Status and future developments for downstream processing of biological products: Perspectives from the Recovery XIX yield roundtable discussions.

Governments and biopharmaceutical organizations aggressively leveraged expeditious communication capabilities, decision models, and global strategies to make a COVID-19 vaccine happen within a period of 12 months. This was an unusual effort and cannot be transferred to normal times. However, this focus on a single vaccine has also led to other treatments and drug developments being sidelined. Society expects the pharmaceutical industry to provide an uninterrupted supply of medicines. However, it is often overlooked how complex the manufacture of these compounds is and what logistics are required, not to mention the time needed to develop new drugs. The overarching theme, therefore, is patient access and how we can help ensure access and extend it to low- and middle-income countries. Despite unceasing efforts to make medications available to all patient populations, this must never be done at the expense of patient safety. A major fraction of the costs in biopharmaceutical manufacturing are for drug discovery, process development, and clinical studies. Infrastructure costs are very difficult to quantify because they often depend on whether a greenfield facility or an existing, depreciated facility is used or adapted for a new product. To accelerate process development concepts of platform process and prior knowledge are increasingly leveraged. While more traditional protein therapeutics continue to dominate the field, we are also experiencing the exciting emergence and evolution of other therapeutic formats (bispecifics, tetravalent mAbs, antibody-drug conjugates, enzymes, peptides, etc.) that offer unique treatment options for patients. Protein modalities are still dominant, but new modalities are being developed that can be learned from including advanced therapeutics-like cell and gene therapies. The industry must develop a model-based strategy for process development and technologies such as continuous integrated biomanufacturing must be adopted. The overall conclusion is that the pandemic pace was unsustainable, focused on vaccine delivery at the expense of other modalities/disease targets, and had implications for professional and personal life (work-life balance). Routinely reducing development time from 10 years to 1 year is nearly impossible to achieve. Environmental aspects of sustainable downstream processing are also described.

Spectinamide MBX-4888A exhibits favorable lesion and tissue distribution and promotes treatment shortening in advanced murine models of tuberculosis.

The spectinamides are novel, narrow-spectrum semisynthetic analogs of spectinomycin, modified to avoid intrinsic efflux by Mycobacterium tuberculosis . Spectinamides, including lead MBX-4888A (Lee-1810), exhibit promising therapeutic profiles in mice, as single drugs and as partner agents with other anti-tuberculosis antibiotics including rifampin and/or pyrazinamide. To demonstrate that this translates to more effective cure, we first confirmed the role of rifampin, with or without pyrazinamide, as essential to achieve effective bactericidal responses and sterilizing cure in the current standard of care regimen in chronically infected C3HeB/FeJ mice compared to BALB/c mice. Thus, demonstrating added value in testing clinically relevant regimens in murine models of increasing pathologic complexity. Next we show that MBX-4888A, given by injection with the front-line standard of care regimen, is treatment shortening in multiple murine tuberculosis infection models. The positive treatment responses to MBX-4888A combination therapy in multiple mouse models including mice exhibiting advanced pulmonary disease can be attributed to favorable distribution in tissues and lesions, retention in caseum, along with favorable effects with rifampin and pyrazinamide under conditions achieved in necrotic lesions. This study also provides an additional data point regarding the safety and tolerability of spectinamide MBX-4888A in long-term murine efficacy studies.

Oral Probiotic Supplementation in Pregnancy to Reduce Group B Streptococcus Colonisation (OPSiP trial): study protocol for a double-blind parallel group randomised placebo trial.

INTRODUCTION: Group B streptococcus (GBS), or Streptococcus agalactiae, remains a leading cause of neonatal morbidity and mortality. Canadian guidelines advise universal maternal screening for GBS colonisation in pregnancy in conjunction with selective antibiotic therapy. This results in over 1000 pregnant individuals receiving antibiotic therapy to prevent one case of early-onset neonatal GBS disease, and over 20 000 pregnant individuals receiving antibiotic therapy to prevent one neonatal death. Given the growing concern regarding the risk of negative sequela from antibiotic exposure, it is vital that alternative approaches to reduce maternal GBS colonisation are explored.Preliminary studies suggest some probiotic strains could confer protection in pregnancy against GBS colonisation. METHODS AND ANALYSIS: This double-blind parallel group randomised trial aims to recruit 450 pregnant participants in Vancouver, BC, Canada and will compare GBS colonisation rates in those who have received a daily oral dose of three strains of probiotics with those who have received a placebo. The primary outcome will be GBS colonisation status, measured using a vaginal/rectal swab obtained between 35 weeks' gestation and delivery. Secondary outcomes will include maternal antibiotic exposure and urogenital infections. Analysis will be on an intention-to-treat basis. PATIENT OR PUBLIC INVOLVEMENT: There was no patient or public involvement in the design of the study protocol. ETHICS AND DISSEMINATION: This study protocol received ethics approval from the University of British Columbia's Clinical Research Ethics Board, Dublin City University and Health Canada. Findings will be presented at research rounds, conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03407157.

Contemporary risk factors associated with ischaemic heart disease in central South Africa: a single-centre study.

BACKGROUND: Deaths from non-communicable diseases have increased in sub-Saharan Africa over the years, with limited data on coronary artery disease (CAD) and the risk factors thereof. The objective of this study was to investigate modifiable and non-modifiable risk factors in central South Africa in patients with CAD. METHODS: Patients with angiographically confirmed CAD who were evaluated in the catheterisation laboratory for the first time over a two-year period (2016 - 2017) were included. Data were extracted from the patients' medical records. RESULTS: Four hundred and eighty-two patients met the inclusion criteria, presenting at a mean age of 58.4 ± 10.8 years, and were predominantly male (66%). Females were significantly older than the males (60.3 ± 9.6 vs 57.4 ± 11.1 years; p < 0.05). The mean age at presentation was comparable between ethnic groups, except Asian patients who presented at a significantly younger age compared to Caucasians (49.8 ± 10.5 vs 59.1 ± 10.8 years; p < 0.05). Hypertension (91%) was the most common risk factor, followed by smoking (67%) and obesity (41%). Black Africans demonstrated a higher incidence of hypertension when compared to Caucasians (96 vs 87%; p < 0.05). Smoking was more prevalent in Caucasians than black Africans (68 vs 55%; p < 0.05) and occurred more commonly in males than females (73 vs 55%; p < 0.05). Most patients presented with acute coronary syndrome (ACS) (72%), mainly with ST-elevation myocardial infarction (STEMI) (36%). The majority of patients presenting with ACS were in the age group 51 - 60 years. The ACS risk-factor profile was similar to that of the total study group. CONCLUSION: CAD was present in all ethnic groups, and modifiable and non-modifiable risk factors were similar to the classical risk factors described worldwide. Minor interracial differences were observed and hypertension was the most prevalent risk factor recorded in central South Africa. Most patients with CAD presented with ACS, particularly STEMI. Recognition of the risk factors associated with CAD would contribute to improved planning of healthcare systems and increased awareness of CAD.

Epidemiology of Group A Streptococcal bacteraemia in Hunter New England Local Health District, 2008 to 2019.

Invasive Group A Streptococcal infection (iGAS) is an uncommon but serious infection with Streptococcus pyogenes in a normally sterile body site. Manifestations include bacteraemia, necrotising fasciitis and toxic shock syndrome with attendant serious morbidity and mortality. An increasing incidence of iGAS has been observed in some regions of Australia. iGAS became a nationally notifiable condition from 1 July 2021. To determine if regional incidence has increased, and to identify priority populations, we undertook a retrospective data analysis of Group A Streptococcal (GAS) bacteraemia cases in Hunter New England Local Health District (HNELHD), New South Wales, Australia, from 1 January 2008 to 31 December 2019, as identified by NSW Health Pathology, John Hunter Hospital. A total of 486 cases were identified (age-standardised rate: 4.05 cases per 100,000 population per year). Incidence in HNELHD gradually increased over the study period (adjusted incidence rate ratio: 1.04; 95% confidence interval: 1.01-1.07) and was significantly higher in children under 5 years of age; in adults over 70 years of age; in males; and in First Nations peoples. A significant peak occurred in 2017 (9.00 cases per 100,000 population), the cause of which remains unclear. GAS bacteraemia is uncommon but severe, and incidence in HNELHD has slowly increased. Public health and clinical guidelines must address the needs of priority populations, which include young children, older adults and First Nations peoples. Routine surveillance and genomic analysis will help improve our understanding of iGAS and inform best public health management.

Using silent area analysis to inform a COVID-19 public health response in Hunter New England, regional New South Wales.

Abstract: In 2020 and 2021, in the context of nationwide efforts to suppress SARS CoV-2 virus transmission while awaiting a vaccine, public health teams were responsible for finding and isolating all cases and quarantining their contacts. The success of this strategy required very high case ascertainment and thus, by inference, ready access to PCR testing, even in large rural areas such as Hunter New England in New South Wales. 'Silent area' analysis entailed the scheduled regular comparison of case and testing rates at local-government-area resolution against larger area and state-wide rates. This analysis provided an easily understood metric for identifying areas with lower testing rates, and for direction of surging of local testing capacity in such areas, by the local health district in partnership with public health services and private laboratory services. Complementary intensive community messaging was also utilised to promote increased testing in identified areas.

FluTracking: Weekly online community-based surveillance of influenza-like illness in Australia, 2019 Annual Report.

Abstract: FluTracking provided evidence for an early, long, but moderate influenza season in the Australian community compared to prior years. Influenza-like illness (ILI) activity in 2019 peaked earlier (week ending 16 June) than any season on record in FluTracking data. ILI attack rates were above average early in the 2019 season (peak of 2.2%), and the duration of peak activity was longer than most prior years. However, ILI attack rates were lower than the five-year average in the latter half of the season. FluTracking participants reported higher vaccination coverage in 2019 (73.3%) compared with 2018 (65.7%), with the most notable increase in children aged less than five years (69.3% in 2019, compared to 55.6% in 2018). The total 2019 count of laboratory notifications (312,945) was higher than prior years (2007 onwards), and the peak weekly count of 18,429 notifications in 2019 was also higher than all prior years, except 2017. FluTracking makes a comparison to another surveillance system each year. The peak weekly percentage of calls to HealthDirect that were influenza-related was higher in 2019 (12.8%) than for 2014-2018 (range of 8.2-11.4% for peak week of activity each year). FluTracking participants reported a 2.5 times increase in influenza testing from 2018 to 2019 and a 1.5 times increase from 2017. Although 2019 was of higher activity and severity than 2018, Flutracking data indicates that 2019 was a lower activity and severity season than 2017, and notifications and influenza-related calls were heightened by increased community concern and testing.

Transmission of SARS-CoV-2 Delta variant from an infected aircrew member on a short-haul domestic flight, Australia 2021.

In June 2021, when COVID-19 incidence in Australia was low, a COVID-19 (Delta variant) cluster occurred on an 81-minute domestic flight, with an aircrew member as the likely source. Outbreak investigation demonstrated that SARS-CoV-2 may be transmitted during short-haul flights and that mask use protected against infection.

Optimized Pyridazinone Nutrient Channel Inhibitors Are Potent and Specific Antimalarial Leads.

Human and animal malaria parasites increase their host erythrocyte permeability to a broad range of solutes as mediated by parasite-associated ion channels. Molecular and pharmacological studies have implicated an essential role in parasite nutrient acquisition, but inhibitors suitable for development of antimalarial drugs are missing. Here, we generated a potent and specific drug lead using Plasmodium falciparum, a virulent human pathogen, and derivatives of MBX-2366, a nanomolar affinity pyridazinone inhibitor from a high-throughput screen. As this screening hit lacks the bioavailability and stability needed for in vivo efficacy, we synthesized 315 derivatives to optimize drug-like properties, establish target specificity, and retain potent activity against the parasite-induced permeability. Using a robust, iterative pipeline, we generated MBX-4055, a derivative active against divergent human parasite strains. MBX-4055 has improved oral absorption with acceptable in vivo tolerability and pharmacokinetics. It also has no activity against a battery of 35 human channels and receptors and is refractory to acquired resistance during extended in vitro selection. Single-molecule and single-cell patch-clamp indicate direct action on the plasmodial surface anion channel, a channel linked to parasite-encoded RhopH proteins. These studies identify pyridazinones as novel and tractable antimalarial scaffolds with a defined mechanism of action. SIGNIFICANCE STATEMENT: Because antimalarial drugs are prone to evolving resistance in the virulent human P. falciparum pathogen, new therapies are needed. This study has now developed a novel drug-like series of pyridazinones that target an unexploited parasite anion channel on the host cell surface, display excellent in vitro and in vivo ADME properties, are refractory to acquired resistance, and demonstrate a well defined mechanism of action.

Clinical Outcomes of Ahmed ClearPath Implantation in Glaucomatous Eyes: A Novel Valveless Glaucoma Drainage Device.

PRCIS: Designed with novel features to facilitate implantation and improve safety, the Ahmed ClearPath (ACP) glaucoma drainage device (GDD) provided intraocular pressure (IOP) reduction comparable with other GDDs in eyes with refractory glaucoma in a multicenter retrospective study. PURPOSE: To present clinical outcomes with a novel valveless GDD (ACP, New World Medical). The 250 and 350 mm2 models feature a contoured plate for optimal globe apposition, anteriorized suture points to facilitate suturing to the globe, and a prethreaded 4-0 polypropylene ripcord suture. METHODS: This was a multicenter retrospective analysis of eyes with medically and/or surgically uncontrolled glaucoma implanted with the 250 or 350 mm2 ACP either as a standalone procedure or in combination with other procedures. Pre-, intra-, and postoperative data through 6 months were collected. RESULTS: A total of 104 eyes (100 subjects) received the ACP by 10 US surgeons, 63.5% of which had primary open-angle glaucoma and 62.5% had severe glaucoma. Mean baseline IOP was 26.3 (9.0) mm Hg and mean medication use was 3.9 (1.3). Through 6 months' follow-up, mean IOP ranged from 13.6 to 16.7 mm Hg and mean medication use from 0.9 to 1.9 medications (P<0.0001 at all timepoints for each outcome measure). At 6 months, mean IOP was 13.7 mm Hg (-13.0 mm Hg, 43.0%, P<0.0001) and mean medication use was 1.9 medications per eye (-2.1, 47.7%, P<0.0001). Common adverse events included anterior chamber inflammation (16.3%), hyphema (15.4%), and hypotony (6.7%). CONCLUSION: The new ACP appears to be safe and efficacious as a standalone procedure or in combination with other procedures for uncontrolled glaucoma, and may be considered as a GDD option for patients in whom its unique design may facilitate the implantation process.

Risk Factors for Interpersonal Violence in Prison: Evidence From Longitudinal Administrative Prison Data in Northern Ireland.

The present study uses a prospective longitudinal research design to examine whether previously identified risk factors for prison interpersonal violence can predict violent prison misconduct in Northern Ireland (NI). Administrative data drawn from the records of 429 adult males imprisoned on November 22, 2017 were used to predict involvement in violent prison misconduct during a 1-year follow-up period. The results revealed that only a small number of previously identified risk factors were found to be significant in the NI context. Nationality, neighborhood deprivation, history of addiction, submission of prison complaints, past involvement in prison misconduct, and number of incarcerations emerged as significant, while religion, head injury/epilepsy, property offences, and prison visits were significant at the marginal level. Given the variation in risk factors identified as significant in the NI context compared to previous research, it is argued that cultural context matters when attempting to generalize the risk factors for prison interpersonal violence from one jurisdiction to another. These results offer some support for the importation theory, although it should be noted that the inclusion of prison environmental factors was limited due to the nature of the data. It is argued that specialist services and supports should be provided to address the factors contributing to interpersonal prison violence, including interventions to improve feelings of fairness, identify and treat underlying medical issues, as well as support visitation.

Twenty-Four-Month Outcome of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Corneal Transplant Surgery.

PURPOSE: Glaucoma is a well-known sequelae of corneal transplant surgery and is a leading cause of visual loss in this patient group. We evaluated the performance and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in this population. DESIGN: Noncomparative retrospective case series. PARTICIPANTS: Consecutive eyes of patients receiving the GATT procedure for uncontrolled intraocular pressure (IOP) following corneal transplant surgery from 2016 to 2019. METHODS: Retrospective analysis of eyes with a history of prior corneal transplant undergoing GATT at Glaucoma Associates of Texas between 2016 and 2019 was performed. Data included IOP, patient demographics, preoperative and postoperative medications, preoperative and postoperative corneal procedures, complications, and need for reoperation for IOP control. MAIN OUTCOME MEASURES: IOP reduction and medication use following the procedure. RESULTS: Thirty-nine eyes of 32 patients with prior corneal transplant surgery underwent a GATT procedure. Prior corneal surgery included penetrating keratoplasty (59.0%), Descemet's stripping endothelial keratoplasty (35.9%), Descemet's membrane endothelial keratoplasty (2.6%), and deep anterior lamellar keratoplasty (2.6%). Patient age ranged from 24 to 94 years (mean 68.0 y) with 44% female and 81% Caucasian. The majority of patients had secondary open angle glaucoma (64.1%). There was a significant reduction in IOP and number of medications at all postoperative time points after censoring patients requiring reoperation to control IOP (P<0.001). At 24 months the pressure decreased from baseline of 30.9±11.5 to 13.9±4.7 mm Hg. Medications decreased from 4.2±1.0 medications at baseline to 0.6±1.0 at 24 months. Visual acuities decreased significantly over the first postsurgical month (all P<0.05), but these recovered at subsequent follow-up visits with 2-Snellen line improvements exceeding losses from month 3 to 36. Seven eyes required reoperation for uncontrolled glaucoma at a median of 8.5 months (range: 1.6 to 16.2 mo) after GATT. The cumulative proportion of eyes undergoing repeat cornea surgery was 2.6%, 2.6%, and 14.3% at 12, 24, and 36 months post-GATT, respectively. CONCLUSIONS: This case series describes a group of glaucoma patients, with a history of prior corneal surgery, that were safely and successfully treated with GATT. While classically traditional glaucoma surgeries are considered the standard of care for eyes following corneal transplant surgery, GATT should be considered as a reasonable, safe and effective alternative for surgically lowering IOP.

Outcomes of bleb revision with ologen following filtering glaucoma surgery.

PURPOSE: This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery. MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas. RESULTS: The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12-84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications. CONCLUSIONS: Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Are the Physical Environments of Treatment Centres Meeting Recommendations for Patient-Centred Care? Perceptions of Haematological Cancer Patients.

The physical environment of a treatment centre may impact the well-being of patients and their perceptions of care. Outpatients with haematological cancer may be in contact with the treatment centre over long periods and could be particularly affected. This study aimed to identify haematological cancer patients' perceptions of supportive design elements in the hospital they attended and associations with self-reported mood or well-being. Outpatients from three large metropolitan hospitals in Australia were mailed a self-report questionnaire and responded to statements about the treatment centre concerning their sense of control over the physical surroundings; access to social support; and access to positive distractions. Participants also reported whether they felt the overall environment affected their mood or wellbeing. Of the outpatients who returned the questionnaire (n = 165), almost one-quarter (24%) agreed that the physical environment of the hospital affected their mood or well-being. Patients who disagreed that the hospital was a comfortable temperature or agreed that waiting rooms were crowded had significantly higher odds of reporting that the treatment environment affected their mood or wellbeing. Implementing systems to reduce overcrowding in waiting rooms and increasing patient control over personal temperature in clinics may be the most effective strategies to improve patient wellbeing.

Filociclovir Is an Active Antiviral Agent against Ocular Adenovirus Isolates In Vitro and in the Ad5/NZW Rabbit Ocular Model.

Presently, there is no FDA- or EMA-approved antiviral for the treatment of human adenovirus (HAdV) ocular infections. This study determined the antiviral activity of filociclovir (FCV) against ocular HAdV isolates in vitro and in the Ad5/NZW rabbit ocular model. The 50% effective concentrations (EC50) of FCV and cidofovir (CDV) were determined for several ocular HAdV types using standard plaque reduction assays. Rabbits were topically inoculated in both eyes with HAdV5. On day 1, the rabbits were divided into four topical treatment groups: (1) 0.5% FCV 4x/day × 10 d; (2) 0.1% FCV 4x/day × 10 d; (3) 0.5% CDV 2x/day × 7 d; (4) vehicle 4x/day × 10 d. Eyes were cultured for virus on days 0, 1, 3, 4, 5, 7, 9, 11, and 14. The resulting viral eye titers were determined using standard plaque assays. The mean in vitro EC50 for FCV against tested HAdV types ranged from 0.50 to 4.68 µM, whereas those treated with CDV ranged from 0.49 to 30.3 µM. In vivo, compared to vehicle, 0.5% FCV, 0.1% FCV, and 0.5% CDV produced lower eye titers, fewer numbers of positive eye cultures, and shorter durations of eye infection. FCV demonstrated anti-adenovirus activity in vitro and in vivo.

The importance of nurturing trusting relationships to embed shared decision-making during pregnancy and childbirth.

OBJECTIVE: To generate greater awareness of the contextual and relational factors that influence women's capacity to participate in shared decision-making during childbirth. METHODS: A three-phase participatory action research approach involving in-depth interviews and co-operative inquiry meetings. SETTING: Dublin, Ireland in a large maternity hospital. PARTICIPANTS: Five postnatal women who gave birth to live healthy babies, and attended obstetric or midwifery-led care and 13 practising midwives. FINDINGS: This paper presents the findings from the third phase of a three-phase action research study exploring the action's women consider necessary to embed informed choice, into practice. The findings reveal that multiple organisational and relational factors influence how women can participate in shared decision-making including the model of care they attended, continuity of carer, power dynamics, hospital policies and trust in self and others. Women's relationships with maternity care professionals reveals that exercising choice is not only defined by but contingent on the degree of trust in their relationships with maternity care professionals.

trans-Translation inhibitors bind to a novel site on the ribosome and clear Neisseria gonorrhoeae in vivo.

Bacterial ribosome rescue pathways that remove ribosomes stalled on mRNAs during translation have been proposed as novel antibiotic targets because they are essential in bacteria and are not conserved in humans. We previously reported the discovery of a family of acylaminooxadiazoles that selectively inhibit trans-translation, the main ribosome rescue pathway in bacteria. Here, we report optimization of the pharmacokinetic and antibiotic properties of the acylaminooxadiazoles, producing MBX-4132, which clears multiple-drug resistant Neisseria gonorrhoeae infection in mice after a single oral dose. Single particle cryogenic-EM studies of non-stop ribosomes show that acylaminooxadiazoles bind to a unique site near the peptidyl-transfer center and significantly alter the conformation of ribosomal protein bL27, suggesting a novel mechanism for specific inhibition of trans-translation by these molecules. These results show that trans-translation is a viable therapeutic target and reveal a new conformation within the bacterial ribosome that may be critical for ribosome rescue pathways.

The Canonical Wnt Signaling Pathway Inhibits the Glucocorticoid Receptor Signaling Pathway in the Trabecular Meshwork.

Glucocorticoid-induced glaucoma is a secondary open-angle glaucoma. About 40% of the general population may develop elevated intraocular pressure on prolonged glucocorticoid treatment secondary to damages in the trabecular meshwork (TM), a tissue that regulates intraocular pressure. Therefore, identifying the key molecules responsible for glucocorticoid-induced ocular hypertension is crucial. In this study, Dickkopf-related protein 1 (Dkk1), a canonical Wnt signaling inhibitor, was found to be elevated in the aqueous humor and TM of glaucoma patients. At the signaling level, Dkk1 enhanced glucocorticoid receptor (GR) signaling, whereas Dkk1 knockdown or Wnt signaling activators decreased GR signaling in human TM cells as indicated by luciferase assays. Similarly, activation of the GR signaling inhibited Wnt signaling. At the protein level, glucocorticoid-induced extracellular matrix was inhibited by Wnt activation using Wnt activators or Dkk1 knockdown in primary human TM cells. In contrast, inhibition of canonical Wnt signaling by ß-catenin knockdown increased glucocorticoid-induced extracellular matrix proteins. At the physiological level, adenovirus-mediated Wnt3a expression decreased glucocorticoid-induced ocular hypertension in mouse eyes. In summary, Wnt and GR signaling inhibit each other in the TM, and canonical Wnt signaling activators may prevent the adverse effect of glucocorticoids in the eye.

Single-Study Approvals: Quantum of Evidence Required.

When does a single positive adequate and well-controlled study of a new drug meet the statutory requirement to demonstrate substantial evidence of effectiveness? The answer to this question, particularly with respect to new molecular entities, has been of considerable debate since 1962 when the requirement that new drugs prove their benefit to patients became law. A 1997 revision to the statute provided one pathway to a single-study approval (a single adequate and well-controlled study plus confirmatory evidence), while a 1998 guidance issued by FDA provided additional pathways, one of which is the one that is most frequently cited by FDA (a single statistically very persuasive study). This paper explains these 2 distinct pathways and provides illustrative examples of how FDA uses each of these 2 pathways. Regulators, industry, patients, and investors should each find this exegesis of these 2 independent, yet equally viable and valuable, pathways to an FDA approval both illuminating and invaluable.