Raising orphans: how clinical development programs of drugs for rare and common diseases are different.

We compared clinical trials described in package inserts from noncancer orphan and nonorphan drugs from 1 January 2001 to 31 December 2011. Among the 37 orphan and 58 nonorphan drugs approved by the US Food and Drug Administration (US FDA) during this period, orphans had fewer clinical trials (2.8 vs. 3.5, P < 0.05) and fewer total participants (390 vs. 2,566, P < 0.001), but proportions with randomization, blinding, and placebo-controlled clinical end points were similar, as were development times. We conclude that small studies of appropriate design can support US FDA approval of new medicines for rare diseases.

Quantitative electron energy-loss spectroscopy (EELS) analyses of lead zirconate titanate.

Electron energy-loss spectroscopy (EELS) analyses have been performed on a sol-gel deposited lead zirconate titanate film, showing that EELS can be used for heavy as well as light element analysis. The elemental distributions within the sol-gel layers are profiled using the Pb N(6,7)-edges, Zr M-edges, Ti L-edges and O K-edge. A multiple linear least squares fitting procedure was used to extract the Zr signal which overlaps with the Pb signal. Excellent qualitative information has been obtained on the distribution of the four elements. The non-uniform and complementary distributions of Ti and Zr within each sol-gel deposited layer are observed. The metal:oxygen elemental ratios are quantified using experimental standards of PbTiO(3), PbZrO(3), ZrO(2) and TiO(2) to provide relevant cross-section ratios. The quantitative results obtained for Ti/O and Pb/O are very good but the Zr/O results are less accurate. Methods of further improving the results are discussed.

Total knee arthroplasty using the S-ROM mobile-bearing hinge prosthesis.

A retrospective study was performed on 15 patients receiving 16 S-ROM mobile-bearing hinge total knee prostheses that were evaluated with at least a 2-year follow-up (range, 27-71 months). Indications for its use included severe instability and bone loss. The average patient age was 63 years (range, 33-83 years). There were 15 revision arthroplasties and 1 primary arthroplasty. Knee Society scores showed notable improvement in pain, motion, and stability (33.6 preoperatively vs 76.5 postoperatively; P <.0001) and approached significant improvement in function (29.2 preoperatively vs 43.5 postoperatively; P =.11). After excluding a patient with a traumatically ruptured patellar tendon, the probability of the latter comparison improved (P <.01). There was no evidence of loosening, and complete bone apposition was seen in nearly all cases. A high percentage of satisfactory results can be achieved when using this mobile-bearing hinge knee prosthesis for these indications.

Development of an RNFA program: a Newfoundland and Labrador adventure.

This inquiry was to determine the feasibility of creating a nursing role for first assisting in the cardiac operating room in Newfoundland and Labrador. A committee was struck to review the role as it existed in the United States and Canada. Following this, the committee gained approval from appropriate professional associations and began developing the program. The result is that three nurses are currently working as RNFA's in Cardiac Surgery and two nurses are piloting a RNFA Program for General Surgery.

The effectiveness of tonsillectomy in diagnosing lymphoproliferative disease in pediatric patients after liver transplantation.

OBJECTIVE: To determine the effectiveness of diagnosing forms of lymphoproliferative disease by performing tonsillectomy in pediatric patients who develop symptomatic or asymptomatic tonsillar hypertrophy during immunosuppressive therapy after liver transplantation. DESIGN: Retrospective chart and pathological review. SETTING: Urban tertiary referral children's hospital. MAIN OUTCOME MEASURES: The presence of a pathological stage of lymphoproliferative disease or Epstein-Barr virus (EBV) diagnosed using tonsillar specimens, resulting in a change in therapy. RESULTS: Of 275 pediatric patients who underwent liver transplantation, 13 had tonsillectomy performed with histopathological review of the tonsillar specimens. The specimens from 5 patients (39%) demonstrated pathological changes thought to be consistent with EBV-related changes or a form of lymphoproliferative disease. Histological changes ranged from tonsillar hyperplasia associated with EBV infection to large cell lymphoma. Immunosuppressive therapy was reduced or discontinued, and antiviral therapy was initiated. CONCLUSION: Children who have undergone liver transplantation and develop tonsillar hypertrophy should undergo a diagnostic tonsillectomy, regardless of the clinical presentation, to rule out a form of posttransplant lymphoproliferative disease. Arch Otolaryngol Head Neck Surg. 2000;126:1444-1447

Predictive value of quantitative PCR-based viral burden analysis for eight human herpesviruses in pediatric solid organ transplant patients.

Human herpesviruses can cause significant morbidity and mortality in pediatric solid organ transplant recipients. It was hypothesized that viral burden quantification by polymerase chain reaction using an internal calibration standard could aid in distinguishing between viral disease and latency. Here we report the results of a 2-year prospective study of 27 pediatric solid organ (liver, kidney, or heart) transplant recipients in which multiple samples were analyzed for levels of all eight human herpesviruses by internal calibration standard-polymerase chain reaction. Herpes simplex viruses 1 and 2, varicella-zoster virus, and Kaposi's sarcoma-associated herpesvirus were not detected in any of these samples. Human herpesvirus types 6 and 7 were detected in half of the patients, but were present at low levels, similar to those found in reference populations. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were detected in 89% and 56% of the patients, respectively. Viral burden analysis suggested distinct patient populations for CMV, with a natural cutoff of 10,000 viral targets/ml blood strongly associated with disease. In some cases, a dramatic increase in CMV levels preceded clinical evidence of disease by several weeks. EBV viral burden was relatively high in the only patient presenting with an EBV syndrome. However, two other patients without evidence of EBV disease had single samples with high EBV burden. Rapid reduction in both EBV and CMV burden occurred with antiviral treatment. These data suggest that viral burden analysis using internal calibration standard-polymerase chain reaction for CMV, and possibly other herpesviruses, is an effective method for monitoring pediatric transplant patients for significant herpesvirus infection and response to therapy.

Comparison of straight chain and cyclic unnatural amino acids embedded in the core of staphylococcal nuclease.

We have determined by X-ray crystallography the structures of several variants of staphylococcal nuclease with long flexible straight chain and equivalent length cyclic unnatural amino acid side chains embedded in the protein core. The terminal atoms in the straight side chains are not well defined by the observed electron density even though they remain buried within the protein interior. We have previously observed this behavior and have suggested that it may arise from the addition of side-chain vibrational and oscillational motions with each bond as a side chain grows away from the relatively rigid protein main chain and/or the population of multiple rotamers (Wynn R, Harkins P, Richards FM. Fox RO. 1996. Mobile unnatural amino acid side chains in the core of staphylococcal nuclease. Protein Sci 5:1026-1031). Reduction of the number of degrees of freedom by cyclization of a side chain would be expected to constrain these motions. These side chains are in fact well defined in the structures described here. Over-packing of the protein core results in a 1.0 A shift of helix 1 away from the site of mutation. Additionally, we have determined the structure of a side chain containing a single hydrogen to fluorine atom replacement on a methyl group. A fluorine atom is intermediate in size between methyl group and a hydrogen atom. The fluorine atom is observed in a single position indicating it does not rotate like methyl hydrogen atoms. This change also causes subtle differences in the packing interactions.

The structure of mitogen-activated protein kinase p38 at 2.1-A resolution.

The structure of mitogen-activated protein (MAP) kinase p38 has been solved at 2.1-A to an R factor of 21.0%, making p38 the second low activity MAP kinase solved to date. Although p38 is topologically similar to the MAP kinase ERK2, the phosphorylation Lip (a regulatory loop near the active site) adopts a different fold in p38. The peptide substrate binding site and the ATP binding site are also different from those of ERK2. The results explain why MAP kinases are specific for different activating enzymes, substrates, and inhibitors. A model presented for substrate and activator interactions has implications for the evolution of protein kinase cascades.

Mobile unnatural amino acid side chains in the core of staphylococcal nuclease.

The structures of several variants of staphylococcal nuclease with long flexible unnatural amino acid side chains in the hydrophobic core have been determined by X-ray crystallography. The unnatural amino acids are disulfide moieties between the lone cysteine residue in V23C nuclease and methane, ethane, 1-n-propane, 1-n-butane, 1-n-pentane, and 2-hydroxyethyl thiols. We have examined changes in the core packing of these mutants. Side chains as large as the 1-n-propyl cysteine disulfide can be incorporated without perturbation of the structure. This is due, in part, to cavities present in the wild-type protein. The longest side chains are not well defined, even though they remain buried within the protein interior. These results suggest that the enthalpy-entropy balance that governs the rigidity of protein interiors favors tight packing only weakly. Additionally, the tight packing observed normally in protein interiors may reflect, in part, the limited numbers of rotamers available to the natural amino acids.

Mutation of position 52 in ERK2 creates a nonproductive binding mode for adenosine 5'-triphosphate.

Among the protein kinases, an absolutely conserved lysine in subdomain II is required for high catalytic activity. This lysine is known to interact with the substrate ATP, but otherwise its role is not well understood. We have used biochemical and structural methods to investigate the function of this lysine (K52) in phosphoryl transfer reactions catalyzed by the MAP kinase ERK2. The kinetic properties of activated wild-type ERK2 and K52 mutants were examined using the oncoprotein TAL2, myelin basic protein, and a designed synthetic peptide as substrates. The catalytic activities of K52R and K52A ERK2 were lower than that of wild-type ERK2, primarily as a consequence of reductions in kcat. Further, there was little difference in Km for ATP, but the Km,app for peptide substrate was higher for the K52 mutants. The three-dimensional structure of unphosphorylated K52R ERK2 in the absence and presence of bound ATP was determined and compared with the structure of unphosphorylated wild-type ERK2. ATP adopted a well-defined but distinct binding mode in K52R ERK2 compared to the binding mode in the wild-type enzyme. The structural and kinetic data show that mutation of K52 created a nonproductive binding mode for ATP and suggest that K52 is essential for orienting ATP for catalysis.

Spectroscopic and kinetic properties of unphosphorylated rat hepatic phenylalanine hydroxylase expressed in Escherichia coli. Comparison of resting and activated states.

The non-heme iron-dependent metalloenzyme, rat hepatic phenylalanine hydroxylase (EC 1.14.16.1; phenylalanine 4-monooxygenase (PAH) was overexpressed in Escherichia coli and purified to homogeneity, allowing a detailed comparison of the kinetic, hydrodynamic, and spectroscopic properties of its allosteric states. The homotetrameric recombinant enzyme, which is highly active and contains 0.7-0.8 iron atoms per subunit, is identical to the native enzyme in several properties: Km, 6-methyltetrahydropterin = 61 microM and L-Phe = 170 microM; Vmax = 9 s-1 (compared to 45 microM, 180 microM, and 13 s-1 for the rat hepatic enzyme). L-Phe and lysolecithin treatment induce the rPAHT-->rPAHR (where r is recombinant) allosteric transformation necessary for rPAH activity. Characteristic changes in the fluorescence spectra, increased hydrophobicity, a large activation energy barrier, and a 10% volume increase of the tetrameric structure are consistent with a significant reorganization of the protein following allosteric activation. However, optical and EPR spectroscopic data suggest that only minor changes occur in the primary coordination sphere (carboxylate/histidine/water) of the catalytic iron center. Detailed steady state kinetic investigations, using 6-methyltetrahydropterin as cofactor and lysolecithin as activator, indicate rPAH follows a sequential mechanism. A catalytic Arrhenius Eact of 14.6 +/- 0.3 kcal/mol subunit was determined from temperature-dependent stopped-flow kinetics data. rPAH inactivates during L-Phe hydroxylation with a half-life of 4.3 min at 25 degrees C, corresponding to an Arrhenius Eact of 10 +/- 1 kcal/mol subunit for the inactivation process. Catechol binding (2.4 x 10(6) M-1) is shown to occur only at catalytically competent iron sites. Ferrous rPAH binds NO, giving rise to an ST = 3/2 spin system.

Crystallization and preliminary X-ray investigation of the recombinant Trypanosoma brucei rhodesiense calmodulin.

Bipyramidal crystals of the recombinant calmodulin from Trypanosoma brucei rhodesiense were obtained by vapor diffusion against 55% (v/v) 2-methyl-2,4-pentanediol in 0.05 M cacodylate buffer, pH 5.6. When few nucleation events occurred, crystals grew to 0.25 x 0.25 x 1.20 mm. The space group of the crystal is I4(1)22, with unit cell dimensions a = b = 56.88 A, c = 230.11 A, alpha = beta = gamma = 90 degrees, z = 16. The molecular mass and volume of the unit cell suggest that there is one molecule in the asymmetric unit. The I/sigma (I) ratio for data at 3.0 A resolution was 3.67, indicating that the final structure can be refined at higher resolution. Molecular replacement methods and the PC-refinement technique have not yet yielded the structure under a variety of search conditions. We are currently investigating the multiple isomorphous replacement approach to determine this crystal structure.

Thyroid function and treatment in premenstrual syndrome.

In 1986 it was reported that a high percentage of women with premenstrual syndrome (PMS) were found to have thyroid hypofunction (TH), mostly subclinical hypothyroidism, as defined by an augmented response of TSH to TRH, and that all affected women had complete relief of PMS symptoms with L-T4 therapy. We studied baseline thyroid function (T4, T3 uptake, T3, TSH, and TSH response to TRH) in 15 normal women (group 1) and 44 women with PMS and treated 22 of the PMS women with L-T4 (group 2; 1.6 micrograms L-T4/kg dose) and the other half with placebo (group 3) for 2 months in a double blinded protocol. We found no evidence of thyroid dysfunction in group 2 or 3, except for 1 subject with slightly elevated TSH (6.2 microIU/mL) and moderate augmented response to TRH (change in TSH, 65 microIU/mL). During the treatment phase we found a complete relief of symptoms in 6 (27%), a partial relief of symptoms in 6 (27%), and some relief of symptoms in 12 (54%) in group 2. Whereas in group 3, 10 (45%) had complete relief, 5 (23%) had partial relief, and 15 (68%) had some relief of symptoms. These results show that 1) there is no significant thyroid disease in PMS; and 2) L-T4 is no better than placebo in treatment of PMS. We conclude that the high incidence of thyroid hypofunction previously reported in PMS is due to an unusually low TSH level for the limit of the normal range for the TRH stimulation test.

Evidence for photosensitive regulation of prolactin secretion in prepubertal bulls.

Changing daily exposure of prepubertal bulls from 8 hr of light: 16 hr of dark (8L:16D) to 16L:8D or 6L:8D:2L:8D increased basal secretion of prolactin 418% 6 weeks later. When daily exposure was changed from 8L:16D (6 weeks) to 6L:14D:2L:2D (6 weeks), basal secretion of prolactin increased only 173%. Among photoperiod exposures, prolactin released into blood after injection of 33 micrograms/100 kg body weight of thyrotropin-releasing hormone paralleled the changes described for basal conditions. There was no repeatable diurnal secretory pattern for secretion of prolactin. The data support the hypothesis that cattle possess a photosensitive rhythm for secretion of prolactin.

Renal failure wit XY gonadal dysgenesis: report of the second case.

The second case is reported of renal failure in association with XY gonadal dysgenesis. The random association of these conditions appears unlikely. Recognition of a possible association is important because of potential fatality due to renal failure or gonadoblastoma in unrecognized cases. In groups at risk, follicle-stimulating hormone (FSH) studies are appropriate in cases of renal disease occurring in phenotypic prepubertal females; in women with XY gonadal dysgenesis, BUN and urinalysis should be studied.