Results of a phase 1, randomized, placebo-controlled first-in-human trial of griffithsin formulated in a carrageenan vaginal gel.

HIV pre-exposure prophylaxis (PrEP) is dominated by clinical therapeutic antiretroviral (ARV) drugs. Griffithsin (GRFT) is a non-ARV lectin with potent anti-HIV activity. GRFT's preclinical safety, lack of systemic absorption after vaginal administration in animal studies, and lack of cross-resistance with existing ARV drugs prompted its development for topical HIV PrEP. We investigated safety, pharmacokinetics (PK), pharmacodynamics (PD), and immunogenicity of PC-6500 (0.1% GRFT in a carrageenan (CG) gel) in healthy women after vaginal administration. This randomized, placebo-controlled, parallel group, double-blind first-in-human phase 1 study enrolled healthy, HIV-negative, non-pregnant women aged 24-45 years. In the open label period, all participants (n = 7) received single dose of PC-6500. In the randomized period, participants (n = 13) were instructed to self-administer 14 doses of PC-6500 or its matching CG placebo (PC-535) once daily for 14 days. The primary outcomes were safety and PK after single dose, and then after 14 days of dosing. Exploratory outcomes were GRFT concentrations in cervicovaginal fluids, PD, inflammatory mediators and gene expression in ectocervical biopsies. This trial is registered with ClinicalTrials.gov, number NCT02875119. No significant adverse events were recorded in clinical or laboratory results or histopathological evaluations in cervicovaginal mucosa, and no anti-drug (GRFT) antibodies were detected in serum. No cervicovaginal proinflammatory responses and no changes in the ectocervical transcriptome were evident. Decreased levels of proinflammatory chemokines (CXCL8, CCL5 and CCL20) were observed. GRFT was not detected in plasma. GRFT and GRFT/CG in cervicovaginal lavage samples inhibited HIV and HPV, respectively, in vitro in a dose-dependent fashion. These data suggest GRFT formulated in a CG gel is a safe and promising on-demand multipurpose prevention technology product that warrants further investigation.

Differences in Vaginal Microbiota, Host Transcriptome, and Proteins in Women With Bacterial Vaginosis Are Associated With Metronidazole Treatment Response.

BACKGROUND: Bacterial vaginosis (BV) treatment failures and recurrences are common. To identify features associated with treatment response, we compared vaginal microbiota and host ectocervical transcriptome before and after oral metronidazole therapy. METHODS: Women with BV (Bronx, New York and Thika, Kenya) received 7 days of oral metronidazole at enrollment (day 0) and underwent genital tract sampling of microbiome (16S ribosomal RNA gene sequencing), transcriptome (RNAseq), and immune mediator concentrations on day 0, 15, and 35. RESULTS: Bronx participants were more likely than Thika participants to clinically respond to metronidazole (19/20 vs 10/18, respectively, P = .0067) and by changes in microbiota composition and diversity. After dichotomizing the cohort into responders and nonresponders by change in α-diversity between day 35 and day 0, we identified that transcription differences associated with chemokine signaling (q = 0.002) and immune system process (q = 2.5 × 10-8) that differentiated responders from nonresponders were present at enrollment. Responders had significantly lower levels of CXCL9 in cervicovaginal lavage on day 0 (P < .007), and concentrations of CXCL9, CXCL10, and monocyte chemoattractant protein 1 increased significantly between day 0 and day 35 in responders vs nonresponders. CONCLUSIONS: Response to metronidazole is characterized by significant changes in chemokines and related transcripts, suggesting that treatments that promote these pathways may prove beneficial.

Acceptability of a Tenofovir Disoproxil Fumarate Intravaginal Ring for HIV Pre-Exposure Prophylaxis Among Sexually Active Women.

INTRODUCTION: Vaginal ring delivery of antiretroviral drugs may provide protection against acquisition of HIV-1 when used as Pre-Exposure prophylaxis. As part of a randomized placebo-controlled safety trial of a tenofovir disoproxil fumarate (TDF) intravaginal ring (IVR), we assessed product acceptability through surveys of women after continuous ring use. METHODS: Sexually active, HIV-negative women were enrolled to investigate the safety and pharmacokinetics of 3 months of continuous TDF IVR use. The study was designed to include 40 US participants randomly assigned (3:1) to a TDF or placebo IVR. Twelve were randomized to TDF and 5 to the placebo group before the study was electively discontinued because of the development of vaginal ulcerations in 8 women in the TDF group. Acceptability data were gathered via self-administered, computer-based questionnaires. RESULTS: The average age of the 17 participants was 31 years (range, 18-42 years). Sixteen participants (94%) completed all questions at 2 study visits. When asked about ring likeability after 1 month of ring use, 12 (75%) of 16 reported overall liking the ring, including 6 (75%) of 8 who developed ulcerations. In addition, 10 (83%) of 12 who had their menses during the first month of ring use were not bothered by the ring, and 11 (69%) of 16 stated that the ring was not bothersome with use during sex. CONCLUSIONS: Despite unanticipated ulcers, TDF and placebo IVRs were acceptable to some women, even when used with menses and during sex, which is promising for continued development of IVRs for HIV prevention.

Evidence-Based Secondary Transition Predictors for Physical Therapists Working With High School Students.

PURPOSE: Individuals with disabilities experience poorer postschool outcomes compared with their peers without disabilities. Youth with orthopedic or physical disabilities experience challenges during transition particularly in the areas of education and employment. Physical therapists should continue to become more involved in transition planning and providing services for transition-age students with physical disabilities. The purpose of this article is to clarify the role of physical therapists who work with students who have disabilities, as they transition from high school to postsecondary roles as well as provide the current evidence-based predictors of postschool success and recommended practices to school-based physical therapists who work with these students. SUMMARY OF KEY POINTS: Evidence-based instructional practices for secondary students with disabilities and identified in-school predictors of postschool success for students with disabilities are aligned with effective practices for physical therapists. Additionally, suggestions for involving physical therapists in transition planning and increasing collaboration in providing transition services for students with disabilities are provided. STATEMENT OF CONCLUSIONS: Physical therapists can provide critical expertise for many individuals with disabilities; however, they are not always included effectively in transition planning and services for students with disabilities. RECOMMENDATIONS FOR CLINICAL PRACTICE: Recommendations for practice include ways to involve physical therapists in transition planning and services and increasing collaboration between teachers, physical therapists, and other members of the Individualized Education Program team to provide effective, comprehensive transition services.

Tenofovir disoproxil fumarate intravaginal ring for HIV pre-exposure prophylaxis in sexually active women: a phase 1, single-blind, randomised, controlled trial.

BACKGROUND: An intravaginal ring that releases the tenofovir prodrug, tenofovir disoproxil fumarate, provided 100% protection in macaques against simian HIV and was safe in a 14-day clinical trial in sexually abstinent women. We aimed to assess the safety and pharmacokinetics of this intravaginal ring over 90 days in sexually active women. METHODS: We did a phase 1, single-blind, randomised, placebo-controlled trial to assess safety, pharmacokinetics, and acceptability of a tenofovir disoproxil fumarate intravaginal ring used continuously with monthly ring changes for 3 months. Sexually active women who were HIV negative were randomly assigned (3:1) to a tenofovir disoproxil fumarate ring or placebo ring. Primary safety endpoint was the proportion of women who had grade 2 or higher genitourinary adverse events judged related to study product and any grade 2 or higher adverse event as defined by the Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events. We quantified tenofovir disoproxil fumarate and tenofovir concentrations in cervicovaginal fluid, tenofovir in plasma, and tenofovir diphosphate, the active metabolite, in cervical tissue and dried blood spots 1 month after each ring insertion. We compared changes over time in cervicovaginal fluid cytokine and chemokine concentrations and vaginal microbiota. The study was electively stopped early and is registered with ClinicalTrials.gov, number NCT02762617. FINDINGS: Between Feb 24 and July 20, 2017, 17 women were enrolled before study termination. 12 were assigned to receive the tenofovir disoproxil fumarate ring and five were assigned to receive the placebo ring. Two participants in the tenofovir disoproxil fumarate ring group completed 3 months of continuous ring use; eight were asked to discontinue ring use early because of ulcerations (grade 1) near the ring; in the remaining two women, rings were electively removed by study staff on day 20 and day 23. Ulcers were detected a mean of 32 days after ring use (range 23-56). Four of eight participants with ulcers were symptomatic with vaginal discharge; four had ulcers identified when examined; three had two ulcers; all ulcers resolved after ring removal. No participants in the placebo group developed ulcers. No grade 2 product-related adverse events were reported in either group and four non-product-related grade 2 adverse events were reported in the tenofovir disoproxil fumarate ring group. Cervicovaginal fluid tenofovir concentrations did not differ at day 14 (p=0·14) comparing the eight patients who did (median 1·0 × 105 ng/mL [IQR 9·1 × 104-1·1 × 105]) with the four who did not (6·0 × 104 ng/mL [5·6 × 104-1·1 × 105]) develop ulcers. No significant changes in vaginal microbiota were detected in either group. Concentrations of multiple inflammatory cytokines and chemokines were significantly higher at days 14 and 28 compared with baseline in the tenofovir disoproxil fumarate ring group but not the placebo group. INTERPRETATION: Future studies are needed to establish whether the unanticipated finding of ulcerations is specific to this tenofovir disoproxil fumarate ring or generalisable to other sustained topical release formulations of tenofovir or its prodrugs. FUNDING: National Institutes of Health.

Exposure to routine availability of immediate postpartum LARC: effect on attitudes and practices of labor and delivery and postpartum nurses.

OBJECTIVES: Nurses play an integral role in intrapartum and postpartum patient education. This exploratory study aims to assess the attitudes, knowledge, and practices of labor and delivery and postpartum nurses regarding contraception and evaluate for changes in these measures 1 year after an institutional initiative allowing routine availability of immediate postpartum long-acting reversible contraception (LARC). STUDY DESIGN: In 2014, Montefiore Medical Center began to routinely offer comprehensive immediate postpartum contraception. The initiative included education and feedback sessions for labor and delivery and postpartum nurses on contraception, including immediate postpartum initiation of LARC. Nurses completed anonymous surveys at the beginning of the initiative (n=59) and at 1 year (n=56). We compared baseline and 1 year survey results of contraceptive knowledge, attitudes and practices using χ2 test, Fisher's Exact Test, or t test as appropriate. RESULTS: Nurses who stated they counseled patients on contraception "always" or "most of the time" increased from 27/59 (46%) to 40/56 (71%) (p=.005). The number of nurses who would recommend the intrauterine device and implant for postpartum contraception increased from 1/59 (2%) to 18/56 (32%) (p<.0001). Attitudes towards injectable contraception and breastfeeding remained negative; 27/59 nurses (46%) at baseline and 34/56 (61%) at 1 year agreed with the statement "DMPA [depot medroxyprogesterone acetate] has a negative effect on breastfeeding." CONCLUSIONS: Experience working in a location with routine access to immediate postpartum contraception is associated with increased awareness among nurses of postpartum contraceptive options, especially LARC, and increased contraceptive counseling. Concerns about the impact of hormonal contraception on breastfeeding, specifically DMPA, are persistent and prevalent. IMPLICATIONS: Labor and delivery and postpartum nurses' knowledge regarding immediate postpartum contraception, particularly LARC methods, may change with exposure to routine access to these methods. This exposure may also impact nurses' practices of providing patient counseling on what methods are appropriate for postpartum women.

Timing of developmental reduction in epithelial glutathione redox potential is associated with increased epithelial proliferation in the immature murine intestine.

BackgroundThe intracellular redox potential of the glutathione (GSH)/glutathione disulfide (GSSG) couple regulates cellular processes. In vitro studies indicate that a reduced GSH/GSSG redox potential favors proliferation, whereas a more oxidized redox potential favors differentiation. Intestinal growth depends upon an appropriate balance between the two. However, how the ontogeny of intestinal epithelial cellular (IEC) GSH/GSSG redox regulates these processes in the developing intestine has not been fully characterized in vivo.MethodsOntogeny of intestinal GSH redox potential and growth were measured in neonatal mice.ResultsWe show that IEC GSH/GSSG redox potential becomes increasingly reduced (primarily driven by increased GSH concentration) over the first 3 weeks of life. Increased intracellular GSH has been shown to drive proliferation through increased poly-ADP-ribose polymerase (PARP) activity. We show that increasing IEC poly-ADP-ribose chains can be measured over the first 3 weeks of life, indicating an increase in IEC PARP activity. These changes are accompanied by increased intestinal growth and IEC proliferation as assessed by villus height/crypt depth, intestinal length, and Ki67 staining.ConclusionUnderstanding how IEC GSH/GSSG redox potential is developmentally regulated may provide insight into how premature human intestinal redox states can be manipulated to optimize intestinal growth and adaptation.

Chemical screen reveals small molecules suppressing fragile X premutation rCGG repeat-mediated neurodegeneration in Drosophila.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a progressive neurodegenerative disorder recognized in fragile X premutation carriers. Using Drosophila, we previously identified elongated non-coding CGG repeats in FMR1 allele as the pathogenic cause of FXTAS. Here, we use this same FXTAS Drosophila model to conduct a chemical screen that reveals small molecules that can ameliorate the toxic effects of fragile X premutation ribo-CGG (rCGG) repeats, among them several known phospholipase A(2) (PLA(2)) inhibitors. We show that specific inhibition of PLA(2) activity could mitigate the neuronal deficits caused by fragile X premutation rCGG repeats, including lethality and locomotion deficits. Furthermore, through a genetic screen, we identified a PLA(2) Drosophila ortholog that specifically modulates rCGG repeat-mediated neuronal toxicity. Our results demonstrate the utility of Drosophila models for unbiased small molecule screens and point to PLA(2) as a possible therapeutic target to treat FXTAS.

Lactobacillus rhamnosus blocks inflammatory signaling in vivo via reactive oxygen species generation.

Uncontrolled inflammatory responses in the immature gut may play a role in the pathogenesis of many intestinal inflammatory syndromes that present in newborns or children, such as necrotizing enterocolitis (NEC), idiopathic inflammatory bowel diseases (IBD), or infectious enteritis. Consistent with previous reports that murine intestinal function matures over the first 3 weeks of life, we show that inflammatory signaling in the neonatal mouse gut increases during postnatal maturation, with peak responses occurring at 2-3 weeks. Probiotic bacteria can block inflammatory responses in cultured epithelia by inducing the generation of reactive oxygen species (ROS), which inhibit NF-kappaB activation through oxidative inactivation of the key regulatory enzyme Ubc12. We now report for the first time that the probiotic Lactobacillus rhamnosus GG (LGG) can induce ROS generation in intestinal epithelia in vitro and in vivo. Intestines from immature mice gavage fed LGG exhibited increased GSH oxidation and cullin-1 deneddylation, reflecting local ROS generation and its resultant Ubc12 inactivation, respectively. Furthermore, prefeeding LGG prevented TNF-alpha-induced intestinal NF-kappaB activation. These studies indicate that LGG can reduce inflammatory signaling in immature intestines by inducing local ROS generation and may be a mechanism by which probiotic bacteria can prevent NEC in premature infants or reduce the severity of IBD in children.

Gait initiation in community-dwelling adults with Parkinson disease: comparison with older and younger adults without the disease.

BACKGROUND AND PURPOSE: Initiation of gait requires transitions from relatively stationary positions to stability with movement and from double- to single-limb stances. These are deliberately destabilizing activities that may be difficult for people with early Parkinson disease (PD), even when they have no problems with level walking. We studied differences in postural stability during gait initiation between participants with early and middle stages of PD (characterized by Hoehn and Yahr as stages 1-3) and 2 other groups of participants without PD--older and younger adults. SUBJECTS: The mean ages of the 3 groups of participants were as follows: subjects with PD, 69.3 years (SD=5.7, range=59-78); older subjects without PD, 69.0 years (SD=3.9, range=65-79); and younger subjects without PD, 27.5 (SD=3.9, range=22-35). METHODS: A 3-dimensional motion analysis system was used with 2 force platforms to obtain data for center of mass (COM) and center of pressure (COP). The distance between the vertical projections of the COM and the COP (COM-COP distance) was used to reflect postural control during 5 events in gait initiation. RESULTS: By use of multivariate analysis of variance, differences in COM-COP distance were found among the 3 groups. An analysis of variance indicated differences for 4 of the 5 events in gait initiation. A Scheffe post hoc analysis demonstrated differences in gait initiation between the subjects with PD and both groups of subjects without PD (2 events) and between the subjects with PD and the younger subjects without PD (2 events). DISCUSSION AND CONCLUSION: The COM-COP distance relationship was used to measure postural control during the transition from quiet standing to steady-state gait. Differences between groups indicated that individuals with impaired postural control allow less COM-COP distance than do individuals with no known neurologic problems. The method used could prove useful in the development and assessment of interventions to improve ambulation safety and enhance the independence of people with impaired postural control.