Protein therapeutics are available as cytokines, clotting factors, enzymes, hormones, growth factors, antibodies et al. They have been shown to be effective in treating a variety of important human diseases. Since human insulin was approved as the first recombinant protein therapeutic, this field has experienced rapid growth. One of the biggest challenges for protein therapeutics in clinical application is their short half-life. Except for monoclonal antibodies, which have serum half-life for weeks, most of the protein therapeutics have half-lives ranging from minutes to hours. Kidney filtration, proteasome degradation and liver metabolism are the main factors that attribute to their short half-lives. The short half-life of protein therapeutics requires a higher dose or frequent application to maintain therapeutic concentration over a certain period. However, higher dose is easy to cause large plasma concentration fluctuation, which is easy to cause side effects. Most of protein therapeutics are not orally bioavailable. Frequent application will increase the burden of patients, affect their life quality, and reduce patient compliance. Thus, it is important to generate long-lasting therapeutics with improved pharmacokinetic properties. The current half-life extension approaches for protein therapeutics include PEGylation, albumin fusion or binding and fusion to an immunoglobulin Fc region. Their primary aim is to increase the size of biotherapeutics or to implement recycling by the neonatal Fc receptor (FcRn). However, the half-life extension by PEGylation, albumin fusion or Fc fusion is at the cost of binding affinity reduction. And the increase of size has limited their application in the field of anticancer agents where tumor penetration is required. Noncovalent albumin binding using albumin binding ligands such as fatty acids could maintain the small size and binding affinity. However, it would increase hydrophobicity, therefore is not suitable for protein therapeutics with low solubility. Here, we present a new approach for half-life extension for biotherapeutics. Human interleukin 2 (IL-2), a low solubility cytokine, was used as a model protein. By conjugating IL-2 with a hydrophilic small molecule that binds reversibly to the serum protein transthyretin, we enhanced its circulation half-life in rodents while maintained its in vitro bioactivity. To the best of our knowledge, this is the first demonstration of a successful approach that harnesses a small molecule in extending the circulation half-life of a protein while at the same time maintains the small size and hydrophilicity.

This study aimed to investigate the drug-polymer interactions between simvastatin (SIM) and three polymers [PVP-VA, HPMC-AS, and Soluplus® (SOL)] in amorphous solid dispersions (ASDs) prepared by hot melt extrusion (HME), and to understand the implications on physical stability. ASDs are of significant interest within the pharmaceutical industry for improving drug bioavailability. However, the amorphous nature of a drug in an ASD presents physical stability challenges. Utilizing novel applications of accessible tools such as ATR-FTIR or DSC aid in understanding the mechanisms of stabilization which are critical to the rational design of ASDs. ASDs were prepared using HME and were characterized using mDSC, ATR-FTIR, TGA, PXRD, PLM, and UPLC. Mathematical processing of ATR-FTIR spectra and Pearson coefficient analysis was used to quantitatively determine the degree of intermolecular bonds between SIM and each polymer. Results were verified using experimental and theoretical approaches such as mDSC and Flory-Huggins Theory. Formulations were stored at 50°C/96%RH, and physical stability was monitored using PXRD, PLM, and mDSC. Pearson coefficient analysis of ATR-FTIR data showed that SIM exhibited a higher degree of interactions with PVP-VA and SOL relative to HPMC-AS. Experimental observations and theoretical calculations of SIM miscibility and solubility in the polymers were used as an indicator of intermolecular interactions, and both were consistent with this ranking of drug-polymer interactions. Stability assessments at 50°C/96%RH demonstrated SIM crystallization in all PVP-VA ASDs and in high SIM load HPMC-AS ASDs, while no crystallization was observed in SOL ASDs. This demonstrated that although the degree of interactions between SIM and PVP-VA were the strongest, the extent of interactions between water and PVP-VA may also play a critical role in the ASD physical stabilization. In addition, although SIM/SOL systems were the lowest overall in glass transition temperature and may perhaps have the highest degree of molecular mobility, the interactions between SOL and SIM were sufficient to inhibit crystallization. These findings highlight the utility of applying Pearson coefficient analysis to accessible tools such as ATR-FTIR on the understanding of drug-polymer interactions in ASDs. While drug-polymer interactions are a significant factor in maintaining SIM’s amorphous nature, other mechanisms of physical stabilization need to be considered in the rational design of ASDs.

As we have been actively involved in various teaching programmes for many years, we wanted to enquire how the students and teachers understood their school and compare it to how we experienced it.  Do the students fully understand the knowledge they are receiving and can they learn from it? Do the teachers believe what they are teaching is understood by the students? What is the underlining knowledge of social practices in the school, which can inspire students in different ways? The aim of the study, as the title suggests, is to convey and describe the various methods practiced in a specific social practice. Our project is a quality study.  We have used observation, specific intense individual and group interviews. In the result, arrives a different message through what there is possible for the students to learn about the matter. These messages are visible in the different attitudes the teacher, the school and the organisation have vis-à-vis the matter. In the discussion, we have focussed on what has arrived in the result around the teacher's and the organisation's attitudes. How can these attitudes influence the students' attitude to the matter and how will one work in order to become aware about the messages that are sent.

Background: Clinical trials represent a significant percentage of the time and cost to bring a drug through the development process and to Food and Drug Administration approval. Despite how critical these trials are to the drug development process, many studies are underpowered due to low accrual. This translates to valuable questions regarding the safety and effectiveness of new agents being left unanswered, requiring additional time and studies. A call for reform of the industry has been made by stakeholders in the clinical research enterprise; however, national change is slow. Thus sites that conduct clinical research must find methods to increase efficiency within the burdensome system currently in place. Throughout cancer centers adhering to the National Cancer Institute (NCI) Cancer Center Support Grant guidelines, efficiencies have been explored individually; however, there is a gap in knowledge on what factors affect sites system-wide. This dissertation seeks to examine factors that affect clinical trial efficiency in the areas of study activation looking at the outcome of local clinical trial accrual. Methods: Protocol and site-specific clinical trial administration data was collected regarding closed, interventional treatment and supportive care clinical trials from cancer centers adhering to NCI Cancer Center Support Grant guidelines during a five-year time period (2009-2014). Study characteristic analyses and hierarchical regression modeling was used to explore the effect of feasibility committee use and protocol workload on the outcomes of clinical trial accrual and time to activate a clinical trial. Sensitivity analyses were utilized when considering protocol workload to account for studies that had not yet closed to accrual, and thus were not included in this dataset. In addition, protocol- and site-specific variables were used to build regression models used to predict clinical trial accrual. Sensitivity, specificity, and accuracy were compared to the current standard, the institutional disease team. Results: Sixteen centers contributed a total of 5,787 protocols (range 93-697 studies). These studies accrued 49,319 subjects. Of all studies, 1,053 (18%) accrued zero subjects. Disease teams predicted 221% of actual accrual. Seven institutions submitted protocol workload information for 2,133 studies (36.9%) and 14,229 accruals (28.9%). Controlling for effect modifiers and interactions, and adjusting for institution, a statistically significant increase in clinical trial accrual and decrease in activation time was seen with the use of a feasibility committee. Regulatory protocol workload was significantly associated with clinical trial accrual and activation time; however, a single, definitive protocol workload was not identified that both minimized activation time and maximized clinical trial accrual. Protocol workload most often maximized accrual at workloads of between 3.5 and 5.0 protocols per staff member/FTE and minimized activation time at workloads between 1.0 and 1.9 protocols per staff member/FTE. Regression models predicted accrual more accurately than disease teams at all 16 centers, with site-specific models consistently having the best performance (versus an adjusted, hierarchical model). Conclusion: Despite institutional differences in variable association with accrual and activation times, the utilization of a feasibility committee was shown to improve clinical trial accrual as well as decrease activation time. Using systematic methods for examining study activation and accrual efficiencies resulted in the development of models that predicted clinical trial accrual better than the current standard (disease team prediction) at all participating centers. Further research is needed to better define and determine optimal workload. This information and these models may better inform study planning and resource allocation decisions by local stakeholders (administrators and investigators) in the clinical research enterprise.

The purpose of this study was to design, develop, and administer an Objective, Structured Management Exam (OSME) on management skills for pharmacy students. Pharmacy preceptors for the University of Arizona College of Pharmacy participated in focus groups that identified business, management, and human resource skills needed by pharmacy graduates. Once the skills were identified, gaps were identified for inclusion into the OSMEs. The OSMEs evaluated pharmacy students' performance on four skills: 1) managerial communication (oral and written); 2) conflict resolution; 3) decision-making; and 4) professionalism. The OSME consisted of a role-playing and a writing document. Both were graded using a developed scoring rubric. The role-playing scoring rubric contained 17 skills and the written document scoring rubric contained 8 skills. During the OSME, students interacted with a trained actor and were graded by a judge on their performance. Upon completion of the OSME, students completed a 29-question survey on a) their perceived ability and confidence to accomplish 8 selected skills; b) their opinion about the OSME and suggestions to improve the process in the future; and c) their background characteristics. Many-facet Rasch analysis provided detailed information with which to evaluate content validity and student performance taking into account difficulty of skills, rating scale function of the scoring rubric, judge leniency and severity. Rasch analysis provided detailed information on the scale performance and student ability and confidence. A step-wise linear regression was used to determine if any student characteristics predicted a higher OSME performance score. Ninety-six student pharmacists completed the OSME and ninety-five students completed the questionnaire. No student failed the role-playing scenario and 1 student did not complete the written document. Significant gaps were calculated between the easiest two skills, empty sounds and eye contact. Additionally, the seventeen items did not align with student performance measures. Finally, there were two separate groups of graders. The writing document scoring rubric had poor fit with the model and significant gaps were calculated. Student measures did not adequately align with item difficulty measures. For students' perceived ability, there was no significant change in overall mean student ability scores from before the educational lectures to after the OSME. However, 46% of students (n=44) had a significant change in ability scores. Three significant gaps were calculated between skills a) between decision-making and communication and between communication and active listening on the pre-educational lectures; and b) between decision-making and communication on after the OSMEs. Students appeared confident with their ability on the 8 skills. The overall mean student confidence measure did not significantly change between the three time points: 1) before the practice cases; 2) after the practice cases; and 3) after the OSMEs. However, 46% of students (n=44) had a significant change in their confidence from before the practice cases to after the completion of the OSMEs. Item difficult measures did not appropriately align with student confidence measures, meaning the items were too easy for students. Significant gaps were also calculated: a) between the motivation and communication items and between the communication and active listening items in the before the practice cases responses; b) between the motivation and decision-making items and between the communication and active listening items for the after the practice cases responses; and c) between the motivation and decision-making items; between the decision-making and communication items; and between the communication and active listening items for after the OSME responses. Based on the result of the regression, three characteristics predicted a higher performance score on the role-playing portion of the OSME: 1) previous management experience; 2) previous leadership experience; and 3) the total grade on the educational lecture quizzes. Three characteristics predicted a higher writing document score: 1) age between 26 and 28 years; 2) English as the primary language; and 3) previous pharmacy experience classified as "other" (i.e., pharmacy experience that was not hospital, community, or managed care). This was one of the first studies to develop a role-playing exercise on management skills in pharmacy education. The grading rubrics provided an initial structure for assessing student performance on these management skills. Some changes to the ability questions and the rubrics are suggested in order to improve the content validity. The findings provide the outline for the use of an OSME at schools/colleges of pharmacy as part of their curriculum. As exposure to management scenarios showed higher performance, educators should include these skills in the education of student pharmacists in order to prepare them for a future career in pharmacy.

Background: Staphylococcus aureus is an aerobic, Gram positive commensal organism that is capable of causing a wide spectrum of disease. This study contributes to previously published literature regarding daptomycin versus vancomycin use in S. aureus bacteremia (SAB). Methods: Adult patients admitted between 2010 and 2014, billed for ICD-9 code V09.0, 038.11, 038.12, 041.11, or 041.12, and received vancomycin and daptomycin were included in this retrospective analysis. Patients were stratified by time to change in antibiotics from vancomycin to daptomycin to the early switch (1-3 days), intermediate switch (4-7 days), or late switch (8 days or later) group. The primary outcome was treatment failure defined as 30-day recurrence, 60-day all-cause mortality, and 90-day all-cause readmission. Results: 193 patients were enrolled in the final cohort. The overall treatment failure rate was 18% with no differences between early switch, intermediate switch, and late switch (P=0.72) groups. Independent predictors of treatment success were length of stay (OR=1.035) and time to positive culture (OR=0.961). Conclusions: Results of this study did not demonstrate a difference in treatment failure based on time to switch from vancomycin to daptomycin. Future research should focus on optimizing use of vancomycin and daptomycin and medical management of SAB.

A key cardiovascular signaling molecule involved in both physiologic and pathologic regulation of cardiomyocytes is the small molecular weight G-protein, Ras. Differential effects of Ras are mediated by multiple effector molecules, including the RalGEFs which activate Ral. Studies performed in cardiomyocytes have indicated a role for Ral in cardiac hypertrophic signaling and the RalGEF family member, Rgl2, was shown to specifically interact with Ras in the heart. Therefore, I hypothesized that Rgl2 was an important Ras effector that would regulate cardiomyocyte signaling. To elucidate the potential importance of Rgl2 in regulating cardiomyocyte signaling, a gain-of-function approach was utilized in which NRVMs were infected with an adenovirus to increase Rgl2 expression. Using this approach, I found that Rgl2 increased Ral-GTP levels, Ras-GTP levels, and PI3-kinase-Akt signaling, but decreased ERK phosphorylation. Overall, my results suggest a model in which Rgl2 disrupts Ras-Raf and Ras-RasGAP interaction to decrease ERK phosphorylation and increase Ras-GTP, respectively. Furthermore, Rgl2-induced Ral activation promotes the enhanced PI3- kinase-Akt signaling. The physiologic consequence of Rgl2 signaling is difficult to predict, but the increase in PI3-kinase-Akt signaling would be expected to promote cardiomyocyte survival and enhance cardiac function, both of which are characteristic of physiologic hypertrophy.

Blackberries are rich in polyphenols including anthocyanins. Polyphenols are hypothesized to have biological activities that impact positively on human health. The purpose of these studies was to develop phenolic extracts from selected cultivars of blackberries currently grown in Kentucky as potential Botanical Drug Products for the treatment and prevention of cancer and inflammatory diseases. An ultrasound-assisted ethanol extraction method was employed to obtain anthocyanin-containing extracts (ACEs) from puree or powder (lyophilized puree) of blackberries. ACEs were analyzed for total anthocyanin and phenolics content, polymeric color, and total antioxidant capacity (TAC). The influence of water content in the extraction system was evaluated. A 90 day stability study of the extract and a 48 h stability study of the extract in biologically relevant buffers were completed. HPLC-MS results showed the anthocyanins in ACE were mainly cyanidin-based. As compared to powder-derived ACEs, puree-derived ACEs contained similar amounts of anthocyanins, but greater levels of phenolics and increased TAC. The in vitro antiproliferative effects of ACEs were evaluated in human leukemia (HL- 60), colon (HT-29), and breast (MCF-7) cancer cells. The anticancer mechanism involving reactive oxygen species (ROS) generation was investigated. It was found puree-derived ACEs significantly enhanced production of H2O2 and cytotoxicity in all cell lines as compared to powder-derived ACEs. Cyanidin 3-glucoside exerted anticancer effect by acting synergistically or additively with other active components in the extracts. Furthermore, the phenolic-enriched fractions were separated from non-phenolic fractions in ACEs and found to have potent antioxidant and antiproliferative activities. Pureederived ACE and corresponding phenolic-enriched methanol fraction (MF) induced cell death through ROS-independent caspase 3 pathway whereas the cytotoxicity induced by powder-derived ACE and corresponding MF is related to ROS mechanisms. The in vitro anti-inflammatory studies showed ACEs inhibited Lipid A-induced Interleukin-12 (IL-12) release from mouse dendritic cells, and modulated lipopolysaccharide (LPS)-induced secretion of tumor necrosis factor-α (TNF-α) and Interleukin-6 (IL-6) from murine macrophages. These studies have important implications for the potential use of blackberry extracts for the treatment and prevention of cancer and inflammation diseases and provide essential information for the development of Botanical Drug Products from extracts derived from blackberries and other fruits.

Microneedles are a minimally invasive method for delivering drugs through the impermeable skin layers, and have been used to deliver a variety of compounds including macromolecules, vaccines, and naltrexone. Microneedles can be applied to the skin once, creating micropores that allow for drug delivery into the underlying circulation from a drug formulation. The utility of this technique, however, is blunted by rapid micropore closure. This research project sought to: 1) characterize micropore lifetime and re-sealing kinetics, and 2) prolong micropore lifetime via inhibition of the skin’s barrier restoration processes. Impedance spectroscopy was used as a surrogate technique in animals and humans to measure micropore formation and lifetime. A proof of concept study in humans, using impedance spectroscopy, demonstrated that diclofenac (a topical anti-inflammatory) applied to microporated skin resulted in slower re-sealing kinetics compared to placebo, in agreement with previous animal studies. The clinical feasibility of prolonging micropore lifetime with diclofenac was confirmed via 7-day delivery of naltrexone through microneedle treated skin in humans (compared to 72 hour delivery with placebo). Lastly, naltrexone gels with calcium salts were applied to microneedle treated skin (hairless guinea pigs) to restore the altered epidermal calcium gradient; this method did not significantly extend micropore lifetime.

Purpose: The purpose of this research was to estimate the impact of Medicare Part D on prescription and medical utilization among Arizona's senior dual eligible population.Methods: Generalized estimating equations were used to analyze changes in utilization among dual eligibles (Arizona Health Care Cost Containment (AHCCCS) beneficiaries between the ages of 66 and 80 as of January 1, 2006) relative to a "comparison" group ineligible for Part D (AHCCCS beneficiaries between the ages of 50 and 62 as of January 1, 2006) for the first two years following the implementation of Part D. Medical and pharmacy claims from AHCCCS from January 1, 2005 to December 31, 2007 were used in this analysis.Results: The dual eligibles and Part D ineligible comparison group were similar in their level and trend of utilization of over-the-counter (OTC) medications and benzodiazepines in the pre-Part D period. Following implementation of Part D, there was an immediate decline in utilization of both OTC medications and benzodiazepines in the dual eligibles relative to the comparison group (p<0.001).Increasing trends for both the dual eligible and comparison group were observed during the pre-Part D period for total prescription utilization, generic medication utilization and antidepressant use. After the implementation of Medicare Part D, utilization of these drug classes was significantly lower among the dual eligibles relative to the comparison group.Trends in physician office visits were similar between the dual eligible group and comparison group for the entire study period. During the first month of Part D, the dual eligibles had a statistically significantly larger increase in physician visits over the previous month relative to the comparison group (p=0.001). The trend in hospitalizations between the two groups significantly differed during the pre-period, precluding meaningful comparisons between the groups for this particular outcome.Conclusion: This study supports the belief that medication use for dual eligible Medicare beneficiaries was disrupted by the transition of outpatient drug benefits from Medicaid to Medicare Part D.