PERSEPT 1: a phase 3 trial of activated eptacog beta for on-demand treatment of haemophilia inhibitor-related bleeding.

INTRODUCTION: Haemophilia A or B patients with inhibitors have been treated with FVIIa-containing bypassing agents for over 20 years. However, due to uncertainty regarding dose response and thrombotic risk, the use of a gradual, titrated, minimal dosing strategy remains prevalent, potentially hampering early haemostasis. AIM: Evaluate the dose-dependent efficacy, safety and immunogenicity of activated eptacog beta (rhFVIIa), a new recombinant inhibitor bypassing agent for the treatment of bleeding episodes (BEs). METHODS: A Phase 3, randomized, cross-over study of initial dose regimens (IDRs) in 27 bleeding congenital haemophilia A or B subjects with inhibitors was conducted to evaluate on-demand treatment of mild/moderate BEs. Intravenous 75 µg/kg or 225 µg/kg initial doses with 75 µg/kg subsequent doses by schedule were administered until clinical response. RESULTS: The primary endpoint was sustained clinical response within 12 hours, determined by a composite of objective and pain measures. In the 75 µg/kg IDR, 84.9% (95% CI; 74.0%, 95.7%) of mild/moderate BEs at 12 hours were successfully treated compared to 93.2% (95% CI; 88.1%, 98.3%) treated in the 225 µg/kg IDR. Efficacy between the IDRs was statistically different (P<.020) in mild/moderate bleeding episodes. Both IDRs were well tolerated with no detectable immunogenic or thrombotic responses to rhFVIIa or host cell proteins. CONCLUSION: The dose-dependent efficacy seen in this study supports individualizing the initial dose of eptacog beta to optimize clinical response. By reducing uncertainty, the PERSEPT 1 results should increase the adoption of early haemostasis as a treatment goal for clinicians who treat haemorrhage in the inhibitor population.

Use of global assays to understand clinical phenotype in congenital factor VII deficiency.

Congenital factor VII (FVII) deficiency is characterized by genotypic variability and phenotypic heterogeneity. Traditional screening and factor assays are unable to reliably predict clinical bleeding phenotype and guide haemorrhage prevention strategy. Global assays of coagulation and fibrinolysis may better characterize overall haemostatic balance and aid in haemorrhagic risk assessment. We evaluated the ability of novel global assays to better understand clinical bleeding severity in congenital FVII deficiency. Subjects underwent central determination of factor VII activity (FVII:C) as well as clot formation and lysis (CloFAL) and simultaneous thrombin and plasmin generation (STP) global assay analysis. A bleeding score was assigned to each subject through medical chart review. Global assay parameters were analysed with respect to bleeding score and FVII:C. Subgroup analyses were performed on paediatric subjects and subjects with FVII ≥ 1 IU dL(-1). CloFAL fibrinolytic index (FI2 ) inversely correlated with FVII:C while CloFAL maximum amplitude (MA) and STP maximum velocity of thrombin generation (VT max) varied directly with FVII:C. CloFAL FI2 directly correlated with bleeding score among subjects in both the total cohort and paediatric subcohort, but not among subjects with FVII ≥ 1 IU dL(-1) . Among subjects with FVII ≥ 1 IU dL(-1), STP time to maximum velocity of thrombin generation and time to maximum velocity of plasmin generation inversely correlated with bleeding score. These preliminary findings suggest a novel potential link between a hyperfibrinolytic state in bleeding severity and congenital FVII deficiency, an observation that should be further explored.

Exploring the biological basis of haemophilic joint disease: experimental studies.

Haemophilia has been recognized as the most severe among the inherited disorders of blood coagulation since the beginning of the first millennium. Joint damage is the hallmark of the disease. Despite its frequency and severity, the pathobiology of blood-induced joint disease remains obscure. Although bleeding into the joint is the ultimate provocation, the stimulus within the blood inciting the process and the mechanisms by which bleeding into a joint results in synovial inflammation (synovitis) and cartilage and bone destruction (arthropathy) is unknown. Clues from careful observation of patient material, supplemented with data from animal models of joint disease provide some clues as to the pathogenesis of the process. Among the questions that remain to be answered are the following: (i) What underlies the phenotypic variability in bleeding patterns of patients with severe disease and the development of arthropathy in some but not all patients with joint bleeding? (ii) What is the molecular basis underlying the variability? (iii) Are there strategies that can be developed to counter the deleterious effects of joint bleeding and prevent blood-induced joint disease? Understanding the key elements, genetic and/or environmental, that are necessary for the development of synovitis and arthropathy may lead to rational design of therapy for the targeted prevention and treatment of blood-induced joint disease.

Gene network shaping of inherent noise spectra.

Recent work demonstrates that stochastic fluctuations in molecular populations have consequences for gene regulation. Previous experiments focused on noise sources or noise propagation through gene networks by measuring noise magnitudes. However, in theoretical analysis, we showed that noise frequency content is determined by the underlying gene circuits, leading to a mapping between gene circuit structure and the noise frequency range. An intriguing prediction from our previous studies was that negative autoregulation shifts noise to higher frequencies where it is more easily filtered out by gene networks--a property that may contribute to the prevalence of autoregulation motifs (for example, found in the regulation of approximately 40% of Escherichia coli genes). Here we measure noise frequency content in growing cultures of E. coli, and verify the link between gene circuit structure and noise spectra by demonstrating the negative autoregulation-mediated spectral shift. We further demonstrate that noise spectral measurements provide mechanistic insights into gene regulation, as perturbations of gene circuit parameters are discernible in the measured noise frequency ranges. These results suggest that noise spectral measurements could facilitate the discovery of novel regulatory relationships.

Distribution and regulation of stochasticity and plasticity in Saccharomyces cerevisiae.

Stochasticity is an inherent feature of complex systems with nanoscale structure. In such systems information is represented by small collections of elements (e.g., a few electrons on a quantum dot), and small variations in the populations of these elements may lead to big uncertainties in the information. Unfortunately, little is known about how to work within this inherently noisy environment to design robust functionality into complex nanoscale systems. Here, we look to the biological cell as an intriguing model system where evolution has mediated the trade-offs between fluctuations and function, and in particular we look at the relationships and trade-offs between stochastic and deterministic responses in the gene expression of budding yeast (Saccharomyces cerevisiae). We find gene regulatory arrangements that control the stochastic and deterministic components of expression, and show that genes that have evolved to respond to stimuli (stress) in the most strongly deterministic way exhibit the most noise in the absence of the stimuli. We show that this relationship is consistent with a bursty two-state model of gene expression, and demonstrate that this regulatory motif generates the most uncertainty in gene expression when there is the greatest uncertainty in the optimal level of gene expression.

Formation of ultrasharp vertically aligned Cu-Si nanocones by a DC plasma process.

We report an effective method for the production of ultrasharp vertically oriented silicon nanocones with tip radii as small as 5 nm. These silicon nanostructures were shaped by a high-temperature acetylene and ammonia dc plasma reactive ion etch (RIE) process. Thin-film copper deposited onto Si substrates forms a copper silicide (Cu3Si) during plasma processing, which subsequently acts as a seed material masking the single-crystal cones while the exposed silicon areas are reactive ion etched. In this process, the cone angle is sharpened continually as the structure becomes taller. Furthermore, by lithographically defining the seed material as well as employing an etch barrier material such as titanium, the cone location and substrate topography can be controlled effectively.

Whole-cell biocomputing.

The ability to manipulate systems on the molecular scale naturally leads to speculation about the rational design of molecular-scale machines. Cells might be the ultimate molecular-scale machines and our ability to engineer them is relatively advanced when compared with our ability to control the synthesis and direct the assembly of man-made materials. Indeed, engineered whole cells deployed in biosensors can be considered one of the practical successes of molecular-scale devices. However, these devices explore only a small portion of cellular functionality. Individual cells or self-organized groups of cells perform extremely complex functions that include sensing, communication, navigation, cooperation and even fabrication of synthetic nanoscopic materials. In natural systems, these capabilities are controlled by complex genetic regulatory circuits, which are only partially understood and not readily accessible for use in engineered systems. Here, we focus on efforts to mimic the functionality of man-made information-processing systems within whole cells.

Gamma-vinyl-GABA treatment of tardive dyskinesia and other movement disorders.

We conducted a single-blind trial of gamma-vinyl-GABA (GVG) in nine patients: seven with tardive dyskinesia, one with Meige syndrome, and one with Tourette syndrome. Five tardive dyskinesia patients completed the entire 11-week study and, as a group, demonstrated significant decreases in dyskinesia scores. Four of these five tardive dyskinesia patients showed clinically evident improvement, with approximately 30% reduction in dyskinetic symptoms. Other patients had no clinical benefit from GVG. Three patients had transient exacerbation of psychiatric symptoms after sudden withdrawal of GVG, and one patient experienced dose-related confusional episodes. Our results suggest that GABAergic drugs may have a role in treating patients with tardive dyskinesia.

Elevated serum angiotensin-converting enzyme (SACE) activity in acute pulmonary histoplasmosis.

Serum angiotensin-converting enzyme (SACE) levels were measured in 44 subjects six weeks after acute pulmonary histoplasmosis. All patients were infected in a common-source outbreak of histoplasmosis which occurred on one day. All patients had both strictly defined clinical and serologic evidence of infection. The SACE activity was elevated at six weeks compared to normal controls, and seven of the 44 had levels more than 2 SD above the normal mean. SACE levels were also measured at three and 24 weeks after acute infection in a smaller number of the same subjects. Serial observations demonstrated that all subjects (including those with normal and elevated SACE at six weeks) had a rise and fall in SACE activity following symptomatic acute pulmonary histoplasmosis. Our findings suggest that elevated SACE does not reliably separate sarcoidosis from histoplasmosis, although elevations in histoplasmosis are much less common and may occur only briefly following acute pulmonary histoplasmosis. More important, it seems that SACE activity rises acutely in all patients with symptomatic acute histoplasmosis and then falls gradually toward baseline over several months, coinciding temporally with the granulomatous response.

Colposcopy, conization, and hysterectomy practices: a current perspective.

Data from the provincial cytology program has shown a progressive increase in the number of cases of cervical carcinoma in situ detected in the general population and a doubling of disease rate in third decade women, with most of the cases now in the 25- to 29-year-old age group. The introduction of a colposcopy service has led to a significant decrease in the number of diagnostic conizations performed over a 5-year period. Conization was still used for therapy in a substantial number of women despite the availability of cryotherapy and laser surgery. Eighty-five percent of all patients undergoing cone biopsy had sever dysplasia or carcinoma in situ (CIN III) on pathological examination. In 25% of patients, the conization specimen revealed either dysplasia or carcinoma in situ extending to resection margins. During review of 2249 patients, 1174 were spared a conization and were treated by either hysterectomy, cryotherapy, or laser surgery. It would appear that, although colposcopy can reduce dramatically the number of diagnostic cone biopsies, conization will still be required for therapy in a substantial number of patients.

Videostroboscopy of the pharyngoesophageal segment in total laryngectomees.

OBJECTIVES: The reconstructed pharyngoesophageal segment (PES) serves as the neoglottis following total laryngectomy, as it provides the source of vibration for production of tracheoesophageal puncture (TEP) voice. To date, little information exists regarding the vibratory characteristics of the PES. The purpose of this investigation was to study the anatomy and physiology of the PES using videostroboscopy. STUDY DESIGN: Prospective study investigating the anatomy and physiology of the PES in 34 laryngectomees who used TEP speech as their primary form of communication. MATERIALS AND METHODS: Videostroboscopy and voice recordings were graded by three trained, blinded judges using a seven-point scale. RESULTS: The patients demonstrated differences that allowed for separation of patients into two main groups: "poor" and "effective" TEP speakers. The voice quality differences were explained by anatomic and physiologic characteristics of the PES. Redundant, thick, and dyssynchronous PES features were observed in patients with poor TEP speech skills; the effective speakers exhibited less redundant, thinner mucosa and more synchronous vibratory patterns. Moreover, the latter subgroup consistently demonstrated a greater degree of volitional PES control and less spasmodic activity than their poorly speaking counterparts. Length of the PES opening (measured in the horizontal plane) as well as amount and consistency of secretions did not appear to influence TEP speech or voice proficiency. CONCLUSION: Videostroboscopy in laryngectomees is a noninvasive, inexpensive, easily performed procedure that may contribute valuable information regarding the anatomy and physiology of the PES, especially in patients who experience difficulties achieving satisfactory TEP voice and speech production.

An integrated CMOS microluminometer for low-level luminescence sensing in the bioluminescent bioreporter integrated circuit.

We report an integrated CMOS microluminometer for the detection of low-level bioluminescence in whole cell biosensing applications. This microluminometer is the microelectronic portion of the bioluminescent bioreporter integrated circuit (BBIC). This device uses the n-well/p-substrate junction of a standard bulk CMOS IC process to form the integrated photodetector. This photodetector uses a distributed electrode configuration that minimizes detector noise. Signal processing is accomplished with a current-to-frequency converter circuit that forms the causal portion of the matched filter for dc luminescence in wide-band white noise. Measurements show that luminescence can be detected from as few as 4 x 10(5) cells/ml.

Videostroboscopy of the pharyngoesophageal segment in laryngectomy patients treated with botulinum toxin.

OBJECTIVES: The purpose of this investigation was to use videostroboscopy to study the physiologic and biomechanical effects of botulinum toxin (Botox) injection on the pharyngoesophageal segment (PES) in total laryngectomy patients with poor-quality tracheoesophageal puncture (TEP) voice caused by PES spasm. METHODS: The following was a prospective study. Videostroboscopy of the PES and videotaped recordings of patients performing TEP voice tasks were conducted before and after Botox injection of the PES. Ratings of videostroboscopic and speech samples were performed by 3 blinded judges with extensive experience with this patient population. RESULTS: Perceptually, TEP voice was more fluent and less strained after injection. Videostroboscopically, patients demonstrated improved PES volitional control and mucosal wave characteristics after Botox injection. CONCLUSION: Botox injection in total laryngectomy patients with poor-quality TEP voice caused by PES spasm provides improved physiologic and biomechanical function of the PES, as demonstrated for the first time videostroboscopically. These findings help explain the perceptual ratings of TEP voice improvement noted after Botox injection. Videostroboscopy can be used to provide diagnostic information to help confirm the clinical impression of PES spasm, as well as to document the effects of Botox injection on PES function.

Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy.

Total laryngectomy patients, after undergoing a tracheoesophageal puncture (TEP), may have poor TEP speech because of hypertonicity or spasm of the pharyngoesophageal segment (PES). Conventional treatment options include speech therapy, PES dilation, pharyngeal neurectomy, and myotomy. Botulinum toxin injection into the PES has recently been reported to be effective for this disorder. However, data accumulated were based primarily on subjective analyses. This prospective investigation used both qualitative and quantitative measures to assess the effects of videofluoroscopy-guided botulinum toxin injection on TEP voice quality in laryngectomees with PES dysfunction. Patients underwent voice analyses, tracheal air pressure measures, and barium swallows before and after botulinum toxin injection. Seven of 8 patients had significant voice quality improvement, and tracheal air pressures normalized in 6 of 8 patients after injection. Videofluoroscopic botulinum toxin injection into the PES is efficacious, safe, and cost-effective and should be considered as a first-line therapy for the treatment of laryngectomees with poor quality TEP speech caused by PES dysfunction.

Use of topical lidocaine in the treatment of muscle tension dysphonia.

This investigation explored the potential usefulness of topical lidocaine in the treatment of muscle tension dysphonia. Three patients with this disorder, who were previously unresponsive to standard voice therapy, were treated with lidocaine. In each case, the outcome was prompt, clinically significant, and sustained. Persistently high-pitched and shrill vocal quality was converted to near normal voice patterns within 15 minutes after transcricothyroid membrane lidocaine injection. We suggest that this temporary and simple laryngeal and tracheal anesthetic technique may have helped to break the perverse cycle of hyperactive glottal and supraglottal muscle contractions evident in each of these patients during phonation efforts. We discuss the possible sensorimotor mechanism of action of this therapeutic technique.

Two methods for teachers' measurement of impulse control.

Offering students immediate versus delayed reward choices is a well known method of measuring delay of gratification used by Mischel. In offering students a set of such choices the classroom teacher may question where to place the cut-off scores separating delay from non-delay. This dilemma is resolved by use of probabilities produced by a binomial distribution for a given set of scores. The probabilities will show the number of choices required for a student to be identified as delaying beyond chance. Some teachers may decide to substitute the estimation of a 60-sec. interval for the classic delayed reward task. This substitution was suggested by Spivack, Levine, and Sprigle in 1959 and confirmed by subsequent work.

Differential performance on Taylor's Manifest Anxiety Scale by black private college freshmen, a partial report.

Distributions of scores from Taylor's 1953 Manifest Anxiety Scale administered to 295 men and 361 women, selected from the 1052 participating students, were presented in graphic form. Means were higher than those reported by Taylor and gender differences were found. Pictorial views of the polygons for both the current freshman data and those for Taylor were similar, including the positive skewness. Results were expected to contribute to refinement of college counseling interventions.

Size-selectivity and anomalous subdiffusion of nanoparticles through carbon nanofiber-based membranes.

A simulation is presented here that serves the dual functions of generating a nanoporous membrane replica and executing the Brownian motion of nanoparticles through the virtual membrane. Specifically, the concentration profile of a dilute solution of fluorescent particles in a stochastic and SiO(2)-coated carbon nanofiber (oxCNF), nanoporous membrane was simulated. The quality of the simulated profile was determined by comparing the results with experimental concentration profiles. The experimental concentration profiles were collected adjacent to the oxCNF membrane surface from time-lapse fluorescence microscopy images. The simulation proved ideal as an accurate predictor of particle diffusion-the simulated concentration profile merged with the experimental profiles at the inlet/exit surfaces of the oxCNF membrane. In particular, the oxCNF barrier was found to hinder the transport of 50 and 100 nm particles and transmembrane trajectories were indicative of anomalous subdiffusion; the diffusion coefficient was found to be a function of time and space.