Helminth exposure and immune response to the two-dose heterologous Ad26.ZEBOV, MVA-BN-Filo Ebola vaccine regimen

BACKGROUND

The exposure to parasites may influence the immune response to vaccines in endemic African countries. In this study, we aimed to assess the association between helminth exposure to the most prevalent parasitic infections, schistosomiasis, soil transmitted helminths infection and filariasis, and the Ebola virus glycoprotein (EBOV GP) antibody concentration in response to vaccination with the Ad26.ZEBOV, MVA-BN-Filo vaccine regimen in African and European participants using samples obtained from three international clinical trials.

METHODS/PRINCIPAL FINDINGS

We conducted a study in a subset of participants in the EBL2001, EBL2002 and EBL3001 clinical trials that evaluated the Ad26.ZEBOV, MVA-BN-Filo vaccine regimen against EVD in children, adolescents and adults from the United Kingdom, France, Burkina Faso, Cote d'Ivoire, Kenya, Uganda and Sierra Leone. Immune markers of helminth exposure at baseline were evaluated by ELISA with three commercial kits which detect IgG antibodies against schistosome, filarial and Strongyloides antigens. Luminex technology was used to measure inflammatory and activation markers, and Th1/Th2/Th17 cytokines at baseline. The association between binding IgG antibodies specific to EBOV GP (measured on day 21 post-dose 2 and on Day 365 after the first dose respectively), and helminth exposure at baseline was evaluated using a multivariable linear regression model adjusted for age and study group. Seventy-eight (21.3%) of the 367 participants included in the study had at least one helminth positive ELISA test at baseline, with differences of prevalence between studies and an increased prevalence with age. The most frequently detected antibodies were those to Schistosoma mansoni (10.9%), followed by Acanthocheilonema viteae (9%) and then Strongyloides ratti (7.9%). Among the 41 immunological analytes tested, five were significantly (p < .003) lower in participants with at least one positive helminth ELISA test result: CCL2/MCP1, FGFbasic, IL-7, IL-13 and CCL11/Eotaxin compared to participants with negative helminth ELISA tests. No significant association was found with EBOV-GP specific antibody concentration at 21 days post-dose 2, or at 365 days post-dose 1, adjusted for age group, study, and the presence of any helminth antibodies at baseline.

CONCLUSIONS/SIGNIFICANCE

No clear association was found between immune markers of helminth exposure as measured by ELISA and post-vaccination response to the Ebola Ad26.ZEBOV/ MVA-BN-Filo vaccine regimen.

TRIAL REGISTRATION

NCT02416453, NCT02564523, NCT02509494. ClinicalTrials.gov.

Long-Term Clinical Safety of the Ad26.ZEBOV and MVA-BN-Filo Ebola Vaccines: A Prospective, Multi-Country, Observational Study

In this prospective, observational study (ClinicalTrials.gov Identifier: NCT02661464), long-term safety information was collected from participants previously exposed to the Ebola vaccines Ad26.ZEBOV and/or MVA-BN-Filo while enrolled in phase 1, 2, or 3 clinical studies. The study was conducted at 15 sites in seven countries (Burkina Faso, France, Kenya, Tanzania, Uganda, the United Kingdom, and the United States). Adult participants and offspring from vaccinated female participants who became pregnant (estimated conception ≤28 days after vaccination with MVA-BN-Filo or ≤3 months after vaccination with Ad26.ZEBOV) were enrolled. Adults were followed for 60 months after their first vaccination, and children born to female participants were followed for 60 months after birth. In the full analysis set (n = 614 adults; median age [range]: 32.0 [18-65] years), 49 (8.0%) had ≥1 serious adverse event (SAE); the incidence rate of any SAE was 27.4 per 1000 person-years (95% confidence interval: 21.0, 35.2). The unrelated SAEs of malaria were reported in the two infants in the full analysis set, aged 11 and 18 months; both episodes were resolved. No deaths or life-threatening SAEs occurred during the study. Overall, no major safety issues were identified; one related SAE was reported. These findings support the long-term clinical safety of the Ad26.ZEBOV and MVA-BN-Filo vaccines.

Immune response of a two-dose heterologous Ebola vaccine regimen: summary of three African clinical trials using a single validated Filovirus Animal Nonclinical Group enzyme-linked immunosorbent assay in a single accredited laboratory

BACKGROUND

This analysis evaluated the immune response to the two-dose, heterologous Ad26.ZEBOV, MVA-BN-Filo Ebola virus vaccine regimen, administered 56-days apart, from multiple African sites based on results from one analytic laboratory.

METHODS

Immunogenicity across three trials (EBL2002, EBL2004/PREVAC, EBL3001) conducted in East and West Africa is summarised. Vaccine-induced Ebola glycoprotein-binding antibody concentrations were analysed by Q2 Solutions laboratory at baseline, 21 days (EBL2002 and EBL3001) or 28 days (EBL2004) post-dose 2 (regimen completion), and 12 months post-dose 1 using the validated Filovirus Animal Nonclinical Group Ebola glycoprotein enzyme-linked immunosorbent assay (ELISA). Responders were defined as those with a >2.5-fold increase from baseline or the lower limit of quantification (LLOQ) if 

FINDINGS

At 21 or 28 (21/28) days post-dose 2, the geometric mean concentration (GMC) range was 3810-7518 ELISA units (EU)/mL (percent responders: ≥98%) in adults, 9929-13532 EU/mL (≥98%) in adolescents aged 12-17 years, 10,212-17388 EU/mL (≥99%) in older children, and 22,568-25111 EU/mL (≥98%) in younger children. When stratified by country, GMCs at 21/28 days post-dose 2 were generally similar among adults and within paediatric cohorts (percent responders: 95%-100%). At month 12, GMC range was 259-437 EU/mL (percent responders: 49%-88%) in adults and 386-1139 EU/mL (70%-100%) in paediatric participants.

INTERPRETATION

Based on data from a single laboratory using a single validated assay, Ad26.ZEBOV, MVA-BN-Filo induced a strong humoral immune response, with ≥95% of participants across countries classified as responders at 21/28 days post-dose 2 (regimen completion), regardless of age.

FUNDING

Janssen Vaccines & Prevention BV; Innovative Medicines Initiative.

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Key Words

• Ad26.ZEBOV
• Africa
• Ebola
• MVA-BN-Filo
• Vaccine

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MESH Headings

• Animals
• Antibodies, Viral
• Ebola Vaccines
• Ebolavirus
• Enzyme-Linked Immunosorbent Assay
• Glycoproteins
• Hemorrhagic Fever, Ebola
• Immunity, Humoral

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Grants

• D43 TW011818 FIC NIH HHS
• HHSN261201500003C NCI NIH HHS
• HHSN261201500003I NCI NIH HHS
• MR/K019708/1 Medical Research Council

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Safety and immunogenicity of 2-dose heterologous Ad26.ZEBOV, MVA-BN-Filo Ebola vaccination in children and adolescents in Africa: A randomised, placebo-controlled, multicentre Phase II clinical trial

BACKGROUND

Reoccurring Ebola outbreaks in West and Central Africa have led to serious illness and death in thousands of adults and children. The objective of this study was to assess safety, tolerability, and immunogenicity of the heterologous 2-dose Ad26.ZEBOV, MVA-BN-Filo vaccination regimen in adolescents and children in Africa.

METHODS AND FINDINGS

In this multicentre, randomised, observer-blind, placebo-controlled Phase II study, 131 adolescents (12 to 17 years old) and 132 children (4 to 11 years old) were enrolled from Eastern and Western Africa and randomised 5:1 to receive study vaccines or placebo. Vaccine groups received intramuscular injections of Ad26.ZEBOV (5 × 1010 viral particles) and MVA-BN-Filo (1 × 108 infectious units) 28 or 56 days apart; placebo recipients received saline. Primary outcomes were safety and tolerability. Solicited adverse events (AEs) were recorded until 7 days after each vaccination and serious AEs (SAEs) throughout the study. Secondary and exploratory outcomes were humoral immune responses (binding and neutralising Ebola virus [EBOV] glycoprotein [GP]-specific antibodies), up to 1 year after the first dose. Enrolment began on February 26, 2016, and the date of last participant last visit was November 28, 2018. Of the 263 participants enrolled, 217 (109 adolescents, 108 children) received the 2-dose regimen, and 43 (20 adolescents, 23 children) received 2 placebo doses. Median age was 14.0 (range 11 to 17) and 7.0 (range 4 to 11) years for adolescents and children, respectively. Fifty-four percent of the adolescents and 51% of the children were male. All participants were Africans, and, although there was a slight male preponderance overall, the groups were well balanced. No vaccine-related SAEs were reported; solicited AEs were mostly mild/moderate. Twenty-one days post-MVA-BN-Filo vaccination, binding antibody responses against EBOV GP were observed in 100% of vaccinees (106 adolescents, 104 children). Geometric mean concentrations tended to be higher after the 56-day interval (adolescents 13,532 ELISA units [EU]/mL, children 17,388 EU/mL) than the 28-day interval (adolescents 6,993 EU/mL, children 8,007 EU/mL). Humoral responses persisted at least up to Day 365. A limitation of the study is that the follow-up period was limited to 365 days for the majority of the participants, and so it was not possible to determine whether immune responses persisted beyond this time period. Additionally, formal statistical comparisons were not preplanned but were only performed post hoc.

CONCLUSIONS

The heterologous 2-dose vaccination was well tolerated in African adolescents and children with no vaccine-related SAEs. All vaccinees displayed anti-EBOV GP antibodies after the 2-dose regimen, with higher responses in the 56-day interval groups. The frequency of pyrexia after vaccine or placebo was higher in children than in adolescents. These data supported the prophylactic indication against EBOV disease in a paediatric population, as licenced in the EU.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02564523.

Safety of Chloroquine or Hydroxychloroquine Plus Azithromycin for the Treatment of COVID-19 Patients in Burkina Faso: An Observational Prospective Cohort Study

INTRODUCTION

Though chloroquine derivatives are used in the treatment of coronavirus disease 2019 (COVID-19) in many countries worldwide, doubts remain about the safety and efficacy of these drugs, especially in African communities where published data are scarce.

METHODS

We conducted an observational prospective cohort study from April 24 to September 03, 2020, in Burkina Faso to assess (as primary outcome) the clinical, biological, and cardiac (electrocardiographic) safety of chloroquine or hydroxychloroquine plus azithromycin administered to COVID-19 patients. The main secondary outcomes were all-cause mortality and median time of viral clearance.

RESULTS

A total of 153 patients were enrolled and followed for 21 days. Among patients who took at least one dose of chloroquine or hydroxychloroquine (90.1% [138/153]), few clinical adverse events were reported and were mainly rash/pruritus, diarrhea, chest pain, and palpitations. No statistically significant increase in hepatic, renal, and hematological parameters or electrolyte disorders were reported. However, there was a significant increase in the QTc value without exceeding 500ms, especially in those who received chloroquine phosphate. Three adverse events of special interest classified as serious (known from chloroquine derivatives) were recorded namely pruritus, paresthesia, and drowsiness. One case of death occurred. The average onset of SARS-CoV-2 PCR negativity was estimated at 7.0 (95% CI: 5.0-10.0) days.

CONCLUSION

Hydroxychloroquine appeared to be well tolerated in treated COVID-19 patients in Burkina Faso. In the absence of a robust methodological approach that could generate a high level of scientific evidence, our results could at least contribute to guide health decisions that should be made based on different sources of scientific evidence including those from our study.

Safety and immunogenicity of 2-dose heterologous Ad26.ZEBOV, MVA-BN-Filo Ebola vaccination in healthy and HIV-infected adults: A randomised, placebo-controlled Phase II clinical trial in Africa

BACKGROUND

We investigated safety, tolerability, and immunogenicity of the heterologous 2-dose Ebola vaccination regimen in healthy and HIV-infected adults with different intervals between Ebola vaccinations.

METHODS AND FINDINGS

In this randomised, observer-blind, placebo-controlled Phase II trial, 668 healthy 18- to 70-year-olds and 142 HIV-infected 18- to 50-year-olds were enrolled from 1 site in Kenya and 2 sites each in Burkina Faso, Cote d'Ivoire, and Uganda. Participants received intramuscular Ad26.ZEBOV followed by MVA-BN-Filo at 28-, 56-, or 84-day intervals, or saline. Females represented 31.4% of the healthy adult cohort in contrast to 69.7% of the HIV-infected cohort. A subset of healthy adults received booster vaccination with Ad26.ZEBOV or saline at Day 365. Following vaccinations, adverse events (AEs) were collected until 42 days post last vaccination and serious AEs (SAEs) were recorded from signing of the ICF until the end of the study. The primary endpoint was safety, and the secondary endpoint was immunogenicity. Anti-Ebola virus glycoprotein (EBOV GP) binding and neutralising antibodies were measured at baseline and at predefined time points throughout the study. The first participant was enrolled on 9 November 2015, and the date of last participant's last visit was 12 February 2019. No vaccine-related SAEs and mainly mild-to-moderate AEs were observed among the participants. The most frequent solicited AEs were injection-site pain (local), and fatigue, headache, and myalgia (systemic), respectively. Twenty-one days post-MVA-BN-Filo vaccination, geometric mean concentrations (GMCs) with 95% confidence intervals (CIs) of EBOV GP binding antibodies in healthy adults in 28-, 56-, and 84-day interval groups were 3,085 EU/mL (2,648 to 3,594), 7,518 EU/mL (6,468 to 8,740), and 7,300 EU/mL (5,116 to 10,417), respectively. In HIV-infected adults in 28- and 56-day interval groups, GMCs were 4,207 EU/mL (3,233 to 5,474) and 5,283 EU/mL (4,094 to 6,817), respectively. Antibody responses were observed until Day 365. Ad26.ZEBOV booster vaccination after 1 year induced an anamnestic response. Study limitations include that some healthy adult participants either did not receive dose 2 or received dose 2 outside of their protocol-defined interval and that the follow-up period was limited to 365 days for most participants.

CONCLUSIONS

Ad26.ZEBOV, MVA-BN-Filo vaccination was well tolerated and immunogenic in healthy and HIV-infected African adults. Increasing the interval between vaccinations from 28 to 56 days improved the magnitude of humoral immune responses. Antibody levels persisted to at least 1 year, and Ad26.ZEBOV booster vaccination demonstrated the presence of vaccination-induced immune memory. These data supported the approval by the European Union for prophylaxis against EBOV disease in adults and children ≥1 year of age.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02564523.

Delivery of the Dementia Friends programme on the MPharm degree course: a qualitative exploration of pharmacy students’ perspectives

Introduction

A person-centred approach to dementia care has been advocated1, but limited literature exists on integration of this into pharmacist undergraduate education. The Alzheimer’s Society Dementia Friends programme was developed to change peoples’ perceptions and promote understanding of living with dementia. In 2019, the School piloted provision of Dementia Friends training; Level 3 MPharm students (n=102) were invited by email to participate as an optional part of a Clinical Therapeutics module. Sixty-three students (61.8%) attended the workshop, which combined Dementia Friends training with an interactive session facilitated by a person living with dementia (PLWD).

Aim

To explore undergraduate pharmacy students’ views and experiences of the Dementia Friends pilot.

Methods

All students who had attended the workshop were invited by email to participate in a focus group during February 2020. Participants provided written informed consent. The topic guide focused on students’ views of workshop delivery, improvements that could be made, their understanding of person-centred care, and the impact of the workshop on their clinical practice. The focus group was audio-recorded, transcribed verbatim, and analysed using thematic analysis.

Results

One focus group was conducted with eight students. Three overarching themes were identified: learning from an expert patient; importance of person-centred care; and dementia education during MPharm degree. Students valued the opportunity to learn from a PLWD and felt it allowed them to relate the condition to a real person: “it felt more personal so you could really connect with them [PLWD] and understand their experience”. Hearing about the ‘lived experience’ helped to contextualise learning from other methods of delivery, e.g. lectures: “you don’t know what’s going on in someone else’s life, and sometimes we’re all a bit quick to judge, I think [the workshop] put that into perspective”. Students described having greater understanding of person-centred care and taking a holistic approach to pharmaceutical care provision for PLWD: “it’s very important to take into account their quality of life…we can focus on the clinical but looking at the person as a whole actually helps their treatment” and “one of the things I found most interesting was that they might not remember the interaction but they will [retain] the feeling or emotion”. Students reported feeling more confident in engaging with PLWD following the workshop, which is something they would not have had the opportunity to learn from lectures alone: “If we hadn’t had that dementia training, I feel like I would still have no confidence chatting to dementia patients”. Students suggested that future Dementia Friends training should be delivered earlier in the MPharm degree course.

Conclusion

This study has shown that Dementia Friends training complemented students’ existing knowledge of dementia and increased their confidence to communicate with PLWD. The use of an expert patient was an effective way of supporting MPharm students to develop a person-centred approach to their professional practice. The study was limited to one university so findings may not be generalisable. However, these data provide a good basis for future development and evaluation of Dementia Friends training provision to MPharm students.

References

1. Kitwood, T. M. Dementia reconsidered: the person comes first. 1997. Buckingham [England], Open University Press

A cross-sectional survey of general practitioners’ experiences with, views of, and attitudes towards, practice-based pharmacists

Introduction

Five-year pilot schemes were announced in both England and Northern Ireland (NI) to integrate practice-based pharmacists (PBPs) into general practices. The NI scheme anticipates that there will be 300 whole time equivalent PBPs in post by the end of the pilot (2020/2021).[1] There is little existing UK literature on PBPs’ role evolution and few studies have explored general practitioners’ (GPs) experiences of pharmacist integration into primary care practice.

Aim

To investigate GPs’ experiences with PBPs, their views about the PBP role and its impact upon patients and GPs, and their attitudes towards collaboration with PBPs.

Methods

A paper-based self-administered questionnaire was mailed to all general practices (n=329) across Northern Ireland (NI) on two occasions during September and October 2019, and was completed by one GP in every practice who had most contact with the PBP. The questionnaire was developed following a comprehensive literature review and comprised four sections (Table 1). Descriptive analyses were conducted using SPSS v26 and responses to open-ended questions were analysed thematically.

Results

The response rate was 61.7% (203/329). Respondents had a median age of 52.0 years and there was at least one PBP per general practice. All GPs had face-to-face meetings with PBPs, with three-quarters (78.7%, n=159) meeting with the PBP more than once a week. GPs reported that two-thirds of PBPs (62.4%, n=126) were qualified as independent prescribers, with 76.2% of prescribers (n=96) currently prescribing for patients. The most common PBP activities were medication reconciliation and medication reviews. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n=162) and knowledge (87.0%, n=167) to provide safe and effective care for patients. However, only 31.1% (n=61) stated that PBPs sometimes had the confidence to make clinical decisions. The majority of GPs (&gt;85%) displayed largely positive attitudes towards collaboration with PBPs. Most respondents agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n=192) and can provide a better link between general practices and community pharmacists (96.1%, n=194). However, 24.8% of GPs (n=50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. Thematic analysis of the open comments indicated that GPs were in favour of more PBP sessions and full-time posts.

Conclusion

This study has revealed that the majority of GPs had positive views and attitudes about the PBP role, its impact in primary care and collaboration with PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Our target sample included all general practices within NI and the response rate enhanced generalisability at the practice level. However, the study sample was limited to NI, and some findings may not be relevant to other parts of the UK. Further work is required to explore PBPs’, community pharmacists’ and patients’ views of this role in general practice to corroborate study findings.

References

1. Strategic Leadership Group for Pharmacy. Practice-based pharmacists' statement. 2016. (Online) Available at: https://www.health-ni.gov.uk/sites/default/files/publications/health/practice-based-pharmacists.pdf (accessed 06 Oct 2020).

2. Van C, Costa D, Mitchell B, Abbott P, Krass I. Development and validation of a measure and a model of general practitioner attitudes toward collaboration with pharmacists. Res Soc Adm Pharm. 2013; 9(6): 688–699.

Adolescents Presenting with Mental Health Crises

Aims The aim of the study is to examine emergency mental health (MH) presentations and assessments of adolescents (16-18) presenting to a Dublin adult emergency department (ED). Methods Clinical data was collected on all patients over a 12 month period. Results Seventy seven adolescents presented, the majority out of hours (n=58, 75%) and with either self-harm (n=34, 44%) or suicidal ideation (n=28, 36%), where females significantly outnumbered males (89% vs 66%; p=.028). Other presentations included low mood, anxiety and behavioural problems, and following assessment from an adult mental health service team member, 55% (n=39) were given an Axis I psychiatric diagnosis. Almost all adolescents were discharged following assessment (n=68, 96%), the majority being referred on to Child and Adolescent Mental Health Service (CAMHS) (55, 78%). Conclusion Crisis presentations to EDs often occur in adolescents with co-existing psychiatric disorders, and require skilled and therapeutic assessment. Knowledge of appropriate services for onward referral is essential, and highlight the importance of a close collaborative between adult EDs and CAMHS.

Evaluation of an innovative recruitment initiative on the attitudes of medical students

Some medical specialties struggle to recruit sufficient trainees to their postgraduate programmes. In many countries including Ireland, psychiatry is one of these specialties. A psychiatric summer school was developed by the trainee committee of the College of Psychiatry of Ireland as a recruitment initiative. All applicants were invited to complete a questionnaire prior, on the day of and three months after the summer school assessing their attitudes to a career in psychiatry. The mean score on the modified Nielson questionnaire in the pre-summer school group was 26.7 (SD +/- 3.8) and this rose significantly 28.3 (SD +/- 3.2) after completion of the summer school. 64% (n = 31) of applicants to the Summer school expressed an interest in a career in psychiatry. This rose to 88% (n = 32) of those who attended. The findings of this study have national and international interest for all specialties who are struggling to recruit to their field.

Multiple teeth showing invasive cervical resorption - an entity with little known histologic features

Invasive cervical resorption is a relatively uncommon form of external root resorption, characterized by resorption of the cervical region of the root. There is progressive loss of cementum and dentine with replacement by fibrovascular tissue derived from the periodontal ligament, with deposition of cementum-like hard tissue. In most cases, a single tooth is involved. We report a case of invasive cervical resorption that resulted in loss of multiple teeth from two different quadrants. The case highlights the diagnostic difficulty that may arise in this uncommon lesion, the pathologic features of which may be mistaken for a fibro-osseous lesion or a low-grade sarcoma.

Inference of personality projected onto fictional characters having an author's first name

Jane Austen projected some of her personality characteristics onto her fictional namesakes Jane Bennet in the novel Pride and Prejudice and Jane Fairfax in the novel Emma. Wishful fantasy seems satisfied by two attributes of both Janes. They are very beautiful, and they marry rich men they love. A feeling of inferiority was expressed by two attributes of both Janes, depicted as deficient in social communication and subordinate to the heroine of the novel.

Pain control with paracetamol from a sustained release formulation and a standard release formulation after third molar surgery: a randomised controlled trial

OBJECTIVE

To compare the analgesic efficacy and safety of a sustained release (SR) paracetamol formulation (Panadol Extend) with a standard immediate release (IR) formulation (Panadol) after third molar surgery.

DESIGN

A multi-centre, double-blind, randomised clinical trial.

METHODS

Patients received either a single oral dose of SR paracetamol or IR paracetamol for pain after the removal of at least one impacted third molar requiring bone removal under general anaesthesia. Post-operative pain and pain relief assessments were undertaken at time intervals up to 8 hours. Global assessments of effectiveness were made at 4 and 8 hours. Any adverse events were also recorded.

RESULTS

Of 627 randomised patients, 314 were treated with SR paracetamol and 313 with IR paracetamol. In the per protocol population at 4 hours, 35.1% of the 252 patients on SR paracetamol rated the study medication as very good or excellent compared with 27.7% of the 258 patients on IR paracetamol. There were few statistically significant differences among the secondary parameters but where they did occur they favoured SR paracetamol. Trends in favour of SR paracetamol were observed among the secondary parameters and these tended to emerge at the later time points. For example, while there was no statistically significant difference in time to re-medication between the treatment groups, the estimated time to re-medication was longer for patients treated with SR paracetamol (4 hr 5 min) compared with IR paracetamol (3 hr 10 min). The high rate of re-medication observed is consistent with that reported for IR paracetamol using the post-operative dental pain model(4,6). No difference was observed between the SR paracetamol and IR paracetamol treatment groups in distribution, incidence or severity of adverse events.

CONCLUSIONS

SR paracetamol and IR paracetamol are clinically and statistically equivalent. While SR paracetamol and IR paracetamol were similar in terms of both onset of analgesia and peak analgesic effect, SR paracetamol had a longer duration of activity than IR paracetamol. The safety profiles of SR paracetamol and IR paracetamol were found to be very similar.

Three last letters identify most female first names

The last spelled letter often indicates the sex of first names. Most female names end with the last letter a, e, or i. Female names are distinctive and therefore easy to identify because of the small number of predominantly female endings. Most male names end with one of 19 last letters. Two last letters, h and y, occur with similar frequency for both sexes. The cultural tradition of higher status for men contributes to the avoidance of predominantly female last letters for male names. A female name with a predominantly male last letter therefore occurs more often than a male name with a predominantly female last letter. The findings were obtained from the 500 most frequent first names given to males and females in Pennsylvania in 1990.

Creation and first 20 years of the society for the stimulus properties of drugs (SSPD)

Clinical observations and novels in the 19th century recognized that memory of some events can be retrieved only under the influence of the same drug condition that was present during the event. This dissociative effect of drugs probably reflects the same drug effects that were later called the discriminative stimulus effects of drugs. The Society for Stimulus Properties of Drugs (SSPD) was founded in 1978 as a forum for communications and periodic meetings on this drug effect. During its early years many of its members were psychologists, but subsequent to that time the most frequent research application has been for the pharmacological purpose of identifying new drugs that have the same discriminative stimulus attributes as a prototype training drug. The majority of members have been in the United States, but several major international meetings have been in Europe. The methods used by the society's members involve both neuropharmacological and psychological processes, allowing them to make unique contributions to the study of both mind and brain.

Cavernous hemangioma in the submandibular gland masquerading as sialadenitis: case report

This report describes a case of cavernous hemangioma in the submandibular gland of a 37-year-old Irish woman. The lesion clinically and radiologically (as shown both by plain radiographs and computed tomography imaging) resembled salivary calculous disease. Numerous phleboliths were present in the hemangioma. The rarity of a cavernous hemangioma in such a location and its simulation of salivary calculous disease stimulated us to report the case.

Day case oral surgery: a review of 25 years experience at the Dublin Dental Hospital

A retrospective analysis of the changing work-load at the Dublin Dental Hospital oral surgery day case unit was undertaken. This involved 26,697 operations performed during the 25-year period 1968-1992. The results show how the practice of oral surgery has changed over this time. Annual totals ranged from 766 to 1549 operations. While most categories of operations remained largely unchanged, the removal of impacted third molars increased from 10.5% of the annual total to 57.0%. Routine extractions of permanent teeth decreased from 53.9% of the annual total to 18.0%.

One experience with 'lower' or 'higher' intensity stressors, respectively enhances or diminishes responsiveness to haloperidol weeks later: implications for understanding drug variability

This laboratory has previously shown that acute exposure to a variety of brief stressful events can have a very long-lasting influence on subsequent responsiveness to pharmacological and non-pharmacological stressors. In some cases the response to these agents is enhanced, while in others it is diminished: the common denominator being that in each instance the influence of the initial stressor grows stronger with the passage of time. Here, we identify one factor that determines which time-dependent effect is manifest. In 3 separate experiments, male rats were subjected to a single exposure to stressors of either lower or higher intensity and their effects on haloperidol-induced catalepsy and dopamine and dihydroxyphenylacetic acid levels in the nucleus accumbens and medial frontal cortex, measured either 1-2 h or 2 weeks later. The stressors were either environmental (needle jab or 1 h of immobilization), metabolic (200 or 750 mg/kg, i.p. of 2-deoxy-D-glucose), or no effect on haloperidol-induced catalepsy when stressors preceded such behavioral testing by 1-2 h. By contrast, when the interval was 2 weeks, the lower-intensity stressors all increased haloperidol catalepsy, whereas the higher-intensity stressors decreased the same response. In other words, a process that progressed with the passage of time was observed regardless of whether sensitization or diminution of haloperidol's action occurred. In contrast to the uniform bipolar behavioral effects observed, depending on the intensity of the prestressor, the neurochemical findings failed to show any evidence of bipolarity whatever.(ABSTRACT TRUNCATED AT 250 WORDS)

Repressive coping style and anxiety in stressful dental surgery

Elevated state-anxiety prior to oral surgery is common and is associated with increased post-operative pain. This paper presents a psychological model of predicting elevated anxiety prior to dental surgery. Elevated anxiety and intraoperative stress can be predicted by measuring trait-anxiety. However, prediction may be improved by using a situationally specific measure of trait-anxiety, and by taking the patient's coping style into account. Thirty-nine patients undergoing wisdom-tooth extraction took part in the study. The Corah Dental Anxiety Scale was a better predictor of pre-operative anxiety than the STAI trait-anxiety scale. Coping style was measured by means of the Marlowe-Crowne Social Desirability Scale in conjunction with scores on trait-anxiety to define three coping style groups: sensitizers (high-anxious), truly low-anxious, and repressors who verbally deny anxiety. Two oral surgeons rated patient intra-operative state on 100 mm visual analogue scales. These ratings indicate that 'repressors' exhibit significantly more stress responses than the truly low-anxious group, in spite of similar (low) trait-anxiety scores. It is concluded that a situationally specific measure of trait-anxiety is the most appropriate predictor of differential state-anxiety elevations prior to oral surgery. Repressive coping style may be a confounding factor, in terms of predicting elevated anxiety, since some people verbally deny being anxious but express it behaviourally.

Controlled comparison of a new sublingual lormetazepam formulation and i.v. diazepam in outpatient minor oral surgery

In a randomized, double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either sublingual lormetazepam 2.5 mg (n = 20) in a new cellulose wafer formulation followed at 35 min by i.v. saline; or sublingual placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of sedation was seen after sublingual lormetazepam, while the course and duration of postoperative sedation, measured using standard psychometric tests, was similar following both treatments. Surgeons' ratings indicated that sublingual lormetazepam was comparable to i.v. diazepam but patients' ratings indicated greater satisfaction with and preference for i.v. diazepam. Significant anterograde amnesia was found following both treatments. Both treatments were tolerated well, with no significant cardiovascular complications. These results indicate that sublingual lormetazepam may have a role in anaesthesia as a premedicant and for conscious sedation.

Comparison of midazolam by mouth and diazepam i.v. in outpatient oral surgery

In a randomized double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either midazolam 15 mg orally followed at 35 min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of sedation was seen after midazolam, while the pattern and duration of postoperative sedation, as measured by standard psychometric tests, indicated slower recovery after midazolam than after diazepam. Ratings by the surgeon indicated superior anxiolysis following midazolam and significantly more patients expressed a preference for oral midazolam sedation. Significant, comparable anterograde amnesia was seen with both treatments. No significant cardiovascular complications occurred with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as midazolam provide safe, effect alternatives to i.v. diazepam for conscious sedation in outpatients undergoing minor surgical procedures.

Benzodiazepine--induced event amnesia following a stressful surgical procedure

In a randomised, double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted third molar teeth received either midazolam 15 mg orally followed at 35 min by intravenous saline or oral placebo followed by intravenous diazepam 10 mg (Diazemuls). Episodic (event) memory was assessed by showing patients photographs of dental and neutral objects both before and after sedation and by testing subsequent recognition at 1 week. Recall of actual surgical events was assessed by questionnaire. Both treatments induced significant amnesia for visual stimuli and for surgical events. However, the degree of amnesia was more profound for artificial stimuli and no relationship was found between the extent of amnesia for the two types of event. Drilling of bone was found to provoke the greatest cardiovascular stress response and a significant relationship was found between the degree of cardiovascular activation and subsequent memory for drilling. It is concluded that the extent of benzodiazepine-induced event-amnesia may be modified by cognitive factors and especially by the extent to which the event is cognitively encoded and elaborated.

Sedation in outpatient oral surgery. Comparison of temazepam by mouth and diazepam i.v

In a randomized double-blind, parallel groups study, 39 patients undergoing surgical removal of impacted third molar teeth received either temazepam 40 mg by mouth (as soft gelatin capsules) followed at 35 min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of significant anxiolytic activity and psychomotor depression was seen following temazepam, while the pattern and duration of postoperative sedation measured with standard psychometric tests, were similar for both treatments. Ratings by the surgeon and by the patients indicated that sedation following the two treatments was comparable. No significant cardiovascular complications were found with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as temazepam provide safe, effective alternatives to i.v. diazepam for sedation in outpatients undergoing minor surgical procedures.

Differential effect of benzodiazepine sedation in high and low anxious patients in a "real life" stress setting

In a randomised, double-blind, parallel groups study, 40 patients referred for surgical removal of impacted third molars received either (a) temazepam 40 mg orally followed at 35 min by IV saline or (b) oral placebo followed by IV diazepam 10 mg (Diazemuls). Patients were divided into High-Anxious and Low-Anxious groups by median split of their anxiety scores on the Speilberger State Anxiety Scale at the time of oral medication. Compared with placebo, temazepam significantly attenuated anticipatory anxiety in the High-Anxious group while in the Low-Anxious group no difference was found between the treatments. Preoperative but not intraoperative heart-rate distinguished between the High-Anxious and Low-Anxious groups and neither oral temazepam nor IV diazepam abolished the heart-rate response to the traumatic stages of the surgical procedure. The results are interpreted as providing support in a "real life" human stress setting for Gray's neuropsychological model of anxiety.

Effects of the training dose on generalization of morphine stimulus to clonidine

The relationship between the stimulus properties of morphine and clonidine was tested in rats trained to discriminate morphine sulfate (4, 2 or 1 mg/kg) from saline in a two-lever food-rewarded task. The response trained in the low dose group generalized to low doses of clonidine (0.125 to 0.5 mg/kg) whereas the response trained with the high dose of morphine generalized only to higher doses of clonidine (0.625 to 1.0 mg/kg). Naloxone blocked the generalization in the low dose group but only partially blocked it in the high dose group. Yohimbine blocked the generalization to clonidine in the high morphine dose group and reversed the response rate suppressant effect of clonidine in all groups.

The effects of SKF 525-A on the analgesic and barbiturate-potentiating activity of delta 9-tetrahydrocannabinol in mice and rats

delta 9-Tetrahydrocannabinol (THC) markedly potentiated barbital Na sleeping time in mice and rats. The magnitude and duration of this effect were markedly enhanced when the animals were pretreated with SKF 525-A, a nonspecific inhibitor of liver microsomal enzymes responsible for drug metabolism. Moreover, depending on the method and species of animal used, THC was found to be one half (mouse hot plate), one third (mouse tail flick), and one eighth (rat tail flick) as potent an analgesic as morphine SO4. However, pretreatment with SKF 525-A significantly potentiated the analgesic activity in mice. These data suggest that intact THC and not necessarily a metabolite(s) is principally responsible for the CNS depressant and analgesic effects observed.

Measuring naloxone antagonism of discriminative opioid stimulus

The numerous studies of opioids as discriminative stimuli, beginning in 1971, have shown specificity, similarity of several opioids, differences in potency (fentanyl greater than heroin greater methadone greater than morphine), and antagonism by naloxone and naltrexone. The discriminative opioid stimulus is differentiated from those of other classes of drugs, such as sedatives and anxiolytics. Greater potency of the opioid stimulus has been found in rats after subcutaneous (s.c.) than intraperitoneal administration. The discriminative opioid stimulus and its antagonism by naloxone or naltrexone have been demonstrated in rats, squirrel monkeys, gerbils, and pigeons. A few studies have quantified the competitive agonist-antagonist interaction at the receptor by calculating the pA2, which reflects the dose of the antagonist that requires doubling the agonist dose to obtain the original agonist response. The pA2 for naloxone is the same in groups of rats trained to discriminate different doses of morphine (1, 2, or 4 mg/kg s.c.) from saline. Higher pA2 values in tests after fentanyl and methadone than after heroin and morphine in rats trained to discriminate fentanyl (0.04 mg/kg s.c.) from saline reflect greater susceptibility of the synthetic than the natural exogenous opioids to antagonism by naloxone. Different pA2 values are usually interpreted as indicating differences among populations of receptors.

Discriminative, disinhibitory, and depressant effects of several anticonvulsants

The discriminative attributes of drugs were used to assess the degree to which several anticonvulsants have behavioral effects resembling those of pentobarbital. Rats were trained to make alternative responses to obtain water, depending on whether they had been injected IP with pentobarbital (10 mg/kg) or saline 10 min before the session. The pentobarbital response was chosen in tests with phenobarbital, dimethylphenobarbital, or methsuximide in the anticonvulsant dosage range. Increasing doses increased the percentage pentobarbital choice. Response rate was generally increased by doses that increased percentage of pentobarbital choice. The rats predominantly chose the saline response when administered phenytoin, primidone, or phenylethylmalondiamide, even at doses that were sufficiently high to reduce the response rate. The results suggest that different types of depressant effects are associated with the anticonvulsants tested.

Bioavailability and dissolution behavior of trisulfapyrimidine suspensions

The bioavailability of seven commercial trisulfapyrimidine suspensions was studied in 14 adult male volunteers. Fifteen blood samples were collected over a 48-hr period following administration of a 1-g dose of each suspension. Serum was assayed for each component (sulfadiazine, sulfamerazine, and sulfamethazine) by high-pressure liquid chromatography. Analysis of variance indicated several significant differences among the seven commercial preparations with respect to Cmax Tmax, and AUC for sulfadiazine, sulfamerazine, and sulfamethazine, The in vitro behavior of each suspension was then studied by the paddle method of the Food and Drug Administration. A 0.5-ml sample was introduced into 900 ml of hydrochloric acid (2.2 x 10(-4) M) at 37 degree and dissolved using a paddle speed of 25 rpm. Samples withdrawn at 15 and 30 min were analyzed by high-pressure liquid chromatography, and the percent of sulfadiazine, sulfamerazine, and sulfamethazine was calculated. Significant correlation was obtained between an in vivo parameter (Cmax for sulfadiazine) and an in vitro parameter (percent sulfadiazine dissolved in 30 min). Results indicate that this method is suitable for the in vitro screening of trisulapyrimidine suspensions.

Childhood family influences on risk of alcoholism

1. The self-destructive behavior of chronic, excessive drinking is motivated by self-hatred in combination with ambivalent expressions of ambition and dependency. These sources of vulnerability to alcoholism develop in early childhood. 2. The protective influence of a favorable, stable self-evaluation is indicated by characteristics of occupational groups with a low incidence of alcoholism, such as monarchs and Presidents of the United States. 3. Characteristics of the personal name may influence development of self-esteem. In a small sample of Presidents and brothers of Presidents with drinking problems, most had a brother with the same first name as the admired, successful father. 4. Primary prevention should help parents to recognize the child's need for love, tolerance, and responsibility. These influences enable the child to develop autonomy and self-esteem.

The effect of repeated administration of delta9-tetrahydrocannabinol on serotonin metabolism in the rat brain

The level of serotonin (5-HT) was increased in the whole rat brain as well as in the hypothalamus plus midbrain region at 0.5 hr after the fifth or sixth daily dose of delta9-tetrahydrocannabinol (THC), 20.0 mg/kg, i.p., respectively. A decreased rate of 5-HT synthesis was also observed. A slight development of tolerance was indicated by the fact that elevation of 5-HT was smaller than that seen after a single dose (1).

Comparative activity of delta9-tetrahydrocannabinol, diphenylhydantoin, phenobarbital and chlordiazepoxide on electroshcok seizure threshold in mice

delta9-Tetrahydrocannabinol (THC) was compared with diphenylhydantoin (DPH), phenobarbital (PB) and chlordiazepoxide (CDP) using two electroshock procedures to determine anticonvulsant activity in mice, i.e., electroshock seizure threshold (EST) and the reduced EST caused by hyponatremia (injection of isotonic glucose). Using doses of each drug which were ineffective against MES, only CDP (10.0 mg/kg) was able to raise the EST by 20%. The lowered EST due to hyponatremia was reveresed by al four drugs. In these tests latency to convulsions and lethality associated with electroshock were more sensitive to THC.

Comparison of the effects of alcohol, chlordiazepoxide, and delta9-tetrahydrocannabinol on intraspecies aggression in rats

The species-specific repertoire of attack, threat, defense, and submission was produced in pairs of male laboratory rats and measured after intraperitoneal injection of a drug or its vehicle to one of the rats. Attack behavior by dominant rats toward nondrugged opponents was increased by a low dose of alcohol (0.5 g/kg) or of chlordiazepoxide (5 mg/kg), but suppressed by delta9-tetrahydrocannabinol (THC). In experienced subordinate rats, the highest alcohol dose (1.5 g/kg) impaired the defensive upright posture whereas THC (2, 4 MG/KG) prolonged immobile crouch and submissivesupine reactions and resulted in more wounds. Naive rats administered alcohol assumed the submissivesupine posture more readily and for a longer duration, but sustained more biting attacks. Chlordiazepoxide and THC, when administered to naive rats, prolonged the immobile crouch reaction, and THC also impaired the defensive upright posture. We conclude that alcohol and chlordiazepoxide both enhance attack behavior in dominant rats, whereas THC has specific anti-aggressive effects and profoundly alters the submissive-defensive reactions.

Discriminative pentobarbital stimulus in rats immediately after intravenous administration

Rats with chronically implanted venous cannulas were trained to make differential active or passive shock-avoidance responses in a 2-compartment box at 15 sec after i.v. adminstration of pentobarbital (5 mg/kg) or saline. The discriminative pentobarbital stimulus persisted for several min after adminstration. The pentobarbital response also was elicited in tests at 15 sec after i.v. injection of chlordiazepoxide (2.5 and 5 mg/kg) or alcohol (500 mg/kg). Subsequent training at 10 min after i.p. injection of pentobarbital (10 mg/kg), followed by tests after i.p. administration of other drugs, indicated that the discriminative drug stimulus is qualitatively similar with this different route and time interval. A general preference for the passive over the active response developed only in the second stage of training, during i.p. injections.