Neutrophils activated by membrane attack complexes increase the permeability of melanoma blood vessels.

The microenvironment of malignant melanomas defines the properties of tumor blood vessels and regulates infiltration and vascular dissemination of immune and cancer cells, respectively. Previous research in other cancer entities suggested the complement system as an essential part of the tumor microenvironment. Here, we confirm activation of the complement system in samples of melanoma patients and murine melanomas. We identified the tumor endothelium as the starting point of the complement cascade. Generation of complement-derived C5a promoted the recruitment of neutrophils. Upon contact with the vascular endothelium, neutrophils were further activated by complement membrane attack complexes (MACs). MAC-activated neutrophils release neutrophil extracellular traps (NETs). Close to the blood vessel wall, NETs opened the endothelial barrier as indicated by an enhanced vascular leakage. This facilitated the entrance of melanoma cells into the circulation and their systemic spread. Depletion of neutrophils or lack of MAC formation in complement component 6 (C6)-deficient animals protected the vascular endothelium and prevented vascular intravasation of melanoma cells. Our data suggest that inhibition of MAC-mediated neutrophil activation is a potent strategy to abolish hematogenous dissemination in melanoma.

Dietary habits and self-reported health outcomes in a cross-sectional survey of health-conscious adults eating a plant-based diet.

BACKGROUND: Given the growing popularity of plant-based diets, this study investigated the dietary habits and self-reported health outcomes of health-conscious adults consuming plant-based diets. METHODS: A cross-sectional online survey (n = 315) was distributed to members of Plant-Based Health Professionals UK, a community interest company. Dietary intake was assessed through a food frequency questionnaire. Data were summarised descriptively. Dietary habits among respondents following a whole food plant-based (WFPB) and vegan diet were compared using hypothesis tests. RESULTS: Respondents reported following a WFPB (61%), vegan (28%) and semi plant-based (11%) diet. Median time on current dietary pattern was 5 years. Daily or more frequent consumption was reported for the following foods: fruits 77%, berries 51%, green vegetables 48%, cruciferous vegetables 45%, other vegetables 64%, beans/legumes 41%, whole grains 62%, nuts and all seeds 63%. Consumption of ultra-processed foods and plant-based meat alternatives was low. About 93% of those on a WFPB or vegan diet supplemented with vitamin B12 and 61% with vitamin D. The median body mass index was 22.4 kg/m2. Fifty per cent of participants reported weight loss after adopting a plant-based diet, with a median loss of 6.4 kg. Thirty-five per cent reported reversing or improving an underlying health condition, and 15% were able to stop or reduce prescribed medication use as a result of dietary changes. CONCLUSIONS: This study suggests that a well-planned plant-based diet is achievable and sustainable in a community setting and can be associated with health benefits. How to best encourage such sustainable diets among the broad population requires further research.

A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study.

AIMS: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. METHODS AND RESULTS: This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. CONCLUSION: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

A multidomain intervention against cognitive decline in an at-risk-population in Germany: Results from the cluster-randomized AgeWell.de trial.

INTRODUCTION: We investigated the effectiveness of a multidomain intervention to preserve cognitive function in older adults at risk for dementia in Germany in a cluster-randomized trial. METHODS: Individuals with a Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) risk score ≥ 9 aged 60 to 77 years were recruited. After randomization of their general practitioner (GP), patients received a multidomain intervention (including optimization of nutrition and medication, and physical, social, and cognitive activity) or general health advice and GP treatment as usual over 24 months. Primary outcome was global cognitive performance (composite z score, based on domain-specific neuropsychological tests). RESULTS: Of 1030 participants at baseline, n = 819 completed the 24-month follow-up assessment. No differences regarding global cognitive performance (average marginal effect = 0.010, 95% confidence interval: -0.113, 0.133) were found between groups at follow-up. Perceived restrictions in intervention conduct by the COVID-19 pandemic did not impact intervention effectiveness. DISCUSSION: The intervention did not improve global cognitive performance. HIGHLIGHTS: Overall, no intervention effects on global cognitive performance were detected. The multidomain intervention improved health-related quality of life in the total sample. In women, the multidomain intervention reduced depressive symptoms. The intervention was completed during the COVID-19 pandemic.

A Phase 1 Open-Label Study to Assess the Tolerability, Safety, and Immunogenicity of Hyaluronidase-Facilitated Subcutaneous Immunoglobulin 20% in Healthy Adults.

PURPOSE: Hyaluronidase-facilitated subcutaneous immunoglobulin (fSCIG) 20% will allow reduced infusion volumes and frequency versus existing subcutaneous therapies such as fSCIG 10% and conventional subcutaneous immunoglobulin 20%, respectively. We assessed the tolerability, safety, and immunogenicity of warmed and unwarmed fSCIG 20%. METHODS: This phase 1, single-dose, open-label, three-arm study enrolled healthy adults aged 19-50 years (inclusive) at a single US center (NCT05059977). Post-screening, participants received a single fSCIG 20% dose comprising recombinant human hyaluronidase and varying doses of in-line warmed or unwarmed immunoglobulin G (IgG) during a 4-day treatment period in a sentinel and sequential dosing design (treatment arm 1, warmed IgG 20% 0.4 g/kg; treatment arm 2, warmed IgG 20% 1.0 g/kg; treatment arm 3, unwarmed IgG 20% 1.0 g/kg). Participants were followed for 12 (± 1) weeks post-infusion. The primary endpoint was tolerability ("tolerable" infusions were not interrupted, stopped, or reduced in rate owing to fSCIG 20%-related treatment-emergent adverse events (TEAEs)). Secondary endpoints included occurrence of TEAEs. RESULTS: Overall, 24 participants were included, 8 per treatment arm (mean age 39.0 years, 54.2% men). All participants tolerated the infusions. All TEAEs were mild (107 events, in all participants), and all participants experienced fSCIG 20%-related (105 events) and local (102 events) TEAEs. Infusion site erythema and infusion site swelling were most frequently reported. No serious TEAEs occurred, and no participants discontinued the study owing to TEAEs. CONCLUSION: fSCIG 20% was well-tolerated with a favorable safety profile in healthy adults. Future studies will evaluate fSCIG 20% in primary immunodeficiency diseases. Trial registration number (ClinicalTrials.gov): NCT05059977 (registered 28 September 2021).

Local blood coagulation drives cancer cell arrest and brain metastasis in a mouse model.

Clinically relevant brain metastases (BMs) frequently form in cancer patients, with limited options for effective treatment. Circulating cancer cells must first permanently arrest in brain microvessels to colonize the brain, but the critical factors in this process are not well understood. Here, in vivo multiphoton laser-scanning microscopy of the entire brain metastatic cascade allowed unprecedented insights into how blood clot formation and von Willebrand factor (VWF) deposition determine the arrest of circulating cancer cells and subsequent brain colonization in mice. Clot formation in brain microvessels occurred frequently (>95%) and specifically at intravascularly arrested cancer cells, allowing their long-term arrest. An extensive clot embedded ∼20% of brain-arrested cancer cells, and those were more likely to successfully extravasate and form a macrometastasis. Mechanistically, the generation of tissue factor-mediated thrombin by cancer cells accounted for local activation of plasmatic coagulation in the brain. Thrombin inhibition by treatment with low molecular weight heparin or dabigatran and an anti-VWF antibody prevented clot formation, cancer cell arrest, extravasation, and the formation of brain macrometastases. In contrast, tumor cells were not able to directly activate platelets, and antiplatelet treatments did reduce platelet dispositions at intravascular cancer cells but did not reduce overall formation of BMs. In conclusion, our data show that plasmatic coagulation is activated early by intravascular tumor cells in the brain with subsequent clot formation, which led us to discover a novel and specific mechanism that is crucial for brain colonization. Direct or indirect thrombin and VWF inhibitors emerge as promising drug candidates for trials on prevention of BMs.

Tumor cell E-selectin ligands determine partialefficacy of bortezomib on spontaneous lung metastasis formation of solid human tumors in vivo.

Extravasation of circulating tumor cells (CTCs) is critical for metastasis and is initiated by adhesive interactions between glycoligands on CTCs and E-selectin on endothelia. Here, we show that the clinically approved proteasome inhibitor bortezomib (BZM; Velcade) counteracts the cytokine-dependent induction of E-selectin in the lung mediated by the primary tumor, thereby impairing endothelial adhesion and thus spontaneous lung metastasis in vivo. However, the efficacy of BZM crucially depends on the tumor cells' E-selectin ligands, which determine distinct adhesion patterns. The canonical ligands sialyl-Lewis A (sLeA) and sLeX mediate particularly high-affinity E-selectin binding so that the incomplete E-selectin-reducing effect of BZM is not sufficient to disrupt adhesion or metastasis. In contrast, tumor cells lacking sLeA/X nevertheless bind E-selectin, but with low affinity, so that adhesion and lung metastasis are significantly diminished. Such low-affinity E-selectin ligands apparently consist of sialylated MGAT5 products on CD44. BZM no longer has anti-metastatic activity after CD44 knockdown in sLeA/X-negative tumor cells or E-selectin knockout in mice. sLeA/X can be determined by immunohistochemistry in cancer samples, which might aid patient stratification. These data suggest that BZM might act as a drug for inhibiting extravasation and thus distant metastasis formation in malignancies expressing low-affinity E-selectin ligands.

[BeoNet-Halle-development of a multifunctional database for the automated extraction of healthcare data from general practitioner and specialist practices]. / BeoNet-Halle ­ Aufbau einer multifunktionalen Datenbank zur automatisierten Extraktion von Versorgungsdaten aus Haus- und Facharztpraxen.

The Beobachtungspraxennetzwerk Halle (BeoNet-Halle) is an innovative database of outpatient care that has been collecting patient data from participating primary care and specialty practices throughout Germany since 2020 and making it available for research and care. The database is set up and maintained by the Institute of Medical Epidemiology, Biometrics and Informatics and the Institute of General Practice and Family Medicine of the Martin Luther University Halle-Wittenberg. Furthermore, the Data Integration Center of the University Medical Center Halle is involved in the project. In principle, anonymized and pseudonymized patient data from all commercially available practice management systems should flow into the databases.In this article, we describe the structure and methods of the multi-purpose database BeoNet and quantify the current data stock. The workflow of collection, transfer, and storage of broad consents is described and advantages and limitations of the database are discussed.BeoNet-Halle currently contains anonymized data of approximately 73,043 patients from five physician practices. Furthermore, it includes data from more than 2,653,437 ICD-10 diagnoses, 1,403,726 prescriptions, and 1,894,074 laboratory results. Pseudonymized data were successfully exported from 481 patients.BeoNet-Halle enables an almost seamless representation of the care provided in the participating practices. In the future, the database will map patient treatment pathways across practices and provide high-quality care data to contribute to health policy decision-making and optimization of care processes.

[Caring relatives in General practice-General practitioners' perspectives and solution approaches]. / Pflegende Angehörige in der hausärztlichen Praxis ­ Hausärztliche Sichtweisen und Lösungsansätze.

BACKGROUND: General practitioners are usually responsible for the early detection of burden due to informal care and the coordination of adequate measures. Their individual perspectives and approaches for identifying and supporting caregiving relatives have hardly been examined yet. OBJECTIVE: The study therefore examined subjective perspectives of general practitioners regarding the identification and care of family caregivers in general practitioners' practices. The results will help to evaluate the needs for improvement and conditions for implementation of an instrument to identify informal carers. MATERIAL AND METHODS: To answer the question, we conducted 12 guideline-based expert interviews with general practitioners from Saxony-Anhalt. To evaluate the interviews, we used qualitative content analysis (Mayring). RESULTS: With respect to the medical care and support of caring relatives, the examination of subjective attitudes and perspectives confirmed that general practitioners occupy a central position. It also showed possibilities to improve or to facilitate support of caring relatives. Time-dependent problems and a lack of communication complicate support. Home care services and regional consulting services are available but a systematic cooperation and coordination of competences is still lacking. CONCLUSION: A screening instrument for family caregivers (identification, measuring subjective burden) represents a meaningful intervention. The special requirements and characteristics of interventions used in general medical practice have to be researched, the burden scale for family caregivers should be adapted and implemented accordingly. The cooperation of all actors must be a central aspect of future efforts.

General practitioners' willingness to participate in research networks in Germany.

OBJECTIVES: To investigate general practitioners' (GPs') willingness to participate in long-term medical research and in research networks (RNs). DESIGN AND SETTING: Cross-sectional survey among German GPs around Halle-Wittenberg and Leipzig in 2020. SUBJECTS: Random sample of 905 GPs. MAIN OUTCOME MEASURES AND RESULTS: Response rate 37%, 69% female. Overall, 57% were interested in participating in medical research, 34% in an active role in a RN. Interest in RN participation was positively associated with male sex, younger age, previous experiences in medical research, being involved in teaching undergraduates, and having qualification in a further specialty. Main motivators were improving patient care, giving a more realistic picture of GP care, and carrying out research on topics within their own interest areas and a reliable contact person at the leading institution. Most GPs were not afraid of reduced earnings; however, time investment was the main barrier for participation. GPs were willing to dedicate twice as much time to research when remuneration was offered. High rated topics were polypharmacy, chronic diseases, drug safety and adverse drug reactions. CONCLUSION: GPs are interested to participate in practice-based research. The study results providing useful and generalizable insights in barriers and motivators should be considered when building and running GP-RNs.KEY POINTSThere is a difference between general practitioners' (GPs') overall interest in clinical research and their job and socio-demographic related readiness to participate in research networks (RNs).GPs are interested in RNs when it is a resource of and leading to enhanced patient-oriented care.GPs are willing to dedicate twice as much time to research when remunerated.GPs need a reliable counterpart within the leading institution.

Assessment of pharmacokinetic linearity after repeated drug administration.

The prediction of drug concentration time courses after different dosing scenarios is greatly facilitated if the pharmacokinetics (PK) can be assumed linear. The assumption of linear PK thus needs careful evaluation for any new drug in development. Under linear PK, exposure is proportional to dose (linear PK across doses) and exposure at steady state can be predicted from a single dose based on the superposition principle (linear PK over time). While investigation of dose-proportionality is common practice, evaluation of time dependent PK has received less attention in the literature. In particular, the superposition principle can be used to assess whether the observed extent of accumulation after repeated administration is expected under the premise of linear PK. This work emphasizes the importance of the time related aspect of linear PK by introducing the predictability ratio (PR). Linear PK over time can be concluded if PR = 1. Accumulation is higher than expected if PR >1, and lower if PR <1. If PK data from multiple dose cohorts are available, the PR is assessed for each dose cohort and a supportive hypothesis test can be applied to test for potential differences between doses in PR.

[Communication Pathways and Difficulties with Nursing Homes and Digital Perspectives: A Survey of German General Practitioners]. / Kommunikationswege und -hürden mit Pflegeheimen und digitale Lösungsperspektiven: eine Fragebogenumfrage unter Hausärzten.

AIM OF THE STUDY: To outline basic information on communication structures and obstacles between GPs and nursing homes as well as GPs' perspectives on usage of E-health technology. METHODS: A questionnaire-based cross-sectional study carried out among n=600 randomly selected GPs in Germany sent by mail. RESULTS: The response rate was 20% (n=114). The respondent's mean age was 53 years (min=35; max=77), two-thirds were women (65%). GPs mainly used fax (92%) and telephone (87%) to communicate with nursing homes. Less than 10% routinely used digital technologies like E-mail (7%), E-health software (6%) or chat-services (1%). About half of GPs reported unnecessary (52%) or unspecific (51%) nursing home visit requests as well as unreported medication plan changes by other physicians (51%) as a common but avoidable problem. Many GPs wanted to use E-medication plans (85%), E-follow-up prescriptions (79%) and E-letters of referral (69%) in the future. 33% of GPs were already using fully digitalized patient files. Only 9% worked exclusively paper-based. CONCLUSION: Though GPs are open to digitalized communication with nursing homes, fax and telephone are still mostly used. GPs prefer to execute less complex tasks digitally, such as change of medication plans and letters of referral. Fewer can imagine digital solutions for complex procedures such as acute health problems and ward rounds. Only 8% do not want to work digitally at all.

Immunothrombotic Mechanisms Induced by Ingenol Mebutate Lead to Rapid Necrosis and Clearance of Anogenital Warts.

Ingenol mebutate (IM) is highly effective in the treatment of human papillomavirus (HPV)-induced anogenital warts (AGW) leading to fast ablation within hours. However, the exact mode of action is still largely unknown. We performed dermoscopy, in vivo confocal microscopy (CLM), histology, immunohistochemistry, and immunofluorescence to gain insights in mechanisms of IM treatment in AGW. In addition, we used in vitro assays (ELISA, HPV-transfection models) to further investigate in vivo findings. IM treatment leads to a strong recruitment of neutrophils with thrombosis of small skin vessels within 8 h, in a sense of immunothrombosis. In vivo and in vitro analyses showed that IM supports a prothrombotic environment by endothelial cell activation and von Willebrand factor (VWF) secretion, in addition to induction of neutrophil extracellular traps (NETosis). IM superinduces CXCL8/IL-8 expression in HPV-E6/E7 transfected HaCaT cells when compared to non-infected keratinocytes. Rapid ablation of warts after IM treatment can be well explained by the observed immunothrombosis. This new mechanism has so far only been observed in HPV-induced lesions and is completely different from the mechanisms we see in the treatment of transformed keratinocytes in actinic keratosis. Our initial findings indicate an HPV-specific effect, which could be also of interest for the treatment of other HPV-induced lesions. Larger studies are now needed to further investigate the potential of IM in different HPV tumors.

Environmental life cycle assessment of nano-cellulose and biogas production from manure.

Due to its unique properties, nano fibrillated cellulose (NFC) has been a popular topic of research in recent years. Nevertheless, literature assessing environmental impacts of NFC production is scarce, especially for using other starting materials than wood pulp. Hence, in this study, a new approach of cascaded use of manure to produce biogas and subsequently use the cellulose containing digestate for NFC production (manure scenario) is compared to the production from Kraft pulp from hardwood chips (wood chips scenario) via life cycle assessment (LCA). To produce comparable outputs (NFC and biogas) in both scenarios a typical Austrian biogas plant with maize silage and pig slurry as input material is included in the wood chips scenario. A proxy approach is used to upscale the manure scenario from laboratory to an industrial scale (except for the pulp to NFC step) to ensure comparability of both scenarios. The impact categories global warming potential (GWP), fossil resource scarcity, freshwater eutrophication, human toxicity, terrestrial acidification (TAP) and terrestrial ecotoxicity potential are analysed referring to the functional unit of 1 kg NFC. Results show that the manure scenario has at least 45% lower impacts in all assessed categories. GWP is 4.41 kg CO2 eq./kg NFC in the manure and 9.74 kg CO2 eq./kg NFC in the wood chips scenario. The transformation step from pulp to NFC is identified as environmental hotspot due to the high electricity demand in both scenarios. Results are additionally assessed only for the industrial scale part (includes biogas and pulp production). In the latter the main difference can be found in the substrate production. While it plays a subordinate role in the manure scenario (up to 8%) as manure is seen as a waste stream with no upstream environmental impacts attached, the production of maize silage is one of the hotspots in the industrial part in the wood chips scenario. This difference is especially prominent in TAP, where the substrate production is responsible for 91% of the 0.06 kg SO2 eq. impact, which is tenfold the impact of the manure scenario. This underlines the issue of using energy crops as substrate in biogas plants. It also highlights the importance of further research of using waste streams as inputs for the electricity production and subsequent use in the pulp and paper industry. This LCA demonstrates that NFC production from manure is a sustainable alternative to the production from hardwood Kraft pulp.

Platelet endothelial cell adhesion molecule-1 is a gatekeeper of neutrophil transendothelial migration in ischemic stroke.

RATIONALE: Adhesion molecules are key elements in stroke-induced brain injury by regulating the migration of effector immune cells from the circulation to the lesion site. Platelet endothelial cell adhesion molecule-1 (PECAM-1) is an adhesion molecule highly expressed on endothelial cells and leukocytes, which controls the final steps of trans-endothelial migration. A functional role for PECAM-1 in post-ischemic brain injury has not yet been demonstrated. OBJECTIVE: Using genetic Pecam-1 depletion and PECAM-1 blockade using a neutralizing anti-PECAM-1 antibody, we evaluated the role of PECAM-1 mediated trans-endothelial immune cell migration for ischemic injury, delayed brain atrophy, and brain immune cell infiltrates. Trans-endothelial immune cell migration was furthermore evaluated in cultured human cerebral microvascular endothelial cells. METHODS AND RESULTS: Transient middle cerebral artery occlusion (tMCAO) was induced in 10-12-week-old male Pecam-1-/- and Pecam-1+/+ wildtype mice. PECAM-1 levels increased in the ischemic brain tissue due to the infiltration of PECAM-1+ leukocytes. Using magnetic resonance imaging, we observed smaller infarct volume, less edema formation, and less brain atrophy in Pecam-1-/- compared with Pecam-1+/+ wildtype mice. The transmigration of leukocytes, specifical neutrophils, was selectively reduced by Pecam-1-/-, as shown by immune fluorescence and flow cytometry in vivo and transmigration assays in vitro. Importantly, inhibition with an anti-PECAM-1 antibody in wildtype mice decreased neutrophil brain influx and infarct. CONCLUSION: PECAM-1 controls the trans-endothelial migration of neutrophils in a mouse model of ischemic stroke. Antibody blockade of PECAM-1 after stroke onset ameliorates stroke severity in mice, making PECAM-1 an interesting target to dampen post-stroke neuroinflammation, reduce ischemic brain injury, and enhance post-ischemic brain remodeling.

Association of mental demands in the workplace with cognitive function in older adults at increased risk for dementia.

OBJECTIVES: Growing evidence suggests a protective effect of high mental demands at work on cognitive function in later life. However, evidence on corresponding associations in older adults at increased risk for dementia is currently lacking. This study investigates the association between mental demands at work and cognitive functioning in the population of the AgeWell.de-trial. METHODS: Cross-sectional investigation of the association between global cognitive functioning (Montreal Cognitive Assessment) and mental demands at work in older individuals at increased risk for dementia (Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE)score ≥ 9; n = 941, age: 60-77 years). Occupational information was matched to Occupational Information Network (O*NET)-descriptors. Associations between cognitive function and O*NET-indices executive, verbal and novelty were investigated using generalized linear models. RESULTS: Higher values of index verbal (b = .69, p = .002) were associated with better cognitive function when adjusting for covariates. No association was observed for indices executive (b = .37, p = .062) and novelty (b = .45, p = .119). Higher education, younger age, and employment were linked to better cognitive function, while preexisting medical conditions did not change the associations. Higher levels of depressive symptomatology were associated with worse cognitive function. CONCLUSIONS: Higher levels of verbal demands at work were associated with better cognitive function for older adults with increased dementia risk. This suggests an advantage for older persons in jobs with high mental demands even after retirement and despite prevalent risk factors. Longitudinal studies are warranted to confirm these results and evaluate the potential of workplaces to prevent cognitive decline through increased mental demands.

Assessing goodness-of-fit for evaluation of dose-proportionality.

For the clinical development of a new drug, the determination of dose-proportionality is an essential part of the pharmacokinetic evaluations, which may provide early indications of non-linear pharmacokinetics and may help to identify sub-populations with divergent clearances. Prior to making any conclusions regarding dose-proportionality, the goodness-of-fit of the model must be assessed to evaluate the model performance. We propose the use of simulation-based visual predictive checks to improve the validity of dose-proportionality conclusions for complex designs. We provide an illustrative example and include a table to facilitate review by regulatory authorities.

SHP656, a polysialylated recombinant factor VIII (PSA-rFVIII): First-in-human study evaluating safety, tolerability and pharmacokinetics in patients with severe haemophilia A.

INTRODUCTION: SHP656 is the first factor VIII (FVIII) product developed using polysialylation (PSA) technology, in which full-length recombinant (r) FVIII (anti-haemophilic factor [recombinant]) is conjugated with a 20 kDa PSA polymer. AIM: To compare the safety, immunogenicity and pharmacokinetics of SHP656 vs the parent rFVIII (octocog alfa) after single infusions of 25-75 IU/kg in patients with severe haemophilia A (FVIII activity <1%). METHODS: Multinational, phase 1, prospective, open-label, two-period, fixed-sequence, dose-escalation trial (clinicaltrials.gov NCT02716194). Patients received single doses of rFVIII and then SHP656 sequentially at the same dose: 25 ± 3 IU/kg (Cohort 1), 50 ± 5 IU/kg (Cohort 2) and 75 ± 5 IU/kg (Cohort 3). RESULTS: Forty patients received rFVIII: 11 in Cohort 1, 16 in Cohort 2 and 13 in Cohort 3. Two patients withdrew before receiving SHP656, leaving 38 patients who completed the study and received both treatments. No treatment-related adverse events (AEs), serious AEs, deaths, study withdrawals, thrombotic events or allergic reactions were reported; and no significant treatment-related changes in laboratory parameters or vital signs. No patients developed FVIII inhibitors or antibodies to PSA. FVIII activity was significantly prolonged following SHP656 administration vs rFVIII with an approximately 1.5-fold extension in mean residence time (P < .05). Exposure increased proportional to the SHP656 dose over the 25-75 IU/kg dose range. CONCLUSION: Polysialylation of rFVIII confers a half-life extension similar to that of approved extended half-life products that use either PEGylation or Fc fusion technology and was not associated with any treatment-related adverse events.

Medical students' perspectives on earning opportunities of self-employed physicians - realistic and relevant for the process of career choice?

BACKGROUND: Several studies report a substantial impact of financial considerations on the process of specialty choice and the willingness to establish one's own practice. In Germany, reliable information on self-employed physicians' earning opportunities is basically available, but not easily accessible and understandable for medical students. Misperceptions might contribute to recruitment problems in some fields, particularly in general practice. In order to identify a possible need for action, we investigated current German medical students' level of information regarding future earnings, and whether net earnings of general practitioners and other physicians working self-employed are estimated realistically. Additionally, we explored students' self-assessments regarding the extent of the impact of expected earnings on their personal career choice process. METHODS: We conducted a cross-sectional questionnaire survey among fourth year (of six) medical students at one medical school (Leipzig). The participants estimated the net earnings of different physicians working self-employed. These estimations were compared with actual earnings data derived from a large German practice panel. RESULTS: Response rate was 73.6% (231/314). The participants' mean age was 24.9 years and 59.1% were women. On a 10-point scale ranging from 1 = 'no influence' to 10='very big influence', 92.6% of the participants described at least some (≥2) influence of earning expectations on their career choice process, and 66.2% stated this influence to be 5 or higher. Every fourth student (26.4%) would rather or definitely reject a certain specialty because of expected low earning opportunities. While 60.4% had already thought about future earnings, only 26.8% had obtained concrete information. Compared with the data derived from the practice panel, the participants substantially underestimated the earning opportunities in self-employed settings, including general practice (median: 4500 vs. 6417€). However, depending on the single estimations, between 87.7 and 95.6% of the students stated they were 'rather uncertain' or 'very uncertain' regarding their estimations. CONCLUSIONS: Despite confirming a relevant impact of financial considerations on career choice, German fourth year medical students are not well informed about earning opportunities in self-employed settings. Providing easily understandable information could enhance transparency and might help students to consider financial issues of career choice on a realistic basis.

Evaluation of Factor VIII Polysialylation: Identification of a Longer-Acting Experimental Therapy in Mice and Monkeys.

Extended half-life (EHL) factor therapies are needed to reduce the burden of prophylaxis and improve treatment adherence in patients with hemophilia. BAX 826 is a novel polysialylated full-length recombinant factor VIII [polysialyic acid (PSA) rFVIII] with improved pharmacokinetics (PK), prolonged pharmacology, and maintained safety attributes to enable longer-acting rFVIII therapy. In factor VIII (FVIII)-deficient hemophilic mice, PSArFVIII showed a substantially higher mean residence time (>2-fold) and exposure (>3-fold), and prolonged efficacy in tail-bleeding experiments (48 vs. 30 hours) compared with unmodified recombinant FVIII (rFVIII), as well as a potentially favorable immunogenicity profile. Reduced binding to a scavenger receptor (low-density lipoprotein receptor-related protein 1) and von Willebrand factor (VWF) as well as a largely VWF-independent circulation time in mice provide a rationale for prolonged BAX 826 activity. The significantly improved PK profile versus rFVIII was confirmed in cynomolgus monkeys [mean residence time: 23.4 vs. 10.1 hours; exposure (area under the curve from time 0 to infinity): 206 vs. 48.2 IU/ml⋅h] and is in line with results from rodent studies. Finally, safety and toxicity evaluations did not indicate increased thrombogenic potential, and repeated administration of BAX 826 to monkeys and rats was well tolerated. The favorable profile and mechanism of this novel experimental therapeutic demonstrated all of the requirements for an EHL-rFVIII candidate, and thus BAX 826 was entered into clinical assessment for the treatment of hemophilia A. SIGNIFICANCE STATEMENT: Prolongation of FVIII half-life aims to reduce the burden of prophylaxis and improve treatment outcomes in patients with hemophilia. This study shows that polysialylation of PSArFVIII resulted in prolongations of rFVIII circulation time and procoagulant activity, together with a favorable nonclinical safety profile of the experimental therapeutic.