Established clinical treatment and/or clinical trial networks generic 100mg januvia fast delivery, frequently sponsored by advocacy groups buy cheap januvia 100mg on line, provide a means for study sponsors to engage experienced investigators at sites caring for patients with the respective rare diseases. Disease-specic treatment centres sponsored by govern- ment and public agencies can also be a powerful tool in gaining access to experienced investigators caring for patients with rare diseases. This network currently comprises more than 130 treatment centres and provides comprehensive services within a single treatment facility for over 10 000 patients with bleeding disorders and their families. For disease areas such as paediatric oncology, highly structured clinical trial networks such as the Children’s Oncology Group in North America and the Innovative Therapies for Children with Cancer consortium in Europe can be accessed by sponsors for varying degrees of collaboration in evaluating new investigational agents to treat childhood cancer. While there are substantial challenges entailed with conduct of clinical studies in small patient populations, there are a host of strategies available to sponsors to facilitate the conduct of rigorous, hypothesis-driven investigations that can support regulatory approval. Natural history studies, disease registry data and repositories of clinical trial data can provide insights into the underlying disease process, disease heterogeneity and progression and standards of care. These tools can also be used to identify appropriate patient populations for clinical investigation and to identify or validate clinically meaningful end points that are accessible in a timeline permissive for drug development. The underlying monogenetic nature of many rare diseases creates the opportunity for enrichment strategies to increase the proportion of subjects likely to respond to eﬀective treatments, permitting robust hypothesis testing while reducing sample size require- ments. The genetic nature of many rare diseases can also ensure a predict- able disease course and an accurate characterisation of patient populations that may be permissive for use of historical controls in order to reduce study sample size requirements. Challenges in gaining access to aﬀected patient populations can be mitigated through collaborations with patient advocacy groups and by engagement with clinical trial networks and consortia dedi- cated to improving treatment outcomes among patients aﬀected by the respective rare diseases. Ongoing evolution in the landscape of drug development promises to provide continued opportunity for development of new therapies to treated individuals aﬀected by rare diseases. Several major pharmaceutical compa- nies have established new research divisions dedicated to orphan diseases. The scope of gene corrective therapies, many uniquely poised to correct underlying genetic causes of rare diseases, continues to expand, creating exciting possibilities for response enrichment strategies in small patient populations. This policy, if implemented, could provide enhanced data to inform clinical study designs, facilitate identication of end points View Online The Challenges of Conducting Clinical Trials in Diseases with Small Target Populations 75 that can support drug development, facilitate validation of surrogate end points to support accelerated or conditional regulatory approval and when justied, facilitate use of historic control groups, all to the potential benet 79 of investigators conducting research in small patient populations. While the challenges are substantial, the climate for clinical research in rare diseases remains promising. The views presented in the chapter reect those of the author and do not necessarily reect those of Pzer. The Committee for Orphan Medicinal Products and the European Medicines Agency Scientic Secretariat, Nat. Bonds and The Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell Anemia, N. View Online The Challenges of Conducting Clinical Trials in Diseases with Small Target Populations 77 33. Turner and American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Circulation, 2012, 125,e2–e220. Kang, View Online The Challenges of Conducting Clinical Trials in Diseases with Small Target Populations 79 E. International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals For Registration of Pharmaceuticals for Human Use, Choice of control group and related issues in clinical trials E10, http://www. View Online Treating Rare Diseases: Business Model for Orphan Drug Development 85 Table 4. Each period outlines tremendous growth in output to a peak at the end of the period. In addition, the second and third periods are characterised by a nadir at the beginning, resulting from a fall-oﬀ in output from the preceding period’s peak due to macro-level market factors, aer which the growth uptick restarts. This paradigm and associated trends, conrmed based on updates with more recent output data, are illustrated in Table 4. Key points to highlight from this three-stage distribution of orphan drug development market output include the importance of market shocks resulting from a fall-oﬀ in output from the previous peak (i. Indeed, among therapeutic areas, oncology represents a majority share of new orphan disease therapies that come to market (i. Current estimates indicate that there are 5000–8000 rare diseases in the world for which Orphanet, a European organisation, has done systematic identication and classication. Many orphan diseases are characterised by a tight-knit community of patients, care-givers and treating healthcare professionals, which shares information among members on symptoms, disease characteristics, treatment options and new therapies being investigated, including potential clinical trials to participate in. Quite oen, these communities are built on the backbone of formal organisations (i. The degree of community ‘stickiness’ for many orphan diseases will inuence many of the key factors that underpin overall product development approaches for new orphan drugs. Orphan drugs, with current global revenues of $83 billion, have become an increasingly large and important part of the global pharmaceutical market, for which global sales in 2012 amounted to $645 billion. View Online Treating Rare Diseases: Business Model for Orphan Drug Development 89 Figure 4. View Online 90 Chapter 4 The following sections will explore orphan drug product development, commercialisation, investment and economics, as well as the future outlook for this rapidly developing and exciting sector within the biopharmaceutical industry. Second, orphan drug clinical programme strategy and execution is further challenged by uncertainties in the selection and characterisation of appropriate trial end points and treatment durations, paucity of robust biomarkers, recruiting the right patient populations and identifying qualied investigators. Special attention must be paid to ensure that the small patient populations for orphan diseases are characterised appro- priately, given biological and pharmacological heterogeneity/variability, as well as geographical distribution and scarcity. Additionally, for many orphan diseases, the lack of regulatory ‘precedent’ presents a challenge in itself. The scientic basis, level of evidence required, and context for biomarker use are areas to clarify. Accordingly, regulatory success oen requires robust and frequent inter- actions with regulatory agencies to gain alignment on key programme design elements including trial design, patient population requirements, clinical end points (e. The next few sections will discuss tradi- tional and emerging orphan drug product development platforms. A key example is bluebird bio, a gene therapy company focused on rare diseases, which uses its non-replicating lentiviral vector View Online 92 Chapter 4 Table 4. Monoclonal Immunoglobulins: based on Many Iniximab, antibodies specicity for antigenic rituximab epitopes 4. Gene therapy Vector-delivered gene sequences: 1 Alipogene replace decient/aberrant tiparvovec gene products 7. Pharmacological Small molecules: stabilize and/or 0 N/A chaperones reshape misfolded proteins aSmall molecules are low molecular weight (<900 Daltons) organic compounds and have been the main molecule platform for drug development. Large molecules (naturally occurring, recombinant, synthetic) comprise a broad cross-section of compound classes (e. LentiGlobin, which uses a similar vector but replaces beta-globin, is being evaluated for the treatment of beta thalassaemia major and sickle cell disease. Alipogene tiparvovec’s approval, based on clinical data from 27 patients, restricts prescribing to the subset of lipoprotein lipase deciency patients who have suﬀered repeated pancreatitis, and requires ongoing monitoring by the company, to demonstrate long-term eﬃcacy and safety. There are a number of arguments for the proposed price: high pharmaceutical R&D costs in general, and alipogene tiparvovec’s high-cost development programme in particular (i. Interestingly, uniQure has proposed an ‘annuity’ approach to charging health systems for alipogene tiparvovec (e. Duchenne’s, an X-linked disease characterised by progressively debilitating natural history disease stages, has a spectrum of manifesta- tions with important implications for selecting clinical end points and trial design, on a background of a wide array of exon-deletion abnormal- ities. Thelattertwostages,aﬀecting teenagers and older patients, exhibit more debilitating disease aﬀecting cardiac, pulmonary and upper limb function. Prosensa’s exon-targeting therapeutic approach, which would create a ‘menu’ of therapies for each exon-deletion abnormality, is inuenced by the decreasing prevalence of the target exon (e. Based on this background, the clinical development and regulatory approach will probably pursue a full devel- opment programme for compounds addressing the most prevalent target exon mutations (e. Chaperones bring about therapeutic eﬀect downstream of translation by ‘protecting’ their target proteins (e. Amicus Therapeutics, arguably the company with the broadest portfolio of small molecule pharmacological chaperones, is leveraging its technology platform to develop orally bioavailable therapies to address lysosomal storage disorders including Fabry, Gaucher and Pompe diseases. More so, orphan drug reim- bursement, by private or public payer, has traditionally been generous, aﬀording most patients in the small orphan disease communities with access to medicines, which are oen life-saving and/or provide signicant quality of life attributes. Some of these payer management tools, approaches and tactics include the use of restrictive tiers, prior authorisation, step therapy, increased patient coinsurance and/or co-payment, genetic testing (i. Creative risk-sharing schemes, in addition to traditional patient access programmes and manufacturer discounts, are increasingly playing an important role in the provision of orphan drugs to patients.
For example buy 100mg januvia with amex, due to the presence of the Folds of Kerckring generic januvia 100 mg free shipping, the villi and the microvilli, the available surface area of the small intestine of the gastrointestinal tract is very large, making this region an extremely important one for oral drug delivery. The surface area of the lungs, which has evolved physiologically for the highly efficient exchange of gases, is also very extensive, making this region a promising alternative route to the parenteral and oral routes for systemic drug delivery. Low metabolic activity Degradative enzymes may deactivate the drug, prior to absorption. Poor drug bioavailability may thus be expected from an absorption site in which enzyme activity is high, such as the gastrointestinal tract. Furthermore, drugs which are orally absorbed must first pass through the intestinal wall and the liver, prior to reaching the systemic circulation. Contact time As described above, the length of time the drug is in contact with the absorbing tissue will influence the amount of drug which crosses the mucosa. Materials administered to different sites of the body are removed from the site of administration by a variety of natural clearance mechanisms. For example, intestinal motility moves material in the stomach or small intestine distally towards the large intestine; it has been estimated that in some cases residence of a drug in the small intestine can be in the order of minutes. In the nasal cavity and the upper and central lungs, an efficient self-cleansing mechanism referred to as the “mucociliary escalator” is in place to remove any foreign material, including undissolved drug particles. Particulates entering the airways are entrapped within a mucus blanket and ciliary action propels the mucus along the airways, to the Table 3. Typical vaginal delivery systems such as foams, gels and tablets are removed in a relatively short period of time by the self-cleansing action of the vaginal tract. In the eye, materials are diluted by tears and removed via the lachrymal drainage system. Blood supply Adequate blood flow from the absorption site is required to carry the drug to the site of action post- absorption and also to ensure that “sink” conditions are maintained (see Section 1. Accessibility Certain absorption sites, for example the alveolar region of the lungs, are not readily accessible and thus may require quite complex delivery devices to ensure the drug reaches the absorption site. Lack of variability Lack of variability is essential to ensure reproducible drug delivery. This is a particularly important criterion for the delivery of highly potent drugs with a narrow therapeutic window. Due to such factors as extremes of pH, enzyme activity, intestinal motility, presence of food/fluid etc. Similarly, diseases such as the common cold and hayfever are recognized to alter the physiological conditions of the nose, contributing to the variability of this site. The presence of disease can also severely compromise the reproducibility of drug delivery in the lungs. Cyclic changes in the female menstrual cycle mean that large fluctuations in vaginal bioavailability can occur. Permeability A more permeable epithelium obviously facilitates greater absorption. For example, the skin is an extremely impermeable barrier, whereas the permeability of the lung membranes towards many compounds is much higher than the skin and is also higher than that of the small intestine and other mucosal routes. The vaginal epithelium is relatively permeable, particularly at certain stages of the menstrual cycle. Parenteral drug delivery The main clinical role of parenteral therapy is to administer drugs that cannot be given by the oral route, either because of their poor absorption properties, or propensity to degrade in the gastrointestinal tract. Injections are unpleasant and patient acceptance and compliance via this route are low. Intravenous injections may only be given by qualified medical professionals, making this route expensive and inconvenient. Intramuscular and subcutaneous preparations are self-injectable; however, patients dislike them. In addition, elderly, infirm and pediatric patients cannot administer their own injections and require assistance, thereby increasing inconvenience to these patients and the cost of their therapy. Increased medical complications can result from the poor compliance associated with the parenteral route. There has always been a need for injectable formulations that could offer a prolongation of action similar to that achievable by the oral route. Novel sophisticated implant devices have been developed which can adequately control drug dosage and provide a prolonged duration of effect. Implants are available as biodegradable and non- biodegradable polymeric devices and as mini-pumps, and are described in detail in Chapter 4; new- generation implantable technologies, such as bioresponsive implants, are discussed in Chapter 16. The other major thrust of research in the parenteral field involves the delivery of drugs to specific targets in the body. Parenteral drug delivery and targeting systems are discussed in detail in Chapter 5. Oral drug delivery It is estimated that 90% of all medicines usage is in oral forms and oral products consistently comprise more than half the annual drug delivery market. It is the preferred route of administration, being convenient, controlled by the patient and needs no skilled medical intervention. Considerable success has been achieved with various types of controlled-release systems for peroral delivery, which are used to prolong drug effects. For example, the oral route is highly variable, so that there is considerable potential for bio-inequivalence amongst orally administered drugs. The route is also characterized by adverse environmental conditions, including extremes of pH, intestinal motility, mucus barriers, the presence of p-glycoprotein efflux systems, high metabolic activity and a relatively impermeable epithelium. Buccal and sub-lingual drug delivery 67 Although currently a minor route for drug delivery, the oral cavity is associated with many advantages as site for drug delivery (Table 3. The sub-lingual route is characterized by a relatively permeable epithelium, and is suited to the delivery of low molecular-weight lipophilic drugs, when a rapid onset of action is required. Advanced drug delivery systems such as buccal adhesive patches are now being developed in order to provide prolonged mucosal adhesion and sustained delivery of drugs. Transdermal drug delivery The transdermal route, discussed in Chapter 8, has emerged as a viable alternative route to the parenteral and oral routes, in order to achieve the systemic delivery of drug molecules. Although the skin provides a highly effective barrier against external damage and desiccation, transdermal technology has been developed to overcome this resistance and now several systemically active drugs are delivered transdermally. Advanced delivery systems include transdermal patches, which are now well established and accepted by patients. Technologies under development include, for example, iontophoresis, which uses a small electric current to propel the drug through the skin. Drug delivery via iontophoresis occurs at enhanced rates and amounts in comparison to patch technology, which uses simple passive diffusion. The development of safe, non-toxic absorption enhancers to facilitate transdermal absorption is a further focus of current research. Nasal drug delivery Nasal sprays are commercially available for the systemic delivery of various peptide drugs, including buserelin, desmopressin, oxytocin and calcitonin. Although currently a relatively small market, the nasal route possesses many properties of an “ideal” delivery site (Table 3. New technologies in nasal delivery are primarily concerned with strategies to increase the rate of systemic drug absorption, in particular, in developing absorption promoters with minimal toxicity. Pulmonary drug delivery Drug delivery by inhalation has a long history and is an obvious way of administering agents that act on the respiratory system. A more recent advance has been the investigation of this route for systemic drug delivery, although the morphology of the lungs makes drug access to the airways difficult. Furthermore, particles that gain access to the upper airways may subsequently be cleared by mucociliary clearance mechanisms. Pulmonary drug delivery research is addressing factors such as the use of optimized drug delivery devices and novel drug delivery systems, such as liposomes. Systemic drug delivery via the lungs has largely focused on nebulization procedures, which are the most efficient at delivering the emitted dose to the peripheral lung. Vaginal drug delivery The vaginal route, discussed in Chapter 11, constitutes another mucosal route of emerging importance for systemic drug delivery. As with other mucosal routes, a major challenge lies in the development of safe, non-toxic absorption enhancers, to potentiate drug absorption.
In the Heidelberg case the subject initially met the hypnotist in a situation where he presented himself as a physician who could relieve a symptom that was causing her acute distress safe 100mg januvia. The subject appeared to have had psychosomatic symptoms before contact with the hypnotist januvia 100 mg with visa, which might have reflected tension in her marriage. In the last case the subject was dejected with intense feelings of worthlessness, as an aftermath of collaboration during the war. The intensity of this relationship can be inferred from the fact that the subject at the time began to feel considerably more comfortable. Thus, in each case the relationship between subject and hypnotist was such that the former derived need gratification from the association. Frequently relationships exist between two individuals that have no connection with hypnosis but are marked by intense feelings and a strong tendency on the part of one individual to comply with whatever requests are made of him by the other. If this type of relationship exists between two individuals, it would seem unnecessary to employ hypnosis to explain behavior on the part of one person which benefits the other. Only in the absence of this kind of pre- -190- existing relationship is it meaningful to speak of hypnosis as being a necessary prerequisite for the behavior. However, if we are to make inferences from these data to the situation of hypnosis in interrogation it is necessary to keep in mind that the relationship between the interrogator and the subject is not often comparable to the long-term relationships which existed in the cases cited. The experimental laboratory studies suffer from the defects of a pseudo-reality situation where the "nansgressive acts" cannot be defined as such in the context of the total situation, and from the defect of the mutually shared wishes and motives of experimenter and subject. The only three cases of criminal acts apparently involving hypnosis which are reliably reported in the recent literature all involve an intense emotional relationship between hypnotist and subject. In the absence of meaningful evidence, any conclusions reached must be of a conjectural nature. Experimental tests of the question are feasible, but would require camouflage of the institutional responsibilities of the investigators. The author would postulate that only in rare interrogation subjects would a sufficiently deep trance be obtainable to even attempt to induce the subject to discuss material which he is unwilling to discuss in the waking state. The kind of information which can be obtained in those rare instances is still an unanswered question. Recall and Accuracy of Information Obtained in Hypnosis Despite the previously discussed technical problems, it may be possible for an interrogator to obtain information from a hypnotized subject. In either case the interrogator must evaluate the veridicality of the elicited material. A great deal has been written, especially in the press, about the unfailing accuracy with which subjects in hypnosis will recall past events. Statements have frequently been made about individuals -191- having perfect memory in hypnosis, about their ability to recall anything that has happened to them even while infants, and, according to some, even prior to birth (37). Two separate issues have to be examined: (a) is the subject in hypnosis able to recall historically accurate information which he cannot remember in the waking state and (b) is information obtained from a subject in hypnosis necessarily accurate when it has been suggested to him that he cannot lie? A mechanism frequently used to facilitate recall is that of hypnotic age regression. The subject is "regressed" or taken back in time to the situations toward which recall is directed. For example, if a subject in deep hypnosis is given the suggestion that he is, let us say, six years old, he will begin to act, talk, and to some extent think in the manner of a six year old. It is often assumed that the information obtained under these circumstances is accurate. Platonov and Prikhodivny (57) published two studies which claim to prove the reality of age regression by means of intelligence tests. One of the most striking studies is by Gidro-Frank and BowersBuch (25), who demonstrated that the infantile type of plantar response appeared in subjects who were regressed in age to approximately five months. Unfortunately they did not investigate whether the subjects were aware of the type of plantar response to be expected in infancy. The subject population included medical students and nurses, and it is reasonable to assume that they were not entirely naive. Single case studies which claim to demonstrate "real" age regression have been reported by a variety of investigators: Spiegel, Shor and Fishman (69), Schneck (66), Mercer and Gibson (47), LeCron (41), Bergman, Graham, and Leavitt (8), and Kline (36). Despite these studies, which are based mostly on single cases, there is little evidence for the validity of hypnotic age regression. Young (85) in a study using a number of subjects has demonstrated that their performance on intelligence tests was not appropriate to their suggested age. Unhypnotized control subjects were more suc- -192- cessful in simulating their age than were subjects in deep hypnosis. There was no correlation between the apparent depth of hypnosis and the extent of regression. Orne (51) conducted a study of hypnotic age regression in ten subjects employing the Rorschach test and drawing samples, and was able to demonstrate that, while some regressive elements appeared, it was clear that nonregressive elements were also present. Furthermore, the changes toward regression did not show any consistency from subject to subject. The drawing samples in age regression were evaluated by Karen Machover who characterized them as "sophisticated oversimplification. For one subject his drawings at age six were available, but there was not even a superficial resemblance. To summarize, the literature on hypnotic age regression fails to demonstrate that the phenomenon is anything more than an extremely convincing form of role-playing, as suggested by Sarbin (61), Young (85), and Orne (51). There is little evidence in any of these studies to indicate that recall for nonernotional material is significantly improved. It is important for our purposes to distinguish between emotionally neutral material and emotionally charged events, which are subject to active forgetting or repression. There is abundant evidence that emotionally laden material that is not normally accessible can be recovered by hypnosis. Probably it is this phenomenon which has led to the erroneous assumption that all types of material may be recalled in this fashion. Two specific studies deal with memory in hypnosis: Stalnaker and Riddle (70) asked subjects in hypnosis to recall the poem "The Village Blacksmith. Much of the apparent improvement was due to appropriate confabulation of poetic material in the manner of Longfellow. The significant point is that subjects in hypnotic -193- trance show a marked tendency to confabulate with apparent verisimilitude. White, Fox, and Harris (82) demonstrated that hypnosis does not improve memory for recently learned material, but appears to improve memory for meaningful material, such as poetry, slightly. The Accuracy of Information Obtained in Hypnosis Considerably less material is available about the veracity of the material furnished by a subject in hypnosis. As the preceding discussion indicates, subjects in deep hypnosis tend to confabulate in the direction of what they perceive to be expected of them. We should like to examine the extent to which subjects in hypnosis can purposely misrepresent material, although it has been suggested to them that they cannot do this. As we have already indicated, Young (84) has shown that subjects can resist specific suggestions if they have decided in advance that they will do so. Beigel (6, 7) reports three cases of hypnosis used in an effort to ascertain the facts in marriage counseling situations. In a personal communication, he maintains that people in hypnosis may lie, refuse to answer, or wake up when asked direct questions on sensitive matters. However, he claims to have successfully elicited information which subjects were reluctant to reveal in the waking state by means of a hypnotic reliving of the situation. However, this approach utilizes a form of age regression, and is, as such, subject to the criticisms already made with regard to this technique. It is, perhaps, not too far fetched to assume that psychotherapy patients "want," at some level, to reveal information to their therapist. In reviewing the existing literature we have found only one author who deals with prevarication under hypnosis (Beigel). However, our own clinical work has amply convinced us that subjects are -194- fully capable of deliberately lying when motivated to do so. Although this report deals specifically with hypnosis, it may, at this juncture, be useful to consider also the question of prevarication under the influeuce of drugs commonly used in narcosynthesis. Its relevance is confirmed by the findings of Grinker and Spiegel (28) and others who, in the treatment of traumatic neurosis by narcosynthesis, obtainod results which closely paralleled those observed by hypnotic treatment of these neuroses (17). Individual differences in response to treatment are found both in narcosynthesis and hypnosis, whereas treatment techniques show marked similarities. Friedlander (24), Schilder (63), and others have described trance-induction techniques utilizing sleep-inducing drugs.
Such approaches can be directed toward 120 Subramani insulin delivery through inhalable nanoparticles order januvia 100 mg without prescription. Insulin molecules can be encapsu- lated within the nanoparticles and can be administered into the lungs by inhaling the dry powder formulation of insulin buy discount januvia 100 mg online. The nanoparticles should be small enough to avoid clogging up the lungs but large enough to avoid being exhaled. Such a method of administration allows the direct delivery of insulin molecules to the bloodstream without undergoing degradation. A few studies have been done to test the potential use of ceramic nanoparticles (calcium phosphate) as drug deliv- ery agents (22,23). Porous hydroxyapatite nanoparticles have also been tested for the intestinal delivery of insulin (24). Preclinical studies in guinea pig lungs with insulin-loaded poly(lactide-co-glycolide) nanospheres demonstrated a signiﬁcant reduction in blood glucose level with a prolonged effect over 48 hours when com- pared with insulin solution (25). Insulin-loaded poly(butyl cyanoacrylate) nanopar- ticles when delivered to the lungs of rats were shown to extend the duration of hypoglycemic effect over 20 hours when compared with pulmonary administra- tion of insulin solution (26). The major factors limiting the bioavailability of nasally administered insulin include poor permeability across the mucosal membrane and rapid mucociliary clearance mechanism that removes the nonmucoadhesive formu- lations from the absorption site (27). To overcome these limitations, mucoadhesive nanoparticles made of chitosan/tripolyphosphate (28) and starch (29) have been evaluated. These nanoparticles showed good insulin-loading capacity, providing the release of 75% to 80% insulin within 15 minutes after administration. Biosensors and nonporous membranes with pores of 6-nm diameter are located in the exterior to detect the changes in blood glucose level and for insulin release. Another implantable, polymer-based micropump system with integrated biosensors for optimal insulin delivery without user intervention has been described in a recent study (33). Micro- fabrication techniques have taken the miniaturization science to the nanoscale level. Microneedles have also been reported as effective transdermal systems for insulin delivery (34). The concept of an assembled biocapsule consisting of two micro- machined membranes bonded together to form a cell-containing cavity bound by membranes with nanopores was reported earlier (Fig. While the nanopores were designed to be permeable to glucose, insulin, and other metabolically active products, the pores were small enough to prevent the passage of larger cytotoxic cells, macrophages, antibodies, and complement (36) (Fig. Other Nanoparticulate Systems for Insulin Delivery and Diabetes-Associated Symptoms Treatment Other than the ceramic and polymeric nanoparticles, gold nanoparticles have also been tested as insulin carriers. The nanoparticles showed long-term stability in terms of aggregation and good insulin loading of 53%. The use of chitosan served dual purpose by acting as a reducing agent in the synthe- sis of gold nanoparticles and also promoting the penetration and uptake of insulin across the oral and nasal mucosa in diabetic rats. The study concluded that oral and nasal administration of insulin-loaded, chitosan-reduced gold nanoparticles improved pharmacodynamic activity of insulin. Dextran nanoparticle–vitamin B12 combination has been tested to overcome the gastrointestinal degradation of vita- min B12–peptide–protein drug conjugates (38). These nanoparticles were found to protect the entrapped insulin against gut proteases. Dextran nanoparticle–vitamin B12 combination showed a release proﬁle that was suitable for oral delivery systems of insulin. The associated conditions are inﬂammatory diseases of skin and gums, diabetic retinopathy (eyes), diabetic neu- ropathy (nervous system), heart diseases, kidney diseases, delayed wound healing, and many more. Nanoparticulate systems have also been tested for the treatment of these associated conditions. Nanoparticle-based ocular drug delivery systems have been already described in the past decade (39,40). The scientiﬁc com- munity is working toward utilizing nanoparticle-based drug delivery systems for the treatment of diabetes-associated complications. These research studies are being conducted to under- stand how matter behaves at the nanoscale level. Factors and conditions governing the behavior of macrosystems do not really apply to the nanosystems. The major limitations and technological hurdles faced by nanotechnology and its applica- tions in the ﬁeld of drug delivery should be addressed (44,45). Scientiﬁc commu- nity has not yet understood completely how the human body would react to these nanoparticles and nanosystems, which are acting as drug carriers. Friction and clumping of the nanoparticles into a larger structure is inevitable, which may affect their func- tion as a drug delivery system. Due to their minute size, these drug carriers can be cleared away from the body by the body’s excretory pathways. When these are not excreted, larger nanoparticles can accumulate in vital organs, causing toxicity lead- ing to organ failure. Recent study in mice revealed that tissue distribution of gold nanoparticles is size dependent, with the smallest nanoparticles (15–50 nm) show- ing the most widespread organ distribution including blood, liver, lung, spleen, kidney, brain, heart, and stomach (46). Liposomes have certain drawbacks, such as being captured by the human body’s defense system. The drug-loading capacity of liposomes is being tested by researchers and still remains inconclusive. All previ- ous studies resulted in posttreatment accumulation of the nanoparticles in skin and eyes. Once the nanoparticles are administered into the human body, they should be controlled by an external control, preventing them from causing adverse effects. These drug deliv- ery technologies are in various stages of research and development. It is expected that these limitations can be overcome and the discoveries to come into practical use within the next 5 to 10 years. Report of the Committee on the classiﬁcation and diagnostic criteria of diabetes mellitus. Formulation of insulin-loaded polymeric nanoparti- cles using response surface methodology. Glucose-sensitive membranes containing glucose oxidase: Activity, swelling, and permeability studies. Control of insulin permeation through a polymer membrane with responsive function for glucose. Novel oral microspheres of insulin with protease inhibitor protecting from enzymatic degradation. Pelleted bioadhesive polymeric nanopar- ticles for buccal delivery of insulin: Preparation and characterization. Preparation of stable insulin-loaded nanospheres of poly(ethylene glycol) macromers and N-isopropyl acrylamide. Bioadhesive polysaccharide in protein delivery system: Chi- tosan nanoparticles improve the intestinal absorption of insulin in vivo. Preparation and characterization of nanoparticles shelled with chitosan for oral insulin delivery. Development and characterization of new insulin containing polysaccharide nanoparticles. Cyclodextrin-insulin complex encapsulated polymethacrylic acid based nanoparticles for oral insulin delivery. Oral and subcutaneous absorption of insulin poly(isobutylcyanoacrylate) nanoparticles. Vesicles from pluronic/poly(lactic acid) block copolymers as new carriers for oral insulin delivery. Poly(dl-lactide-co-glycolide) nanoparticle-based inhalable sustained drug delivery system for experimental tuberculosis. Self-assembled carbohydrate-stabilized ceramic nanopar- ticles for the parenteral delivery of insulin. Prolonged hypoglycemic effect of insulin-loaded polybutyl- cyanoacrylate nanoparticles after pulmonary administration to normal rats. Absorption of peptides and proteins from the respiratory tract and the potential for development of locally administered vaccine. Effective insulin delivery using starch nanopar- ticles as a potential trans-nasal mucoadhesive carrier.
Furthermore januvia 100mg sale, vaginal administration of micronized progesterone has been shown to enhance progesterone delivery to the uterus by about 10-fold in comparison to im injection discount januvia 100mg without prescription, despite the markedly higher (about 7- fold) circulating drug concentration achieved with im injection. Uterine selectivity after vaginal 288 administration has further been observed for both danazol and the β-agonist terbutaline and the vaginal-to- uterine delivery of misoprostol is currently being investigated for the reliable termination of early pregnancy (see below). Hence considerable evidence has accumulated demonstrating that the vaginal route permits targeted drug delivery to the uterus. This phenomenon opens new therapeutic options for the administration of compounds whose primary site of action is the uterus, thereby maximizing the desired effects, while minimizing the potential for adverse systemic effects. The retrieval system comprises a Dacron polyester net which proximally surrounds the insert and has a long ribbon end. The insert is placed in the posterior fornix of the vagina; insertion is performed digitally, thereby obviating the need for speculum examination. The system is effective in producing cervical ripening at term by releasing a small amount of the drug over a prolonged period. Furthermore, the system allows the obstetrician to control the dose administered and to terminate drug delivery by removal of the device, if uterine hyperstimulation or abnormal fetal heart rate changes should occur during the ripening process. Thus the system offers particular advantages in cases where there is concern about fetal condition or a risk of uterine over-activity. Misoprostol The most widely used medical method of terminating second-trimester pregnancy for fetal malformations or previous fetal death is the intravaginal use of prostaglandins; in particular, clinical interest is growing in the use of a synthetic prostaglandin E1 analog, misoprostol. The bioavailability of vaginally administered misoprostol is 3 times higher than that of orally administered misoprostol, which may explain why intravaginal misoprostol has been reported to be more effective than oral misoprostol for medical abortion. Recently, there has been renewed interest in the possibility of delivering therapeutic peptides and proteins via the vaginal epithelium. However, in this investigation, the analog was applied selectively at the early and mid-follicular phases, when the vaginal epithelium is thick and cohesive; greater bioavailability is to be expected during the luteal phase of the cycle, when the epithelium is porous and thin. The uptake of leuprorelin via a variety of routes (iv, sc, rectal, nasal, oral, and vaginal) has been compared in diestrous rats. Insulin Rapid dose-related changes in the plasma glucose and insulin levels have been demonstrated in alloxan- induced diabetic rats and rabbits, after vaginal administration of insulin suspended in a poly(acrylate) aqueous gel (0. However, the hypoglycemic effect was less than that achieved using the rectal route in the same base, or using the ip route. Penetration enhancers may be used to promote peptide absorption across the vaginal epithelium. However, less extensive investigations on the use of penetration enhancers for the vaginal route have been carried out in comparison to other routes, such as intranasal and transdermal (see Sections 9. The mechanism of enhancement of vaginal absorption of peptides by organic acids has been attributed to their acidifying and chelating abilities. In the case of the peptide leuprorelin, it seems that the effect of lowering the pH causes self-association or conformational changes of the peptide resulting in changes in the charge of leuprorelin and the epithelial surface. Removal of Ca2+ from the tight junctions of the epithelial cells by the chelators results in opening of the junctions, thereby creating a leaky epithelium and enhancing drug delivery via the paracellular route. The chelating effects are reversible, for example changes in the vaginal epithelium produced by citric acid were rapidly reversed after the epithelium was washed with physiological saline solution. Cyclodextrins can be used to solubilize drugs and thus potentially increase the concentration gradient driving passive diffusion across membranes. New research suggests that their enhancing effect may also be partly due to the removal of fatty acids, such as palmitic and oleic acids, which are minor membrane components. Toxic effects A major disadvantage associated with the use of penetration enhancers is their potential deleterious effect on the epithelial tissue. The damaging effects of various absorption enhancers have been investigated in vaginal absorption studies of gentamicin using ovariectomized rats. It was found that the penetration enhancers laureth-9 and lysophosphatidylcholine caused severe desquamation of the epithelium, whereas citric acid and palmitoylcarnitine were able to enhance absorption while causing only minor epithelial damage. The vaginal absorption of insulin was studied in ovariectomized rats and in the absence of any enhancer, no decrease in blood glucose was observed. Co-administration of various absorption enhancers was able to significantly increase the degree of hypoglycemia. The histological changes in the vaginal epithelium after treatment with the enhancer systems were variable and often severe: • palmitoylcarnitine chloride exhibited the greatest local toxicity including reduction of epithelial thickness and cell death. However, no conclusions can be drawn at this stage about the likely tolerability, safety and efficacy of the gel in the context of sexual intercourse. Antiviral vaginal devices Nonoxynol-9 is an approved spermicide with strong antiviral activity. The device, available as a diaphragm or a disk pessary, is fabricated from silicone elastomer matrix system. The drug release profile demonstrates square root time kinetics (M ∞ t / ) (see1 2 Section 4. While the spermicide-containing reusable diaphragms currently on the market are relatively effective when used in combination with a spermicidal formulation, they require careful fitting, insertion and maintenance. Moreover, adverse reactions, such as urinary tract infections, alterations in vaginal flora and occurrence of toxic shock syndrome, have been associated with their use. In contrast the silicone-based device described above has been reported to be stable, non-irritating and non-toxic. A vaginal sponge has also been recently developed comprising a soft poly(urethane) sponge impregnated with a gel containing 1% benzalkonium chloride, 0. The sponge therefore combines the actions of: • a physical barrier that blocks the cervix; • a material that absorbs the ejaculate; • a spermicide; • an antiviral agent. Antiviral liposomal preparations Intramuscular injection of α interferon was shown to be fairly efficacious in the treatment of genital warts; however, this route was associated with a number of side-effects including fever, myalgia, headache, nausea and fatigue. A liposomal preparation of α interferon for topical vaginal delivery has been developed, which offers the advantage of treating latent human papillomavirus infections as well as visible genital warts. The liposomal preparation can be self-administered intravaginally, without the need for multiple painful local, or im, injections. In the vagina, mucosal immune responses are initiated by the uptake of antigens from the vaginal surfaces (Figure 11. Whereas the gastrointestinal tract has identifiable aggregates of lymphoid tissue within the epithelium known as the Peyer’s patches (see Section 6. Antigen-specific effector lymphocytes (B cells and T cells) migrate through the lymphatics and exit via the thoracic duct into the bloodstream. The primed B and T cells home to various mucosal sites including the genital mucosa, where they undergo maturation and secretion. A vaginal vaccine has been developed for the treatment of recurrent urinary tract infections. The multi- strain vaccine, composed of 10 heat-killed bacterial uropathogenic strains, has been shown to be efficacious against cystitis in non-human primates when administered by the vaginal route. Bladder infections were significantly reduced and both systemic and local immune responses were generated. It was determined that vaginal immunization resulted in two different types of immune responses in mice: high and low. High responders to the immunizations had been immunized in the diestrous phase of the cycle. As explained above, the vaginal epithelium is thin and porous during this phase, which facilitates vaccine uptake. Similarly, rectal immunization induced high levels of specific IgA and IgG in rectal secretions, but not in female genital tract secretions. Thus, generation of optimal immune responses to sexually transmitted organisms in both the rectal and the genital mucosa of women may require local immunization at both of these sites. Association of an antigen with an appropriate microparticulate carrier may enhance antigen uptake by vaginal antigen-presenting cells. The effect was further enhanced when the penetration enhancer lysophosphatidylcholine was used. Hyaluronan ester microspheres Hyaluronan is a naturally occurring mucopolysaccharide, consisting of repeating disaccharide units of D- glucuronic acid and N-acetyl-D-glucosamine. By esterification of the carboxyl groups of the glucuronic acid residue with alcohols, modified biopolymers can be produced which are biocompatible, mucoadhesive and biodegradable. The degradation rate can be controlled by the degree of esterification and by the type of alcohol substituent. Experiments using radio-labeled microspheres have shown that after vaginal administration the microspheres are dispersed along the length of the vagina for prolonged periods, thereby demonstrating their potential as a long-acting intravaginal delivery system.
Of two studies varying the personal commitment factor cheap januvia 100 mg free shipping, one by Deutsch and Gerard (35) introduced three variations buy januvia 100 mg with mastercard. The highest frequency of shifting occurred when recording was not required, with lowest frequencies resulting when the responses were recorded, personally signed, and given to the experimenter. Fisher, Rubinstein, and Freeman (43) used a tachistoscopic presentation for the task of indicating the number of dots exposed on a trial-by-trial basis. The conditions were: first, judging without partners; second, judging only after the partner; third and fourth, judging both prior to and following the partner. Although subjects did not shift significantly for any one trial, judgments given prior to the confederate steadily increased. An individual who makes a definite commitment prior to being subjected to pressures resists and maintains his position more strongly. The degree of public commitment is positively related to the degree of resistance to influence. Variations in relations among members that have been studied are perceived independence on a partner to attain a goal, and perceived success jointly with the partner in working toward a goal. Approximately half the subjects in the study by Bovard (22) participated in "leadercentered" classes, i. Individual judgments showed significant convergence toward the announced group norm in all groups. Both the dispersion of initial judgments and degree of convergence after the announced group norm and during the last week of the course were significantly greater for group-centered classes. Maier and Solem (94) arranged for half the groups to have leaders instructed to encourage member participation, and the other half, observers free -241- to participate only in member roles. After an eight-minute discussion of the Maier Horse Trading Problem, groups with leaders significantly increased their per cent of correct answers. Preston and Heintz (108) had students first give individual rankings of the names of twelve prominent men for their desirability as President of the United States; next, a group ranking of the twelve names in four- to five-person groups having either participatory or supervisory leaders; and a final individual ranking. Final individual rankings of participatory leaders and followers correlated significantly higher with the group rankings. There also was more shifting from initial to final rankings for those working under participatory leaders. Hare (56) replicated the experiment by Preston and Heintz (108), and reports similar findings. Berkowitz (12) had partners send and decode messages transmitted by telegraph keys to each other. Subjects who believed they would gain a prize worked fastest on improvement trials; those who believed only their partners would gain a prize worked faster than subjects who knew nothing of the prize. Facilitation from perceived dependency on another for attaining a goal constitutes a significant influence factor. Kidd and Campbell (77) varied reported success of the group on a preliminary anagram task. Members who had had prior experience of success with one another conformed to a significantly greater degree to the attributed group norm for a later task. This may be because individual differences become more evident and greater possibilities exist for the exertion of pressure. Findings also indicate that greater pressure exists when one member recognizes that another member is dependent on his performance for success, and that greater susceptibility occurs among members who have shared success. Cohesion and Valuation of Group Membership Cohesion is a variable in the group situation. Both subjects wrote a story about three sets of pictures, differing primarily in details, and then discussed them with each other. Festinger, Gerard, Hymovitch, Kelley, and Raven (40) report similar findings, as does Berkowitz (13). Schchater, Ellertson, McBride, and Gregory (116) created high and low cohesion among undergraduate women subjects in three person groups. During interaction each subject worked alone, but communicated with fictitious other persons through a series of notes controlled by an experimenter. Positive influence induction consisted of notes encouraging increased production for half of the subjects under each condition, and negative influence for the other half. Under negative influence, high cohesion subjects significantly decreased their productivity; the low cohesion group showed no changes. In a study of children by Grossner, Polansky, and Lippitt (53), the collaborator was friendly with half the subjects and encouraged their working together; with the other half, he acted withdrawn and worked separately. The critical subject more frequently chose the same toy as the friendly collaborator. High cohesion subjects shifted their opinions toward the group recommendation significantly more than those under the low cohesion condition. In the study by Dittes and Kelley (37), group members were given false ratings of the degree to which others present liked them and wished them to remain in the discussion. Those in the very low acceptance group, who had the lowest index of private conformity, showed the highest degree of public conformity. Those participating under average attraction conditions exhibited the greatest degree of shifting toward the group view, indicating a consistency in private conviction and public expression. The finding implies that the person of indeterminate or average acceptance is probably least secure and most susceptible. Jackson and Saltzstein (68) varied both the congeniality dimension and experimentally induced acceptance and rejection. The four conditions were: (a) psychological membership, in which the member felt highly accepted and the group held high attraction for him; (b) psychological nonmembership, in which the person had low -243- acceptance and the group was not attractive to him; (c) preference group membership, in which the person had low acceptance by the group but high attraction to it; and (d) a marginal group relationship characterized by high acceptance and low attraction. Subjects worked in four- or five-man groups under two different orientations to the task: a normative condition, competing with other groups, and modal conditions, in which they were compared as individuals. Conformity was greater in the normative than in the modal situation and in the high attraction than in the low attraction situation. However, conformity for the low attraction condition was uniformly higher than had been predicted. The combination of telling subjects that their performance was inferior and that they were least accepted apparently led to feelings of rejection and anxiety and to higher conformity. In the study by Kelley and Shapiro (74), the hypothesis that more highly accepted members would conform less because the wrong answer would be detrimental to attaining the group goal was not confirmed. Thibaut and Strickland (127) varied pressure by high, moderate, or low confidence expressed by others in the subjects working under either the set to solve the problem or the set to maintain group membership. Under group membership orientation, conformity increased as other members, by ballots, showed increased confidence in the judgments of subjects. The study demonstrates the greater susceptibility of individuals motivated to maintain group membership. Each of the studies agrees in showing that subjects in high cohesion groups are more susceptible to conformity pressures. Pressures toward Uniformity The effect of increasing pressures toward uniformity has been investigated in several studies. Festinger and Thibaut (41) found a significant increase in shifting as pressure toward uniformity increased (see above). Jones, Wells, and Torrey (71) found that correct feedback was more significant in increasing independence than incorrect feedback in increasing conformity. A second study, in which subjects were told they would participate in later sessions with the same group members and be evaluated by them, revealed an increased amount of conformity. A significantly greater change from pre- to postdiscussion occurred for the high pressure condition, but only for subjects participating also under attributed homogeneity. Festinger, Gerard, Hymovitch, Kelley, and Raven (40) found that significantly more shifting occurred among groups told there was a "correct" answer (see above). Brehm and Festinger (24) tested and confirmed the hypothesis that greater pressures toward uniformity occur when the task is described as important. Blake, Mouton, and Olmstead (20) emphasized the importance of accuracy, and implied team penalties for mistakes by individuals on a metionome-counting task. Accuracy requirements reinforced by fear of penalty increase the readiness of individuals to shift their opinions. Increases in pressures toward uniformity have been shown to be related positively to increases in frequency of conformity behavior. Emphasis on rewards for successful performance and the importance of accuracy or penalties for mistakes also have been found to be related to susceptibility. Psychologic and Physiologic Properties of the Person Personal characteristics of the subject may be psychologic, physiologic, or differing amounts or types of prior experience. Experimentally Created Differential Experience in Subjects Individual differences have been created experimentally by different amounts of familiarity with the task, prior experiences of success or failure, differences in anxiety and insecurity, variations in properties of the prior task, and pretraining with reward.
The protein concen- 19 under debate discount januvia 100 mg online, studies in different intracellular pathogens tration was determined using the Folin procedure cheap 100 mg januvia otc. To have shown that antibodies can also have a function in eliminate endotoxins, the recombinant protein was passed restricting the infection when the parasite is exposed to through an EndoTrapÒred column (Profos, Germany) 10 the extracellular milieu. Two weeks two other related protein sequences can be found in after ﬁnal immunization, spleens and sera were collected. Laborchnik, Solingen, Germany) were coated overnight at 4° with one of the following reagents in 0Á01 M carbonate/ bicarbonate buffer pH 8Á5: unlabelled goat anti-mouse Spleen B-cell isolation immunoglobulin (5 lg/ml), total L. The concentration of non-speciﬁc antibody was determined by comparison to a standard curve generated Flow cytometry determinations with unlabelled puriﬁed isotypes. In previous studies we have examined the antibody response during human and canine L. The 20 data represent the mean and the standard deviations of three animals analysed individually and are representative of two independent 10 experiments. The results are from a representative experiment of three car- of spleen cells is much greater than that of B cells, we can ried out independently. The myosin) or another recombinant Leishmania ribosomal data represent the mean and the standard deviations of three animals protein namely LmS3a. However, very low reactivity was analysed individually and are representative of two independent observed when using L. The data shown in Table 1 demonstrated response with speciﬁc antibodies secretion. Several experiments demon- As shown in Table 2, the percentage of killing of amasti- strated that the B lymphocytes were responding directly Ó 2006 Blackwell Publishing Ltd, Immunology, 119, 529–540 535 R. Thus, these responses might be dependent on differentiation-inducing % Lysis at a dilution 28 a factors produced by antigen non-speciﬁc cells. Thus, the amastigotes were incubated with indicated sera samples (1 : 10 crude extracts of L. The asterisk indicates a statistically signiﬁcant difference (*P<0Á01) in comparison with the values cause strong in vitro polyclonal activation of hamster 7 obtained using normal serum. Moreover, an excreted factor derived from experiment of three carried out independently. How- S3a named LmS3a exhibiting dual activity being stimula- 33 ever, the classic division of antigens in these two categor- tory and inhibitory towards T and B cells, respectively. In fact, previous studies in hepatitis B The investigations on the immunogenicity of LmS3a and vesicle stomatites virus have already reported the have revealed that in vivo, a single injection of the existence of antigens that can induce B-cell activation and recombinant protein without any adjuvant into mice proliferation through both T-dependent and -independent induced a quick increase in the number of B cells and 25,26 mechanisms. However, other possible interpretations the production of high levels of immunoglobulins, can be made. The IgM response was mostly petent mice, after activating the B cells, some T-inde- unrelated to the antigens present in the total parasite pendent antigens require a ‘second signal’ in order to extracts or to the protein itself. However, so far the support for Indeed, although the protein triggered B-cell differenti- the ‘second signal hypothesis’ has been elusive. This may ation, the antibodies produced reacted speciﬁcally against Ó 2006 Blackwell Publishing Ltd, Immunology, 119, 529–540 537 R. Reconstitu- mediated killing of amastigotes and inhibition of their tion of the B cell-mutant with the immune anti-Leishma- multiplication inside macrophages. Indirect immunoﬂuo- nia serum increased the pathological processes in the rescence assays of L. To our knowledge, this report is cess of the amastigote and/or further multiplication of the the ﬁrst description of a protein belonging to this large parasite. Indeed, metacylic promastigotes and trigger preferentially B-cell effector functions. The high amastigotes are relatively resistant to direct serum kill- degree of homology within this family of proteins, and 40 49 ing. However, previous studies have shown that anti- the fact that homologues have been found in mouse 50 bodies that were able to bind to living parasites and lyse and human has led us to perform additional experi- them in conjunction with complement were associated ments in order to verify the possibility of the existence of 20 with host protection. In fact, by using B cell-mutant mice and restrain the capacity of the parasites to infect macro- genetically modiﬁed mice lacking circulating antibodies phages. New perspectives on a subclinical a 43 kDa antigen related to silent information regulatory-2 pro- form of visceral leishmaniasis. Infect Immun nity in American visceral leishmaniasis: reversible immuno- 1989; 57:2372–7. Mol Bio- ting immune complexes and autoimmunity in American visceral chem Parasitol 2000; 110:195–206. 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