Bioadhesive-based dosage forms: the next generation

Prolonged contact time of a drug with a body tissue, through the use of a bioadhesive polymer, can significantly improve the performance of many drugs. These improvements range from better treatment of local pathologies to improved drug bioavailability and controlled release to enhanced patient compliance. There are abundant examples in the literature over the past 15 years of these improvements using first generation or "off-the-shelf" bioadhesive polymers. The present mini-review will remind us of the success achieved with these first-generation polymers and focus on proposals for the next-generation polymers and attendant benefits likely to occur with these improved polymeric systems.

Carrier-enhanced human growth hormone absorption across isolated rabbit intestinal tissue

Small molecular weight alpha acid derivatives are able to enhance the intestinal absorption of human growth hormone through isolated rabbit intestinal tissue. The enhancement is not through the usual tissue modification associated with traditional penetration enhancers nor is it through an active transport process. Rather these small molecules associate with human growth hormone in solution to make it more transportable through intestinal tissue. It is shown that the enhancer has specificity for a particular protein and the enhancer and human growth hormone must be in solution together to be effective, i.e. pretreating the tissue with enhancer and then adding the protein does not increase tissue permeability. Moreover, the enhancer does not increase the permeability of mannitol or progesterone, thus providing additional evidence of specificity and establishing that these agents are not classical penetration enhancers.

Transport of human growth hormone across Caco-2 cells with novel delivery agents: evidence for P-glycoprotein involvement

Emisphere Technologies, Inc. has synthesized a series of small molecules which have been shown to improve protein absorption through mucosal tissue. This enhancement is specific between protein and a particular delivery agent. Despite the specificity of interaction, the mechanism of enhanced tissue penetration is still unclear. The purpose of this work is to understand the enhancement mechanism(s) of these delivery agents by using Caco-2 cells as a model membrane. It was found that the bidirectional transepithelial fluxes of human growth hormone (hGH) in the presence of these delivery agents across human intestinal epithelial Caco-2 cell line showed marked asymmetry. Average permeability coefficient values obtained in the apical (AP) to basolateral (BL) direction were lower than those of the reverse (BL to AP) direction. On the other hand, the fluxes for human growth hormone alone were symmetric. When P-glycoprotein inhibitors were included in the transport medium, the permeability coefficient values of BL to AP direction were significantly decreased while the transport was increased in the reverse direction in the presence of delivery agents. P-glycoprotein inhibitors had no effect on the transport of human growth hormone alone. This study shows that human growth hormone alone can be transported across Caco-2 cells in very limited quantities by passive diffusion, but in the presence of delivery agents, human growth hormone can be effluxed in a P-glycoprotein-mediated fashion. This also indirectly shows that the human growth hormone has become more lipophilic in the presence of delivery agents.

Transcellular and lipophilic complex-enhanced intestinal absorption of human growth hormone

PURPOSE

To evaluate the transcellular mechanism of novel enhancers absorption enhancement of human growth hormone (hGH), by examining the involvement of a P-glycoprotein-like efflux system, changes in membrane fluidity, and membrane damage.

METHODS

Caco-2 cell monolayers were grown on Snapwell filter supports and placed in a side-by-side diffusion apparatus. Transport in both the apical to basolateral (AP to BL) and basolateral to apical (BL to AP) direction was measured at different temperatures and in the presence of potential inhibitors. Fluorescence anisotropy measurement was used to measure membrane fluidity. The fluorescence anisotropy of DPH- and TMA-DPH-labeled cell suspensions was measured at room temperature. LDH (a measure of cytosolic lactate dehydrogenase) leakage assay was used to evaluate cytotoxicity.

RESULTS

The bi-directional transepithelial fluxes of hGH in the presence of these novel enhancers across Caco-2 cells showed marked asymmetry. Average permeability coefficient values obtained in the apical to basolateral (AP to BL) direction were lower than those of the reverse (BL to AP) direction. On the other hand, the fluxes for hGH alone were symmetric. When P-gp-like efflux inhibitors were included in the transport medium, the permeability coefficient value of BL to AP direction was significantly decreased while the transport was increased in the reverse direction in the presence of novel enhancers. In addition, lowering the temperature to 25 degrees C completely eliminated the asymmetry of hGH transport in the presence of novel enhancers. It was also shown by fluorescence anisotropy that these novel enhancers alone only slightly increased membrane fluidity. On the other hand, upon addition of hGH to the novel enhancers, the cell membrane showed a dramatic change as compared to treatment with novel enhancers alone. The results from the LDH assay showed that the novel enhancers and/or hGH did not cause cell damage, at least up to 1 hour, and the damage seen at the 2 hour point is also much lower than other known enhancers.

CONCLUSIONS

This study shows that human growth hormone alone cannot be transported across Caco-2 cells, except in small quantities, by passive diffusion, but in the presence of novel enhancers, human growth hormone permeation is substantial. In addition, the asymmetry of transport of the complexed hGH appears to be due to a P-gp-like efflux system. Assuming that the present substrate specificity of the P-gp-like efflux system shows the same preference for hydrophobic molecules as p-gp, the present work also indirectly shows that human growth hormone has become more lipophilic in the presence of these novel enhancers. Furthermore, membrane fluidity data also supports the premise that these novel enhancers interact and stabilize hGH, to make them more hydrophobic and easier to be transported through cell membranes.

The natural history of mental disorder in old age: Alzheimer's disease and depressive illness compared

BACKGROUND

Depressive illness (DI) and Alzheimer's disease (AD) are important causes of morbidity in old age and the relationships between these two disorders are uncertain.

METHOD

In a prospective, descriptive, comparative study of consecutive referrals aged over 65 years to one consultant, 218 patients with AD and 280 patients with DI were followed up for 15 years.

RESULTS

The prognosis of DI uncomplicated by physical illness at referral was reasonably good and 5-year survival was double that of AD. The rate of occurrence of AD in DI is no greater than in the general population. The higher mortality from cancer in DI than in AD is unexplained but may relate to differences in aetiology of these two disorders.

CONCLUSION

Although their symptoms frequently overlap, AD and DI are distinct disorders with very different prognoses and accurate diagnosis may have important implications for appropriate treatment.

Scleral permeability to hydrocortisone and mannitol in the albino rabbit eye

To further explore barrier properties of the sclera, the diffusion of 3H-hydrocortisone and 14C-mannitol was measured across isolated rabbit scleral membrane. In vitro permeability studies were performed using side by side diffusion cells. Bicarbonated Ringer Solution with oxidized glutathione (GBR) at pH 7.4 was the perfusion medium, and the temperature was kept at 37 degrees C. Diffusion of hydrocortisone through the cornea was also measured to compare scleral and corneal permeation. Scleral permeability was found to be five times greater than corneal permeability. Drug analyses were performed by radionuclide counting (LSC), and permeability coefficients were obtained. In vitro metabolism of hydrocortisone was examined by incubation of tissue in hydrocortisone solution in GBR for 5 hours and 37 degrees C. Permeability coefficients of hydrocortisone diffusion through the sclera were also obtained at 25 degrees C, 15 degrees C, and 5 degrees C. Activation energy of scleral transport of hydrocortisone was calculated from an Arrhenius plot. The low activation energy suggests an aqueous pore pathway unlike permeation of the drug across the cornea which uses a transcellular pathway.

Mechanistic studies on effervescent-induced permeability enhancement

PURPOSE

To determine the mechanism(s) by which effervescence induces penetration enhancement of a broad range of compounds ranging in size, structure, and other physiocochemical properties across rat and rabbit small intestinal epithelium.

METHODS

Effervescent induced penetration enhancement was investigated in vitro by utilization of a modified Ussing chamber diffusion cell apparatus and in vivo by single-pass intestinal perfusion.

RESULTS

Carbon dioxide (CO2) bubbling directly onto rabbit ileum epithelium induced an increase in drug permeability. Mechanistic studies indicated that effects due to CO2 bubble evolution, such as increased drug dissolution rates, mucus thinning/stripping, and pH buffer effects did not contribute to increases in drug flux. Cellular enzyme (5'-ND and LDH) and total protein release assays did not indicate cell membrane perturbation and/or damage. CO2 bubbling induced a reduction in transepithelial electrical resistance (TEER) indicating epithelial disruption due to a structural change of the paracellular pathway. This was further substantiated by a MW dependence on paracellular marker flux. In addition, tissue recovery was relatively rapid, approximately 20 min.

CONCLUSIONS

CO2 bubbling directly onto the intestinal epithelium induced enhanced drug permeability due to an alteration of the paracellular pathway. This, in addition to fluid flow and membrane hydrophobicity concepts, may account for observed increases in drug flux.

Partially unfolded proteins efficiently penetrate cell membranes--implications for oral drug delivery

We have previously reported on the biological activity of members of a library of low molecular weight compounds (carriers) that enable the oral delivery of proteins (Milstein, Proceedings of the 1995 Miami Bio/Technology Winter Symposium on Protein Engineering and Structural Biology, IRL Press at Oxford University Press, 1995, p. 13; Leone-Bay et al., J. Med. Chem. 38 (1995) 4263-4269; Leone-Bay et al., J. Med. Chem. 39 (1996) 2571-2578; [1-3]). When rats or primates are orally administered a solution of carrier and either recombinant human alpha-interferon (rhIFN), insulin or recombinant human growth hormone (rhGH) significant serum concentrations of the proteins are detectable. The transport activity of these compounds is positively correlated with their structural effects on the protein molecules. Direct measurement of the interaction of these carrier molecules with the proteins indicates that they reversibly destabilize the native state of the molecule favoring a partially unfolded conformation. Apparently these intermediate protein conformations are transport competent and are able to be absorbed through the intestinal tissue and into the bloodstream. Since the measured binding of the carriers to the partially unfolded proteins is relatively weak (Kb = 100 M(-1)) and the systemic activity of the proteins appears to be unaffected, the changes in the structure of the proteins are manifestly reversible.

Differential induction of apoptosis by fludarabine monophosphate in leukemic B and normal T cells in chronic lymphocytic leukemia

Fludarabine (F-ara-A), an adenine nucleoside analog with efficacy in B-cell chronic lymphocytic leukemia (B-CLL), has also been shown to have a long-lasting suppressive effect on T lymphocytes. In heterogeneous clinical samples, apoptosis cannot be detected by standard methods in small cellular subsets. We developed, therefore, a combined assay of in situ end-labeling of nicked DNA by terminal deoxynucleotide transferase, with measurements of cellular DNA content and surface antigens (CD3, CD4, CD8, and CD19) by multiparametric flow cytometry. This assay was used to determine F-ara-A-induced apoptosis in different lymphocyte subsets from CLL patients and normal controls treated with F-ara-A in vitro. Apoptosis was also correlated to bcl-2 protein levels. We observed a direct effect of F-ara-A on both B-CLL and T lymphocytes. The response to F-ara-A in B-CLL lymphocytes in vitro was Rai stage-dependent, the early-stages being more responsive (P = .01). Higher levels of spontaneous apoptosis were observed in B-CLL lymphocytes from early stage patients (P = .02). No difference was observed in spontaneous apoptosis of normal T cells in B-CLL, although T lymphocytes in late-stage disease were more sensitive to F-ara-A-induced apoptosis. Incubation with cyclosporin A did not affect B-CLL and T-lymphocyte survival compared with control cultures. Results suggested a direct apoptotic effect of F-ara-A on B-CLL lymphocytes that decreases with increasing clinical stage. No correlation was found between bcl-2 and spontaneous or F-ara-A-induced apoptosis. Apoptosis occurred at all cell-cycle stages and was not restricted to cells in S phase. The mechanisms of this stage-dependent apoptosis in CLL remain to be elucidated.

Reliability of the Manitoba Mental Health Management Information System for Research

OBJECTIVES

To determine the accuracy of data contained in Manitoba's Mental Health Management Information System (MHMIS) as compared with client charts and to determine which factors influence completeness and accuracy.

METHODS

Data on diagnosis, open date and close date, demographic information, and contact information were obtained from client charts and compared with data extracted from the MHMIS. Semistructured interviews were conducted with individuals who contribute data to the MHMIS.

RESULTS

Data on required demographic variables, primary diagnosis, and open and close dates are highly similar in the 2 sources. The correlation between data sources on the number of client contacts is also good.

CONCLUSION

This study establishes the reliability of MHMIS data. MHMIS data, in combination with hospital abstracts and physician claims data, provide the information needed to serve as a psychiatric case register (PCR) and can be used for psychiatric epidemiology as well as for planning, monitoring, and evaluating mental health services.

Estimating the burden of disease. Comparing administrative data and self-reports

OBJECTIVES

A cardiovascular health survey of a representative sample of the adult population of Manitoba, Canada was combined with the provincial health insurance claims database to determine the accuracy of survey questions in detecting cases of diabetes, hypertension, ischemic heart disease, stroke, and hypercholesterolemia.

METHODS

Of 2,792 subjects in the survey, 97.7% were linked successfully using a scrambled personal health insurance number. Hospital and physician claims were extracted for these individuals for the 3-year period before the survey.

RESULTS

The authors found no benefits to using restrictive criteria for entrance into the study (ie, requiring more than one diagnosis to define a case). Using additional years of data increased agreement between data sources. Kappa values indicated high levels of agreement between administrative data and self-reports for diabetes (0.72) and hypertension (0.59); kappa values were approximately 0.4 for the other conditions. Using administrative data as the "gold standard," specificity was generally very high, although cases with hypertension and hypercholesterolemia (diagnosed primarily by laboratory or physical measurement) were associated with a lower specificity than the other conditions. Sensitivity varied markedly and was lowest for "other heart disease" and "stroke". For diabetes and hypertension, inclusion criteria calling for more than one diagnosis reduced the accuracy of case identification, whereas increasing the number of years of data increased accuracy of identification. For diabetes and hypertension, self-reports were fairly accurate in detecting "true" past history of the illness based on physician diagnosis recorded on insurance claims.

CONCLUSIONS

This study demonstrates the feasibility of linking a large health survey with administrative data and the validity of self-reports in estimating the prevalence of chronic diseases, especially diabetes and hypertension. A linked data set offers unusual opportunities for epidemiologic and health services research in a defined population.

Improved ocular bioavailability of indomethacin by novel ocular drug carriers

The ability of different drug carriers to improve the ocular bioavailability of drugs was investigated in the rabbit eye. The assayed drug carriers were suspensions of nanoparticles, nanocapsules and microparticles made of poly-epsilon-caprolactone (PECL) and a submicron emulsion. Results indicated that the three submicron systems, nanoparticles, nanocapsules and emulsion, increased more than 3-fold the indomethacin concentration in the cornea, aqueous humour and iris-ciliary body at 0.5 and 1 h post-instillation. Furthermore, an increased indomethacin ocular bioavailability of 300% was observed after instillation of the submicron systems in comparison with the value obtained for a commercial solution. In contrast, the microparticles hardly increased the ocular bioavailability of indomethacin. The mechanism of interaction of the colloidal carriers with the corneal epithelium was investigated by confocal laser scanning microscopy. Confocal images indicated that submicron particles penetrate into the corneal epithelium cells by an endocytic mechanism. The similar behaviour of the three colloidal carriers suggests that any of their specific ingredients (PCEL, lecithin and oil) acts as a penetration enhancer or an endocytotic stimulator. On the other hand, the favourable ocular penetration of indomethacin when encapsulated in the colloidal carriers, but not in the microparticles, led us to assume that the colloidal nature of these carriers is the main factor responsible for the increased ocular bioavailability of indomethacin. PECL nanoparticles and nanocapsules as well as submicron emulsions are shown to be novel corneal drug carriers, thus representing a useful approach for increasing the ocular bioavailability of drugs.

Primary amoebic meningoencephalitis after swimming in the Rio Grande

We report a case of fatal primary amoebic meningoencephalitis (PAM) with Naegleria fowleri in a 13-year-old male, and review the clinical course and diagnostic autopsy findings. The boy developed the infection after swimming with relatives in the Rio Grande and in a holding tank containing water pumped from the river. The clinical and neuropathologic features of PAM are presented. The microscopic features of motile unicellular organisms with pathognomonic broad, lobate pseudopodia are diagnostic and, if recognized before death, allow for timely treatment. A public health investigation into this case implicated river water from the Rio Grande polluted with sewage as the infection source. Exposure to polluted river water from some areas of the Rio Grande may represent a risk factor for infection with Naegleria fowerli, because the high levels of coliform bacteria found in sewage and the warm, sluggish water of the river are favorable growth conditions for the amoebae. Because the Rio Grande is an international border, this case illustrates the importance of international cooperation in pollution control in the prevention of a potentially fatal infectious disease.

Quality of attachment as a predictor of maternal visitation to young hospitalized children

Tested a comprehensive model of factors predicting maternal visitation with hospitalized children. Subjects were 86 mothers who completed the Spielberger State-Trait Anxiety Inventory, a 12-item attachment measure derived from the Waters and Deane Attachment Q-sort, and a demographic questionnaire. Children were 10 months to 4 years old (37 female, 49 male) and hospitalized for acute nonsurgical illness. Hierarchical regression analyses indicated that, of the subset of variables tested (SES, number of children at home, gender, age, number of previous hospitalizations, state anxiety, and security of attachment), quality of attachment was the only significant predictor of maternal visitation rate. Mothers who reported that their children displayed insecure attachment behaviors maintained a significantly lower rate of visitation than mothers who reported that their children displayed secure attachment behaviors. Results of this study highlight the importance of understanding parent-child attachment in predicting maternal visitation when a child is hospitalized.

Vaginal permeability and enzymatic activity studies in normal and ovariectomized rabbits

PURPOSE

This study was initiated to develop an animal model, using ovariectomized rabbits, for the post-menopausal human, based on in vitro vaginal tissue permeability and aminopeptidase activity.

METHODS

An enkephalin derivative [D-ala(2),N-methyl-phe(4)-glycol(5)][tyrosyl-3,5-(3)H] enkephalin {[(3)H] RX 783006), which has relative enzymatic stability to aminopeptidases and dipeptidyl peptidase, was used as a model peptide drug for permeability experiments. Aminopeptidase activity in vaginal homogenates, as well as in tissue pieces, was determined using 4-methoxy-2-naphthylamides of leucine, alanine, arginine, and glutamic acid as specific substrates. In addition, histological examination of normal and ovariectomized vaginal tissues was performed.

RESULTS

Vaginal permeability of the drug was significantly increased in the ovariectomized compared to the intact animal. The full vaginal tissue became thinner and mucosal epithelial thickness was reduced about two-fold after ovariectomization and vaginal cells from the castrated rabbit were typically immature. Aminopeptidase activity, leucine aminopeptidase, aminopeptidase B and A, was the same in vaginal tissue homogenates and whole-tissue specimens in both normal and ovariectomized rabbits whereas the activity of aminopeptidase N was significantly decreased in ovariectomized as compared to normal rabbits.

CONCLUSIONS

Based on the present data, the ovariectomized rabbit may be useful as an animal model for postmenopausal vaginal studies.

Skull base tumors. A critical appraisal and clinical series employing image guidance

Two of the most significant developments in neurosurgery over the past ten years have been the application of intraoperative navigational units and the widespread use of "skull base" surgical techniques. These developments have independently revolutionized the way in which neurosurgeons approach intracranial pathology. The combination of these two developments has had a profound effect in our clinical practice to improve outcome and extend our capabilities. This ability to see around the corner, "x-ray" vision as some have called it, provides an added measure of safety for the patient while allowing the surgeon to treat the lesion in a more aggressive fashion.

Hypermetaphase fluorescence in situ hybridization for quantitative monitoring of Philadelphia chromosome-positive cells in patients with chronic myelogenous leukemia during treatment

Using Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML) as a model, our aim has been to develop a molecular cytogenetic method of high resolution analysis for monitoring the frequency of cells with nonrandom chromosome rearrangements in the bone marrow of patients receiving treatment for hematologic malignancies. Long-term exposure (24 hours) of bone marrow cultures to colcemid (0.1 microgram/mL) maximized a high frequency of metaphase collection. Such preparations were subjected to fluorescence in situ hybridization (FISH) using a 5 Mb probe that overlapped the region of the translocation at chromosome 9q34. This detected the Ph translocation in the resultant large number of overly contracted chromosome spreads. The procedure was validated and verified by studying 70 double-blind marrow samples from patients in different stages of Ph+ CML and from patients with Ph- hematologic malignancies (controls). This hypermetaphase FISH (HMF) method clearly identified Ph+ metaphases and allowed the analysis of 500 hypermetaphases per sample in less than 1 hour after FISH. HMF (1) identified statistically significant differences between the frequencies of Ph+ cells in samples that differed by less than 4%; (2) resolved such differences among patient samples that were all judged 100% Ph+ by standard G-band cytogenetics (CG); (3) resulted in the reclassification of response status in 23% of the patients initially classified by CG; (4) recognized Ph+ cells in 16% of patients characterized as having a complete cytogenetic response and in one patient with an original diagnosis of Ph- CML; and in one patient with an original diagnosis of Ph- CML; and (5) was informative where insufficient metaphases were obtainable for analysis by CG. HMF appears to be uniquely suitable for monitoring the status of patients with CML receiving treatment. It should also be applicable for patients with any hematologic diseases where chromosomal alterations are known and appropriate FISH probes are available.

Expression of basement membrane and endothelial cell adhesion molecules in vascular malformations of the brain: preliminary observations and working hypothesis

Little is known about the pathogenesis and subsequent cellular biologic behaviour of human cerebral vascular malformations. Innovative therapeutic strategies will depend on more fundamental understanding of structural and functional lesion biology. We have freeze-processed four specimens of arteriovenous malformation (AVM), two cavernous malformations (CM), and resected cortex from one case of Sturge-Weber disease (SWD) for immunohistochemical studies. Probes of vascular maturity and cellular adhesion were examined, including Factor 8 related antigen (F8RAG), laminin, fibronectin, and adhesion molecules VCAM, ELAM and ICAM-1 (CD 54). Sections of the same lesions were permanently fixed and stained using Haematoxylin and Eosin, and MOVAT Pentachrome stain for identification of vascular wall structures. A double antibody staining battery was utilized with ultraviolet fluorescent microscopy, and was analysed by an observer blinded to the antibody and lesion type. All malformations showed strong expression on their luminal endothelial surface for F8RAG. There was no expression of ELAM in any lesion. Two AVMs expressed VCAM on the endothelial surface of some vessels. ICAM-1 was expressed faintly within two AVMs. The CMs expressed fibronectin within the endothelium and subendothelial matrix, and both lesions were devoid of laminin expression. The AVMs and the SWD vessels stained for laminin, while none of the AVMs expressed fibronectin. These preliminary observations are consistent with the hypothesis that AVMs and SWD represent more mature vessels, consistent with possible lesion genesis during early phases of embryonic vascular development (dysvasculogenesis). In contrast, CMs represent immature vessels devoid of laminin and other features of mature vessels, consistent with ongoing dysangiogenesis within a fibronectin rich matrix. Further studies should be aimed at better elucidation of these biologic probes, and correlation with specific lesion behaviour.