Summary of the WHO hearing on the development of product-specific reference materials for coagulation factor VIII and factor IX products.

In recent years, several modified recombinant factor (F) VIII and FIX therapeutics with extended half-life have been licensed internationally for the treatment of haemophilia. Safe and effective use of these products requires monitoring of factor activity in patient plasma. The potency of all FVIII and FIX products is currently assigned in International Units (IU) which anchors the relationship between potency labelling, dosing and clinical monitoring. However, varying degrees of discrepancies in factor activity assays are observed between and within the factor activity analytical methods (one-stage clotting and chromogenic), when measuring these modified products against plasma and plasma-derived (concentrate) International Standards (IS) or in-house reference standard traceable to the IS. Availability of product-specific reference reagents would mitigate assay discrepancies, facilitate independent testing of assay methods and reagents, and ensure long-term continuity of the IU related to each product. A hearing meeting was organised by the WHO to discuss the requirements for product-specific reference materials for these products and whether these reference materials should be produced by the WHO. Advantages and disadvantages of product-specific reference materials were identified and discussed.

Activity measurements of dalcinonacog alfa.

INTRODUCTION: Many recombinant and modified FIX products have been, and continue to be, developed with the aim of improving treatment for patients with haemophilia B. One such new product is dalcinonacog alfa, a recombinant FIX with modifications to provide improved features such as subcutaneous administration. AIM: In view of previously observed assay discrepancies with modified FIX therapeutics, the aim of this study was to assess potential discrepancies in potency measurement of dalcinonacog alfa between and within different assay methods. METHODS: Potency of dalcinonacog alfa was measured against the 5th International Standard (IS) for FIX Concentrate and the 4th IS for FIX Plasma by One-Stage Clotting Assay, using 9 different APTT reagents and 2 commercially available FIX chromogenic kits. Plasma-derived concentrate and recombinant FIX samples were also included for comparison in every assay. RESULTS: Substantial discrepancies were observed when assaying dalcinonacog alfa using the one-stage clotting assay against both standards. No statistically valid results were obtained when testing dalcinonacog alfa using either chromogenic kit. Increasing the incubation time with the activation reagent in both chromogenic kits resulted in valid assays and increased the potency to become more in line with potencies by one-stage clotting assays. Increasing the incubation time in the chromogenic kits had no effect on the potencies of the plasma-derived or recombinant samples. However, incubation time influenced in the one-stage clotting assay using Dapttin. CONCLUSIONS: Within and between assay method discrepancy was found when assaying dalcinonacog alfa. Methods for potency labelling and clinical monitoring should be given careful consideration.

The Relationship Between Self-Esteem, Emotional Intelligence, and Empathy Among Students From Six Health Professional Programs.

Theory: Psychosocial skills such as communication, empathy, and emotional intelligence are now considered key attributes of health professionals. Self-esteem is another important construct that is less well studied. Self-esteem is important because low levels have been linked to depression, suicide, and eating disorders. Given that health professional students experience high levels of stress and are at increased risk for similar psychopathology, self-esteem may be an important variable in student well-being and performance after graduation. Hypotheses: This study sought to explore self-esteem during students' 1st year of training hypothesizing that several would demonstrate low self-esteem. It is also hypothesized that emotional intelligence and empathy would be associated with self-esteem. Method: A cross-sectional survey was conducted, and data were gathered from dental, medical, nursing, optometry, pharmacy and veterinary students. Self-report questionnaires assessing self-esteem, emotional intelligence, and empathy were completed and demographic information was collected. Scores were calculated and differences between groups analyzed with analysis of variance and chi-square testing. Pearson's correlation was used to assess associations between the constructs. Results: The mean self-esteem score was 26.2 ± 2.3 but 21% of the sample evidenced low self-esteem. There was no difference in the proportion of students demonstrating low self-esteem among programs. Gender did not have a significant effect on self-esteem scores, though ethnicity did. Emotional intelligence scores were higher among male individuals than among female. Emotional intelligence and empathy showed a small association with self-esteem. Conclusions: A significant proportion of health professional students suffer from low self-esteem during their 1st year of study. Such students may be more susceptible to the stresses associated with study and the development of psychopathology. More research needs to be conducted to explore the relationships between self-esteem, emotional intelligence, and empathy with a view to strengthening training in these areas and managing the challenges faced by health professional students.

Aggregated initiators: defining their role in the ROP of rac-lactide.

Reported examples of aggregated initiators for the ring-opening polymerisation (ROP) of lactide often lack detailed investigations as to the nature of the active species, making it difficult to reconcile ligand design with performance. Here, we offer additional stability to the polynuclear titanium complexes, TiL(OiPr) (L = 9-14), through a bridging carboxylate anchored to the supporting amine bis(phenolate) ligands. An in-depth study of solution-state behaviour determined the process of assembly was driven by interactions between the carboxylate and a vacant site on a neighbouring titanium centre. Furthermore, we establish that mononuclear units form dynamic mixtures of polynuclear aggregates, with a clear relationship between nuclearity of the aggregates and the steric bulk on the ligand. Smaller aggregates displayed increased activity towards the ROP of rac-lactide. Furthermore, addition of a chiral centre, on the ligand framework, was investigated as a route to influence the selectivity of the polymerisation via easily-accessible initiators.

An exploration of changes in cognitive and emotional empathy among medical students in the Caribbean.

OBJECTIVE: This study explored the empathy profile of students across five years of medical training. In addition the study examined whether the Jefferson Scale for Physician Empathy correlated with a measure of cognitive empathy, the Reading the Mind in the Eyes Test and a measure of affective empathy, the Toronto Empathy Questionnaire. METHODS: The study was a comparative cross-sectional design at one Caribbean medical school. Students were contacted in class, participation was voluntary and empathy was assessed using all three instruments Descriptive statistics were calculated and differences between groups evaluated using non-parametric tests. RESULTS: Overall 669 students participated (response rate, 67%). There was a significant correlation between the Jefferson Scale of Physician Empathy and the Toronto Empathy Questionnaire (ρ = 0.48), both scales indicating a decline in medical student empathy scores over time. There was, however, little correlation between scores from the Reading the Mind in the Eyes Test and the Jefferson Scale of Physician Empathy. Female students demonstrated significantly higher scores on all three measures. CONCLUSIONS: Medical students' lower empathy scores during their final years of training appear to be due to a change in the affective component of empathy. These findings may reflect an adaptive neurobiological response to the stressors associated with encountering new clinical situations. Attention should be paid not only to providing empathy training for students but also to teaching strategies for improved cognitive processing capacity when they are encountering new and challenging circumstances.

Stakeholder perspectives on outcome expectations of pharmacy graduates from a Caribbean school of pharmacy.

OBJECTIVES: To explore stakeholders' views regarding the performance of pharmacy graduates upon entering the workforce and to identify curricular deficiencies and possible solutions. METHODS: Practicing pharmacists, many of whom were members of government and pharmacy organizations, were asked to complete a 40-item questionnaire to determine their views regarding the educational outcomes of pharmacy graduates from a Caribbean pharmacy school. In addition, the stakeholders participated in focus group discussions to capture feedback not gathered on the questionnaire. RESULTS: Ten stakeholders completed the questionnaire and 11 participated in the focus group discussions. Stakeholders rated graduates higher than average in 13 educational outcomes: application of knowledge and skills, patient care, communication skills, confidentiality, ethics, problem solving, and innovation. However, responses to open-ended questions and comments made during the focus group discussions identified deficiencies, which included a lack of clinical faculty members and qualified preceptors to teach pharmacy students, and the need to revise basic sciences courses. CONCLUSION: Feedback from key stakeholders suggests that the quality of pharmacy graduates is above average for the most part; however, additional work is needed to address the deficiencies identified.

Nonverbal communication in a Caribbean medical school: "Touch is a touchy issue".

BACKGROUND: The heath communication curriculum at the Trinidad campus of the University of the West Indies was developed out of practices advocated in large Western countries. Many students and tutors observed that the nonverbal skills advocated in these approaches did not fit the complex cultural dynamics of the Caribbean. PURPOSE: A study was developed to understand the problems Caribbean students faced with these nonverbal communication practices. METHODS: Thirty-six students representing different Caribbean territories were randomly selected from the two compulsory communication skills courses: Communication Skills for Health Personnel and Communication Skills for the Health Professions class list. These students participated in 4 focus group discussions (FGD). The FGD questions were formulated on the nonverbal skills advanced in the Calgary-Cambridge Guide to the doctor-patient interview. RESULTS: The findings supported the view that recommended nonverbal skills were in conflict with expected doctor-patient behavior in different Caribbean territories. Students felt that nonverbal communication needed to be treated with greater cultural sensitivity. CONCLUSIONS: These findings stimulated changes to the health communication program. this article identifies changes made to the communication skills program in response to cultural difference.

Indoor Tanning within UK Young Adults: An Extended Theory of Planned Behaviour Approach.

The indoor tanning industry poses a long-term public health risk. Despite the adverse health effects, indoor tanning seems to be gaining considerable popularity. The study examined indoor tanning intentions and behaviour within UK young adults using an extended theory of planned behaviour model, which included variables on "appearance reasons to tan," "perceived susceptibility to damaging appearance," "perceived susceptibility to health consequences," and "tanning knowledge." The model was successful in predicting indoor tanning intentions and behaviour (explained 17% and 71%, resp.). An interesting outcome was the magnitude of the variable "appearance reasons to tan." A current tanned appearance therefore seemed to outweigh any adverse future appearance or health consequences caused by indoor tanning. Appearance-focused interventions to reduce such behaviour may now prove to be efficacious within a UK sample.

The need to teach non-verbal skills with multicultural sensitivity

The communication models that have been framed to guide medical practitioners through the determinative medical interview have primarily been conceived, evaluated and approved in the west. However, the student population at the Faculty of Medical Sciences at the University of the West Indies (UWI) in Trinidad and Tobago, where this material is concentrated, come from a number of Caribbean countries, as far north as the Bahamas and as far south as Trinidad. Consequently, the faculty at St Augustine is a very diverse campus. Interaction and fusion among Caribbean cultures have facilitated a great deal of intra-and inter-cultural diversity in the region. The non-verbal communication skills that theorists advocate, however, often cannot be easily applied to the Caribbean context. As a result, health communication educators encounter a number of problems in implementing so-called Western-based non-verbal communication skills in the classroom. This chapter is based on data collected at the Faculty of Medical Sciences at UWI. Thirty-six registered year 1 students from eight Caribbean countries were selected from the class list and asked to participate in focus group discussion between individual Caribbean territories and that put forward by the Calgary-Cambridge Guide to the doctor-patient interview. Here, the results of this study and its implications for health communication education in the region are interrogated. Ultimately, the chapter develops an approach from which regional health communication educators and medical practitioners can draw to achieve cultural competence in the classroom and in Caribbean medical practice.

The interplay between tissue plasminogen activator domains and fibrin structures in the regulation of fibrinolysis: kinetic and microscopic studies.

Regulation of tissue-type plasminogen activator (tPA) depends on fibrin binding and fibrin structure. tPA structure/function relationships were investigated in fibrin formed by high or low thrombin concentrations to produce a fine mesh and small pores, or thick fibers and coarse structure, respectively. Kinetics studies were performed to investigate plasminogen activation and fibrinolysis in the 2 types of fibrin, using wild-type tPA (F-G-K1-K2-P, F and K2 binding), K1K1-tPA (F-G-K1-K1-P, F binding), and delF-tPA (G-K1-K2-P, K2 binding). There was a trend of enzyme potency of tPA > K1K1-tPA > delF-tPA, highlighting the importance of the finger domain in regulating activity, but the differences were less apparent in fine fibrin. Fine fibrin was a better surface for plasminogen activation but more resistant to lysis. Scanning electron and confocal microscopy using orange fluorescent fibrin with green fluorescent protein-labeled tPA variants showed that tPA was strongly associated with agglomerates in coarse but not in fine fibrin. In later lytic stages, delF-tPA-green fluorescent protein diffused more rapidly through fibrin in contrast to full-length tPA, highlighting the importance of finger domain-agglomerate interactions. Thus, the regulation of fibrinolysis depends on the starting nature of fibrin fibers and complex dynamic interaction between tPA and fibrin structures that vary over time.

Inflammatory osteoarthritis which was precipitated by Arimidex and resolved with tamoxifen.

We report the case of a 51-year-old woman who presented with an inflammatory flare of osteoarthritis of the small joints of her hands occurring in a temporal relationship with the commencement of Arimidex, prescribed to reduce systemic oestrogen levels to treat breast cancer. Following the cessation of Arimidex and the initiation of tamoxifen, a specific oestrogen receptor antagonist, this flare resolved. It has long been observed that during the menopause, as oestrogen levels decline, many women develop osteoarthritis or experience progression of the disease. However, this theory of oestrogen-dependent osteoarthritis has not been consistently demonstrated in animal models. As far as the authors are aware, this is the first case in which systemic oestrogen reduction has resulted in a severe osteoarthritis flare but targeted oestrogen receptor blockade led to a resolution of symptoms. These findings may inform the pathophysiological process underlying oestrogen-dependent osteoarthritis, although further series are needed.

A novel bioassay for B-cell activating factor (BAFF) based on expression of a BAFF-receptor ectodomain-tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) receptor-2 endodomain fusion receptor in human rhabdomyosarcoma cells.

B-cell activating factor (BAFF) is a type II transmembrane glycoprotein belonging to the tumour necrosis factor ligand superfamily. Active soluble forms of BAFF are generated either by cleavage of the extracellular domain or by recombinant DNA technology. The current bioassay for measuring the activity of soluble BAFF involves stimulation of the proliferation of mouse splenic B-cells in the presence of goat anti-mouse IgMmicro chain which is rather cumbersome and lengthy and yields variable results. We have therefore developed an alternative functional assay which relies on the ability of BAFF to induce an apoptotic response in human rhabdomyosarcoma cells. For this, we constructed a chimeric receptor containing the ectodomain of the MuBAFF-R--the major cell receptor for BAFF--and the endodomain of the HuTRAIL-R2--one of the two functional receptors for TRAIL--which is known to contain a death domain and trigger apoptosis. When the chimeric receptor was expressed in the TRAIL-sensitive human rhabdomyosarcoma cell line KD4 clone 21, recombinant BAFF of either human or mouse sequence stimulated apoptosis, similar to TRAIL, in a dose-dependent manner. The transfected cell population, called FL17, expressing the MuBAFF-R/ HuTRAIL-R2 thus provided the basis of a novel functional bioassay for BAFF that is simple and relatively fast to perform. The construction of the chimeric receptor, development of the transfected cells expressing this receptor and the development of sensitive and reproducible bioassays for BAFF and anti-BAFF neutralising antibodies are described.

Thermal stability of the WHO international standard of interferon alpha 2b (IFN-alpha 2b): application of new reporter gene assay for IFN-alpha 2b potency determinations.

A World Health Organization requirement for biological standards is that they should exhibit long-term stability at their recommended storage temperature. Thermal stability is usually predicted in accelerated thermal degradation studies, where ampoules of the lyophilized standard are stored at elevated temperatures for relatively short times before testing. To confirm the predicted thermal stability of the 2nd international standard of human interferon alpha 2b (IFN-alpha2b; 95/566), we tested the potency of the ampouled contents of this standard after 9 years storage at the customary storage temperature of -20 degrees C in comparison with ampoules of the IS which had been stored continuously at temperatures ranging from -150 degrees C to 56 degrees C. Since IFN-alpha2b potency estimates derived from the results of antiviral assays (AVA) showed high within-assay variability, we investigated a novel reporter gene assay (RGA) based on induction of secreted alkaline phosphatase (SEAP) for comparability and precision of such estimations. We show that this RGA generated comparable estimates with overall lower variation. Additionally, the SEAP conversion of p-nitrophenyl phosphate to yellow product could be followed kinetically. Absorbance readings were shown to increase with time in proportion with increasing concentration of IFN-alpha2b. When the time-dependent increments of absorbance were plotted graphically, the slopes of lines corresponded to concentration. This approach enabled single dilutions of IFN samples, identical in molecular structure to an IFN-alpha2b standard, to be used for potency estimates by interpolation of slope value against those of the standard at fixed concentrations. It appears attractive for high through-put potency testing of various R&D IFN-alpha2b samples.