Secondary profunda femoris artery injury after intramedullary femoral nailing in a geriatric pertrochanteric femur fracture: case report.

We present a case of a secondary injury to the femoral artery in a geriatric male patient who sustained a pertrochanteric femoral fracture. Six days after closed fracture reduction and intramedullary femoral nailing, the patient presented with persistent hematocrit level drops, femoral swelling and pain. A computed tomography angiography of the femur revealed a perforation of the profunda femoris artery through the dislocated lesser trochanter fragment, and immediate surgical revision was induced. The patient returned to his pre-injury mobilization level without any peripheral vascular or neurological deficiencies. A literature review suggests that the occurrence of vascular damage in proximal femoral fractures is rare but mainly presents in geriatric patients due to atherosclerosis and brittle bone mass.

Examining breast cancer screening barriers among Central American and Mexican immigrant women: fatalistic beliefs or structural factors?

Researchers have examined "cancer fatalism" (the belief that cancer is predetermined, beyond individual control, and necessarily fatal) as a major barrier to breast cancer screening among Latinas. The authors examine perceptions of breast cancer, its causes, and experiences with screening among Salvadoran, Guatemalan, Mexican, and Bolivian immigrant women in Washington, DC. Two salient themes emerged: (a) perceptions of breast cancer causes and breast cancer screening; and (b) structural factors are the real barriers to breast cancer screening. Findings demonstrate participants' awareness and motivation to get screened and elucidate structural barriers that are obscured by the discourse of fatalism and hinder breast cancer screening.

A framework for assessing the impact of accelerated approval.

The FDA's Accelerated Approval program (AA) is a regulatory program to expedite availability of products to treat serious or life-threatening illnesses that lack effective treatment alternatives. Ideally, all of the many stakeholders such as patients, physicians, regulators, and health technology assessment [HTA] agencies that are affected by AA should benefit from it. In practice, however, there is intense debate over whether evidence supporting AA is sufficient to meet the needs of the stakeholders who collectively bring an approved product into routine clinical care. As AAs have become more common, it becomes essential to be able to determine their impact objectively and reproducibly in a way that provides for consistent evaluation of therapeutic decision alternatives. We describe the basic features of an approach for evaluating AA impact that accommodates stakeholder-specific views about potential benefits, risks, and costs. The approach is based on a formal decision-analytic framework combining predictive distributions for therapeutic outcomes (efficacy and safety) based on statistical models that incorporate findings from AA trials with stakeholder assessments of various actions that might be taken. The framework described here provides a starting point for communicating the value of a treatment granted AA in the context of what is important to various stakeholders.

Induced, selective proteolysis of MLK3 negatively regulates MLK3/JNK signalling.

MLK3 (mixed lineage kinase 3) is a MAP3K [MAPK (mitogen-activated protein kinase) kinase kinase] that activates multiple MAPK pathways, including the JNK (c-Jun N-terminal kinase) pathway. Immunoblotting of lysates from cells ectopically expressing active MLK3 revealed an additional immunoreactive band corresponding to a CTF (C-terminal fragment) of MLK3. In the present paper we provide evidence that MLK3 undergoes proteolysis to generate a stable CTF in response to different stimuli, including PMA and TNFalpha (tumour necrosis factor alpha). The cleavage site was deduced by Edman sequencing as between Gln251 and Pro252, which is within the kinase domain of MLK3. Based on our homology model of the kinase domain of MLK3, the region containing the cleavage site is predicted to reside on a flexible solvent-accessible loop. Site-directed mutagenesis studies revealed that Leu250 and Gln251 are required for recognition by the 'MLK3 protease', reminiscent of the substrate specificity of the coronavirus 3C and 3CL proteases. Whereas numerous mammalian protease inhibitors have no effect on MLK3 proteolysis, blockade of the proteasome through epoxomicin or MG132 abolishes PMA-induced production of the CTF of MLK3. This CTF is able to heterodimerize with full-length MLK3, and interact with the active form of the small GTPase Cdc42, resulting in diminished activation loop phosphorylation of MLK3 and reduced signalling to JNK. Thus this novel proteolytic processing of MLK3 may negatively control MLK3 signalling to JNK.

The dinosaur from 600 BCE! Interpreting the dragon of Babylon, from archaeological excavation into fringe science.

In 1918, German archaeologist Robert Koldewey, excavator of Babylon, Iraq, observed that the depiction of the fantastical "dragon of Babylon" on the sixth century BCE Ishtar Gate must reference a real animal whose closest relatives would be dinosaurs like the iguanodon. Though ignored within archaeology, Koldewey's comments were taken up in German-American popular science writer Willy Ley's "romantic zoology" (1941), then by Bernard Heuvelmans (1955), founding figure in the fringe field of cryptozoology. Their interpretations would ultimately inspire expeditions by the International Society of Cryptozoologists in Central Africa to find the Mokele-Mbembe, a "living dinosaur," and migrate into Young Earth Creationist and ancient aliens theories. An analysis of Koldewey's marginal academic observation serves as a means of considering the process of knowledge formation and canonization and the unpredictable life of scholarly ideas.

Adaptive Designs: Results of 2016 Survey on Perception and Use.

BACKGROUND: The DIA Adaptive Designs Scientific Working Group has a devoted subteam to performing surveys, literature reviews, and registry reviews every 4 years to assess the perception and use of adaptive designs (ADs) in the development of drugs and biologics. METHODS: A survey was distributed to pharmaceutical companies, academic institutions, and contract research organizations to collect information about the usage of ADs of different types and perception of challenges for their use. Literature and registry reviews were conducted to assess the prevalence of ADs of different types in drug and biologics development. These results were compared to previous surveys and reviews using summary statistics. RESULTS: ADs appear to be more widely considered in the last 4 years as compared to earlier 4-year periods. CONCLUSIONS: The most common types of ADs remain early stopping, treatment group adaptations, and sample size re-estimation. Both stopping early for safety and changing the endpoint of the analyses were rarely mentioned in literature prior to 2012 but are now appearing more frequently. The barriers of change management and negative experiences by some institutions with ADs remain a source of concern. Additional, consistent training would be helpful to choose the right adaptation(s) needed for specific clinical trials and for planning appropriately for operational efficiency such as for drug supply management and data management. The perceived barrier of regulatory acceptance also remains a concern, which could be alleviated by additional interaction with agencies and an update of the FDA draft guidance to industry on adaptive designs.

Interleukin-13 associates with life-threatening rhinovirus infections in infants and young children.

OBJECTIVE: Delineate risk factors associated with severe hypoxemia (O2 sat ≤87%) in infants and children younger than 2 years hospitalized with single pathogen HRV infection. STUDY DESIGN: Prospective study in a yearly catchment population of 56 560 children <2 years old between 2011 and 2013 in Argentina. All children with respiratory signs and O2 sat <93% on admission were included. HRV infections were identified by reverse transcriptase-polymerase chain reaction. Epidemiologic, clinical, viral, and immunological risk factors were assessed. RESULTS: Among 5012 hospitalized patients, HRV was detected as a single pathogen in 347 (6.92%) subjects. Thirty-two (9.2%) had life-threatening disease. Traditional risk factors for severe bronchiolitis did not affect severity of illness. HRV viral load, HRV groups, and type II and III interferons did not associate with severe hypoxemia. Interleukin-13 Levels in respiratory secretions at the time of admission (OR = 7.43 (3-18.4); P < 0.001 for IL-13 >10 pg/mL) predisposed to life-threatening disease. CONCLUSIONS: Targeted interventions against IL-13 should be evaluated to decrease severity of HRV illness in infancy and early childhood.

Ethical Considerations in Adaptive Design Clinical Trials.

Adaptive design clinical trial methodologies offer both opportunities and challenges for observing basic ethical principles in human subject research. Using both published and unpublished adaptive design clinical trials, we have selected and reviewed examples of clinical trials with different design adaptations to discuss the ethical obstacles presented and often successfully resolved by these approaches, including (1) confirmatory trials for treatments widely accepted on the basis of uncontrolled case series or open-label trials (clinical equipoise and "justice" in the sense of which trial groups will "receive the benefits of research and bear its burdens") (infantile hemangioma/propranolol); (2) interim results analysis by unblinded data monitoring committees ("withholding information necessary to make a considered judgment" ["respect for persons"] versus compromising the trial's scientific basis) (BIG 1-98); (3) adaptations involving sample size reassessment or dose adjustment via dropping or adding treatment arms, allowing fewer subjects to produce statistically significant results, fewer subjects treated with ineffective/toxic doses, and more subjects given doses showing tolerance and treatment activity ("beneficence" or "protecting from harm and making efforts to secure wellbeing") (ECMO, Neuromyelitis Optica); (4) adaptive randomization inferential problems balanced against ethical benefits (trastuzumab vs taxane in advanced gastric cancer; ADVENT); (5) more efficient allocation of societal resources for research, in both public and commercial realms, versus uncertain regulatory acceptance (indicaterol; VALOR); and (6) platform, umbrella, and basket trials offering additional efficiencies (I-SPY II, BATTLE, Lung-MAP). The importance of careful design, meticulous planning, and rigorous ethical review of adaptive design trials on a case-by-case basis cannot be overemphasized.

Addressing Challenges and Opportunities of "Less Well-Understood" Adaptive Designs.

The draft adaptive design guidance released by FDA in 2010 included references to adaptive study designs that were described as "less well-understood." At that time, there was relatively little regulatory experience with such designs, and their properties were felt to be insufficiently understood. In order to promote greater use of adaptive designs, especially those categorized as less well-understood, the Best Practice Subteam of the DIA Adaptive Designs Scientific Working Group (ADSWG) has worked on describing and characterizing these designs, identifying challenges associated with them and suggesting improvements to design or study conduct aspects that might make them more acceptable. This paper summarizes the work from the subteam.

DIA's Adaptive Design Scientific Working Group (ADSWG): Best Practices Case Studies for "Less Well-understood" Adaptive Designs.

Adaptive design (AD) clinical trials use accumulating subject data to modify the parameters of the design of an ongoing study, without compromising the validity and integrity of the study. The 2010 US Food and Drug Administration (FDA) Draft Guidance on Adaptive Design Clinical Trials described a subset of 7 primary design types as "less well-understood." FDA defined these designs as those with limited regulatory experience. To better understand the properties of these less well-understood ADs and to promote their use when applicable, the Best Practices Subteam for DIA's Adaptive Design Scientific Working Group conducted an extensive nonsystematic search and reviewed trials from multiple sponsors who had employed these designs. Here, we review 10 specific case studies for which less well-understood ADs were employed and share feedback about their challenges and successes, as well as details about the regulatory interactions from these trials. We learned that these designs and associated statistical methodologies can make difficult research situations more amenable for study and, therefore, are needed in our toolbox. While they can be used to study many diseases, they are particularly valuable for rare diseases, small populations, studies involving terminal illnesses, and vaccine trials, in which it is important to find efficient ways to bring effective treatments to market more rapidly. It is imperative, however, that these methodologies be utilized appropriately, which requires careful planning and precise operational execution.

Respiratory Severity Score Separates Upper Versus Lower Respiratory Tract Infections and Predicts Measures of Disease Severity.

Background: A respiratory severity score (RSS) describing acute respiratory illness (ARI) severity would be useful for research and clinical purposes. Methods: A total of 630 term infants presenting with ARI had their RSS measured. Results: RSS was higher in those with lower respiratory tract infection (LRTI) compared with those with upper respiratory infection (URI; LRTI 6.5 [4-8.5]; URI 1 [0-2], p<0.001) and in hospitalized infants compared with outpatients (hospitalized 6.5 [4-9]; outpatient 1 [0-3], p<0.001). Conclusions: RSS is higher in LRTI compared with URI and in hospitalized compared with nonhospitalized infants.

Views on Emerging Issues Pertaining to Data Monitoring Committees for Adaptive Trials.

In this paper, the authors express their views on a range of topics related to data monitoring committees (DMCs) for adaptive trials that have emerged recently. The topics pertain to DMC roles and responsibilities, membership, training, and communication. DMCs have been monitoring trials using the group sequential design (GSD) for over 30 years. While decisions may be more complicated with novel adaptive designs, the fundamental roles and responsibilities of a DMC will remain the same, namely, to protect patient safety and ensure the scientific integrity of the trial. It will be the DMC's responsibility to recommend changes to the trial within the scope of a prespecified adaptation plan or decision criteria and not to otherwise recommend changes to the study design except for serious safety-related concerns. Nevertheless, compared with traditional data monitoring, some additional considerations are necessary when convening DMCs for novel adaptive designs. They include the need to identify DMC members who are familiar with adaptive design and to consider possible sponsor involvement in unique situations. The need for additional expertise in DMC members has prompted some researchers to propose alternative DMC models or alternative governance model. These various options and authors' views on them are expressed in this article.