Efficacy of Vesicular Monoamine Transporter 2 Inhibition and Synergy with Antipsychotics in Animal Models of Schizophrenia.

Antipsychotic medications function by blocking postsynaptic dopaminergic signaling in the central nervous system. Dopamine transmission can also be modulated presynaptically by inhibitors of vesicular monoamine transporter 2 (VMAT2), which inhibit loading of dopamine into presynaptic vesicles. Here we investigated the combination of these mechanisms in animal models of schizophrenia and weight gain (a primary side effect of antipsychotics). When dosed alone, the highly selective VMAT2 inhibitor RRR-dihydrotetrabenazine (RRR-DHTBZ, also known as [+]-α-HTBZ) elicited efficacy comparable to conventional antipsychotics in prepulse inhibition and conditioned avoidance models without eliciting weight gain. In combination experiments, synergy was observed: subthreshold doses of RRR-DHTBZ and risperidone or olanzapine produced robust efficacy, and in dose response experiments, RRR-DHTBZ increased the antipsychotic potency in the efficacy models but did not affect weight gain. The combinations did not affect plasma compound concentrations. The synergy is consistent with VMAT2 inhibition blocking the counterproductive presynaptic stimulation of dopamine by antipsychotics. These results suggest a therapeutic strategy of adding a VMAT2 inhibitor to lower the antipsychotic dose and reduce the side effect burden of the antipsychotic while maintaining and potentially enhancing its therapeutic effects. SIGNIFICANCE STATEMENT: Antipsychotics are often necessary and life-changing medications that reduce psychotic symptoms; however, these benefits come with a high side effect burden. This study shows that combining these postsynaptic dopaminergic modulators with a presynaptic dopamine modulator (vesicular monoamine transporter 2 [VMAT2] inhibitor) potentiates efficacy synergistically in animal models of schizophrenia without potentiating weight gain. Our data suggest that adding a VMAT2 inhibitor may be a viable therapeutic strategy for reducing antipsychotic side effects by lowering antipsychotic dose while maintaining therapeutic efficacy.

A proinflammatory diet is associated with an increased likelihood of first clinical diagnosis of central nervous system demyelination in women.

BACKGROUND: While a number of studies have examined associations between dietary factors and risk of multiple sclerosis (MS), little is known about intakes of inflammation-modulating foods and nutrients and risk of MS. OBJECTIVES: To test associations between the Dietary Inflammatory Index (DII®) and risk of a first clinical diagnosis of central nervous system (CNS) demyelination (FCD) (267 cases, 507 controls) using data from the Ausimmune Study. METHODS: The 2003-2006 Ausimmune Study was a multicentre, matched, case-control study examining environmental risk factors for an FCD, a common precursor to MS. The DII is a well-recognised tool that categorises individuals' diets on a continuum from maximally anti-inflammatory to maximally pro-inflammatory. The DII score was calculated from dietary intake data collected using a food frequency questionnaire. Conditional logistic regression models were used to estimate the association between DII and FCD separately for men and women. RESULTS: In women, a higher DII score was associated with increased likelihood of FCD, with a 17% increase in likelihood of FCD per one-unit increase in DII score (adjusted odds ratio 1.17, 95% confidence interval 1.04-1.33). There was no association between DII and FCD in men (adjusted odds ratio 0.88, 95% confidence interval 0.73-1.07). CONCLUSIONS: These findings suggest that a pro-inflammatory diet is associated with an increased likelihood of FCD in women.

Bone morphology of the proximal femoral canal: ethnicity related differences and the influence on cementless tapered wedge stem designs.

BACKGROUND: Differences in proximal femoral morphology between ethnicities may have implications on the design of cementless tapered wedge stems. This study analyses the differences in Asian and Caucasian bone morphology as well as the related fit of various cementless tapered wedge stem designs. METHODS: A computed tomography database and modelling software was used to retrospectively analyse a total of 1345 femora. Ethnicity related comparisons as well as the fit of the stem designs were analysed. RESULTS: Statistically significant differences between canal shape of Caucasian and Japanese as well as non-Japanese Asians were observed. The fit of the stems within the femoral canal was highly dependent on the respective stem shape. CONCLUSIONS: The shape differences in stem designs had a larger influence on the fit within the femoral canal than the differences in ethnicity related to bone morphology.

A numeric approach for anatomic plate design.

Osteosynthesis plate designs with high levels of anatomical compliance have been demonstrated to have numerous clinical benefits. The purpose of this paper is to introduce a systematic numeric approach for anatomic plate design on the example of the distal medial tibia. The advantage of using numeric approaches for plate design is to gain objective and complete anatomical input as opposed to cadaveric investigations with limited sample sizes. A recent development in this area is a proprietary technology called SOMA which is based on a large database of 3D bone models generated from thin-slice computer tomographic scans plus associated software tools. In this paper, one of these associated software tools is described which automatically assesses the anatomic fit of osteosynthesis plates based on a large database of bone models. As an example, this tool was applied to assess the mean plate to bone distance of distal medial tibia plates, when fitted onto 444 Caucasian and 310 Asian 3D bone models respectively. The analyses revealed differences in the anatomical compliance of plates from different generations and manufacturers. The anatomical compliance of SOMA designed plates was statistically significantly better compared to all other plates in all groups "Short", "Intermediate" and "Long" and for both ethnicities "Caucasian" and "Asian" (P<0.001). The study has shown that using an underlying database with accompanying computational tools such as SOMA can be a powerful and efficient approach towards the development and advancement of osteosynthesis plates in trauma surgery, ultimately resulting in plates with high levels of anatomical compliance and potential clinical benefits.

Kinetic operational models of agonism for G-protein-coupled receptors.

The application of kinetics to research and therapeutic development of G-protein-coupled receptors has become increasingly valuable. Pharmacological models provide the foundation of pharmacology, providing concepts and measurable parameters such as efficacy and potency that have underlain decades of successful drug discovery. Currently there are few pharmacological models that incorporate kinetic activity in such a way as to yield experimentally-accessible drug parameters. In this study, a kinetic model of pharmacological response was developed that provides a kinetic descriptor of efficacy (the transduction rate constant, kτ) and allows measurement of receptor-ligand binding kinetics from functional data. The model assumes: (1) receptor interacts with a precursor of the response ("Transduction potential") and converts it to the response. (2) The response can decay. Familiar response vs time plots emerge, depending on whether transduction potential is depleted and/or response decays. These are the straight line, the "association" exponential curve, and the rise-and-fall curve. Convenient, familiar methods are described for measuring the model parameters and files are provided for the curve-fitting program Prism (GraphPad Software) that can be used as a guide. The efficacy parameter kτ is straightforward to measure and accounts for receptor reserve; all that is required is measurement of response over time at a maximally-stimulating concentration of agonist. The modular nature of the model framework allows it to be extended. Here this is done to incorporate antagonist-receptor binding kinetics and slow agonist-receptor equilibration. In principle, the modular framework can incorporate other cellular processes, such as receptor desensitization. The kinetic response model described here can be applied to measure kinetic pharmacological parameters than can be used to advance the understanding of GPCR pharmacology and optimize new and improved therapeutics.

Perceptions of medical graduates and their workplace supervisors towards a medical school clinical audit program.

OBJECTIVES: This study explores how medical graduates and their workplace supervisors perceive the value of a structured clinical audit program (CAP) undertaken during medical school. METHODS: Medical students at the University of Notre Dame Fremantle complete a structured clinical audit program in their final year of medical school.  Semi-structured interviews were conducted with 12 Notre Dame graduates (who had all completed the CAP), and seven workplace supervisors (quality and safety staff and clinical supervisors).  Purposeful sampling was used to recruit participants and data were analysed using thematic analysis. RESULTS: Both graduates and workplace supervisors perceived the CAP to be valuable. A major theme was that the CAP made a contribution to individual graduate's medical practice, including improved knowledge in some areas of patient care as well as awareness of healthcare systems issues and preparedness to undertake scientifically rigorous quality improvement activities. Graduates perceived that as a result of the CAP, they were confident in undertaking a clinical audit after graduation.  Workplace supervisors perceived the value of the CAP beyond an educational experience and felt that the audits undertaken by students improved quality and safety of patient care. CONCLUSIONS: It is vital that health professionals, including medical graduates, be able to carry out quality and safety activities in the workplace. This study provides evidence that completing a structured clinical audit during medical school prepares graduates to undertake quality and safety activities upon workplace entry. Other health professional faculties may be interested in incorporating a similar program in their curricula.

Non-peptide CRF-Receptor Antagonists: Allosterism, Kinetics and Translation to Efficacy in Human Disease.

G-Protein coupled receptors (GPCRs) have been, and remain a key target of drug discovery programs for human disease. While many drugs have been developed that interact with these proteins in the simple classic manner - that is - physically blocking the cognate ligand from simply binding to its target receptor, drug discovery approaches have elucidated alternative more complex methods by which small molecules can interact with these receptors and block their function. This is most evident in the Class B GPCRs where the cognate ligands are relatively large peptides with multiple points of contact on the GPCR spanning both hydrophilic and hydrophobic domains on the same protein to elicit function. It has therefore been difficult to precisely determine not only the mechanism by which a small molecule can inhibit the function of a large peptide but also the nature of that mechanism that drives the differences in efficacy. This review will examine in detail the nature of small molecule inhibition of corticotropin-releasing factor receptors and illustrate the role that allosteric binding and kinetics play in the functional inhibition of this Class B GPCR.

Higher intake of omega-3 polyunsaturated fatty acids is associated with a decreased risk of a first clinical diagnosis of central nervous system demyelination: Results from the Ausimmune Study.

BACKGROUND: There is contradictory evidence for a role of dietary fat in risk of multiple sclerosis (MS). OBJECTIVES: To examine the association between usual fat intake (total, saturated, monounsaturated (MUFA), polyunsaturated (PUFA), omega-3 and omega-6) and risk of a first clinical diagnosis of CNS demyelination (FCD). METHODS: Multi-centre incident case-control study in four regions of Australia during 2003-2006. Cases were aged 18-59 years and had a FCD; controls were matched to a case on age, sex and location. Dietary data were collected using a validated food frequency questionnaire. RESULTS: In 267 cases and 517 controls with dietary data, higher intake (per g/day) of omega-3 PUFA (adjusted odds ratio, AOR=0.61 (95% CI 0.40-0.93)), and particularly that derived from fish (AOR=0.54 (95% CI 0.31-0.93)) rather than from plants (AOR=0.75 (95% CI 0.39-1.43)) was associated with a decreased risk of FCD. Total fat intake and intake of other types of fat were not associated with FCD risk. CONCLUSIONS: There was a significant decrease in FCD risk with higher intake of omega-3 PUFA, particularly that originating from fish. There was no evidence to indicate that the intake of other types of dietary fat or fat quantity in the previous 12 months was associated with an altered risk of FCD.

Comparing the effects of sun exposure and vitamin D supplementation on vitamin D insufficiency, and immune and cardio-metabolic function: the Sun Exposure and Vitamin D Supplementation (SEDS) Study.

BACKGROUND: Adults living in the sunny Australian climate are at high risk of skin cancer, but vitamin D deficiency (defined here as a serum 25-hydroxyvitamin D (25(OH)D) concentration of less than 50 nmol/L) is also common. Vitamin D deficiency may be a risk factor for a range of diseases. However, the optimal strategies to achieve and maintain vitamin D adequacy (sun exposure, vitamin D supplementation or both), and whether sun exposure itself has benefits over and above initiating synthesis of vitamin D, remain unclear. The Sun Exposure and Vitamin D Supplementation (SEDS) Study aims to compare the effectiveness of sun exposure and vitamin D supplementation for the management of vitamin D insufficiency, and to test whether these management strategies differentially affect markers of immune and cardio-metabolic function. METHODS/DESIGN: The SEDS Study is a multi-centre, randomised controlled trial of two different daily doses of vitamin D supplementation, and placebo, in conjunction with guidance on two different patterns of sun exposure. Participants recruited from across Australia are aged 18-64 years and have a recent vitamin D test result showing a serum 25(OH)D level of 40-60 nmol/L. DISCUSSION: This paper discusses the rationale behind the study design, and considers the challenges but necessity of data collection within a non-institutionalised adult population, in order to address the study aims. We also discuss the challenges of participant recruitment and retention, ongoing engagement of referring medical practitioners and address issues of compliance and participant retention. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry: ACTRN12613000290796 Registered 14 March 2013.

Lead optimization of 2-(piperidin-3-yl)-1H-benzimidazoles: identification of 2-morpholin- and 2-thiomorpholin-2-yl-1H-benzimidazoles as selective and CNS penetrating H1-antihistamines for insomnia.

The structure-activity relationships of 2-(piperidin-3-yl)-1H-benzimidazoles, 2-morpholine and 2-thiomorpholin-2-yl-1H-benzimidazoles are described. In the lead optimization process, the pK(a) and/or logP of benzimidazole analogs were reduced either by attachment of polar substituents to the piperidine nitrogen or incorporation of heteroatoms into the piperidine heterocycle. Compounds 9a and 9b in the morpholine series and 10g in the thiomorpholine series demonstrated improved selectivity and CNS profiles compared to lead compound 2 and these are potential candidates for evaluation as sedative hypnotics.

Influence of pKa on the biotransformation of indene H1-antihistamines by CYP2D6.

Structure-activity relationship studies were conducted to reduce CYP2D6-mediated metabolism in a series of indene H(1)-antihistamines. Reductions in pK(a) via incorporation of a ß-fluoro substituent or a heteroaryl moiety were shown to reduce contributions to metabolism through this pathway. Several compounds, including 8l, 8o, and 12f were identified with promising primary in vitro profiles and reduced biotransformation via CYP2D6.

Identification of a novel selective H1-antihistamine with optimized pharmacokinetic properties for clinical evaluation in the treatment of insomnia.

Analogs of the known H(1)-antihistamine R-dimethindene with suitable selectivity for key GPCRs, P450 enzymes and hERG channel were assessed for metabolism profile and in vivo properties. Several analogs were determined to exhibit diverse metabolism. One of these compounds, 10a, showed equivalent efficacy in a rat EEG/EMG model to a previously identified clinical candidate and a potentially superior pharmacokinetic profile as determined from a human microdose study.

Selectivity profiling of novel indene H(1)-antihistamines for the treatment of insomnia.

A series of indene analogs of the H(1)-antihistamine (-)-R-dimethindene was evaluated for selectivity in the search for potentially improved sedative-hypnotics. Variation of the 6-substitutent in the indene core in combination with a pendant electron rich heterocycle led to the identification of several potent H(1)-antihistamines with desirable selectivity over CYP enzymes, the M(1) muscarinic receptor and the hERG channel. These compounds were candidates for further ADME profiling and in vivo evaluation.

Novel benzothiophene H1-antihistamines for the treatment of insomnia.

SAR of lead benzothiophene H(1)-antihistamine 2 was explored to identify backup candidates with suitable pharmacokinetic profiles for an insomnia program. Several potent and selective H(1)-antihistamines with a range of projected half-lives in humans were identified. Compound 16d had a suitable human half-life as demonstrated in a human microdose study, but variability in pharmacokinetic profile, attributed to metabolic clearance, prevented further development of this compound. Compound 28b demonstrated lower predicted clearance in preclinical studies, and may represent a more suitable backup compound.

The discovery and structure-activity relationships of 2-(piperidin-3-yl)-1H-benzimidazoles as selective, CNS penetrating H1-antihistamines for insomnia.

A series of 2-(3-aminopiperidine)-benzimidazoles were identified as selective H(1)-antihistamines for evaluation as potential sedative hypnotics. Representative compounds showed improved hERG selectivity over a previously identified 2-aminobenzimidazole series. While hERG activity could be modulated via manipulation of the benzimidazole N1 substituent, this approach led to a reduction in CNS exposure for the more selective compounds. One example, 9q, retained a suitable selectivity profile with CNS exposure equivalent to known centrally active H(1)-antihistamines.

Characterization of novel selective H1-antihistamines for clinical evaluation in the treatment of insomnia.

Analogues of the known H(1)-antihistamine R-dimethindene were profiled as potential agents for the treatment of insomnia. Several highly selective compounds were efficacious in rodent sleep models. On the basis of overall profile, indene 1d and benzothiophene 2a had pharmacokinetic properties suitable for evaluation in night time dosing. Compound 2a did not show an in vivo cardiovascular effect from weak hERG channel inhibition.

Brain-penetrating 2-aminobenzimidazole H(1)-antihistamines for the treatment of insomnia.

The benzimidazole core of the selective non-brain-penetrating H(1)-antihistamine mizolastine was used to identify a series of brain-penetrating H(1)-antihistamines for the potential treatment of insomnia. Using cassette PK studies, brain-penetrating H(1)-antihistamines were identified and in vivo efficacy was demonstrated in a rat EEG/EMG model. Further optimization focused on strategies to attenuate an identified hERG liability, leading to the discovery of 4i with a promising in vitro profile.

Drugability of extracellular targets: discovery of small molecule drugs targeting allosteric, functional, and subunit-selective sites on GPCRs and ion channels.

Beginning with the discovery of the structure of deoxyribose nucleic acid in 1953, by James Watson and Francis Crick, the sequencing of the entire human genome some 50 years later, has begun to quantify the classes and types of proteins that may have relevance to human disease with the promise of rapidly identifying compounds that can modulate these proteins so as to have a beneficial and therapeutic outcome. This so called 'drugable space' involves a variety of membrane-bound proteins including the superfamily of G-protein-coupled receptors (GPCRs), ion channels, and transporters among others. The recent number of novel therapeutics targeting membrane-bound extracellular proteins that have reached the market in the past 20 years however pales in magnitude when compared, during the same timeframe, to the advancements made in the technologies available to aid in the discovery of these novel therapeutics. This review will consider select examples of extracellular drugable targets and focus on the GPCRs and ion channels highlighting the corticotropin releasing factor (CRF) type 1 and gamma-aminobutyric acid receptors, and the Ca(V)2.2 voltage-gated ion channel. These examples will elaborate current technological advancements in drug discovery and provide a prospective framework for future drug development.