Translational and Regulatory Challenges for Exon Skipping Therapies

Several translational challenges are currently impeding the therapeutic development of antisense-mediated exon skipping approaches for rare diseases. Some of these are inherent to developing therapies for rare diseases, such as small patient numbers and limited information on natural history and interpretation of appropriate clinical outcome measures. Others are inherent to the antisense oligonucleotide (AON)-mediated exon skipping approach, which employs small modified DNA or RNA molecules to manipulate the splicing process. This is a new approach and only limited information is available on long-term safety and toxicity for most AON chemistries. Furthermore, AONs often act in a mutation-specific manner, in which case multiple AONs have to be developed for a single disease. A workshop focusing on preclinical development, trial design, outcome measures, and different forms of marketing authorization was organized by the regulatory models and biochemical outcome measures working groups of Cooperation of Science and Technology Action: "Networking towards clinical application of antisense-mediated exon skipping for rare diseases." The workshop included participants from patient organizations, academia, and members of staff from the European Medicine Agency and Medicine Evaluation Board (the Netherlands). This statement article contains the key outcomes of this meeting.status: publishe

Tracheotomy does not affect reducing sedation requirements of patients in intensive care – a retrospective study

INTRODUCTION: Translaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients. METHODS: We performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy. RESULTS: Of 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 ± 0.93 DD/MDD versus 0.30 ± 0.65 for morphine, 0.84 ± 1.03 versus 0.11 ± 0.46 for midazolam, and 0.62 ± 1.05 versus 0.15 ± 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups. CONCLUSION: In our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed

Typha latifolia paludiculture effectively improves water quality and reduces greenhouse gas emissions in rewetted peatlands

Paludiculture, the cultivation of crops on wet or rewetted agricultural peatlands, sustainably integrates productive land use with the provision of multiple ecosystem services. Paludiculture crops thrive under waterlogged conditions that stimulate nitrogen (N) and phosphorus (P) removal from soil and water and convert serious drainage-induced carbon (C) losses to C sequestration. Nutrient uptake by paludicrops can prevent mobilisation after rewetting and provide opportunities for purification of nutrient-rich water. Uncertainty remains, however, if and to what extent N loading and a subsequent increase in biomass productivity affect nutrient cycling as well as emissions of the potent greenhouse gases methane (CH4) and nitrous oxide (N2O). In this study, we use mesocosms with rewetted peat to investigate the effect of different N sources in surface water on biomass production of Typha latifolia, a typical paludiculture crop, and the emissions of CH4 and N2O. Organic (Azolla filiculoides; urea) or mineral (KNO3 ; NH4NO) N was supplied either a single time (steady state) or repeatedly (pulse) to simulate a total surface water load of 150 kg N ha(-1) . We found that N stimulated aboveground and belowground biomass production and nutrient uptake by T. latifolia. These effects were absent in Azolla treatments. Whereas after two months CH4 emissions arose to substantial amounts (> 10 mg CH4 m(-2) day(-1)) in unvegetated mesocosms loaded with organic N, they remained very low (<1 mg CH4 m(-2) day(-1)) in vegetated mesocosms, despite the labile C pool in the extensive belowground biomass and organic N loading. Overall, N2O emissions were close to zero and were only detected episodically after NO(3)(- )loading, irrespective of plant presence. Our findings support that T. latifolia as a paludicrop effectively removes various forms of N and P when harvested, and strongly mitigates CH4 emission after the rewetting of agricultural peat soils compared to unvegetated conditions

Advancing Administrative Supports for Research Development

Research intensive universities have raised the bar for all academic units, expecting them to increase research grants and contracts to support knowledge creation and scholarship. Similarly, performance requirements for faculty have changed, with annual reviews and tenure and promotion decisions weighting obtaining grants along with publication of scholarly products, teaching effectiveness, and service to the school, university and community. These expectations compel Deans and Directors of schools of social work to undertake new roles related to research development and administrative capacity building in order to help faculty and their units succeed. Social work schools and departments must stay or become strategically positioned in their university or college, even as the context for research development has been dramatically altered as colleges and universities invest in the nanosciences or bio- technology rather than the social sciences. A $4 billion nanoscience operation dwarfs the$20 million that a robust research enterprise that a few schools of social work enjoy. This paper highlights some of the opportunities, barriers, challenges, as well as stepping stones to success in the process of building research supports and infrastructures. Drawing upon presentations at recent meetings of the National Association of Deans and Directors of Schools of Social Work (NADD) that have been organized by the Institute of Social Work Research (IASWR), we feature several examples of approaches advancing supports for research development. Brief scenarios illustrating efforts underway at several schools depict challenging and often rewarding research capacity building endeavors. This paper presents the perspective of several Deans and Directors in the development of administrative research supports. The paper also features one model for a supportive research administration structure in the pre- and post-award environment

Non-nucleoside reverse transcriptase inhibitor-based combination antiretroviral therapy is associated with lower cell-associated hiv rna and dna levels as compared with therapy based on protease inhibitors

BACKGROUND: It remains unclear whether combination antiretroviral therapy (ART) regimens differ in their ability to fully suppress HIV replication. Here, we report the results of two crosssectional studies that compared levels of cell-associated (CA) HIV markers between individuals receiving suppressive ART containing either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). METHODS: CA HIV unspliced RNA and total HIV DNA were quantified in two cohorts (n=100, n=124) of individuals treated with triple ART regimens consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) plus either a NNRTI or a PI. To compare CA HIV RNA and DNA levels between the regimens, we built multivariable models adjusting for age, gender, current and nadir CD4+ count, plasma viral load zenith, duration of virological suppression, NRTI backbone composition, low-level plasma HIV RNA detectability, and electronically-measured adherence to ART. RESULTS: In both cohorts, levels of CA HIV RNA and DNA strongly correlated (rho=0.70 and rho=0.54) and both markers were lower in NNRTI-treated than in PI-treated individuals. In the multivariable analysis, CA RNA in both cohorts remained significantly reduced in NNRTI-treated individuals (padj=0.02 in both cohorts), with a similar but weaker association between the ART regimen and total HIV DNA (padj=0.048 and padj=0.10). No differences in CA HIV RNA or DNA levels were observed between individual NNRTIs or individual PIs, but CA HIV RNA was lower in individuals treated with either nevirapine or efavirenz, compared to PI-treated individuals CONCLUSIONS: All current classes of antiretroviral drugs only prevent infection of new cells but do not inhibit HIV RNA transcription in long-lived reservoir cells. Therefore, these differences in CA HIV RNA and DNA levels by treatment regimen suggest that NNRTIs are more potent in suppressing HIV residual replication than PIs, which may result in a smaller viral reservoir size

Guidance in social and ethical issues related to clinical, diagnostic care and novel therapies for hereditary neuromuscular rare diseases: "translating" the translational.

Drug trials in children engage with many ethical issues, from drug-related safety concerns to communication with patients and parents, and recruitment and informed consent procedures. This paper addresses the field of neuromuscular disorders where the possibility of genetic, mutation-specific treatments, has added new complexity. Not only must trial design address issues of equity of access, but researchers must also think through the implications of adopting a personalised medicine approach, which requires a precise molecular diagnosis, in addition to other implications of developing orphan drugs. It is against this background of change and complexity that the Project Ethics Council (PEC) was established within the TREAT-NMD EU Network of Excellence. The PEC is a high level advisory group that draws upon the expertise of its interdisciplinary membership which includes clinicians, lawyers, scientists, parents, representatives of patient organisations, social scientists and ethicists. In this paper we describe the establishment and terms of reference of the PEC, give an indication of the range and depth of its work and provide some analysis of the kinds of complex questions encountered. The paper describes how the PEC has responded to substantive ethical issues raised within the TREAT-NMD consortium and how it has provided a wider resource for any concerned parent, patient, or clinician to ask a question of ethical concern. Issues raised range from science related ethical issues, issues related to hereditary neuromuscular diseases and the new therapeutic approaches and questions concerning patients rights in the context of patient registries and bio-banks. We conclude by recommending the PEC as a model for similar research contexts in rare diseases

Non-nucleoside reverse transcriptase inhibitor-based combination antiretroviral therapy is associated with lower cell-associated HIV RNA and DNA levels compared to protease inhibitor-based therapy

Background: It remains unclear whether combination antiretroviral therapy (ART) regimens differ in their ability to fully suppress human immunodeficiency virus (HIV) replication. Here, we report the results of two cross-sectional studies that compared levels of cell-associated (CA) HIV markers between individuals receiving suppressive ART containing either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). Methods: CA HIV unspliced RNA and total HIV DNA were quantified in two cohorts (n = 100, n = 124) of individuals treated with triple ART regimens consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) plus either an NNRTI or a PI. To compare CA HIV RNA and DNA levels between the regimens, we built multivariable models adjusting for age, gender, current and nadir CD4+ count, plasma viral load zenith, duration of virological suppression, NRTI backbone composition, low-level plasma HIV RNA detectability, and electronically measured adherence to ART. Results: In both cohorts, levels of CA HIV RNA and DNA strongly correlated (rho = 0.70 and rho = 0.54) and both markers were lower in NNRTI-treated than in PI-treated individuals. In the multivariable analysis, CA RNA in both cohorts remained significantly reduced in NNRTI-treated individuals (padj = 0.02 in both cohorts), with a similar but weaker association between the ART regimen and total HIV DNA (padj = 0.048 and padj = 0.10). No differences in CA HIV RNA or DNA levels were observed between individual NNRTIs or individual PIs, but CA HIV RNA was lower in individuals treated with either nevirapine or efavirenz, compared to PI-treated individuals. Conclusions: All current classes of antiretroviral drugs only prevent infection of new cells but do not inhibit HIV RNA transcription in long-lived reservoir cells. Therefore, these differences in CA HIV RNA and DNA levels by treatment regimen suggest that NNRTIs are more potent in suppressing HIV residual replication than PIs, which may result in a smaller viral reservoir size

Nose to Tail: Using the Whole Employment Relationship to Link Worker Participation to Operational Performance

Although many employers continue to adopt various forms of worker participation or employee involvement, expected positive gains often fail to materialize. One explanation for the weak or altogether missing performance effects is that researchers rely on frameworks that focus almost exclusively on contingencies related to the workers themselves or to the set of tasks subject to participatory processes. This study is premised on the notion that a broader examination of the employment relationship within which a worker participation program is embedded reveals a wider array of factors impinging upon its success. I integrate labor relations theory into existing insights from the strategic human resource management literature to advance an alternative framework that additionally accounts for structures and processes above the workplace level — namely, the (potentially implicit) contract linking employees to the organization and the business strategies enacted by the latter. The resulting propositions suggest that the performance-enhancing impact of worker participation hinges on the presence of participatory or participation-supporting structures at all three levels of the employment relationship. I conclude with implications for participation research