decreasing rapidly after 15 minutes. There was no clear evidence of systemic exposure after administration of rHuPH20, and no discernible rHuPH20 activity was observed in lymph or plasma as a function of time after dosing. In the dye dispersion study, delivery of rHuPH20 at one site did not impact dye dispersion at a distal skin site. CONCLUSION: These observations support the classification of rHuPH20 as a transiently active and locally acting permeation enhancer.

Perspectives on Subcutaneous Route of Administration as an Immunogenicity Risk Factor for Therapeutic Proteins.

An increasing number of therapeutic proteins are being developed for delivery through the subcutaneous (SC) route of administration. Relative to intravenous (IV) administration, the SC route offers more convenience to patients, flexibility in dosing, and potential to reduce health care costs. There is a perception that SC administration can pose a higher immunogenicity risk than IV administration for a given protein. To evaluate whether there is a difference in therapeutic protein immunogenicity associated with administration routes, a more detailed understanding of the interactions with the immune system by each route is needed. Few approved therapeutic proteins have available clinical immunogenicity data sets in the public domain that represent both IV and SC administration routes. This has prevented a direct comparison of the 2 routes of administration across a large sample size. Of the 6 marketed products where SC and IV route-related incidences of anti-drug antibody (ADA) were available, 4 were associated with higher immunogenicity incidence with SC. In other cases, there was no apparent difference between the SC and IV routes. Overall, the ADA incidence was low (<15%) with no impact on safety or efficacy. The challenges associated with identifying specific risk factors unique to SC administration are discussed.

Impact of human neutralizing antibodies on antitumor efficacy of an oncolytic adenovirus in a murine model.

PURPOSE: The purpose of this study was to assess the impact of anti-adenovirus neutralizing antibodies (AdNAbs) on the distribution, tolerability, and efficacy of intravenously administered oncolytic adenovirus. A translational model was developed to evaluate the impact of humoral immunity on intravenous administration of oncolytic adenovirus in humans. EXPERIMENTAL DESIGN: Initially, severe combined immunodeficient (SCID)/beige mice were passively immunized with various amounts of human sera to establish a condition of preexisting humoral immunity similar to humans. A replication-deficient adenovirus encoding beta-galactosidase (rAd-betagal) was injected intravenously into these mice. An AdNAb titer that mitigated galactosidase transgene expression was determined. A xenograft tumor-bearing nude mouse model was developed to assess how a similar in vivo titer would impact the activity of 01/PEME, an oncolytic adenovirus, after intravenous administration. RESULTS: In SCID/beige mice, there was a dose dependence between AdNAbs and galactosidase transgene expression; 90% of transgene expression was inhibited when the titer was 80. A similar titer reconstituted in the nude mice with human serum, as was done in the SCID/beige mice, did not abrogate the antitumor efficacy of the replicating adenovirus after intravenous administration. Viral DNA increased in tumors over time. CONCLUSIONS: In intravenous administration, preexisting AdNAb titer of 80 significantly attenuated the activity of a 2.5 x 10(12) particles per kilogram dose of nonreplicating adenovirus; the same titer had no affect on the activity of an equivalent dose of replicating adenovirus. Our results suggest that a majority of patients with preexisting adenovirus immunity would be candidates for intravenous administration of oncolytic adenovirus.

Secondary structure and NMR resonance assignments of the C-terminal DNA-binding domain of Uup protein.

ATP-binding cassette (ABC) systems belong to a large superfamily of proteins that couple the energy released from ATP hydrolysis to a wide variety of cellular processes, including not only transport of various molecules, but also gene regulation, and DNA repair. Mutations in the bacterial uup gene, which encodes a cytosolic ABC ATPase, lead to an increase in the frequency of precise excision of transposons Tn10 and Tn5, suggesting a role of the Uup protein in DNA metabolism. Uup is a 72 kDa polypeptide which comprises two ABC domains, separated by a 75-residue linker, and a C-terminal domain (CTD) of unknown function. The Uup protein from Escherichia coli has been shown to bind DNA in vitro, and the CTD domain contributes to the DNA-binding affinity. We have produced and purified uniformly labeled (15)N- and (15)N/(13)C Uup CTD domain (region 528-635), and assigned backbone and side-chains resonances using heteronuclear NMR spectroscopy. Secondary structure evaluation based on backbone chemical shifts is consistent with the presence of three α-helices, including two long ones (residues 564-590 and 601-632), suggesting that Uup CTD may fold as an intramolecular coiled coil motif. This work provides the starting point towards determining the first atomic structure of a non-ATPase domain within the vast REG subfamily of ABC soluble ATPases.

Recombinant human hyaluronidase PH20 (rHuPH20) facilitates subcutaneous infusions of large volumes of immunoglobulin in a swine model.

Many patients with primary immunodeficiency disease (PIDD) require lifelong immunoglobulin (Ig) replacement therapy. Home-based subcutaneous (SC) infusion provides advantages to patients with PIDD compared to hospital-based intravenous infusion. One limitation of current practice with SCIg infusion is the need for small-volume infusions at multiple injection sites on a frequent basis. A method was developed for large-volume SC infusion that uses preinfusion of recombinant human hyaluronidase (rHuPH20) to facilitate fluid dispersion. Miniature swine was used as a preclinical model to assess the effects of rHuPH20-facilitated infusions, of a single monthly dose, on fluid dispersion, infusion-related pressure, swelling, induration, and tissue damage. Preinfusion of vehicle (control) or rHuPH20 (75 U/g Ig) was performed simultaneously on contralateral abdominal sites on each animal, followed by infusion of 300 mL 10 % Ig (30 g) at each site. Compared to control infusions, rHuPH20 significantly reduced infusion pressure and induration (p < 0.05) and accelerated postinfusion Ig dispersion. Histological evaluation of infusion site tissue showed moderate to severe swelling for the control. Swelling after rHuPH20-facilitated infusion was mild on day 1 and had completely resolved shortly thereafter. Laser Doppler imaging of control infusion sites revealed local cutaneous hypoperfusion during Ig infusion, which was reduced almost 7-fold (p < 0.05) with the use of rHuPH20. These results demonstrate that rHuPH20-facilitated Ig infusion is associated with improved dispersion of Ig, resulting in reduced tissue pressure, induration, and reduced risk of tissue damage from mechanical trauma or local ischemia, thus enabling SC administration of large volumes of Ig at a single site.

Subcutaneous administration of biotherapeutics: current experience in animal models.

In recent years, many peptide- and protein-based biotherapeutics have been approved for subcutaneous (SC) delivery. The mechanisms and factors affecting the uptake and distribution of such large molecules following SC administration are not well understood. This review outlines the factors influencing uptake, transport, distribution and species differences following the SC administration of biotherapeutics; improved understanding of these factors will facilitate the appropriate selection of animal models and improve predictivity for the bioavailability of drugs in humans. Morphological differences between species, such as the presence or absence of the panniculus carnosus muscle, may have significant effects on SC delivery. Following SC administration, small molecules, peptides and small proteins (< or = 16 kDa) primarily diffuse through the blood vessel walls directly into capillaries, whereas large molecules are taken up into the more porous lymphatics. Critical parameters that may impact the availability in blood of compounds administered SC, other than molecular weight, include host-related factors, such as animal motility, age and gender, structural and functional characteristics of the SC interstitium and the lymphatics, and extrinsic factors, such as anesthesia, injection technique, potential precipitation or degradation at the injection site, and the use of SC delivery technology. A review of regulatory approval information for SC administered biotherapeutics is provided for comparison. Careful control of parameters during SC administration will reduce inter-individual and inter-species variability.

Impact of immigration on complementary and alternative medicine use in Hispanic patients.

BACKGROUND: Although previous research has demonstrated frequent complementary and alternative medicine (CAM) use by Hispanic patients, it remains unclear whether the status of immigration plays a role in the frequency and reasons for use. METHODS: A survey of 164 patients from a federally qualified health center in South Central Los Angeles was used; the health center serves a predominantly Latino immigrant patient population. The study included the following variables: patient age; sex; place of birth; number of years living in the United States; CAM use within the last year; and, if positive CAM use, what type(s) and for what condition(s). RESULTS: Sixty-six percent of patients had used a CAM substance within the past year. Ninety-seven percent of the patients were immigrants (primarily from Mexico, El Salvador, and Guatemala). Differences in CAM use between recently arrived (< or =9 years) and long-term immigrants (> or =10 years) were not significant. Ninety-four percent of patients using CAM reported using herbal/tea/plant-based substances, with the most frequent reason for CAM use being digestive problems. Although most CAM substances were obtained from a market (64%), a not insignificant number of CAM substances were grown at home (23%). CONCLUSIONS: Time since immigration does not seem to impact the frequency of CAM use by Hispanic immigrant patients. Herbal/tea/plant-based substances are frequently used in the Hispanic patient population, often for digestive complaints.

Dichlorodiphenyldichloroethylene exposure during the first trimester of pregnancy alters the anal position in male infants.

Anogenital distance (AGD) at birth is regarded as a useful measurement that reflects the prenatal androgenic status in rodents. However, the impact of xenoantiandrogens on human development is largely unknown. The aim of this study was to evaluate the potential antiandrogenic impact of prenatal DDT metabolites (p,p'-DDE and p,p'-DDT) exposure on infant AGD, using a non-age-dependent anal position index (API). As part of an ongoing perinatal cohort study on the effects of organochlorine pesticides in children's neurodevelopment, we conducted a cross-sectional study in 71 infants (37 males and 34 females). Maternal serum levels of DDT metabolites (p,p'-DDE and p,p'-DDT) before and during each trimester of pregnancy were determined by electron capture gas-liquid chromatography. During postnatal home visits at 3, 6, and 12 or 18 months of age, the children's weight and API were evaluated. Multiple lineal regression models were used to estimate the potential endocrine disruptor activity of prenatal p,p'-DDE exposure. Boys had significantly higher API values than girls (0.6 versus 0.5; P < 0.001). Only among boys, a doubling increase of maternal p,p'-DDE serum levels during the first trimester of pregnancy, were associated with a significant reduction of API (beta=-0.02; P= 0.02). No effect of p,p'-DDT on AGD was observed. Evidence of the effect of prenatal p,p'-DDE on external genital differentiation is scarce and not consistent in the literature. Further studies are needed to confirm a hormonal disruptive effect on the development of external genitalia, due not only to p,p'-DDE but also due to other antiandrogenic persistent compounds.

Recombinant adenovirus-p21 attenuates proliferative responses associated with excessive scarring.

Excessive cutaneous scarring is an important clinical disorder resulting in adverse tissue growth and function as well as undesirable cosmetic appearance. p21WAF-1/Cip-1 is a cyclin-dependent kinase inhibitor that blocks cell cycle progression and inhibits cell proliferation. We used a recombinant adenovirus containing the human p21WAF-1/Cip-1 cDNA (rAd-p21) to evaluate proliferative responses in skin models. In vitro dose-response studies using primary human dermal fibroblasts resulted in a dose-dependent expression of p21WAF-1/Cip-1 protein and a 3- to 80-fold reduction in cell proliferation as measured by 5-bromodeoxyuridine incorporation. Further, rAd-p21 reduced type I procollagen production when compared to control virus. A rat polyvinyl alcohol sponge model was used to determine rAd-p21 effects on granulation tissue formation in vivo. Sponges pretreated with a granulation tissue stimulator, rAd-PDGF-B and subsequently rAd-p21 on a second injection, showed a p21WAF-1/Cip-1 specific dose-dependent decrease in percent granulation fill as the rAd-p21 dose increased (p < 0.001). Immunohistochemistry identified human p21WAF-1/Cip-1 expression in sponges treated with rAd-p21 5 days postinjection. Additionally, 5-bromodeoxyuridine and Ki67 staining in sponges treated with rAd-p21 showed a significant decrease in proliferation when compared to rAd-platelet-derived growth factor-B alone or vehicle control groups (p < 0.01). These data support the utility of p21WAF-1/Cip-1 in targeting hyperproliferative disorders of the skin.

Synthetic biocompatible cyclodextrin-based constructs for local gene delivery to improve cutaneous wound healing.

The localized, sustained delivery of growth factors for wound healing therapy is actively being explored by gene transfer to the wound site. Biocompatible matrices such as bovine collagen have demonstrated usefulness in sustaining gene therapy vectors that express growth factors in local sites for tissue repair. Here, new synthetic biocompatible materials are prepared and shown to deliver a protein to cultured cells via the use of an adenoviral delivery vector. The synthetic construct consists of a linear, beta-cyclodextrin-containing polymer and an adamantane-based cross-linking polymer. When the two polymers are combined, they create an extended network by the formation of inclusion complexes between the cyclodextrins and adamantanes. The properties of the network are altered by controlling the polymer molecular weights and the number of adamantanes on the cross-linking polymer, and these modifications and others such as replacement of the beta-cyclodextrin (host) and adamantane (guest) with other cyclodextrins (hosts such as alpha, gamma, and substituted members) and inclusion complex forming molecules (guests) provide the ability to rationally design network characteristics. Fibroblasts exposed to these synthetic constructs show proliferation rates and migration patterns similar to those obtained with collagen. Gene delivery (green fluorescent protein) to fibroblasts via the inclusion of adenoviral vectors in the synthetic construct is equivalent to levels observed with collagen. These in vitro results suggest that the synthetic constructs are suitable for in vivo tissue repair applications.