Monthly Archives: April 2019

Awareness of HPV Infection and Vaccination among Teens in Urban High School

DOI: 10.31038/AWHC.2019225

Abstract

To assess the level of awareness and knowledge of HPV infection and vaccination among 648 Teens from secondary schools and colleges in four metro cities of Port Harcourt Nigeria.

Materials and methods: This cross-sectional study was conducted by from 1st March to 31st August, 2018. Girls of 13–19 years, with an average of 16 years are targeted. A written questionnaire with two parts has been applied. A preliminary written questionnaire included questions of HPV infection and vaccination awareness.

Results: The study participants are poorly aware about HPV infection and vaccination but are intensely willing to know about it. 98% (n-632) are not aware of HPV infection, while, 98% (n–636) is not aware of the vaccination.

Conclusion: This study brings out the unawareness about HPV infection and vaccination in urban adolescent in four metro cities in Port Harcourt Nigeria. Adolescent understanding and being aware of the HPV virus is needed to have successful vaccination programs in Nigeria.

Keywords

Adolescents and HPV, Cancer cervix, HPV Awareness, HPV Vaccination

Background

Human Papillomavirus (HPV) is a common virus reported to be responsible to some type of cancers. HPV infection is the major risk factor for cervical cancer [1]. The prevalence rate of more than 85% global cervical cancer occurs in developing countries. This health burden is a public health issue that could be prevented by early vaccination of adolescents against HPV. A prophylactic vaccination against the HPV has the ability to reduce HPV infection and cervical cancer occurrence, thereby saving HPV many lives [2]. HPV vaccine approved by FDA has been in circulation since the year 2006 [3]. Notwithstanding, HPV vaccine implementation is still facing challenges in acceptance and lack of awareness despite its futuristic benefits. Awareness has been found to be low in some population and high in another [4, 5], but studies are yet to investigate the awareness of teens in Nigeria, If one exist, it does not measure the awareness of both the HPV infection and HPV vaccination of teenagers in high school. To enable practical programmed of HPV vaccination in the future, it will be required to assess the awareness and knowledge regarding HPV and vaccination among the teens population. If awareness could influence the acceptability of the uptake of the vaccination, it may then be wise to target public awareness as commonly done [6]. More research focus should be targeted on adolescent population as they constitute the interest group. This study therefor, explores the teens urban dwellers’ awareness and knowledge about HPV infection and it vaccination.

Methods

Design

A longitudinal cohort study design with a cross sectional quantitative analysis. The study assessed baseline awareness and knowledge of HPV infection and HPV vaccination among teens in a four selected High School in Port Harcourt, Nigeria. The study was conducted from 1st March to 31st August, 2018.

Study population and Recruitment

For the teens studied, the eligibility criteria included ages 13 – 19 years in High School. The method of selection and sampling units (high school) was through random. Four urban High Schools were purposively selected. Six hundred and forty eight (648) Teens were then randomly selected from the four high schools.

Data Collection

Each respondent completed a consent form and a questionnaire. Participation was voluntary and anonymous. Selected Teens were assembled in a room on the day of the survey. Each respondent filled the questionnaire under close supervision and the purpose and procedure of the survey explained. Data was collected, starting from the first school to the 4th school. The research questionnaire consisted of two parts; social demographic profile, and awareness questions form the second part. The demographic data included information regarding sexual activity. This was done in other to predict the sexual behavior risk factor to HPV infection.

Result and Statistical Analysis

In this study, simple descriptive statistics were used. The study question items were organized into categories: demographic 5 items, awareness based 8 items which include awareness of HPV infection and awareness of HPV vaccination. Questions were answered in “Yes” or ‘NO’ items. Those with answers “Yes” = 1 point and “No” = 0 point. All scores were summed up to calculate the overall awareness scores for HPV infection and HPV vaccination.

The study considered 648 Teens between the ages of 13 to 19 years, with 16 years as mean age. The rationale for the sample size and sampling is to see if there are any significant gaps between the level of awareness on HPV infection and HPV vaccination and between the girls and boys participants (Table 1). Of the study population (n-648) Teens, 41% (n- 264) were boys and 59% (n- 384) were girls. The preliminary questionnaire assessed the awareness. Awareness was low. Only 2% (n – 16) were aware of HPV infection, and 98% (n = 632) were not. Also 2% (n – 12) knew about HPV vaccination and 98% (n – 636) did not know. Out of 12 and 16 participants that had heard about HPV infection and HPV vaccination respectively, 1% (n-3) were boys and 3% (n –13) were girls. Majority of both boys and girls were not aware. Few of the participants that were aware heard about HPV from their parents and friends (Table 2).

Table 1. The demographic data of the study population.

Variable

Classification

Frequency

Percentage

Age

9 – 14

15 – 19

432

216

67%

33%

Sex

Boys

Girls

264

384

41%

59%

Have had sex

Yes

No

182

466

28%

72%

Age at first sex

13 years

14 years

15 years

16 years and above

7

22

48

105

4%

12%

26%

58%

Table 2. Awareness on HPV Infection and HPV Vaccination and between boys and girl.

Awareness

Classification

Frequency

Percentage

HPV Infection

No Awareness

Yes Awareness

632

16

98%

2%

HPV   Vaccination

No   Awareness

Yes  Awareness

636

12

98%

2%

 Boys

Yes  Awareness

No   Awareness

3

261

1%

99%

Girls

Yes  Awareness

No   Awareness

13

381

3%

97%

Discussion

The study found result not consistent with some previous studies on high school students’ knowledge and awareness of HPV infection and vaccination [7, 8]. It was anticipated that there would be unawareness across participants as there is no knowledge programmes in schools and colleges regarding HPV and its vaccination. Nigeria adolescences seem to be disadvantaged group both economically and by their lack of knowledge and health awareness like many other African countries. However the findings of this study may have limited generalizability to Nigerians with cultural diversity, different religions, and socioeconomic status that are distinctively different from western societies. Adequate knowledge and awareness of the clinical health importance of HPV infection and vaccination usually provide positive influence.

In addition, when comparing the social and demographic characteristics among the respondents from four schools based on their gender, the differences were rather small, majority of participants had little knowledge and awareness on HPV infection or HPV vaccination across the four schools in the study. Researchers from west found out that adolescents who have high knowledge levels about HPV and cervical cancer, their acceptance of vaccine is also high [9]. Ninety nine percent girls and 97% boys have not heard of HPV virus and but were willing to know more about the infection. The new option of HPV vaccine as a primary prevention in adolescents is a unique opportunity of this era which promises a significant reduction of cervical cancer in the coming decades [10]. More efforts are needed to provide adolescence with information which will help them to be excluded from among those thousands of women who die from this preventable condition.

Conclusion

 This study brings out the unawareness about HPV infection and vaccination in urban Teens in 4 High schools in Port Harcourt city, Nigeria. The study participants are poorly aware about HPV infection and vaccination but are intensely willing to know about them. In conclusion, findings of this study suggest that HPV infection and vaccination are not likely to encourage adolescent sexual activity. In addition, efforts should be made to increase knowledge-based programs in schools and colleges.

Acknowledgement

The authors gratefully acknowledged Dr. C. TobI-West, and Dr. EO. Oranu for their contributions. I also acknowledge all the high school students who participated.

Authors Contributions

FCD had primary responsibility for protocol development, data collection, analysis and writing of the paper. KND performed final data analysis, participated in the development of the protocol and analytical framework for the study and contributed to the writing of the study.

What this study Add

It raised alarm on the poor awareness on HPV infection and Vaccination. It also highlight that the relevant group for HPV vaccination are willing to receive the vaccine.

References

  1. Cohen J (2005) Public health. High hopes and dilemmas for a cervical cancer vaccine. Science 308: 618–621. [crossref]
  2. Smith JS, Lindsay L, Hoots B (2007) Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. Int J Cancer 121: 621–632
  3. Walsh CD, Gera A, Shah M (2008) Public knowledge and attitudes towards human papilloma virus (HPV) vaccination. BMC Public Health 8: 368.
  4. Fu LY, Bonhomme LA, Cooper SC, Joseph JG, Zimet GD (2014) Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine 32: 1901–1920
  5. Small SL, Sampselle CM, Martyn KK (2013) Dempsey AF. Modifiable influences on female HPV vaccine uptake at the clinic encounter level: a literature review. J Am Assoc Nurs Pract [published online ahead of print August 22, 2013].
  6. Blasi PR, King D, Henrikson NB (2015) HPV Vaccine Public Awareness Campaigns: An Environmental Scan. Health Promot Pract 16: 897–905. [crossref]
  7. Jill B, Melissa KF, Michael JW Jr (2012) Adolescent understanding and acceptance of the HPV vaccination in an underserved population in New York City. J Oncol 2012, Article ID 904034.
  8. Ericka C (2001) Lambert-college students’ knowledge of human papillomavirus and effectiveness of a brief educational intervention. J Am Board Fam Pract 14: 178–183.
  9. Marlow LA, Waller J, Wardle J (2007) Public awareness that HPV is a risk factor for cervical cancer. Br J Cancer 97: 691–694. [crossref]
  10. Brabin L, Roberts SA, Henry CK (2007) A semi-qualitative study of attitudes to vaccinating adolescents against HPV without parental consent-BMC Public health 2007. http://www.biomedcentral.com/1471–2458/7/20.

Psychopedagogic intervention according to Piagetian Theory in three girls with Turner Syndrome: performance improvement revealed by Bender Test

DOI: 10.31038/AWHC.2019224

Abstract

Turner syndrome (TS) carriers seem to present cognitive compensation of profile of reduction in visuospatial skills during development. Thus, a psychopedagogical intervention was performed in order to optimize this mechanism.

Three pairs of age matched 45, X girls were evaluated at two moments (pre and posttest) for the Bender test (BT) and specific Piaget’s tasks or scales (PS). The experimental intervention through the environmental solicitation process was applied for one year to each pair girl with learning disabilities.

Experimental subjects (ES) revealed more ability to planning and organizing their graphic expression in the posttest, as well as presented a decrease in number of brain lesion indicators on their BT performance. ES also showed performance improvement in half of PS (e.g. conservation and measurement of volumes task).

Data suggest that the present intervention instruments may have contributed to the performance increment of the experimental TS girls.

Keywords

Turner syndrome cognition; cognitive compensation; psychopedagogic intervention; Piaget’s tasks or scales; Bender-Gestalt test.

Introduction

Turner syndrome is consequent to total or partial absence of one X-chromosome. Specific profile of reduction in visuospatial skills besides other cognitive or neuropsychological (arithmetic and executive function) and neurophysiological characteristics among subjects with Turner syndrome (TS) has been widely described [1–8]. TS girls seem to have cognitive compensation of that visual deficit throughout their growing-up [7, 9]. With the hypothesis of a gradual increasing to this mechanism, a Piagetian psychopedagogic intervention was planned in order to optimize the heteromodal connections of brain areas, associated to the development of neuropsychological compensation.

Piagetian scales and experimental intervention through the environmental solicitation process [10] “make use of the clinical method [11], which guarantees an affective-emotional optimization in order to promote the best child intellectual performance and to more accurately evaluate their individual cognitive potential”[7].

In addition, clinical method seems to be particularly appropriate for a evaluation or/and intervention with Turner syndrome carriers as far as their verbal performance is within (or above) most population average [12–15], since this method facilitates the establishment of relations and the argumentation in favor of the subject’s own ideas [11, 16]. ZAIA, [17] still expounds that “the critical clinical method is to follow the unfolding of the child’s thinking, adapting questions to the actions and speeches of the child, enabling the free and personal expression of the child’s ideas. This process is still characterized by the adult’s effort to use the child’s language, not to suggest anything, not to give clues to the answers and to understand the child’s point of view without deforming it.”

Materials and Methods

This investigation was approved by the Ethics Committee of Federal University of São Paulo- Paulista School of Medicine (UNIFESP-EPM), protocol number 1040/08. Only patients whose legal guardians signed an informed consent were included in this study.

Three pairs of age matched 45, X girls were evaluated at two moments (evaluation and revaluation; or pretest and posttest) for the Bender test (BT) and specific Piaget’s tasks or Piagetian scales (the latter apparently have been applied to TS carriers only twice before [4, 7]).

In between, the experimental intervention through the environmental solicitation process (developed by Mantovani de Assis [10], according to Piaget’s theory; and adapted to psychopedagogic intervention by Zaia [18]) was applied to experimental subjects in order to propitiate thinking development. The experimental intervention, lasting one year, was performed to each pair girl that presented learning disabilities.

The BT was administered according to Clawson [19] (Figure 1). The examiner registered each subject’s visual motor performance, which was further analyzed with Koppitz method [20] by psychologists specialized in BT.

AWHC 2019-110 - Fatima Ricardi Brazil_F1

Figure 1. Stimulus-models from Bender visual motor gestalt test used on the present investigation according to Clawson (1980).

Piagetian scales (PS) consisted of the construction of reflective abstraction (Correlate Formation (FC); and Relationships between Surfaces and Perimeters of Rectangles (SP) [21]); representation space (projective straight line construction (PSL); and viewpoints or perspectives coordination (“three mountains”; 3M) [22, 23]; and conservation of physical quantities (Conservation and Measurement of Volumes; CMV [24]) tasks. In addition, the Discover the Animal Game (DA) [25] was employed to evaluate logical structures and concept construction.

Intervention process comprised a series of appropriate psychopedagogic instruments, selected in order to develop those aspects which presented development delay during evaluation through Piagetian tasks: Discover the Animal Game (classification) [25], Memory Game (memory) [26], activity of making rolls into several formats using the same amount of modeling clay, for the construction of conservation of continuous quantities [27] and wooden building blocks (Playing Engineer [28]) for the conservation of discrete quantities. For the construction of spatial relations, Headsnake [29] and Magic Bag [29] games were picked out as well as activities like puzzles [30], figures assembly [31], free drawing and geometrical figures fitting. Causal relationships establishment was stimulated by the Semblance [29], Total Balance [29] and Pick-up-Sticks [32] games besides the fluctuation of body’s activity [27]. Furthermore, narrative construction [33] and activities with numbers (Semblance game [29], e.g.) were applied to facilitate the construction of school skills. Finally, in order to provide own body knowledge and mastery, the following activities were proposed: body scheme, making the child’s body outline with wax pencil followed by requesting her to represent different body parts of her own; songs with gestures (e.g.: “Hokey- Pokey”); clay doll followed by its drawing. Table 1 presents the games and activities used in the intervention for each experimental subject beyond the total number of intervention sessions per subject.

Table 1. Games and activities employed during psychopedagogical intervention (environmental solicitation) applied to each experimental subject (ES) and their respective purposes; and total number of sessions per subjects.

Games and activities to propitiate

Subjects

Logical relationships development

ES1

ES2

ES3

Classification: Discover the animal Game

X

X

X

Continuous quantities conservation: making rolls

X

X

X

Memory: Memory Game

X

X

X

Real construction

Space:

Headsnake Game

X

Puzzles

X

X

X

Magic Bag Game

X

X

X

Free drawing

X

X

X

Playing Engineer (wooden building blocks)

X

X

X

Figures assembly

X

X

X

Geometrical figures fitting

X

Causality:

Sambalance Game

X

X

X

Activities with objects that float or sink

X

X

Total Balance Game

X

X

X

Pick-up sticks Game

X

X

Oral and written language construction

Narrative construction

X

X

X

Dictation

X

Number recognition (and arithmetic operations)

Sambalance game

X

X

X

Calculation (regarding the pick up sticks game play)

X

Psychomotor activities: body image construction, rhythm and movement control

Body outline made with wax pencil complemented with different body parts representation

X

X

“Hokey Pokey” (music with gestures)

X

Modeling-clay (e.g.: clay doll)

X

X

X

Doll drawing

X

Songs

X

X

X

TOTAL NUMBER OF INTERVENTION SESSIONS

36

36

27

It is noteworthy that both the application of Piagetian tasks and the process of psychopedagogic intervention used the critical Piagetian clinical method [11, 16–17], which fundamental aspects were previously reported in this paper.

Results

Bender test

Data referring to performance by experimental and control subjects on Bender test (Table 2; Figures 2 to 7) exhibit that from seven years old on impulsivity diminished. On the other hand, time required to perform BT increased with age (Table 2). Furthermore, both experimental TS girls younger than ten during posttest (ES1 and ES2) improved the use and planning of spaces of gestalts.

AWHC 2019-110 - Fatima Ricardi Brazil_F2

Figure 2. Evaluation of ES2, at five yr and 2nd examination at six yr.

AWHC 2019-110 - Fatima Ricardi Brazil_F3

Figure 3. Evaluation of CS2, at five yr and 2nd examination at six yr.

AWHC 2019-110 - Fatima Ricardi Brazil_F4

Figure 4. Evaluation of ES1, at six yr, and 2nd evaluation at eight yr.

AWHC 2019-110 - Fatima Ricardi Brazil_F5

Figure 5. Evaluation of CS2, at seven yr, and 2nd evaluation at eight yr.

AWHC 2019-110 - Fatima Ricardi Brazil_F6

Figure 6. Evaluation of ES3, at nine yr. and 2nd evaluation at 10 yr.

AWHC 2019-110 - Fatima Ricardi Brazil_F7

Figure 7. Evaluation of CS3, at nine yr, and new assessment at 10 yr.

Legend
1- Age; 2-Time; 3-Form distortion; 4-Rotation: 5-Integration; 6-Perseveration: 7-Score

Table 2. Performances of experimental (ES) and control (CS) subjects on Bender test and respective ages (A) and significative (+) or not significative (-) number of brain lesion (BL) indicators.

Subjects

A (y;m)

Step

Time

F

R

I

Pe

Score

Visual motor perception level

BL

BL#

BL##

BL (meaning)

BL (difference) (R-E)

ES1

(06;10)

Evaluation

11’

7

7

5

0

19

Below 5 years

21

+

+

anxiety and space disorganization

-6

(07;11)

Revaluation

18’

4

5

5

2

16

Below 5 years

15

+

+

improved in space planning and decreased in impulsivity

CS1

(07;01)

Evaluation

12’

4

6

4

3

17

Below 5 years

17

+

+

CS1 erased during performance and exhibited disorganization and lack of space planning

-4

(08;02)

Revaluation

11’

5

5

3

0

13

5 years and 5 years and 5 months

13

+

+

disorganization and lack of space planning

ES2

(05;00)

Evaluation

05’

6

8

6

1

21

Below 5 years

13

+

+

impulsivity and space disorganization

-5

(06;02)- (06;03)

Revaluation

06’

5

4

6

0

15

Below 5 years

08

+

ES2 retouches copies during performance and shows impulsivity and disorganization

CS2

(05;03)

Evaluation

05’

7

8

7

3

25

Below 5 years

25

+

+

CS2 retouches a lot during performance besides exhibiting space disorganization

-5

(06;02)

Revaluation

05’

6

5

5

2

18

Below 5 years

20

+

+

CS2 showed improvement in perception although space kept disorganized

ES3

(09;00)

Evaluation

03’

6

8

5

0

19

Below 5 years

20

+

+

impulsivity and lack of space planning

-16

(10;04)

Revaluation

06’

5

4

2

0

11

5½ and 5 years and 11 months

04

Anxiety. Nevertheless, ES3 exhibited an outstanding improvement in space planning

CS3

(09;02)

Evaluation

07’

2

4

2

0

08

6 and 6 years and 5 months

05

CS3 retouches during performance

2

(10;05)

Revaluation

13’

3

2

2

0

07

6½ and 6 years e 11 months

07

CS3 erased a lot and retouched copies. Also still showed good usage of space. However, exhibited anxiety to improve gestalt

Age = (years; months); F = form distortion; R = rotation; I = integration; Pe = perseveration; #UnG (Guarulhos University) standard: n = 8; ##APEP (Psychology and Psychotherapy Studies Association) standard: n = 10; E = evaluation; R = revaluation.

Table 2 also shows that most (5/6) of all subjects presented decrease in number of brain lesion indicators from evaluation to revaluation. It is noteworthy that such difference was greater for two experimental subjects (ES1 and ES3).

On the contrary, ES2 did not present a BL decrease greater than her respective control (CS2). Although ES2 and CS2 showed the same BL decrease, the former diminishment was from a significative to a non significative value, according to one of the two considered standards (Table 2).

Moreover, nearly all propositii (5/6) showed improvement on all scores of their performances on Bender test (evaluation and revaluation compared; table 2), either experimental (3/3) or control (2/3) ones.

Piagetian tasks or Piagetian Scales

Data referring to performance by experimental and control subjects on conservation and measurement of volumes and other Piagetian tasks during evaluation and revaluation are given in Table 3.

Table 3. Performances of experimental (ES) and control (CS) subjects classified by Piagetian Scales (PS) and respective ages (A) and final diagnoses (FD)

AWHC 2019-110 - Fatima Ricardi Brazil_F9

PS tasks: CMV = conservation and measurement of volumes; 3M = viewpoints or perspectives coordination (“three mountains”); CF = correlate formation; SP = relationships between surfaces and perimeters of rectangles; PSL = projective straight line construction. Game: DA = discover the animal. For abbreviations of diagnosis, see legend to Table 4.

Table 4 exhibits the reference values for the final operatory diagnosis corresponding to the sum of points of individual performance on each Piagetian task.

Table 4. Reference values for the final operatory diagnosis corresponding to the sum of points of individual performance on each Piagetian task.

Total points

Final diagnosis

6,0

PO1

6,5 – 11,5

tPO1/2

12

PO2

12,5 – 17,5

tPO/CO

18,0

CO1

18,5 – 22,5

tCO1/2

23

CO2

23,5 – 24,5

tCO/FO

25 – 30

FO1

PO = pre-operatory period; PO1 = the beginning stage of the pre-operatory period; tPO1/2 = transition between Pre-Operatory Stage 1 and the Pre-Operatory Equilibrium Level; PO2 = Pre-Operatory Equilibrium Level; tPO/CO = transition between pre-operatory and concrete operatory periods; CO = concrete operatory period; CO1 = the beginning stage of the concrete operatory period; tCO1/2 = transition between the beginning stage and the stage in equilibrium of the concrete operatory period; CO2 = concrete operatory equilibrium level; tCO/FO = transition between the concrete operatory and the formal operatory periods; FO1 = the beginning stage of the formal period; FO = formal operatory period.

In addition, Figure 8 presents the comparison between experimental (ES) and control (CS) subjects performances classified by Piagetian scales (PS) during evaluation and revaluation. Table 3 and Figure 8 analyses enable to compare the progress achieved by the experimental and control subjects in the different Piagetian tasks.

AWHC 2019-110 - Fatima Ricardi Brazil_F8

Figure 8. Comparison between experimental (ES) and control (CS) subjects performances classified by Piagetian scales (PS) during evaluation and revaluation. PS tasks: CMV = conservation and measurement of volumes; 3M = viewpoints or perspectives coordination (“three mountains”); CF = correlate formation; SP = relationships between surfaces and perimeters of rectangles; PSL = projective straight line construction. Game: DA = discover the animal.

The great majority (5/6) achieved progress in Conservation and Measurement of Volumes task (CMV). In groups comparison, all experimental (three) and most (2/3) control subjects presented better performance in CMV during posttest than in the pretest (Table 3)

Thus, in CMV task and among controls, one subject (CS3) did not achieve progress, whereas the other two presented one (CS1) and two (CS2) levels of progress. In addition, among experimental subjects, two (ES2 and ES3) achieved one level while ES1 achieved two levels of progress (Figure 8). However, in Discover the Animal game 4/6 of the subjects presented progress on their performances, that means every control and one experimental subject (ES2; Figure 8).

Data referring to performance by control and experimental subjects in representation space tasks revealed that two of each group (4/6) achieved progress in the “Three Mountains” (CS2 and CS3; ES2 and ES3) and in the Projective Straight Line (CS2 and CS3; ES1 and ES3; Figure 8) tasks. Also considering the progress amplitude, only ES2 presented two levels whereas the other experimental and both control subjects showed one level of progress in 3M, in pretest and posttest comparison.

Concerning reflective abstraction, half of the subjects (3/6) achieved progress on their performance in Correlate Formation task that means two controls (CS1 and CS2) and one from the experimental group (ES3). The progress amplitude corroborates this observation, as far as one of the controls (CS2) presented three levels while CS1 and the experimental subject showed only one level of progress (Figure 8).

Nevertheless, still considering abstraction, despite only one subject of each group (CS1 and ES3) have achieved progress on their performances in the Relationships between Surfaces and Perimeters of Rectangles task, the control showed one level whereas the experimental subject, two levels of progress.

Discussion

It is noteworthy that Turner syndrome has a cognitive impact besides a physical one [8, 34–36]. Thus TS girls and teenagers should be provided a demanding formal assessment, orientation and/or intervention [7, 8, 34, 37].

In the present investigation, there was a difference on BT performance in favor of the experimental subjects (ES), who presented more ability to planning and organizing their graphic expression.

Increase in time required to perform BT with age was probably due to older subjects effort in order to more carefully accomplish gestalts.

Furthermore, improvement in use and planning of spaces of gestalts of both experimental TS girls younger than ten during posttest (ES1 and ES2) suggests those subjects took more advantage of intervention procedures than the eldest one (ES3). Also, it is likely that neurological functions in development have been benefited by intervention process stimuli. This assumption is based on number of brain lesion indicators (BL) decrease revealed by BT.

Unlike both other experimental subjects, ES2 did not present a BL decrease greater than her respective control (CS2) inasmuch as the observed hindrance to cooperate in the beginning of the intervention process, specifically refusing several times to accomplish or to repeat the suggested activity. The latter behavior could be due to pre-operativeness characteristics ES2 presented at that time.

Improvement of nearly all propositii on all scores of their performances on Bender test may be assumed mostly to their natural development, in controls case. On the other hand, it is reasonable to consider the benefit of intervention that favours the subject in order to explain the considerable decrease ES3 presented for brain lesion indicators on her BT performance.

However, a new investigation with a greater number of subjects and its replication by other researchers would be necessary to corroborate such supposition.

The present data may reinforce how important psychopedagogic intervention process can be to Turner syndrome carriers. In addition, the earlier such intervention occurs the more convenient it will be, as well as should the family be advised with this purpose.

Besides, on three Piagetian tasks (CMV, 3M and SP) a greater progress was observed in most experimental subjects.

This mentioned difference, if explained by the influence of psychopedagogic intervention, shows how the instruments employed along the latter might influence conservation construction on TS girls.

This may be confirmed by the amplitude (namely the relationship between the beginning performance level at the pretest and that achieved at the posttest) of progresses achieved by experimental and control subjects performances analysis.

This relationship suggests the intervention process might have influenced on the conservation construction.

Moreover, on projective straight line task subjects performances were similar in both groups.

On the other hand, controls achieved higher progress in CF and in Discover the Animal game as in number of subjects as in the amplitude of progresses.

Therefore, this led us to consider that concept construction and classification were not influenced by psychopedagogic intervention instruments. This finding may be confirmed by the progresses amplitude as far as the only experimental subjects and all the controls achieved one level of progress each.

So, considering the number of subjects which achieved progresses in the space construction, we do not find there was influence from the intervention process, as far as it was the same in both experimental and control groups. However, if we also consider the progress amplitude, only ES2 presented two levels whereas the other experimental and both control subjects showed one level of progress in 3M, in pretest and posttest comparison. In conclusion, we suppose there was a slight influence of psychpedagogic intervention, in this case. Finally, it is noteworthy that a more detailed analysis of intervention through the environmental solicitation process and its influence on experimental subjects performances will be addressed in an upcoming publication.

Conclusion

According to Bender [38], the gestalt visual-motor functions basically may be associated with language aptitude, time and space organization, and to manual motor abilities. One concluded there was an improvement on the quality of gestalt functions, observed in the paper organization and drawings planning, and that psychopedagogical activities have probably influenced on the Bender test organization and planning, so presumably contributing to ameliorate cognitive performance of three girls with Turner syndrome. In conclusion, greater performances progresses observed among experimental subjects on Bender test, when compared to those presented by controls, suggest the psychopedagogic intervention accomplished during the present study may have contributed to optimize the cognitive compensation of the experimental subjects visual motor deficit.

Nevertheless, the environmental solicitation process should be applied to a greater number of TS girls and preferably for a longer period of time in order to confirm the conclusion above.

References

  1. Shaffer JW (1962) A specific cognitive deficit observed in gonadal aplasia (Turner’s syndrome). J Clin Psychol 18: 403–406. [crossref]
  2. Garron DC (1977) Intellegence among persons with Turner’s syndrome. Behav Genet 7: 105–127. [crossref]
  3. Money J (1968) Cognitive deficits in Turner’s syndrome. In: Vandenberg SG. (Ed.) Progress in human behavior genetics. J. Hopkins, Baltimore, USA.
  4. Ricardi FCF (1996) Cognição na síndrome de Turner: investigação de 28 sujeitos com o Teste de Bender e as Escalas de Piaget. Masters of Science thesis, São Paulo: USP.
  5. Ross J, Stefanatos GA, Kushner H, Zinn A, Bondy C, Roeltgen D (2002) Persistent cognitive deficits in adult women with Turner syndrome. Neurology 58: 218–225. [crossref]
  6. Ross J, Roeltgen D, Zinn A (2006) Cognition and the sex chromosomes: studies in Turner syndrome. Horm Res 65: 47–56. [crossref]
  7. Ricardi FCF, Zaia LL, Pellegrino-Rosa I, Rosa JT, Mantovani de Assis OZ, et al. (2010) Psychogenetics of Turner syndrome: an investigation of 28 subjects and respective controls using the Bender test and Piagetian scales. Genet Mol Res 9: 1701–1725. [crossref]
  8. Hong DS, Reiss AL (2012) Cognition and behavior in Turner syndrome: a brief review. Pediatr Endocrinol Rev 9: 710–712. [crossref]
  9. Ricardi FCF, Pellegrino-Rosa I, Rosa JT, Saldanha PH (2002) Síndrome de Ullrich-Turner: investigação de 21 sujeitos com o teste de Bender. Águas de Lindóia: Sociedade Brasileira de Genética (Ed.), Resumos do 48. Congresso Nacional de Genética, CD-ROM.
  10. Mantovani de Assis OZ (1976) A solicitação do meio e a construção das estruturas lógicas elementares na criança. Ph.D. thesis. Campinas: Unicamp.
  11. Vinh-Bang (1970) El método clinico y la investigación en psicologia del niño. In: Ajuriaguerra J et al. (Eds). Psicologia y epistemologia genéticas: temas piagetianos. Buenos Aires: Proteo.
  12. Shankar RK, Backeljauw PF2 (2018) Current best practice in the management of Turner syndrome. Ther Adv Endocrinol Metab 9: 33–40. [crossref]
  13. Temple CM, Shepard EE (2012) Exceptional lexical skills but executive language deficits in school starters and young adults with Turner syndrome: implications for X chromosome effects on brain function. Brain Lang 120: 345–359. [crossref]
  14. Hong D, Scaletta Kent J, Kesler S (2009) Cognitive profile of Turner syndrome. Dev Disabil Res Rev 15: 270–278. [crossref]
  15. Ross JL, Stefanatos GA, Kushner H, Zinn A, Bondy C, Roeltgen D (2002) Persistent cognitive deficits in adult women with Turner syndrome. Neurology 58: 218–225. [crossref]
  16. Piaget J (1975) Os problemas e os métodos. In: A Representação do Mundo na Criança. Rio de Janeiro: Brazil.
  17. Zaia LL (2015) O atendimento psicopedagógico pelo processo de solicitação do meio. Revista Educação 9: 117–127.
  18. Zaia LL (1996) A solicitação do meio e a construção das estruturas operatórias em crianças com dificuldades de aprendizagem. Ph.D. thesis, Campinas: Unicamp, Brazil.
  19. Clawson A (1980) Bender infantil: manual de diagnóstico clínico. Porto Alegre: ArtMed, Brazil.
  20. Koppitz EM (1966) The Bender gestalt test for young children. New York: Grune & Stratton, USA.
  21. Piaget J (1995) Abstração reflexionante: relações lógico-aritméticas e ordem das relações espaciais. Porto Alegre: ArtMed, Brazil.
  22. Piaget J, Inhelder B (1993) A representação do espaço na criança. Porto Alegre: Artmed, Brazil.
  23. Kobayashi MCM (1998) A construção das relações espaço-geométricas em crianças de educação infantil: um estudo de epistemologia genética. Masters of Science thesis. Marília: Unesp, Brazil.
  24. Piaget J, Aebli MH, Pitsou MF (1948) La conservation et la mesure des volumes. In: Piaget J, Inhelder B, Szeminska A. La géométrie spontanée de lénfant. Paris: Presses Universitaires de France, France: 448–483.
  25. Piaget J, Sakellaropoulo M, Henriques-Christophides A (1996) Em direção à circularidade dialética mais geral das conexões lógicas: a determinação de alguns animais ou objetos. In: Piaget J. As formas elementares da dialética. São Paulo: Casa do Psicólogo, Brazil.
  26. Jogo da Memória- Brinquedos (Memory Game- Toys) (24 peças em madeira). Xalingo brinquedos. Fabricado por: Xalingo S/A Indústria e Comércio. CNPJ: 95.425.534/0001-76. Santa Cruz do Sul, Brazil.
  27. Mantovani de Assis OZ, Assis MC (Orgs.) (2004) PROEPRE: prática pedagógica. Campinas: Graf. FE; LPG, 3.
  28. Brincando de Engenheiro (Playing Engineer) (42 peças). Xalingo brinquedos. Fabricado por: Xalingo S/A Indústria e Comércio. Santa Cruz do Sul, Brazil.
  29. Zaia LL (2008) A construção do Real na criança: a função dos jogos e das brincadeiras. Schème 1: 74–94.
  30. Quebra-cabeça: The Flintstones (30 peças em madeira- 22X18 cm). Start. Fabricado por: L. Moller. São Paulo, Brazil.
  31. Monta-figuras (Mounting Pictures): Turma da Mônica (24 peças em madeira). Xalingo brinquedos. Fabricado por: Xalingo S/A Indústria e Comércio, Santa Cruz do Sul, Brazil.
  32. Pega-Varetas (28 varetas). Fabricado por: Algazarra Ind. e Com. de Brinquedos Ltda. São Paulo, Brazil.
  33. Sauer MIM (2000) A construção da narrativa infantil e suas relações com a construção do espaço. Masters of Science thesis, Campinas: UNICAMP, Brazil: 73–107.
  34. Erhan H, Belotserkovsky J (2014) Neuropsychological impact of Turner syndrome: importance of parent education, early detection and intervention: a case study. Arch Clin Neuropsychol 29: 544–545.
  35. Saad K, Abdelrahman AA, Abdel-Raheem YF, Othman ER, Badry R, Othman HA, Sobhy KM (2014) Turner syndrome: review of clinical, neuropsychiatric and EEG status: an experience of tertiary center. Acta Neurol Belg 114: 1–9. [crossref]
  36. Kesler SR, Sheau K, Koovakkattu D, Reiss AL (2011) Changes in frontal-parietal activation and math skills performance following adaptive number sense training: preliminary results from a pilot study. Neuropsychol Rehabil 21: 433–454. [crossref]
  37. Mueller SC (2013) Magnetic resonance imaging in paediatric psychoneuro-endocrinology: a new frontier for understanding the impact of hormones on emotion and cognition. J Neuroendocrinol 25: 762–770. [crossref]
  38. Bender L (1938) A visual motor Gestalt test and its clinical use. New York: American Orthopsychiatric Association, Res. Monograph, USA: 103.

Caring for Confused Community Dwelling Seniors: Contributing and Obstructing Factors in Daily Care for Healthcare Assistants in District Nursing

DOI: 10.31038/ASMHS.2019321

Abstract

Older people with confused behavior, have behavioral problems due to dementia, mental problems or social problems. For the Healthcare Assistant (HA) in district nursing, it is a daily challenge to care for older people with confused behavior. Aim of this research is to achieve an insight in the strategies the HA uses to deal with the daily care for older people with confused behavior. It is also the aim to have insight in factors which contribute to the daily care in a positive or negative way. Method: a qualitative explorative research. 17 HA’s in district nursing participated in semi-structured interviews. All respondents had experience with caring for older people with confused behavior. The most important influencing factors are the experienced relationship between HA and the client and the experienced support by the team. Particularly behavioral problems due to mental problems can impede a relationship with the client. Further research is recommended to study the level of knowledge and competences of all levels of employees in district nursing.

Keywords

Confused persons, vulnerable elderly, older adults living at home, mental disorder, home care staff, district nursing

Short Commentary

The number of seniors confronted by chronic illness and dementia is rising, due to the fact that people are getting older and stay at home longer. Because of rising healthcare costs, people are to assumed to stay at home as long as possible [1]. Though, age-related physical and cognitive decline can make aging at home challenging [2]. Psychiatric problems among community dwelling seniors is frequently recognized by healthcare assistants (HA’s) in district nursing [2]. One of the consequences of these problems is an increase of the so-called confused community dwelling seniors. Seniors with confused behaviour show problems like agitation, aggression or apathy. For HA’s it is a daily challenge to manage the care for confused community dwelling seniors. It is important that HA’s have sufficient knowledge of confused behaviour in seniors in order to recognize and manage psychiatric problems [2]. However, little is known about what HA’s experience themselves as contributing or obstructing factors to daily care and how to respond in a right way to confused behaviour as well as to provide good care. We conducted an explorative research among seventeen HA’s in the Netherlands to gain insight in these contributing and obstructing factors. The qualified HA’s, with a variety in age and work experience, provide basic personal care under supervision of a district nurse.

The professionals were asked, in an individual interview, to share their experiences with confused community dwelling seniors and how they manage daily care. The Cohen-Mansfield mapping of problem behaviour, an instrument for assessing agitation, was used to stimulate participants to give more detailed information and examples of problem behaviour they experienced [3]. Most of the participants experience an increase of confused community dwelling seniors, which was in line with research conducted by Grundberg and colleagues concerning the role of home care assistants recognizing mental health problems in community dwelling seniors [4]. HA’s reported daily difficulties and challenges in caring for confused community dwelling seniors. The HA’s were confronted with verbal aggressive behaviour like threats, berate or curse by the seniors. They were also confronted with physically non-aggressive behaviour like compulsive or risky behaviours of the seniors. According to the HA’s, there is no ‘standard recipe’ to manage problem behaviour: the way the HA’s approach confused seniors depends on factors related to the seniors as well as characteristics of the HA. These factors are for example age and work experience of the professional as well as the type and cause of behaviour problem of the senior. The presence or absence of a relation of trust, information and support are the main contributing or obstructing factors.

Despite the fact that a relation of trust is seen as essential for providing good care, it seems very difficult to achieve such a relation with confused community dwelling seniors. According to the HA’s, a relation of trust can be reached when they have the opportunity to get to know the client. HA’s experience more difficulties to become familiar with the senior and building up a relation of trust in case a diagnose is missing and psychiatric problems are suspected. A study of Gleason and Coyle regarding the experiences of home care workers providing homecare to clients diagnosed with mental and behavioural problems, also mentioned the struggles in building a relation of trust in such cases [5]. In addition, in cases where psychiatric problems are suspected, the HA’s in our study seemed to have less tendency to build this relation of trust. Several factors might explain this low tendency: having a primary focus on personal care and not on a relation of trust, uncertainty of the HA or not having the required knowledge on how to respond to clients with (suspected) psychiatric diagnoses. These factors are also identified in a study on how nursing staff in a hospital manage patients with psychiatric problems [6].  Also a lack of collaboration with professionals in social care can obstruct a relation of trust [7].

The second factor, as mentioned by the HA’s, is the presence or absence of information on the underlying cause of the behaviour problem, for example dementia or loneliness of the senior. Olivera and colleagues studied the factors contributing to the development of psychiatric problems in community dwelling seniors [8]. When professionals in home care are aware of these factors, problems could be recognized at an early stage. In our study, HA’s stated that when information about the cause and reason of the behaviour is available, this increases their ability to recognize the problems. In such cases, HA’s experience a better management of problem behaviour and they feel like they succeed (more) in providing daily care.

At last, the HA’s perceive the available support of the district nursing team as a contributing or obstructing factor in the daily care for confused community dwelling seniors. Important is sharing knowledge and experiences within the team and with other professionals in healthcare and social care The importance of exchanging knowledge and experiences is confirmed in a study by Gleason and Coyle [5]. When confronted with problem behaviour, (emotional) support of other experts seems very important. Of course, attention is also still needed by strengthen (theoretical) knowledge about psychiatric problems and how to recognize such problems.

Stay longer at home by seniors, including confused community dwelling seniors might be desired and needed because of rising health costs. Though professionals both health and social care need help and more attention to overcome contributing and obstructing factors. Specifically providing information and (emotional) support, can support professionals in district nursing and can increase their feeling of being capable of building up a relation of trust with confused community dwelling seniors. Subsequently, this relation of trust can contribute to the provision of optimal care to the client.  Development of further collaboration of health care and social care professionals can contribute to more optimal and integrated care for both personal and mental health care [1, 7].

Note: Accepted for publication in the Dutch Journal of Gerontology and Geriatrics in Dutch (Tijdschrift voor Gerontologie en Geriatrie).

References

  1. Josefsson K, Meranius, MS (2018) Complexity in daily living of older adults with multimorbidity: health, social and informal care utilization and costs. J Gerontol Geriatr Med 4:017.
  2. Haddad M, Plummer S, Taverner A, Gray R, Lee S, Payne F, Knight D (2005) District nurses’ involvement and attitudes to mental health problems: a three-area cross-sectional study. J Clin Nursing 14: 976–985. [Crossref]
  3. Cohen-Mansfield J, Marx MS, Rosenthal AS (1989) A description of agitation in a nursing home. J Gerontology 44: 77–84. [Crossref]
  4. Grundberg A, Hansson A, Religa D, Hilleras P (2016) Home care assistants’ perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity. J Multidisciplinary Healthcare 9: 83–95. [Crossref]
  5. Gleason HP, Coyle CE (2016) Mental and behavioral conditions among older adults: implications for the home care workforce. Aging Mental Health 20: 848–855. [Crossref]
  6. Lethoba KG, Netswera FG, Rankhumise E (2006) How professional nurses in a general hospital setting perceive mental ill patients. Curationis, 29: 4–11. [Crossref]
  7. Rämgård M, Blomqvist K, Petersson P (2015) Developing health and social care planning in collaboration. J Interprofessional Care, 29: 354–358. [Crossref]
  8. Olivera J, Benabarre S, Lorente T, Rodrigues M, Barros A, Quintana C, Pelegrina V, Aldea C (2011) Detecting psychogeriatric problems in primary care: factors related to psychiatric symptoms in older community patients. J Mental Health in Family Medicine 8: 11–19. [Crossref]

Synovial Chondromatosis with Os Trigonum

DOI: 10.31038/IJOT.2019221

Case

A 25-year old male physical therapist had severe right ankle pain immediately following a workout with lunges, drop jumps, and single leg hops. The patient reported 10/10 anterior and posterior ankle pain and was unable to run or fully weight bear immediately or for the next 24-hours.  The patient had a long history of multiple inversion sprains resulting in ankle pain and edema throughout his prior high school/college football career.

Motion loss of 10 degrees in dorsiflexion/plantarfexion resulting in a reduced stance, stride, and push-off (antalgic gait) was evident. Palpation tenderness was noted over the anterior talus and distal tibia. The patient referred himself to an orthopedic physician two days following the injury due to the palpatory tenderness over the anterior distal tibia and pain with weight bearing (Ottawa Ankle Rules) [1].

No evidence of a fracture was noted on the anterior-posterior or mortise radiographic views of the ankle (Figure 1). Synovial chondromatosis [2], or “popcorn” was present on both anterior-posterior and lateral views.  Os trigonum [3] (an accessory ossicle) was also present between the posterior talus and calcaneus (Figure 2).   MRIs confirmed radiographic findings. The patient was referred to an orthopedic ankle surgeon for an arthroscopic resection of the os trigonum and synovial osteochondromatosis 3-weeks post-injury date. The patient wore a CAM boot for 2-weeks at WBAT status and resumed full weight bearing ambulation at 3-weeks post-op without residual pain or dysfunction. He resumed running at 2-months post-surgery without pain.

IJOT 19 - 113_Marsha Rutland_F1

Figure 1. Anterior- posterior and Mortise view radiographs of the right ankle. Some small chondromatosis is seen in mid area of distal tibia and talus.

IJOT 19 - 113_Marsha Rutland_F2

Figure 2. Lateral view radiograph of right ankle, demonstrating significant synovial chondromatosis in the anterior aspect of the tibia and talus. Os trigonum is also present between the posterior talus and calcaneous.

References

  1. Stiell IG, McKnight RD, Greenberg GH, et al (1994) Implementation of the Ottawa ankle rules. J Am Med Assoc 271:827-832.  [Crossref]
  2. Sedeek SM, Choudry Q, Garg S (2015) Synovial chondromatosis of the ankle joint: clinical, radiological, and intraoperative findings. Case Rep Orthop. 2015.
  3. D’Hooge P, Alkhelaifi K, Almusa E Tabben M, Wilson MG, Kaux JG (2018) Chronic lateral ankle instability increases the likelihood for surgery in athletes with os trigonum syndrome. Knee Surg Sports Traumatol Arthrosc 2018.

Successful Delivery at 37 Weeks via C-Section and Simultaneous Total Hysterectomy, After IVF Oocytes Donor Transfer in an Ovarian Cancer Patient

DOI: 10.31038/IGOJ.2019223

Abstract

A salpingo-oophorectomy due to an ovarian malignancy could be accompanied with great stress and a number of risks for childless but, still fertile women. This situation poses a great challenge for an obstetrical point of view. A successful twin pregnancy at 37 weeks via c-section with simultaneous total hysterectomy is reported to a woman who was diagnosed with ovarian cancer (sex cord granulose tumor) and treated with right salpingo-oophorectomy 3 years prior to a successful fourth trial of IVF implantation. This woman underwent a c-section at 37 weeks, giving birth to twin females neonates with a simultaneous total hysterectomy. Antenatally, no complications were reported, rather than an admission due to premature contractions at 26+3, which resolved with adequate medication 5 days later, when the patient was fit for discharge and appointed for the operation. Her post-operative course was uneventful.

Introduction

Infertility causes a great deal of stress to a large number of women all over the world. Imaging complicates an already complex situation with the presence of ovarian cancer. Time limits become narrower and the obstetric team needs to evaluate and assess the risk of cancer versus the risk of failure in conception. Ovarian sex cord-stromal tumors (SCSTs) are extremely rare with a favorable long-term prognosis [1]. These types of ovarian cancer results to 7% of the all ovarian tumors [2]. For the reasons above, fertility sparing technique should be encouraged. Since the majority of women affected are young and at a reproductive age the safety of fertility-sparing operations must be assessed [3]. More specifically, GCTs illustrate a 5-year-survival prognosis of 92% to 100% in cases of surgical staging [4, 5].

History

A 40-yer-old gravida 1 para 0 with a history of thrombophilia (antithrombin III deficiency) underwent a laparoscopy due to a cyst foun via ultrasound suring her preIVF assessment in late 2014. Due to the size of the cyst, the specimen had to be resected in order to be removed through the trocar openings. The pathologist review revealed a sex cord ovarian tumor-granulosa cell tomor (GCT) stage IC. The stage of the tumor was possibly overestimated since the resected specimen could not provide to the pathologist clear limits for staging. After 2 months, the patient underwent an open surgery removal of right adnexa, appendicectomy and omentomectomy. No chemotherapy was proposed. In addition, she received IVF with 2 cycles of citric clomifaine ovarian hyperstimulation without any result since she had an incident of miscarriage at 8 weeks. Another 2 courses of treatment with donor ovarian foccicles were perfomed. The first led to a miscarriage at 5 weeks but the latest led to success with 2 MCDA twin female embryos. During her pregnancy no pathology was noted. At 26+3 weeks she was admitted in the hospital due to premature contractions for which she received 2 courses of Atosiban till 27+4 weeks. At 27+5 she was discharged by the hospital and she was appointed for a ceasearian section at 37 weeks with a simultaneous hysterectomy and left salpingo-ophorectomy. The perinatal outcome was successful resulting to twin healthy females neonates with an Apgar score 10 out of 10 within the first minute of their birth and adequate weight. They required no incubators.

Literature Review

Fertility-sparing operation has been proposed in order to achieve a viable pregnancy for women who are younger and usually present with early stages of cancer [6]. Nevertheless, the risk of recurrence is high, almost 45% in cases of cystectomy which means that fertility methods must work in a timely manner [6, 7]. In this case no chemotherapy was proposed, since international literature suggests platinum-based chemotherapy in cases of advanced ovarian cancer or recurrent disease [8].

Due to the rarity of this GCTs, no large scale randomized trials have been conducted, leaving a vague approach in cases, where fertility must be preserved [9, 10]. However, it seems that women at stage I have a very low risk of further recurrence, when adequate surgical staging has been performed [3]. Further investigation in literature reveals a unexpected increased female neonates ratio as well as a full term births for women in pregnancies complicated with SCTs [11]. Usually after delivery, a second operation must be perform [12, 13]. Total hysterectomy with bilateral salpingo-oophorectomy must be performed ± chemotherapy [14].

Conclusion

The evolution of obstetrics and gynecology even in severe cases such as ovarian cancer, gives women, who wish to maintain their fertility, many options. In this case, this patient not only was treated for ovarian cancer, patient’s fertility was preserved for further pregnancy. IVF treatment was successful and the obstetrics team achieved an appointed birth via c-section at 37 weeks despite all odds.

Discussion

For complicated cases as the one presented above, a multidisciplinary team must be sought [15–17]. The need for a collaboration of an obstetrician, a pediatrician, an oncologist and a pathologist is self-explanatory [18]. Platinum –based chemotherapy should be sought since the stage of the ovarian tumor is higher than I. (see figure 1 below) [19].

IGOJ - Orestis Tsonis - F1

Authors have no conflict of interest.

References

  1. Serov SF, Scully RE, Sobin LH (1973) Histological typing of ovarian tumours: Citeseer.
  2. Koonings PP, Campbell K, Mishell JD, Grimes DA (1989) Relative frequency of primary ovarian neoplasms: a 10-year review. Obstetrics and Gynecology 74: 921–926.
  3. Evans AT 3rd, Gaffey TA, Malkasian GD Jr, Annegers JF (1980) Clinicopathologic review of 118 granulosa and 82 theca cell tumors. Obstet Gynecol 55: 231–238. [crossref]
  4. Malmström H, Högberg T, Risberg B, Simonsen E (1994) Granulosa cell tumors of the ovary: prognostic factors and outcome. Gynecologic oncology 52: 50–55.
  5. Zhang M, Cheung MK, Shin JY (2007) Prognostic factors responsible for survival in sex cord stromal tumors of the ovary-an analysis of 376 women. Gynecologic oncology 104: 396–400.
  6. Cadron I, Leunen K, Van Gorp T, Amant F, Neven P, et al. (2007) Management of borderline ovarian neoplasms. Journal of clinical oncology 25: 2928–2937.
  7. Marret H, Lhommé C, Lecuru F (2010) Guidelines for the management of ovarian cancer during pregnancy. European Journal of Obstetrics & Gynecology and Reproductive Biology 149: 18–21.
  8. Colombo N, Parma G, Zanagnolo V, Insinga A (2007) Management of ovarian stromal cell tumors. J Clin Oncol 25: 2944–2951. [crossref]
  9. Gershenson DM (2005) Fertility-sparing surgery for malignancies in women. J Natl Cancer Inst Monogr 43–47. [crossref]
  10. Morice P, Denschlag D, Rodolakis A (2011) Recommendations of the Fertility Task Force of the European Society of Gynecologic Oncology about the conservative management of ovarian malignant tumors. International Journal of Gynecological Cancer 21: 951–963.
  11. Blake EA, Carter CM, Kashani BN (2014) Feto-maternal outcomes of pregnancy complicated by ovarian sex-cord stromal tumor: a systematic review of literature. European Journal of Obstetrics & Gynecology and Reproductive Biology 175: 1–7.
  12. Young RH, Dudley AG, Scully RE (1984) Granulosa cell, Sertoli-Leydig cell, and unclassified sex cord-stromal tumors associated with pregnancy: a clinicopathological analysis of thirty-six cases. Gynecologic oncology 18: 181–205.
  13. Behtash N, Zarchi MK, Gilani MM, Ghaemmaghami F, Mousavi A, et al. (2008) Ovarian carcinoma associated with pregnancy: a clinicopathologic analysis of 23 cases and review of the literature. BMC pregnancy and childbirth 8: 3.
  14. Zhao X, Huang H, Lian L, Lang J (2006) Ovarian cancer in pregnancy: a clinicopathologic analysis of 22 cases and review of the literature. International Journal of Gynecological Cancer 16: 8–15.
  15. Bernhard LM, Klebba PK, Gray DL, Mutch DG (1999) Predictors of persistence of adnexal masses in pregnancy. Obstet Gynecol 93: 585–589. [crossref]
  16. Wong H, Low J, Chua Y, Busmanis I, Tay E, et al. (2007) Ovarian tumors of borderline malignancy: a review of 247 patients from 1991 to 2004. International Journal of Gynecological Cancer 17: 342–349.
  17. Amant F, Van Calsteren K, Halaska MJ (2011) Gynecologic cancers in pregnancy: guidelines of an international consensus meeting. Rare and Uncommon Gynecological Cancers: Springer 209–227.
  18. Sherard GB 3rd, Hodson CA, Williams HJ, Semer DA, Hadi HA, et al. (2003) Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 189: 358–362. [crossref]
  19. Schneider DT, Calaminus G, Wessalowski R, Pathmanathan R, Selle B, et al. (2003) Ovarian sex cord-stromal tumors in children and adolescents. J Clin Oncol 21: 2357–2363. [crossref]

Oral Drug Compounding in Pediatric Patients: a Japanese Perspective

DOI: 10.31038/JPPR.2019231

Body Text

Many medicines used for pediatric patients are not available in pharmaceutical forms adapted to their needs. Actually, most oral medications are developed for adults as tablets and capsules. These forms are lack of dosing flexibility and it does not meet dosage requirements for pediatric patients from neonates to adolescents [1]. According to the updated review that including new pediatric formulations marketed in the United States (US), the country of European Union (EU), and Japan spanning the years 2007 to 2018, 16 kinds of pediatric oral formulations of which 7 drugs are ready-to-use and manipulation is required in 9 drugs, and 51 total new pediatric oral formulations of which 21 drugs are ready-to-use and manipulation is required in 30 drugs [2]. Furthermore in Nigeria, that is one of the low-middle income countries, 121 of 143 oral essential medicines (85%) were not available as flexible solid oral dosage forms and manipulation is forced [3].  When this manipulation is forced, the adult dosage forms are manipulated by either a health care provider, such as pharmacist, or by the parents and caregivers (e.g., crashing or grinding a tablet, capsule opening and sprinkling it into some foods or drink). These processes are called compounding and are commonplace for those medicines that lack pediatric formulations. Compounding procedures are regulated by provincial pharmacy standards, based on guidelines published by the National Pharmacy Regulatory Authorities (NPRA) in Canada or the US Pharmacopeia (USP). However, compounded medicines are not approved by rigorous process in each country such as Food and Drug Administration (FDA), European Medical Agency (EMA), Health Canada, Pharmaceuticals and Medical Devices Agency (PMDA) and the other region’s regulatory authorities.

The compounded medication’s characteristics and its physical property and specifications are not always known, and its compounding procedure is not well established or controlled and validated before their use in children. This is particularly true with reference to: stability, potency, content uniformity, purity or bioavailability, and so on. First and most important, the administration of the appropriate dose cannot be guaranteed. Moreover, most of the compounded medicines have an unpleasant and bad taste, which leads to adherence challenges. Even if every compounding process is taken to ensure, errors have a potential to do occur. Some compounding is needed in oncologic drugs with the concerns and obvious health risks to health providers and/or caregivers. It has the potential to expose the entire family to these toxic chemical agents.  Furthermore, the vehicle (e.g., juice, milk or yogurt) used to dissolve drugs and administer these compounded medicines, or to mask the bad taste of compounded drugs, has a potential to influence drug absorption. Especially, physicians and pharmacist need to be aware of the consequences of compounded medicines for drugs with a narrow therapeutic and safety drug index. Compounding at home also increase the variability in the product by inaccurate measurement, issues with stability or errors in instruction for manipulation [4]. Caregivers often mistake the procedure of the extemporaneous preparation [5]. A lack of bioequivalence study of compounded drugs is also concerned [6]. It is important as the formulation can lead the difference between successful treatment and therapeutic failure.

According to our survey results of 328 hospitals that have a pediatric department in Japan, that account for approximately a half of pediatric department, a total of 320 compounded drugs were identified and most of them were administered as a powder formulation. Top five percentile of compounded drugs were briefly indicated in Table 1. In Canada, the Goodman Pediatric Formulation Center which is a not-for-profit organization that is working as a facilitator between industry, regulatory and reimbursement agencies to bring commercialized pediatric formulations into Canada, also conducted a survey with hospital pharmacists from a dozen pediatric Canadian institutions in 2017. A total of 12 drugs were identified as a priority by at least one third of investigated institutions. Noteworthy, 11 of 16 drugs were same with the result of our survey, suggesting that a lack of appropriate formulation for pediatric patient is common issue in the world and global drug development may be an effective solution (Table 1, the 5th column).

Table 1. The current state of compounding in 328 hospitals that have pediatric departments in Japan and availability in other regulatory authorities.

Active ingredients name

Frequency of compounding No. (%)

Pre-compounded dosage form (strength)

Compounded Dosage Form

Common desired flexible dosage forms among Japan and Canadaa

Already approved flexible dosage forms in FDA, MHRA and EMAb

Dantrolene sodium hydrate

67 (20.6%)

Capsule (25mg)

Powder

N/A

Ramelteon

65 (20.0%)

Tablet (8mg)

Powder

N/A

Baclofen

58 (17.9%)

Tablet (10mg)

Powder

Oral liquid 5mg/5ml

Hydrocortisone

56 (17.2%)

Tablet (10mg)

Powder

N/A

Dexamethasone

49 (15.1%)

Tablet (0.5mg)

Powder

Elixir 0.1mg/mL

Prednisolone

49 (15.1%)

Tablet (5mg)

Powder

Syrup 3mg/mL

Enalapril maleate

45 (13.9%)

Powder (5mg)

Powder (dilution)

Oral solution 1mg/mL

Tadalafil

42 (12.9%)

Tablet (20mg)

Powder

N/A

Carvedilol

41 (12.6%)

Tablet (2.5mg)

Powder

N/A

Sildenafil citrate

30 (9.2%)

Tablet (20mg)

Powder

Powder for oral suspension 10mg/ml

Clonidine hydrochloride

30 (9.2%)

Tablet (75µg)

Powder

N/A

Levothyroxine sodium

30 (9.2%)

Tablet (50µg)

Powder

Oral solution 100µg/5ml

Diazoxide

26 (8.0%)

Tablet (25mg)

Powder

Oral suspension 50mg/mL

Aspirin

23 (7.1%)

Powder (1g/g)

Powder (dilution)

N/A

Propranolol hydrochloride

22 (6.8%)

Tablet (10mg)

Powder

Oral solution 8mg/mL

Methotrexate

22 (6.8%)

Tablet (2.5mg)

Powder

Oral solution 2mg/ml

a. The information about compounding in Canadian hospital was provided by the Goodman Pediatric Formulations Centre. Check marks (✔) indicate the common drugs that are desired from both Canada and Japan.
b. Approved drug information was searched using the websites provided from Food and Drug Administration (FDA) in the United States, Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom, and European Medical Agency (EMA)
Compounded drugs in the top 5 percentile was indicated. No., number; N/A, not available.

If the global product development is proceeding, which formulation is acceptable?

In many cases, commercialized pediatric formulations are available in other jurisdictions, such as in the US and in Europe and these are often developed as liquids or suspensions (Table 1, right column). Oral liquid medicines have some disadvantages over solid medicines. The major barrier in development of oral liquid formulations is taste-masking of drugs as almost all of health provider for pediatric patients in the US reported that a taste and palatability were the greatest barriers to appropriate medication [7]. The excipients used in the development of a product need to be safe and acceptable for use in children. Excipients are typically used to optimize the formulation of the medicine to improve palatability, shelf-life and/or manufacturing processes [8]. Another problem is that liquid medicines are less chemically stable than solid medicines and require refrigeration in hot climates to guarantee their quality and efficacy. When a company manufactures develop a product for different regions, it may be necessary to adapt tastes and flavors in order to different regional preferences. Having knowledge about caregivers’ perceptions would also be needed. These issues become a bottleneck restricting to facilitating the age-appropriate drug development. In 2008, the challenges of ensuring access to appropriate drug formulations for pediatric patients led the World Health Organization (WHO) to propose flexible solid oral dosage forms as the preferred formulations for them [9]. The use of oral solid dosage forms such as dispersible tablets, powders, granules, films or sprinkles for reconstitution have a potential to be an excellent substitute for liquid formulations, because the solid product has typically better stability compared with a liquids. However, the instructions for reconstitution can be complicated for untrained or uneducated individuals, yet it is important that the final product contains the correct dosage for the patients. If these forms are administered in the absence of water they are only applicable to infants who are accepting solid such as a baby food. The risk of any error also remains.

From these compelling issues, the Academy of Pharmaceutical Science and Technology in Japan and its subcommittees named ‘the individualized medicine focus group’ and ‘the clinical formulation focus group’, decided to prepare countermeasures in medically ensured compounding procedures. We aimed to collect accurate information about the present status of compounding and unclose what information is needed to the medically ensured compounding procedure.

To facilitate the drug development globally, no regulatory and financial drivers to develop age-appropriate medicines for pediatric patient become a heavy drag, especially about off-patent drugs. In the European countries, there is a significant number of existing drugs where age-appropriate formulations are needed [10, 11]. Almost all of these drugs are generic drugs developed in the remote past for which there are no incentives or any intellectual property protection, making these drugs less interesting to invest time and cost. Requesting an age-appropriate drug development to industrial companies is one of the best solutions, however, ensuring the quality of compounded formulation by the health professionals is required as an urgent issue. While the future of ideal pediatric oral formulations may increasingly be with taste-masked, preservative-free, and user-friendly formulations including multi-particulate solid dosage forms such as mini-tablets, orally disintegrating tablets, and granules, to assure the quality of compounded drug that is not on the radar of manufacturer is needed.

Acknowledgement

This work was supported by a Research Program from the Japanese Agency for Medical Research and Development under Grant Number JP19mk0101134, awarded to H.N. We are grateful to collaborated 328 hospital pharmacists who supported us to perform our survey.

References

  1. Venables R, Marriott J, Stirling H (2012) FIND OUT: key problems with children’s medicines formulations … It’s a taste issue! Int J Pharm Pract 20: 23.
  2. Strickley RG (2019) Pediatric oral formulations: an updated review of commercially available pediatric oral formulations since 2007. J Pharm Sci 108: 1335–1365.
  3. Orubu ES, Tuleu C (2017) Medicines for children: flexible solid oral formulations. Bull World Health Organ 95: 238–240.
  4. Richey RH, Shah UU, Peak M, Craig JV, Ford JL, et al. (2013) Manipulation of drugs to achieve the required dose is intrinisic to paediatric practice but is not supported by guidelines or evidence. BMC Pediatr 13: 1–8.
  5. Tomlin S, Cokerill H, Costello I, Griffith R, Hicks R, et al. (2009) Making medicines safer for children – guidance on the use of unlicensed medicines in paediatric patients. Guidelines 1–12.
  6. Batchelor HK, Marriott JF (2015) Formulations for children: problems and solutions. Br J Clin Pharmacol 79: 405–418.
  7. Milne CP, Bruss JB. (2008) The economics of pediatric formulation development for off-patent drugs. Clin Ther 30: 2133–2145.
  8. Fabiano V, Mameli C, Zuccotti GV. (2011) Paediatric pharmacology: remember the excipients. Pharmacol Res 63: 362–365.
  9. WHO. Annex 5. (2012) Development of paediatric medicines: points to consider in formulation. World Health Organ Tech Rep Ser 970: 197–225.
  10. EMA. (2013) Revised provisional priority list for studies into off-patent paediatric medicinal products. EMA/98717/2012: 1–12.
  11. WHO. (2015) WHO Model List of Essential Medicines for Children. 5th Edition: 1–42.

Comparison of Various Selection Strategies Used for Isolation of Human Monoclonal scFv Antibody Specific to GPCRs Heteromers

DOI: 10.31038/JPPR.2019224

Abstract

Currently, novel drug design focused on the searching pharmacological compounds acting via influence on GPCRs heteromers. The strategy allows obtaining highly selective effects since these heteromers appear only on specific cells and tissues. Therefore, human monoclonal scFv antibodies able to recognizing GPCRs heteromers may constitute a valuable tool in modern therapies. Antibody phage display technique together with high throughput screening play a key role in the development of clinically useful immunomolecules. Therefore in the present work we focused on the comparison of various strategies used for biopanning process during phage display procedure, dedicated to isolation scFv antibodies specifically recognizing GPCRs heteromers. Experiments were conducted in two different cell lines (CHO-K1 and HEK 293) and six various selection procedures were described. Elimination of nonspecific bindings constitutes a key point during the process. Results obtained duing selection conducted in the conditions promoting internalization process were the most satisfactory.

Keywords

Phage Display, scFv antibody, GPCRs, Hetromer, Biopanning

1. Introduction

Recently heteromers (receptor heterodimers) formed by human G-Protein Coupled Receptors (GPCRs) constitute extremely important targets in the design of modern treatment strategies [1]. Alteration of pharmacological properties of the receptors included in the heterocomplex have been proven and widely described in the literature [1–3]. Research focused on finding therapeutic compounds able to selective recognition of GPCRs heteromers are currently very popular. Such strategy allows to obtain a tissue-specific acting, since the interaction between receptors engaged in the complex formation can only take place when the receptors are simultaneously expressed on the same cell. Recent data indicate the existence of clinically relevant GPCRs heteromers, important in the treatment of, among others, pain, asthma or Parkinson’s disease [3–7].

Creation of the human monoclonal antibodies with specificity towards membrane GPCRs heteromers still remains sizable challenge. To fulfil its role, the kind of antibody must recognize the structural epitope formed within the GPCRs heteromeric structure and, at the same time, not show specificity for monomeric or homomeric forms of the receptors. The phage display technology provided the best conditions for the isolation of human monoclonal antibody specifically recognizing the spatial epitope formed by GPCRs heteromers.

Currently phage display technology attracts most attention since the methods is a powerful tool, among others, in drug discovery, nanotechnology, immunology, agriculture, diagnostics, neurobiology, molecular imaging etc [8–12]. The technology developed by George P. Smith in 1985 [13] constitutes a very useful tool for the study of protein–protein, protein–peptide, and protein–DNA interactions [14]. The methodology is based on the fact that phage phenotype and genotype are physically linked [14]. A gene encoding a protein of interest inserted into a gene of bacteriophage coat protein is expressed and presented on the phage surface. The concept is simple: a population of phage is engineered to express random-sequence peptides, proteins or antibodies on their surface [8]. From this population, a selection is made of those phage that bind the desired target [8]. Hereby, large proteins libraries can be screened and unique molecules which bind to their targets with high affinity and specificity can be isolated [15]. The advantage of the method is the possibility of the production of monoclonal antibodies recognizing antigens that cannot be used to immunize an animal due to their toxicity, non-immunogenicity or presence in complexes on the surface of cell membranes [16].

ScFvs (Single Chain Variable  Fragment) are small monoclonal antibody fragments composed of immunoglobulin-heavy (VH) and light chain-variable (VL) regions with a flexible peptide linker designed to connect the two chains such that the antigen binding site is retained in a single co-linear molecule [17]. The kind of antibodies can be derived from phage display libraries [18,19]. ScFvs are very useful in pharmacology and diagnostic fields as well as in drug delivery issues since they can function as targeting ligands. Functionalization of the surface of drug carriers by scFvs enable controlled transport of pharmacological compounds directly to the desired place of action [20].  ScFvs, in comparison to the much larger Fab, F(ab)2, and IgG forms, are characterized by better tissue penetration, lower retention times in non-target tissues, faster blood clearance and, above all, reduced immunogenicity. These features cause that they are very useful for therapeutic applications [21].

The main purpose of presented work was the description of different strategies which may be used during phage display procedure for the isolation of scFvs antibodies specifically recognizing human GPCRs heteromers. To separate the phages that effectively bind defined heteromer it is extremely important to carry out the selection rounds in conditions most similar to those in which desirable receptors occur naturally in the cells, which allowed to preserve the native spatial conformation of the heteromer. Elimination of nonspecific binding without losing rare specific ones seems a serious challenge. Therefore, in the work several various types of selection were presented. The experiments were independently conducted for two GPCRs pair: dopamine D2 (D2R) and serotonin 5-HT1A (5-HT1AR) receptors as well as  dopamine Dand serotonin 5-HT2A receptors. Similar results were obtained for both cases. For simplicity in the work the outcomes for D2–5-HT1A were presented.

2. Materials and Methods

2.1 Cell culture and Transfection

CHO-K1 cells (ATCC) were grown in RPMI (Sigma) medium; HEK 293 cells (ATCC) were grown in minimal essential medium (MEM) (Sigma) with 1% L-glutamine. Both medium were supplemented with 10% heat-inactivated fetal bovine serum (FBS) (Sigma). All cells were cultured at 37 °C inside a humidified incubator in an atmosphere of 5% CO2. Transient and stable transfections were made by using the TurboFect reagent (Thermo Sci.) according to the manufacturer’s protocol. Early passages of CHO-K1 as well as HEK 293 cells were stably transfected (1.5 µg DNA) with the plasmid pcDNA3.1(+) encoding the human 5-HT1AR or the human D2R (UMR cDNA Resource Centre) separately or cotransfected with both vectors. Stable cell lines expressing D2R and/or 5-HT1AR were obtained after the addition of the selection antibiotic, G418 (Sigma), at a final concentration of 0.75 mg/ml. Cells resistant to the antibiotic and stably expressing investigated receptors were analysed by RT-PCR (data not shown). Forty-eight hours before the selection experiment, stable cell lines were, additionally, transiently transfected with 0.5 µg DNA (per 10 mm plate area) encoding the desired receptors.

2.2 Screening of phage-displayed scFv libraries

The human antibody scFv phagemid library Tomlinson I+J (Geneservice) was used. The library J was amplified and titrated (used the library size was 1.9×1012 cfu) according to the manufacturer’s protocols using E. coli TG1 cells [18]. Biopanning was performed on positive (+) and negative (-) cells expressing desired receptors. CHO-K1 as well as HEK 293 cell lines were used. CHO+ and HEK+ cells constituted cells expressing D2–5–HT1A heteromers whilst CHO- and HEK- cells expressed separately D2R or 5–HT1AR and were mixed before experiment in a 1:1 ratio. Four – six positive rounds of selection followed by prenegative selection and one final negative selection were performed independently on both mentioned above cell lines. Briefly, during preselection amplified phages were blocked for 2 hr at room temperature (RT) in 3% MPBS (with stirring from time to time) and then were added to the negative cells (growing on 150 mm plates (15x) 95% confluence) or to the cells suspension – 108 cells) for 2 hr at RT (with stirring from time to time). Next, the cells were collected and centrifuged (10 min at 1000 rpm). Supernatant containing unbound phages was used to positive selection. The final negative selection were performed similarly to preselection.

2.2.1 Positive selection – type A and B

Phages derived from preselection were added to the culture medium of positive cells growing on 150 mm plates (10x, 95% confluence) and were incubated with shaking for 2 hr at 37 °C (type A) or at RT (type B). After that time, unbound phages were washed away with PBS buffer. The number of washes after each round of selection has been shown in Table 1. In the next step, the cells were collected, centrifuged and resuspended in PBS containing 1 mg/ml trypsin. The suspension was incubated on the rotator for 10 min at RT and then centrifuged (10 min, 1000rpm, 4 °C). The supernatant containing the desired phages after titration and amplification was used for another round of biopanning.

Table 1. Number of washing steps performer after each round of selection during phage display procedure.

NUMBER OF WASHING STEPS

Selection case

I

II

III

IV

V

VI

A

5

10

20

30

30

30

B

5

10

20

30

30

30

C

3

6

12

24

30

30

D

4

6

8

10

12

15

E

4

6

8

10

12

15

F

4

6

8

10

12

15

2.2.2 Positive selection – type C

Positive cells growing on 150 mm plates (10x, 95% confluence) were used. Phages after preselection were added to the cell medium for 2 hr (at 0 °C). Then, the medium was removed and cells were washed 3 times with cold PBS. Between washings, RPMI medium was added, and the cells were incubated on ice for 10 min. Then, the temperature of incubation was changed to 37 °C for 20 min. In the next step, the cells were washed 4 times using elution buffer (100 mM glycine, 150 mM NaCl, pH 2.8). The number of washes increased (twice each time) with subsequent rounds of selection. Finally, cells were harvested from the plates and resuspended in PBS containing trypsin (1 mg/ml) for approximately 15 min (until cell lysis). Then, the obtained suspension was centrifuged (10 min, 4000 rpm, 4 °C), and the supernatant containing the desired phages after titration and amplification was used for another round of biopanning.

2.2.3 Positive selection – type D

The experiment was performed in the cells suspension expressing both desired receptors (positive cells). The number of used cells (in the first round was 2 × 107) increased twice with subsequent rounds of selection. Phages were incubated with the cells for 2 hr with shaking at RT. Then unbounded phages were eliminated by washing (PBS) and centrifugation (10 min, 1000 rpm, RT) (Table 1). In the next step cell pellet was resuspended in PBS containing trypsin (1 mg/ml) for approximately 5 min. Then the suspension was centrifuged (10 min, 4000 rpm, RT), the supernatant was collected and after titration and amplification was used for another round of biopanning.

2.2.4 Positive selection – type E and F

In case E and F experiments were performed similarly to type D. Differences appeared at the stage of acquiring bounded phages. In type E, after washing steps cell pellet was incubated with H2O (caused cell lysis) for 10 min with shaking at RT. Then trypsin (1 mg/ml) in PBS was added to the suspension for 10 min incubation at RT. Finally, the desired phages were obtained from the supernatant after centrifugation (10 min, 4000 rpm, RT).

In case F, after washing steps the cell pellet was incubated for 15 min at RT with clozapine (10–9 M). Then, after centrifugation (10 min, 1000 rpm, RT) the supernatant was collected and the trypsin (1 mg/ml) in PBS was added. Obtained phages after titration and amplification were used for another round of biopanning.

2.3 Polyclonal phage ELISA

The quality of the biopanning process was monitored using polyclonal phage ELISA. Amplificated phages (50 µl) obtained after selection rounds were incubated with 50 µl of 4% MPBS for 2 hr at 37 °C. Then, 1.5 × 105 cells (resuspended in 50 µl of medium with 5% FBS) were mixed with previously blocked phages. Both the positive (CHO+ or HEK+ cells expressing D2–5-HT1A heteromers) and the negative (CHO- or HEK- cells  expressing a single type of receptor mixed at the 1:1 ratio) probes were used. After 1 hr ice incubation, the washing step was conducted 3 times at 4 °C using 200 µl cold PBS. Each washing round ended with centrifuging (1000 rpm x g, 10 min, 4 °C), and the supernatant rejection. Detection of bound phages were determined by horseradish peroxidase (HRP)-conjugated anti-M13 monoclonal antibodies (GE Healthcare). Briefly, after washing, the probes were incubated with the antibody resuspended in a 1:5000 ratio in 3% MPBS for 30 min on ice and then washed 4 times as described above. Finally, 100 µl of TMB substrate (GE Healthcare) and 100 µl of 1 M HCl (per well) were used to induce the reaction. The absorbance was measured at 450 nm. Experiments were performed in triplicate.

2.4 Monoclonal phage ELISA

Based on the results of polyclonal phage ELISA, phage clones from rounds characterized by the highest affinity against positive cells (CHO+ or HEK+) cells were randomly selected for monoclonal phage ELISA experiments. Individual bacterial colonies were inoculated into 96-well plates containing 100 µl 2xTYAG (2xTY (Bioshop) with 100 μg/ml ampicillin (Sigma) and 1% glucose (Bioshop)) medium per well and cultured overnight at 37 °C (250 rpm shaking). Then, 5 µl of the culture (from each well) was added to fresh 200 µl 2xTYAG medium and cultured with shaking (250 rpm) at 37 °C for 2 hr. Next, 109 helper phages were added to the each well and incubated for 1 hr and at 37 °C with shaking at 250 rpm. After centrifugation (1800 x g, 10 min), the supernatants were removed, and bacterial pellets were resuspended in 200 µl 2xTYAKG (2xTY containing 100 μg/ml ampicillin, 50 µg/ml kanamycin (Sigma) and 1% glucose) medium and incubated overnight at 30 °C (250 rpm). Finally, after plates centrifugation (1800 x g, 10 min), the 50 µl of supernatants (containing monoclonal phages) were used in the phage ELISA as described above (2.3).

3. Results and Discussion

The phage display technology has provided the ability to create antibody libraries that contain a great number of phage particles, from which each one encodes and displays different molecules (106–1011 different ligands in a population of > 1012 phage molecules) [14]. Finding the most suitable molecule that reflects desired properties depends largely on proper conduction of biopanning experiments. It is extremely important especially in case of isolation of monoclonal scFv antibodies directed towards GPCRs heteromers.  Because the kind of antibody must recognize spatial epitope that naturally occurs within heteromer structure, the key issue constitute such choice of experimental conditions which would ensure a natural environment in which heteromers may be formed. Generally the biopanning method is based on repeated cycles of incubation, washing, amplification and reselection of bound phage [14]. The target molecule may be immobilized on solid support as microtiter plate wells, PVDF membrane column matrix or immunotubes magnetic beads and even on whole cells [14]. In our case target antigen (defined heteromer) was presented on the surface of living cells. This kind of biopanning process is more complicated than in case when purified antigen is immobilized on the plate surface. A large number of variables can affect the behaviour of cells, which can translate into the quality of expressed heteromers and the key parameter here is the presentation of the ideal heteromer structure for the selection.

Several parameters affect biopanning efficiency, including antigen concentration, temperature, washing stringency (washing number and composition of wash buffer) as well as blocking and elution buffer composition [22]. Therefore, in the present work six various strategies (types A-F) of selection were described. Experiments were performed depending on the temperature (0 oC, RT, 37 oC), in the conditions that promote internalization process (type C), in the conditions where heteromer-bounded phages were isolated from interior of the cells after water lysis (type E), in the conditions where heteromer-bounded phages were displaced by clozapine (type F). Moreover during experiments washing stringency was maintained (Table 1). Additionally, two different cell line (CHO-K1 and HEK 293) were adopted to the procedure. Experiments were performed for attached cells as well as in the cells suspension. CHO-K1 cells are well attached to the surface than HEK 293 cells which makes them better for experiments conducted on plates where rigours washing steps are made. Comparison both used cell lines indicate that results obtained for such experiments using HEK 293 cells were definitely worse (Table 2 A,B). Probably most phages were lost during washing steps which was related to the easy detachment of cells from the plate.

Table 2. Titre of phages after each selection round (I-VI positive selection followed by negative preselection, VII – negative selection). Procedure performed on A) CHO-K1 cells, B) on HEK 293 cells.

A) CHO-K1 cell line

Selection type

I

II

III

IV

V

VI

VII

A

1,4 ×105

2,3 ×107

2,8 ×108

4,4 ×108

6,1 ×109

B

2,6 ×105

1,2 ×107

3,1 ×108

2,4 ×108

6,7 ×109

C

4,0 ×103

2,1 ×106

1,9 ×106

3,2 ×108

6,4 ×109

D

2,9 ×104

2,6 ×106

1,5 ×107

3.2 ×107

4,7 ×108

E

1,9 ×103

0,5 ×106

0,9 ×106

1,2 ×107

2,1 ×107

F

6,8 ×104

4,7 ×106

2,8 ×107

4,8 ×107

5,2 ×108

B) HEK 293 cell line

Selection

type

I

II

III

IV

V

VI

VII

A

0,9 ×104

5,3 ×105

1,8 ×106

1,2 ×106

2,3 ×106

1,7 ×106

6,8 ×106

B

7,6 ×103

1,6 ×105

3,9 ×105

2,7 ×106

2,9 ×106

1,9 ×106

3,7 ×106

C

3,0 ×103

2,7 ×104

1,9 ×105

2,3 ×105

2,7 ×106

1,9 ×106

5,4 ×106

D

2,1 ×103

4,2 ×104

5,4 ×106

1,4 ×107

4,1 ×108

3,8 ×108

1,8 ×109

E

0,9 ×103

2,1 ×103

4,5 ×104

6,7 ×104

9,5 ×103

1,2 ×105

4,8 ×105

F

2,9 ×103

5,1 ×105

7,1 ×106

8,3 ×107

9,7 ×107

4,3 ×107

1,9 ×108

The selection process was assessed by monitoring the enrichment ratio and polyclonal phage ELISA. The increasing titre of phages as well as polyclonal phages ELISA results indicates the correctness of the biopanning process and corresponds with the enrichment of phages that specifically recognized the defined heteromer. Preselection conducted on negative cells provided initial elimination of phages exhibited binding affinity towards monomeric forms of receptors included into D2–5-HT1A heteromers as well as towards other molecules presented on the cell surface. It was very important and critical move because it enrich the amount of phages acquiring potentially, desired binding properties before the actual positive selection. Results obtaining during experiments performed without negative preselection was not as satisfying as expected (data not shown). The biopanning rounds were repeated until the obtained results (phages titre and polyclonal ELISA) related to positive (specific to defined heteromer) phages reached a plateau or started to decline (Figure 1,2, Table 2A,B). In case of experiments performed on CHO-K1 cells the plateau was achieved faster (after 4 round of selection) (Table 2A). For both cell lines. the level of polyclonal phages binding to positive cells increase with the number of selection. Moreover, in the initial rounds the difference between “phages” binding affinity to positive vs. negative cells was much smaller than in case of further rounds. Similarly to preselection, the last, only negative selection plays also an important role in the elimination of nonspecific bounded phages. As we can see the phages titre as well as binding specificity significantly increased after the last negative selection. Conducting further, only negative selection did not caused further increase of phages titre and binding affinity (data nor shown).

JPPR 19 - 114 Sylwia Łukasiewicz_F1

Figure 1. Polyclonal phage ELISA. Enrichment of phages that specifically recognized the D2–5-HT1A heteromer. Experiments performed in CHO-K1 cell line. A-F various selection types.

JPPR 19 - 114 Sylwia Łukasiewicz_F2

Figure 2. Polyclonal phage ELISA. Enrichment of phages that specifically recognized the D2–5-HT1A heteromer. Experiments performed in HEK 293 cell line. A-F various selection types.

After the selection process, the specific binding of individual monoclonal phages to cells presenting defined heteromers was determined by monoclonal phage ELISA techniques. Such tests were conducted on various cell lines (CHO-K1, HEK293) expressing desired receptors in pairs or individually. The kind of experiment enable real identification of monoclonal phages displaying desired scFv molecules on the surface. About 1000 phages obtained after each type of selection were tested. Table 3 presents the results obtained for the three best phages for a given type of selection. The most satisfactory results (the highest heteromer specificity) were obtained in case of selection in conditions conducive to internalisation (type C) as well as in case of selection F where phages were displaced by clozapine. Clozapine is a pharmacological compounds which well-known affinity towards both D2R and 5-HT1AR [23–25]. Moreover its influence on various GPCRs heteromer formation has been documented [26–27]. As we can see here (Fig 1,2, Table 2), the titre of phages after final selection round (type F) was not as higher as in C case, however, the quality of isolated scFvs were very promising (Table 3).

Table 3. Binding level of various monoclonal phages specific to D2–5HT1A heteromer (results for 3 the best phages) presented on positive cells (CHO+ or HEK+ cells) in relation to: CHO-K1, CHO- cells – or HEK 293, HEK- , determined by ELISA technique. [R] –ratio of positive (absorbance 450nm positive cells) vs negative signal (absorbance 450nm negative cells).

Phage code

CHO-K1
[R]

CHO-
[R]

Phage
code

HEK 293
[R]

HEK-
[R]

Selection A

5E/5r1

4.44

4.67

experiments were not carried out due to the poor results of polyclonal ELISA

1F/5r4

3,54

3,21

1G/5r3

5,26

4,31

Selection B

1E/5r1

5,01

5,76

experiments were not carried out due to the poor results of polyclonal ELISA

10F/5r1

4,87

4,56

2G/5r2

6,89

7,02

Selection C

10G/5r1

38.81

36.82

experiments were not carried out due to the poor results of polyclonal ELISA

6H/5r2

16.87

16.32

2D/5r4

22.57

23.86

Selection D

2C/5r2

6,77

7,32

1G/7r4

10,54

11,23

1E/5r3

3,73

4,77

1H/7r3

4,67

3,32

1G/5r3

5,21

4,88

1G/7r3

5,32

4,54

Selection E

6D/5r1

2,32

2,76

10G/7r1

2,13

2,44

1C/5r3

3,91

2,98

1D/5r2

2,67

1,87

6F/5r2

3,76

1,76

4E/7r3

2,31

1,76

Selection F

2H/5r4

16,21

14,32

4G/7r3

14,36

14,21

6D/5r4

15,44

13,21

5B/7r2

9,37

7,32

3C/5r1

10,17

10,09

7G/6r2

7,67

6,88

Comparison of the results obtained for both used cell lines indicates that in case of experiments performed on HEK 293 cells, effects were not as promising as in case of CHO-K1 cells. The visible differences appeared only at the monoclonal phages analysis stage. Phages, isolated based on selection on HEK 293 cells were less specific to desired heteromer (Table 3). The phenomenon, beyond the quality of the experiment itself, may be correlated with endogenous expression of D2R on the HEK 293 cell surface.

4. Conclusion

In conclusion presented results indicate the phage display technique as a valuable tool for isolation of human monoclonal scFv antibodies towards GPCRs heteromers. At the same time, they point to the key role of appropriate conditions during biopanning process. Based on our experience the best binding parameters were obtained for phages isolated after selection in the conditions promoting internalization process. A very important is also a proper choice of cell line dedicated to such procedure.  Elimination of nonspecific bindings by negative preselection as well as the last round of the only negative selection constitutes a key point during the biopanning process.

5. Acknowledgment

The Faculty of Biochemistry, Biophysics and Biotechnology is partner with the Leading National Research Centre (KNOW) supported by the Ministry of Science and Higher Education. The work was also co-financed from European Union within Regional Development Fund – Grants for innovation – PARENT/BRIDGE Programme – POMOST/2011–4/5 and N N401 009640 project.

References

  1. Gomes I, Ayoub MA, Fujita W (2016) G Protein-Coupled Receptor Heteromers. Annu Rev Pharmacol Toxicol 56: 403–425. [crossref]
  2. Rozenfeld R, Devi LA (2011) Exploring a role for heteromerization in GPCR signalling specificity. Biochem J 433: 11–18. [crossref]
  3. Albizu L, Moreno JL, González-Maeso J, Sealfon SC (2010) Heteromerization of G protein-coupled receptors: relevance to neurological disorders and neurotherapeutics. CNS Neurol Disord Drug Targets 9: 636–650.
  4. Fujita W, Gomes I, Devi LA (2014) Revolution in GPCR signalling: opioid receptor heteromers as novel therapeutic targets: IUPHAR review 10. Br J Pharmacol 171: 4155–4176.
  5. Derouiche L, Massotte D (2018) G protein-coupled receptor heteromers are key players in substance use disorder. Neurosci Biobehav Rev 29: 0149–7634.
  6. Kamal M, Jockers R (2011) Biological Significance of GPCR Heteromerization in the Neuro-Endocrine System. Front Endocrinol (Lausanne) 1 2: 2.
  7. Carriba P, Ortiz O, Patkar K (2007) Striatal adenosine A2A and cannabinoid CB1 receptors form functional heteromeric complexes that mediate the motor effects of cannabinoids. Neuropsychopharmacology 32: 2249–2259.
  8. Hamzeh-Mivehroud M, Alizadeh AA, Morris MB, Church WB, Dastmalchi S (2013) Phage display as a technology delivering on the promise of peptide drug discovery. Drug Discov Today 18: 1144–1157.
  9. Kushwaha R, Payne CM, Downie AB (2013) Uses of phage display in agriculture: a review of food-related protein-protein interactions discovered by biopanning over diverse baits. Comput Math Methods Med 2013: 653759.
  10. Hairul Bahara NH, Tye GJ, Choong YS, Ong EB, et al. (2013) Phage display antibodies for diagnostic applications. Biologicals 41: 209–216.
  11. Bradbury AR (2010) The use of phage display in neurobiology. Curr Protoc Neurosci Apr;Chapter 5:Unit 5.12.
  12. Cochran R, Cochran F (2010) Phage display and molecular imaging: expanding fields of vision in living subjects. Biotechnol Genet Eng Rev 27: 57–94.
  13. Smith GP (1985) Filamentous fusion phage: novel expression vectors that display cloned antigens on the virion surface, Science 228: 1315–1317.
  14. Bazan J, Calkosinski I, Gamian A (2012) Phage display-a powerful technique for immunotherapy: 1. Introduction and potential of therapeutic applications. Hum Vaccin Immunother 8: 1817–1828.
  15. Tan Y, Tian T, Liu W, Zhu Z, J Yang C (2016) Advance in phage display technology for bioanalysis. Biotechnol J 11: 732–745. [crossref]
  16. Pansri P, Jaruseranee N, Rangnoi K, Kristensen P, Yamabhai M (2009) A compact phage display human scFv library for selection of antibodies to a wide variety of antigens. BMC Biotechnol 9: 6. [crossref]
  17. Bird RE, Hardman KD, Jacobson JW, Johnson S, Kaufman BM, et al. (1988) Single- chain antigen-binding proteins, Science 242: 423–426.
  18. Barbas CF (2001) Phage display: a laboratory manual. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press.
  19. Lee CM, Iorno N, Sierro F, Christ D (2007) Selection of human antibody fragments by phage display. Nat Protoc 2: 3001–3008. [crossref]
  20. Lockman PR, Mumper RJ, Khan MA, Allen DD (2002) Nanoparticle technology for drug delivery across the blood-brain barrier. Drug Dev Ind Pharm 28: 1–13. [crossref]
  21. Frenzel A, Hust M, Schirrmann T (2013) Expression of recombinant antibodies. Front Immunol 4: 217. [crossref]
  22. Rahbarnia LL, Farajnia S, Babaei H, Majidi J, Veisi K, et al. (2016) Invert biopanning: A novel method for efficient and rapid isolation of scFvs by phage display technology, Biologicals 44:567–573.
  23. Newman-Tancredi A, Kleven MS (2011) Comparative pharmacology of antipsychotics possessing combined dopamine D2 and serotonin 5-HT1A receptor properties. Psychopharmacology 216: 451–473.
  24. Lukasiewicz S, Blasiak E, Szafran-Pilch K, Dziedzicka-Wasylewska M (2016) Dopamine D2 and serotonin 5-HT1A receptor interaction in the context of the effects of antipsychotics – in vitro studies. J Neurochem 137: 549–560.
  25. Meltzer HY, Huang M (2008) In vivo actions of atypical antipsychotic drug on serotonergic and dopaminergic systems. Prog Brain Res 172: 177–197. [crossref]
  26. Lukasiewicz S, Faron-Górecka A, Kedracka-Krok S, Dziedzicka-Wasylewska M (2011) Effect of clozapine on the dimerization of serotonin 5-HT(2A) receptor and its genetic variant 5-HT(2A)H425Y with dopamine D(2) receptor. Eur J Pharmacol 659: 114–123.
  27. Lukasiewicz S, Polit A, Kedracka-Krok S, Wedzony K, Mackowiak M, Dziedzicka-Wasylewska M. Hetero-dimerization of serotonin 5-HT(2A) and dopamine D(2) receptors. Biochim Biophys Acta. (2010) 1803:1347–1358.

Can One-Stage In Vitro Dissolution Using Water As Medium Represent Guaifenesin Release From Extended- Release Bilayer Tablets?

DOI: 10.31038/JPPR.2019223

Abstract

Guaifenesin is used as an expectorant. One of its available over-the-counter tablets is immediate- and extended-release bilayer in design. The purposes of this project were [1] to compare the in vitro release profiles between one-stage dissolution (using water as medium) and two-stage dissolution (using 0.1 N HCl and phosphate buffer pH 6.8), and [2] to explore the polymeric release mechanism from the tablet. We also proposed a less acidic liquid chromatographic mobile phase, 50% methanol (which stability indication method was validated), to compare with the mobile phase described in the Guaifenesin Tablets monograph (methanol/water/glacial acetic acid, 40:60:1.5 v/v/v). With the dissolution duration, temperature, paddle stir rate, and sampling schedule being kept the same, the release profiles using Monograph mobile phase to quantify the samples collected from both dissolution methods were found similar (n = 4). When the same set of two-stage dissolution samples were subject to two different mobile phases, the profiles in the acid stage were similarly. But 50% methanol quantified the Buffer Stage samples less than Monograph mobile phase since hour 3, when 250 mL of 0.2 N tribasic sodium phosphate was added and the medium adjusted with 2 N NaOH to pH 6.8. The differences were 12.7% ± 1.4% at hour 4, and 20.9% ± 1.6% at hour 12 (n = 4, p < 0.001). As to the polymeric control, the computed exponent (n value) in the Peppas power law approximation was in the range of 0.7, which suggested release mechanism is anomalous transport. The cross-section of the retrieved tablets at end of the dissolution studies supported the inference.

Keywords

Extended-Release Bilayer Tablets, Liquid Chromatography, One-Stage Vs. Two-Stage In Vitro Dissolution, Peppas Power Law Approximation, Polymeric Control.

Introduction

Guaifenesin, an expectorant, is available over-the-counter in two strengths, 600 mg and 1200 mg [1, 2]. One brand is ER bilayer tablets containing white Immediate Release (IR) and blue ER layers (Figure 1). The Guaifenesin Tablets monograph in USP-NF 2018 (3) describes its dissolution procedure as medium: water; 900 mL; apparatus 2: 50 rpm; time: 45 min and procedure: determine the amount dissolved using UV absorbance at 274 nm, the tolerance was not less than 75% (Q) of the labeled amount dissolved in 45 min [3]. Judging from the dissolution time of 45 min, it is for IR. There are no guidelines specifically written for Guaifenesin ER Tablets in the monograph.

JPPR 19 - 113 Monica Chuong_F1

Figure 1. Guaifenesin 1200-mg bilayer ER tablets. (a) Dissecting an intact tablet illustrated no coating was applied to the core tablet, (b) a tablet retrieved from a dissolution vessel at the end of the 12-h study.

Nicholas Peppas introduced a power law approximation to describe drug release from a dosage form. Both the exponent n and the prefactor k of the equation depend on the dosage form geometry, the relative importance of relaxation and diffusion in the pure polymer swelling controlled drug delivery system [4, 5]. Therefore, the first objective of this project was to search within the General Chapters of USP-NF [3] for an in vitro dissolution method, which might be used to study Guaifenesin ER Tablets. Second, a less acidic Liquid Chromatographic (LC) mobile phase (50% methanol, apparent pH 7.0). Both the Monograph mobile phase (methanol/water/glacial acetic acid, 40:60:1.5, apparent pH 3.08) and the proposed mobile phase (50% methanol) were used to establish standard curves of guaifenesin dissolved in the media used for dissolution study, and quantify the dissolution samples to determine the cumulative drug release from the tablet. Third, it aimed at the comparison of the in vitro release profiles between a one-stage dissolution method × 12 h (using water as medium) and two-stage method (composed of Acid Stage × 3 h, and then Buffer Stage × 9 h). Furthermore, the in vitro release data were plotted according to power law approximation to differentiate the drug release mechanism among Fickian diffusion, anomalous transport and polymer chain relaxation (polymer swelling).

Materilas and Methods

Materials

Over-the-counter 1200 mg Guaifenesin ER Bi-layer Tablets containing a white IR layer, and a blue ER layer for 12 h release (Lot BY646, distributed by Reckitt Benckiser, NJ) were purchased from a local pharmacy. Guaifenesin (Spectrum Chemical, Lot 2EC0288), methanol, glacial acetic acid, 10 mL syringes, 0.22 micron 25 mm Nylon syringe filters were obtained from VWR International (Bridgeport, NJ).

Methods

Examination of Tablet Formulation Development

Four tablets randomly taken from the original container were weighed. The tablets were cut vertically to inspect any coat being applied to the tablet core. The inactive ingredients and their pharmaceutical functions were conducted through literature search [3, 6].

Standard Preparations

Guaifenesin powder was dissolved in three different matrices to address the aims of this study. They were deionized water, 0.1 N HCl and phosphate buffer pH 6.8. In deionized water it was made into 2 mg/mL as the stock solution. It was further diluted with a diluent (made of one part of water and four parts of 45% methanol) into different concentrations of standard preparations, 0.0002, 0.002, 0.08, 0.2, 0.4, 1, 1.2, 2 and 10 mg/mL. For constructing the standard curves with 0.1 N HCl and phosphate buffer 6.8, the standard stock solution was prepared into 10 mg/mL. It was further diluted with a diluent: water – 45% methanol (1:4, v/v) to ensure the work ranges were covered.

UV Spectroscopy

The Scan mode of a Cary 50 UV-Vis Spectrophotometer from Agilent Technologies determined the optimal wavelength of guaifenesin, and Sample Read mode recorded the absorbance of standard solutions.

Liquid Chromatographic Conditions

Agilent Series 1100 (Hewlett Packard) contained Vacuum Degasser, Binary Pump, Auto Sampler, Column Thermostated Compartment, and Variable Wavelength Detector. Two different mobile phases quantifying the standard solutions and in vitro dissolution samples were the mobile phases which may be found in Guaifenesin Tablet Monograph (methanol/water/glacial acetic acid, 40:60:1.5, v/v/v [3], apparent pH was 3.08), and our proposed mobile phase (50% methanol, apparent pH was 7.0). The flow rate was set at 1.0 mL/min and run time 7 min/cycle. The selected column was Luna C18 (USP L1, 4.6 × 150 mm, 5 µm) and the injection volume was 20 microliters.

Potency tests determine the drug content in a sample using HPLC, titration or microbial assay. Stability test, shelf-life and beyond-use date are interchangeable.

Methods of determining potency may or may not be stability indicating, but a stability-indication method can determine both potency and stability [7]. Because we proposed using 50% methanol as the mobile phase, which was considered as a new LC method, the stability-indication method must be validated. A know amount of guaifenesin was dissolved in water (one-stage dissolution medium) and in two-stage dissolution media (0.1 N HCl, and phosphate buffer at pH 6.8 respectively). The samples were subject to the following conditions: (a) 50 oC Heat for 1 h, then cooled to room temperature quickly, (b) 0.1 N HCl (acid) for 1 h prior to neutralized by 0.1 N NaOH, (c) 0.1 N NaOH (base) for 1 h and neutralized with 0.1 N HCl, and (d) 3% hydrogen peroxide solution for 5 min (8). The samples were then quantified using our proposed mobile phase (50% methanol) to ensure the degradant peaks generated by the experimental conditions were separated from analyte (guaifenesin) peak by the resolution (Rs) ≥ 2 [8].

In Vitro Dissolution Methods

Within the USP-NF 2018 two different dissolution methods are stated. One method is in the section of Extended-release Dosage Forms of General Chapters: <711> Dissolution. It describes as “Procedures and medium are as directed for Immediate-Release Dosage Forms in the monographs. But the test-time points generally are three and are expressed in hours.” The dissolution procedures and medium were searched within Guaifenesin Tablets monographs as directed in General Chapters: <711>. The description was medium: 900 mL water; Apparatus 2: 50 rpm; and time: 45 min. This method will refer as one-stage method in the remaining text. The second method is a two-stage acid-buffer method. It is present in General Chapters: <711> Dissolution, but in the section of Delayed-release Dosage Forms, Method A and Method B. This project followed Method a procedure to avoid contamination, loss of tablets, or breakage of a dissolution vessel. The dissolutions and assays are briefly described in the below.

One-stage Dissolution

The one-stage 12-h dissolution study followed the guidelines in Guaifenesin Tablets monograph (medium: 900 mL water; apparatus 2: 50 rpm), except the time was extended to 12 h to study the drug release mechanism. The sampling schedule was at 0.25, 0.75, 1, 3, 4, 6, 8, 10 and 12 h. One part of each dissolution sample was diluted with four parts of 45% methanol prior to subject to LC assay using mobile phases, 50% methanol as well as methanol/water/glacial acetic acid, 40:60:1.5, respectively. The LC AUC of each time point was converted into the cumulated amount of drug release using the established standard curve which medium in the one-stage dissolution was water (n = 3).

Two-stage Dissolution

For the two-stage 12-h dissolution study, an ER bilayer tablet (Figure 1a) was placed in a vessel of USP Dissolution Apparatus 2 containing 750 mL of 0.1 N HCl at 37.0 ± 0.5 oC and stirred at 50 rpm for 3 h. Then 250 mL of 0.2 M tribasic sodium phosphate was added, pH was adjusted to 6.8 with 2 N NaOH. The study continued for another 9 h at 50 rpm while the vessel medium maintained at 37.0 ± 0.5°C. Sampling schedule was selected the same for both one-stage and two-stage dissolution groups, 0.25, 0.75, 1, 3 h (Acid Stage), and 4, 6, 8, 10, and 12 h (Buffer Stage). One part of a dissolution sample was diluted with four parts of 45% methanol (diluent) prior to LC assay. Both mobile phases stated in Section 2.2.4 were applied in the LC system, respectively. The LC AUC of each time-point dissolution sample was converted into the cumulated amount and cumulative percent of drug release using the established standard curves which media were 0.1 N HCl and phosphate buffer pH 6.8.

Data Management for Peppas Power Approximation

After the amount of drug release at a sampling time was known (Mt), it was divided by the infinite amount of release (M), which equaled the tablet label strength (1200 mg). This ratio was then plotted against time (in h) to form a power equation (Equation 1) using the power trend line option in the scatter chart of an Excel worksheet. The power exponent (n) and prefactor (k) in the Peppas equation [6] were thus known from the trend line. The obtained values of release exponent from power trend line was further matched the n value in Table 1 [4, 5] to determine the drug release mechanism.

JPPR 19 - 113 Monica Chuong_SF14

Table 1. The release exponent n of the Peppas power equation and drug release mechanism from polymer-controlled delivery systems in cylinder geometry (4, 5)

Exponent (n)

Drug Release Mechanism

0.45

Fickian diffusion

0.45 < n < 0.89

Anomalous transport

0.89

Polymer swelling

Results

Examination of Tablet Rational Development Approach

The ER bilayer tablets taken from its original container were weighed as 1.454 ± 0.011 g (n = 4, relative standard deviation of the tablet weight was 0.76%). Judging from the dissection the tablet cores were not coated (Figure 1a). The inactive ingredients are FD&C blue #1 aluminum lake (coloring agent), hypromellose (controlled-release agent), magnesium stearate (lubricant), microcrystalline cellulose (tablet diluent and disintegrant), and sodium starch glycolate (tablet disintegrant).

Ultraviolet Spectrophotometric and HPLC Linearity

Guaifenesin dissolved in water to prepared into two different concentrations, 0.008 and 0.2 m/mL, then they were scanned from 190 to 790 nm using Cary 50 spectrophotometer (Agilent). In addition to 274 and 276 nm described in the Guaifenesin and Guaifenesin Tablets monographs [3], 270 nm can also be used as the wavelength to quantify guaifenesin. Thererfore, 270 nm was used in the remaining project including assaying dissolution samples. The standard linearity built using water as solvent and quantified using UV spectrophotometer was 0.001 mg/mL to 0.2 mg/mL (100 fold), while that quantified using LC was 0.001 mg/mL to 1.2 mg/mL (1200 fold). The R2 (coefficiency of determination) when LC AUC (y-axis) in correlation with UV absorbance (x-axis) ranged from 0.001 to 0.2 mg/mL was 0.9999.

The chromatograms of stability indication method showed the degradant peaks generated by subjecting to 0.1 N HCl (acid), 0.1 N NaOH (base), 50 oC (heat) and 3% hydrogen peroxide solution under the exposure time periods described in Section 2.24 either did not produce degradant peak or separated well from analyte (guaifenesin) peak. All the resolution (Rs) were greater than 2 (Please refer to supplemental file).

One-stage In Vitro Dissolution Study Using Water as Medium

The dissolution duration and temperature, paddle stir rate, and sampling schedule were chosen as 12 h, 37.0 ± 0.5 oC, 50 rpm and 0.25, 0.75, 1, 3, 4, 6, 8, 01 and 12 h. When the dissolution samples were quantified using Monograph mobile phase, the bilayer ER tablets released 28.0 ± 1.4 % guaifenesin into water at 45 min, 30.4 ± 1.7 % at 1 h, 44.1 ± 6.0 % at 3 h, and 72.1 ± 4.4 % at 12 h (n = 4, Table 2a). When the same samples were assayed using 50% methanol as the mobile phase, the drug releases were: 29.5 ± 1.5 % at 45 min, 32.2 ± 1.6 % at 1 h, 44.7 ± 3.0 % at 3 h, and 75.7 ± 4.3 % at 12 h (n = 4, Table 2a). The dissolution profiles were almost identical and displayed as bi-phasic release when either mobile phase was used to quantify the same set of dissolution samples (n = 4, Figure 2).

JPPR 19 - 113 Monica Chuong_F2

Figure 2. Similarity of one-stage 12-h in vitro dissolution profiles between the Monograph mobile phase (methanol/water/glacial acetic acid, 40:60:1.5, v/v/v) and the proposed mobile phase (50% MeOH) when water was the chosen dissolution medium.

Table 2. Cumulative percent of guaifenesin release from bi-layer tablets at key sampling points

(a) One-stage dissolution with different mobile phases

Sampling Time (h)

Monograph MP

50% MeOH
as MP

P Value*
Paired-t test
(Independent-t test)

0.75

28.0 ± 1.4

29.5 ± 1.5

< 0.001 (< 0.05)

1

30.4 ± 1.7

32.2 ± 1.6

< 0.001 (> 0.05)

3

44.1 ± 6.2

44.7 ± 3.0

< 0.001 (> 0.05)

4

47.4 ± 2.9

49.6 ± 3.0

< 0.001 (> 0.05)

12

72.1 ± 4.4

75.7 ± 4.3

< 0.01 (> 0.05)

*Two-tailed distribution

(b) Different dissolution methods, but same mobile phase (monograph MP) to assay

Sampling
Time (h)

Cumulative Release (%) in One-stage Method (Water)

Cumulative Release (%) inTwo-stage Method
(0.1 N HCl 3 h, Buffer 9 h)

P Value*
Independent-
t test

0.75

28.0 ± 1.4

31.7 ± 4.1

> 0.05

1

30.4 ± 1.7

36.3 ± 4.0

< 0.05ξ

3

44.1 ± 6.2

56.4 ± 4.4

< 0.01ξ

4

47.4 ± 2.9

55.2 ± 2.1

< 0.01ξ

12

72.1 ± 4.4

79.4 ± 1.9

< 0.05ξ

*Two-tailed distribution
ξ Statistically significant

(c) Same two-stage (0.1 N HCl 3 h, then Buffer 9 h) dissolution method with different mobile phases

Dissolution

Sampling

Time (h)

Cumulative Release (%) Using

Monograph MP

Cumulative Release (%) Using 50% MeOH as MP

P Value*

Paired-t test

(Independent

t-test)

0.1 N HCl

0.75

31.7 ± 4.1

32.2 ± 2.8

> 0.05 (> 0.05)

1

36.3 ± 4.0

36.0 ± 3.0

> 0.05 (> 0.05)

3

56.4 ± 4.4

55.0 ± 5.6

> 0.05 (> 0.05)

Phosphate Buffer

4

55.2 ± 2.1

45.8 ± 0.9

< 0.001
(< 0.001)¥

pH 6.8

12

79.4 ± 1.9

62.3 ± 0.7

< 0.001
(< 0.001)¥ 

*Two-tailed distribution
¥ Statistically significant in both paired and independent t-tests.

One-stage versus Two-stage In Vitro Dissolution Study Using Monograph Mobile Phase

The dissolution duration and temperature, paddle stir rate, and sampling schedule were kept the same as Section 3.4, but only the Monograph mobile phase (methanol/water/glacial acetic acid, 40:60:1.5, v/v/v [3], apparent pH was 3.08) was used. The drug release between one-stage and two-stage methods were 28.0 ± 1.4 % vs. 31.7 ± 4.1 % at 45 min, 30.4 ± 1.7 % vs. 36.3 ± 4.0 % at 1 h, 44.1 ± 6.2 % vs. 56.4 ± 4.4 % at 3 h, and 72.1 ± 4.4 % vs. 79.4 ± 1.9 % at 12 h (n = 4, Table 2b). These releases in these sampling points were different statistically after 45 min dissolution study (Table 2b, Figure 3a).

JPPR 19 - 113 Monica Chuong_F3

Figure 3. Dissolution method and mobile phase as factors impacting guaifenesin release profiles: (a) design of dissolution method: one-stage in water versus two-stage (acid and buffer stages) when USP Guaifenesin Tablets monograph mobile phase, and (b) selection of mobile phase: 50% MeOH versus USP Guaifenesin Tablets monograph mobile phase. A depression of 12.7% ± 1.4% (n = 4) present 1 h after the medium pH was adjusted to 6.8 (that is the end of 4 dissolution hours). This depression continued until dissolution ended (see text).

Two-stage In Vitro Dissolution Study Using 50% Methanol versus Monograph Mobile Phase

The dissolution method was a tablet was placed in 750 mL of 0.1 N HCl for 3 h, and then 250 mL of 0.2 M tribasic sodium phosphate was added into the apparatus vessel with the pH being adjusted to 6.8. The dissolution duration and temperature, paddle stir rate, and sampling schedule were kept the same as Section 3.4, but both monograph mobile phase (methanol/water/glacial acetic acid, 40:60:1.5, v/v/v [3], apparent pH was 3.08) and the proposed mobile phase (50% methanol) were used respectively. The resultant AUC were converted into cumulative % of release and compared. The release profiles in Acid stage (time 0 to 3 h) quantified by both mobile phases were almost identical (Figure 3b). The cumulative percent of releases in Acid stage using Monograph mobile phase and 50% methanol as mobile phase were 31.7 ± 4.1 % vs. 32.2 ± 2.8 % at 45 min, 36.3 ± 4.0 % vs. 36.0 ± 3.0 % at 1 h, 56.4.1 ± 4.4 % vs. 55.0 ± 5.6 % at 3 h (Table 2c). Never the less, the profiles were statistically different in the Buffer stage (3 to 12 h, Figure 3b, and Table 2c). The cumulative percent of releases in Buffer stage using Monograph mobile phase and 50% methanol as mobile phase were 55.2 ± 2.1 % vs. 45.8 ± 0.9 % at 4 h (which means one hour after the pH had been adjusted to 6.8), 79.4 ± 1.9 % vs. 62.3 ± 0.7 % at 12 h (Table 2c).

Power Law Approximation

On order to fit Power Law Approximation equation, the data had to be taken from extended release region. Since the studied tablet was designed as IR/ER bilayer, we subtracted the cumulative amount of release from the dissolution study at a particular sampling point from the cumulative amount of drug release in the first hour (immediate layer) as Mt iin Equation 1, and further divided Mt by M. M was the label amount (1200 mg) minus cumulative amount in 1 hour. The fraction was then plotted against the time of drug released from the ER layer (the total dissolution time minus 1 hour in immediate release layer). Power equations in different dissolution methods and mobile phases were obtained using Excel scatter plot trendline options. The value of the power exponent (n) was 0.767 for both mobile phases, while the prefactor (k) was 0.1007 for Monograph mobile phase and 0.1068 for the proposed mobile phase (50% methanol). The reason of choosing data from hour 2 to hour 12 to fit Peppas power law was based on General Chapter <1088> In Vitro and In Vivo Evaluation of Dosage Forms describes that “For immediate-release dosage forms the in vitro dissolution process typically requires no more than 60 min…” [3]. According to Table 1, the obtained power exponent illustrate that the ER layer of this bi-layer tablet follows Fickian diffusion (Table 3). The Peppas power law was also applied to two-stage dissolution from hour 2 to hour 12 as well as hour 4 to hour 12 using both mobile phases. But the data from hour 2 to hour 12 in the two-stage dissolution method using either mobile phase to quantify are not reported here due to the transition of Acid stage into Buffer stage at the end of hour 3 (Table 3) to avoid misguiding.

Table 3. The release exponent n of the Peppas power equation and drug release mechanism using the ER layer dissolution data from hour 2 to hour 12, and hour 4 to hour 12

Dissolution Method

Dissoultion

Period

LC

Mobile Phase

Exponent (n)

Drug Release Mechanism

One-stage

h 2 to h 12

Monograph

0.767

Anomalous transport

One-stage

h 4 to h 12

Monograph

0.692

Anomalous transport

One-stage

h 2 to h 12

50% methanol

0.767

Anomalous transport

One-stage

h 4 to h 12

50% methanol

0.703

Anomalous transport

Two-stage

h 2 to h 12

Monograph

Not reported*

Two-stage

h 4 to h 12

Monograph

0.639

Anomalous transport

Two-stage

h 2 to h 12

50% methanol

Not reported*

Two-stage

h 4 to h 12

50% methanol

0.775

Anomalous transport

*Due to the transition between acid stage and buffer stages at hour 3 (see text).

Discussion

Hydrogels are polymer networks that contain a substantial amount of water. Dry polymer networks can absorb tens, hundreds, or even thousands of times their weight in water without or with dissolving. They have the properties to those of soft biological tissues and of great utility in pharmacy due to a low interfacial tension and less irritation [9]. The polymer network was able to sustain its own structural integrity through cross-linkage [10]. According to General Chapters: <1088> In Vitro and In Vivo Evaluation of Dosage Forms describes that “For immediate-release dosage forms the in vitro dissolution process typically requires no more than 60 min…”. Using this definition, the drug load in an ER bilayer tablet was determined as approximate ≤ 30% in IR white layer, and the remaining in ER blue layer. The residual tablets were retrieved at the end of the 12-h dissolution study showed white layer of the ER bilayer tablet disappeared, but the blue layer swelled but the integrity was still kept (Figure 4). When the bilayer tablet was cut vertically, the polymers in the core were still densely packed reflecting that dissolution medium had penetrated into the tablet core, but the polymer had not yet fully swelled or disintegrated, which resulted in the tolerance for only about 70% to 75% (Q) of the labeled amount. In addition, the leaching of the colorant and erosion of polymer were evidenced by the dissolution medium changed from clear into light blue and the medium became more viscous and slightly sticky in the 12-h release study.

JPPR 19 - 113 Monica Chuong_F4

Figure 4. A studied tablet was retrieved from a dissolution vessel: (a) at the end of the 12-h study, and (b) the cross-section shows the core was still densely packed. No significant difference was noticed whether the tablet was retrieved from water or phosphate butter pH 6.8.

The in vitro release data of the ER bilayer tablets from 2 h to 12 h (as the extended release region based on General Chapter < 1088 >) was able to format into a power equation with the power exponent (n) in the range of 0.7 (n = 4, Table 3). Matching the exponent (n value) with those cylindrical geometry in Table 1, its release mechanism was anomalous transport (between Fickian diffusion and polyer swelling), but was closer to polymer swelling mechanism. Peppas and coworkers [4, 5, 6] studied theophylline release from poly(HEMA-co-NVP) [poly(2-hydroxyethylmethacrylate-co-N-vinylpyrrolidone)] disks into distilled water. The tablet geometry of this project was a caplet shape (Figure 1). Siepmann J and Siepmann F also mentioned that the thicker the samples a slightly slowing down of release with time is displayed [6]. This was probably due to drug diffusion becoming increasing more rate limiting. Diffusion is slower at greater distances. When plotting the cumulative amount of drug release versus time, geometry, drug solubility and inhomogeneous initial drug distribution [4, 5, 6] may also impact the value of n (power exponent).

The six inactive ingredients of the ER bilayer tablets and their pharmaceutical functions were stated in Section 3.1. They were composed of coloring agent, controlled-release agent, lubricant, tablet diluent, tablet disintegrant, and gelling agent. Therefore, photos taken after a tablet retrieved from the vessel at the end of a dissolution study were dissected to support the release mechanism of anomalous transport determined from Peppas power law power exponent (n). As seen in Figure 4, there is a clearly defined font between the swollen polymer layer and damped tablet core suggesting that polymer relaxation is required for guaifenesin to be released into either water or phosphate buffer pH 6.8.

Conclusion

In vitro dissolution study may be applied to approximate the drug loaded in IR layer and ER layers of an oral tablet. The current study also supports the use of water as the dissolution medium for extended release dosage forms, because time efficacy and green laboratory practice bring affordable products to our patients. Never the less the selection of a proper mobile phase is of essential. The project suggests that for sake of accuracy and precision, one-stage and two-stage dissolution profiles be compared with the same selected mobile phase. If they are similar, the one-stage study using water as dissolution medium may then be preceded. From Peppa power law as well as the dissection examination of retrieved tablets, the ER layer of the bilayer tablet most likely used anomalous transport mechanism to release guaifenesin.

References

  1. https://medical-dictionary.thefreedictionary.com/guaifenesin
  2. http://www.mucinex.com/media/854/drug-facts-maximum-strength-mucinex-se.pdf
  3. U.S. Pharmacopeial Convention (2018) USP Monographs: Guaifenesin, Guaifenesin Tablets, NF Monographs: Sodium Starch Glycolate, General Chapters: <711> Dissolution. In: USP42-NF37. Rockville MD: U.S. Pharmacopeia; 2018: 2121, 2124, 5962, and 6870.
  4. Peppas NA (1985) Analysis of Fickian and non-Fickian drug release from polymers. Pharmaceutica Acta Helvetiae 60: 110–111.
  5. Siepmann J, Peppas NA (2001) Modeling of drug release from delivery systems based on hydroxypropyl methycellulose (HPMC). Adv Drug Deliv Rev 48: 139–157.
  6. Siepmann J, Siepmann F (2012) Swelling Controlled Drug Delivery Systems. In: Siepmann J, Siegel RA, Rathbone MJ (eds.), Fundamentals and Applications of Controlled Release Drug Delivery. Springer Pg No: 154–162.
  7. Rowe RC, Sheskey  PJ, Quinn ME (2009) Handbook of Pharmaceutical Excipients, 6thedn: Pharmaceutical Press: London, UK.
  8. Kupiec T, Skinner R, Lanier L (2008) Stability Versus Potency Testing: The Madness is in the Method. Int J Pharmaceutical Compounding, 12: 50–55.
  9. L.R, Kirkland JJ, Glajch JL (1997) Completing the Method: Validation and Transfer. In: L.R., Kirkland J.J., Glajch J.L. (Eds.), Practical HPLC Method Development. Snyder John Wiley & Sons Pg No: 709
  10. Siegel RA, Alvarez-Lorenzo C (2017) Hydrogels. In: Hillery A, Park K (eds.), Drug Delivery: Fundamentals and Applications CRC Press Pg No: 333.
  11. Hydrogel Materials (2014) Drug Delivery: Materials Design and Clinical Perspective. In: Holowka EP, Bhatia SK (eds.), Springer Pg No: 225.

Supplemental Material

Validation of HPLC Method to Assay Guaifenesin in Acid Stage, Buffer Stage Media and Water Using Proposed Mobile Phase (50% Methanol)

Stability Indication Method of Guaifenesin in Acid Stage, Buffer Stage Media and Water using HPLC with the proposed mobile phase (50% Methanol): in acid-stage medium and subjected to 0.1 N HCl for 1 h; (b) in acid-stage medium and subjected to 0.1 N NaOH for 1 h; (c) in acid stage medium and subjected to 50oC for 1 h; (d) acid-stage medium and subjected to 3% hydrogen peroxide for 5 min; (e) in buffer stage medium and subjected to 0.1 N HCl for 1 h; (f) in buffer stage medium and subjected to 0.1 N NaOH for 1 h; (g) in buffer stage medium and subjected to 50 oC for 1 h; (h) in buffer stage medium and subjected to 3% hydrogen peroxide for 5 min; (i) in purified water and subjected to 50 oC for 1 h; (j) in purified water and subjected to 0.1 N HCl for 1 h; (k) in purified water and subjected to 0.1 N NaOH for 1 h; (l) in purified water and subjected to 3% hydrogen peroxide for 5 min; and (m) in purified water without guaifenesin and subjected to 3% hydrogen peroxide for 5 min as control.

  1. Guaifenesin in acid stage medium (0.1 N HCl) – subject to 0.1 N HCl for 1 hour prior to being neutralized with 0.1 N NaOH to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF1

  2. Guaifenesin in acid stage medium (0.1 N HCl) – subject to 0.1 N NaOH for 1 hour prior to being neutralized with 0.1 N HCl to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF2

  3. Guaifenesin in acid stage medium (0.1 N HCl) – subject to 50 oC for 1 hour prior to cooling to room temperature (n = 3, please refer to pdf version of chromatograms)

    JPPR 19 - 113 Monica Chuong_SF3

  4. Guaifenesin in acid stage medium (0.1 N HCl) – subject to 3% hydrogen peroxide for 5 min prior to decomposing hydrogen peroxide into water and oxygen and allowing the excess oxygen to escape (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF4

  5. Guaifenesin in buffer stage medium (phosphate buffer, pH 6.8) – subject to 0.1 N HCl for 1 hour prior to being neutralized with 0.1 N NaOH to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF5

  6. Guaifenesin in buffer stage medium (phosphate buffer, pH 6.8) – subject to 0.1 N NaOH for 1 hour prior to being neutralized with 0.1 N HCl to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF6

  7. Guaifenesin in buffer stage medium (phosphate buffer, pH 6.8)– Subject to 50 oC for 1 hour prior to cooling to room temperature (n = 3, please refer to pdf version of chromatograms)

    JPPR 19 - 113 Monica Chuong_SF7

  8. Guaifenesin in buffer stage medium (phosphate buffer, pH 6.8) – subject to 3% hydrogen peroxide for 5 min prior to decomposing hydrogen peroxide into water and oxygen and allowing the excess oxygen to escape (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF8

  9. Guaifenesin in purified water – subject to 50 oC for 1 hour prior to cooling to room temperature (n = 3, please refer to pdf version of chromatograms)

    JPPR 19 - 113 Monica Chuong_SF9

  10. Guaifenesin in purified water – subject to 0.1 N HCl for 1 hour prior to being neutralized with 0.1 N NaOH to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF10

  11. Guaifenesin in purified water – subject to 0.1 N NaOH for 1 hour prior to being neutralized with 0.1 N HCl to neutral pH (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF11

  12. Guaifenesin in purified water – subject to 3% hydrogen peroxide for 5 min prior to decomposing hydrogen peroxide into water and oxygen and allowing the excess oxygen to escape (n = 3, please refer to pdf version of chromatograms.)

    JPPR 19 - 113 Monica Chuong_SF12

  13. Purified water without guaifenesin – subject to 3% hydrogen peroxide for 5 min prior to decomposing hydrogen peroxide into water and oxygen and allowing the excess oxygen to escape (as a control group)

    JPPR 19 - 113 Monica Chuong_SF13

Action of an Indolinone Derivative on Plasma Hemostasis

DOI: 10.31038/JPPR.2019222

Abstract

The action of a new pharmaceutical substance of indolinone series, an sGC inducer with antiplatelet activity, on rat blood plasma hemostasis was studied. It was shown that the antiplatelet substance after single oral administration to rats considerably increases thrombin time after 3 hours (24.5 versus 17.3 in control, р < 0.05). Other plasma hemostasis parameters were unchanged.

Key words

antiplatelet, indolinone derivative, plasma hemostasis.

Introduction

Thrombosis plays a key role in the development of acute coronary syndrome, making antiplatelet therapy an important part of prevention and treatment of cardiovascular diseases [1]. One of the main risk factory of cardiovascular disease relapse is insufficiency of existing therapy in people resistant to aspirin and clopidogrel [2,3]. This problem can be solved by using antiplatelet drugs with a novel mechanism of action. Also, increased blood clotting plays a role in cardiovascular complications [4,5]. There were no earlier studies of the action of the indolinone derivative on blood plasma hemostasis.

Study goal – Assess the action of a new antiplatelet compound on rat blood plasma hemostasis after oral administration.

Materials and Methods

Test article – pharmaceutical substance 2-[2-[(5RS)-5-(hydroxymethyl)-3-methyl-1,3-oxazolidine-2-yliden]-2-cyanoethylidene]-1H-indol-3(2H)-one.

Outbred Wistar rats (n=10) were used as test system. Rat handling was performed in accordance with the European Convention and other regulating documents [6].

Intact blood was sampled from common carotid artery of anesthetized rats. The blood was stabilized with 3.8% solution of sodium citrate in 9:1 (v:v) ratio, blood plasma was produced by centrifuging at 2000 g for 20 min.

Plasma hemostasis was assessed by fibrinogen content, activated Partial Thromboplastin Time (aPTT), Prothrombin Time (PT) and Thrombin Time (TT). These parameters were assessed by KG-4 coagulometer (Cormay, Poland). Fibrinogen content was assessed using Claus method.

The antiplatelet drugs were administered to rats once orally in 10 mg/kg dose. At the end of experiment the animals were sacrificed by СО2.

Statistical analysis was performed by «R» software. The data is presented as mean values and mean standard deviation (M ± m). Significance of difference (р<0.05) between the tests was assessed using Mann–Whitney U test.

Result and Discussion

No significant changes of main parameters of plasma hemostasis: fibrinogen, aPTT and PT, were found 3 hours after single oral administration of the antiplatelet drug in 10 mg/kg dose. TT was increased by 42% compared to the control group (Table 1).

Table 1. Effects of the new antiplatelet drug (10 mg/kg) on rat blood plasma hemostasis.

Group

Fibrinogen

aPTT

PT

TT

Control (n=5)

2.0 ± 0.1

14.8 ± 0.7

20.4 ± 0.6

17.3 ± 2.3

Antiplatelet drug (n=5)

1.8 ± 0.1

15.2 ± 0.6

20.1 ± 0.3

24.5 ± 1.0*

Note: * –р < 0.05 compared to control.

The new antiplatelet drug doesn’t affect blood plasma fibrinogen content, activated partial thromboplastin time and prothrombin time, but considerably increases the thrombin time, 3 hours after single oral administration in 10 mg/kg dose [7]. The reduction of platelet aggregation by the new drug leads to reduced exit of active components of the coagulation system from the platelets, which may account for the lengthening of thrombin time. There may also be other explanations for this. Additional studies are required for confirmation or discovery of another mechanism, including, possibly, direct inhibition of thrombin.

References

  1. Popova LV, Axenova MB, Khlevchuk TB (2016) Antiplatelet activity in cardiology. Clinical medicine 10: 729–36.
  2. Shantsila E, Lip GY (2009) Variability of response to antiplatelet therapy: what should we do next? Fundam Clin Pharmacol 23: 19–22. [crossref]
  3. Lee PY, Chen WH, Ng W, Cheng X, Kwok JY, et al. (2005) Low-dose aspirin increases aspirin resistance in patients with coronary artery disease. Am J Med 118: 723–727. [crossref]
  4. Frere C, Cuisset T, Quilici J, Camoin L, Carvajal J, et al. (2007) ADP-induced platelet aggregation and platelet reactivity index VASP are good predictive markers for clinical outcomes in non-ST elevation acute coronary syndrome. Thromb Haemost 98: 838–843. [crossref]
  5. Patrono C (2003) Aspirin resistance: definition, mechanisms and clinical read-outs. J Thromb Haemost 1: 1710–1713. [crossref]
  6. Carkishenko NN, Grachev SV (2003) Guidelines on laboratory animals and alternative models in biomedical technology. Profile: Moscow.
  7. Triplett DA (2000) Coagulation and bleeding disorders: review and update. Clin Chem 46: 1260–1269. [crossref]

Manual Therapy Techniques and their Effectiveness on Improving Posture in Adults: A Narrative Review of the Literature

DOI: 10.31038/IJOT.2019216

Abstract

Objective: To review the literature regarding the use of manual therapy techniques and their effectiveness on improving posture in adults.

Background: Hyperkyphosis of the upper spine is a condition that increases with age and leads to decreased pulmonary function, balance, and muscle strength. Numerous reviews have looked at the effect of therapeutic exercise, but few have examined the effects of manual therapy techniques on hyperkyphotic posture.

Methods: Three electronic databases were searched. All of the studies published in English that have considered the effects of manual therapy (including soft tissue mobilization and joint mobilizations) on posture were included in this review (7 randomized controlled trials, 4 case studies, and 1 preliminary trial).

Results: Of the 7 randomized controlled trials, 2 studies utilized soft tissue mobilizations, 3 used joint mobilizations of the cervical and/or thoracic spine, and 2 used both techniques. 3 of the studies also combined the manual therapy treatment with other techniques, including stretching, taping, and therapeutic exercise. Outcome measures varied and included thoracic index, inclinometer or kyphometer readings, and goniometric measurements. All but one of the randomized studies found manual therapy to be an effective intervention for improving posture. Of the 4 case reports, each used a different manual therapy approach, but all were either joint mobilizations of the spine or shoulder girdle or myofascial release. 3 of the reports combined the manual therapy with other types of treatment, including proprioceptive neuromuscular facilitation (PNF) and therapeutic exercise. Postural alignment was found to improve in all of the cases, though this was measured subjectively via photo or visual analysis by 3 of the studies, while 1 study used goniometric measurements.

The final study included was a non-randomized preliminary study using an ATM2 machine to assist with joint mobilizations using Mulligan’s mobilization-with-movement concept. This study found mobilizations to be effective for improving posture as assessed by photographic analysis.

Conclusion: Of the 12 studies reviewed, 11 demonstrated an improvement in posture after treatment with manual therapy techniques. This indicates that manual therapy is a promising treatment for a condition that affects a large proportion of individuals as they age.

Introduction

As people age, their thoracic spine tends to undergo an increase in angle of kyphosis, or forward rounding of the back, which can affect both the cervical and lumbar spine [1, 2]. While the normal values for angle of thoracic kyphosis in adults aged 20–39 are 27.66° for males and 27.62° for women, these values increase more in women after age 40 [3]. The mean value for women aged 60–69 is 44.86°, compared with 34.67° for males [3].

Hyperkyphosis is defined as a value greater than 40° and such a condition leads to decreased pulmonary function, balance, and muscle strength [4, 5]. Because of these potentially harmful consequences, an intervention must be sought for treatment to prevent or correct hyperkyphosis in older adults.

The etiology behind this increase in kyphosis with age is multi-factorial, and many of the underlying causes are linked to one another. It has long been assumed that vertebral fractures related to osteoporosis play the most important role in determining whether or not someone develops hyperkyphosis. While having multiple vertebral fractures (especially thoracic anterior wedge fractures) may increase the risk of hyperkyphosis, it is far from the only cause. Other factors commonly associated with aging include degenerative disc disease, loss of proprioception, muscle weakness or atrophy, and ligamentous degeneration. Muscle weakness, especially in the spinal extensors, often leads to habitually poor posture, which increases spinal kyphosis [1, 4].

Treatments that have been studied to prevent and treat hyperkyphosis include exercise, bracing, taping, and manual therapy [4]. Therapeutic exercise is the most commonly studied intervention for poor posture and hyperkyphosis, and it has shown promising results as a conservative treatment [1, 4]. Manual Therapy (MT) is a technique used to treat various musculoskeletal conditions including but not limited to adhesive capsulitis [6], subacromial impingement syndrome [7], and osteoarthritis [8]. Treatment using manual therapy techniques has not been studied as extensively as the other therapeutic modalities, and therefore a literature review on the topic was conducted to determine if it is a viable treatment for kyphotic posture.

Methods

Selection Criteria

Studies included randomized controlled trials, nonrandomized trials, and case studies and the search was restricted to papers published in English. Because of the fact that poor posture is often linked to other conditions and the limited number of studies conducted on the topic, studies including patients with various orthopedic conditions such as osteoporosis, ankylosing spondylosis, cystic fibrosis, neck pain, and scoliosis were included in the search. Studies focusing on neurological disorders were not included in the search.

Studies where at least one application of manual therapy (including joint mobilization, soft tissue techniques, or massage) was administered were included. Body parts receiving the therapy included one or more of the following areas: shoulder girdle, pectoral muscles, cervical spine, or lumbar spine. Studies that combined MT with other forms of therapy were also included if the MT technique was an independent variable. Age of study participants was limited to adults (over 18) because both the causes and the prognosis of hyperkyphosis may differ in children, whose bodies are still developing. Only studies that compared the posture of patients before and after treatment were included in the search.

Search Strategy

A search was conducted for published articles that answer the question: do manual therapy techniques improve posture in adults? An electronic search of databases including Ovid, PubMed, and Web of Science was conducted through August 2016. Search terms included a variety of phrases related to posture and MT. The summary of search terms can be seen in table 1, and common strings included “posture”, “manual therapy”, “musculoskeletal manipulations”, “spinal mobilization”, “soft tissue mobilization”, and “kyphosis”. The first search was limited to ages 65 and older, but subsequent searches were expanded because there was found to be limited research in this age group. Supplementary searches were conducted by screening reference lists of relevant articles for additional studies.

Table 1. Search Strings

Database

Date

Search Terms

Hits

Articles Used

Ovid

9/21/2016

“posture” AND “musculoskeletal manipulations” (limited to “all aged 65 and over” OR “aged 80 and over”)

76

1

Ovid

9/21/2016

“posture” and “musculoskeletal manipulations” and “physical therapy modalities”

371

4

PubMed

9/26/2016

“physical therapy modalities” AND “musculoskeletal manipulations” OR “manual therapy” OR “spinal manipulation” OR “manipulation, osteopathic” AND “posture”

1152

4

Web of Science

9/26/2016

“posture” and “manual therapy” OR “spinal mobilization” OR  “soft tissue mobilization” AND “kyphosis”

298

2

Reference list review

9/29/2016

“posture” AND “physical therapy” OR “manual therapy”

3

3

Data Synthesis

7 RCTs (n = 236) from 1897 hits on database searches and reference list screenings were included. 4 case reports and 1 nonrandomized intervention were also included and will be analyzed separately.

Manual therapy interventions included soft tissue mobilization [5, 6, 10], myofascial release [11], thoracic spine mobilizations [5, 11–13], cervical joint mobilizations [13, 14], and rib mobilizations [11]. MT was used in isolation [10, 13, 14], or in combination with stretching [9], exercise [5, 11, 12], taping [5, 12], or postural reeducation [11]. Controls included no Physical Therapy (PT) [5, 1012], PT without mobilizations [11], passive light manual placebo touch and pectoralis major stretching [9], or cervical mobilization only [13, 14].

Treatment length varied with one study assessing the outcomes after a single MT session (Wong et al), one with 6 sessions over 6 weeks [11], one with 10 sessions over 10 weeks [5], two with 12 sessions over 4 weeks [13, 14], one with 16 sessions over 2 weeks [10], and one study with 18 sessions over 12 weeks [12].

Outcome measures used to assess changes in posture also varied considerably between studies, with each one using differing techniques. One study measured the distance from the acromion to the table, a process that has been used in several previous studies to measure rounded shoulder posture [9]. Three studies measured thoracic kyphosis, two using inclinometers [5, 12], and the other finding thoracic index by using a flexible ruler to determine the thoracic curve in the sagittal plane [11]. One study measured both cervical kyphosis using a pair of compasses and a ruler as well as thoracic and lumbar kyphosis using a kyphometer [10]. Two studies measured cervical lordosis using the absolute rotation angle [14], or cranial vertical angle and cranial rotation angle [13].

6 of the 7 randomized trials found an improvement in posture with MT techniques versus control. The one study that showed no difference between groups compared MT to no PT treatment, with 10 sessions over 10 weeks and used thoracic kyphosis as the primary outcome measure [5]. The patient population in this study was one of the two RCTs with a mean age above 60 years, focusing on osteoporotic patients with vertebral fracture. This study utilized passive accessory central posterior-anterior mobilization of the thoracic spine with 5 movements at each level and 2 reps, applying a grade II or III mobilization and MT was used in combination with exercise and taping techniques [5].

For the case studies and nonrandomized trial, approaches to MT that were used included cervical [15], scapular [15], lumbar [16], and lumbosacral mobilizations [17], myofascial release [18], and the use of an ATM2 machine to assist with thoracic and lumbar mobilizations-with-movement [19].

Two of the studies did not combine MT with other forms of treatment [18, 19]. The other 4 studies combined MT with therapeutic exercise [17], breathing and therapeutic exercise [15], or Proprioceptive Neuromuscular Facilitation (PNF) [16]. The PNF technique used was described as dynamic reversal of antagonist technique of the shoulder [16].

Treatment was also wide-ranging in both duration and frequency of the treatment. The shortest treatment duration was 4 weeks, with 3 studies choosing this time frame but varying the number of sessions with either 8 [19], 11 [15], or 12 [16]. One study chose a 6-week time frame with 12 sessions [18]. The final study chose a 16-week duration, with 9 sessions [17].

Outcome measures to demonstrate changes in posture that were used included visual assessment [15, 18, 19], video assessment [17], and angle of spinal curvature using a spinal mouse [16]. An additional case study did not specifically look at posture as an outcome measure, but rather function (assessed with the Oswestry), quality of life (assessed with the QUALEFFO), and pain (McGill Pain Scale) [20]. This study was not included as part of the review but is mentioned here because it was looking for adverse effects of manual therapy on a patient with osteoporosis, which is an important group to consider for the assessment of older adults with kyphosis.

All 4 of the case reports measuring posture as an outcome measure showed improvement after treatment with MT, and the case report that measured quality of life, pain, and function also showed no adverse effects with MT treatment. The nonrandomized trial likewise showed similar improvements in posture after spinal mobilization treatments [20].

Discussion

The MT approaches varied between studies in the RCT group. The one study that utilized Soft Tissue Mobilization (STM) performed 3 minutes of strumming perpendicular to the pectoralis minor muscle belly [9]. Of the studies utilizing joint mobilizations of the spine, only one described using a grade II or III mobilization [5]. One study described the number of repetitions as 10–15 free passive angular movements of thoracic spine with end-range positions held for 5 seconds or as tolerated [12]. The next study gave a limited description of active angular and passive mobility exercises in 4 directions (flexion, extension, lateral flexion, and rotation) [10]. In the study by Gong et al, passive motion analysis was done on the cervical spine and then mobilization was applied by checking mobility in the joint of interest while preventing motion in surrounding joints [14]. The study by Lee et al applied passive extension mobilizations at end range for the cervical spine joints and for the thoracic spine “the therapist pushed hard at the end range to increase mobility” [13]. The final study did not include details on how the manual therapy was applied [11].

For the case study group, one case described using grade III mobilizations of the lumbar spine [16], while the other three studies utilizing mobilizations described only the joints at which the techniques were applied [15, 17], or the number of sets and repetitions [19]. The final study in this group used myofascial release techniques applied for 90–120 seconds at each muscle group [18].

The wide ranging descriptions of the manual therapy techniques used in each of these studies points to the need for more precise documentation in future studies. The details provided in the text of a study should allow another researcher to replicate the treatment protocol, which means that manual mobilizations should not only be described in detail, but the grade(s) of pressure used should also be noted.

While all of the RCTs utilized physical therapists to administer MT intervention, two studies specifically used certified Orthopedic Clinical Specialist physical therapists [9, 13]. Only one other RCT mentioned training the therapists involved in the study to perform interventions in a specified manner [5]. The case study authors were less descriptive of the physical therapists administering treatment, but in the studies where the PT credentials were not explicitly mentioned, therapy was conducted by the study author. One study utilized MFR treatment by a licensed massage and bodywork therapist [18], while another used a PT that had completed a Kaltenborn-Evjenth Orthopedic Manual Therapy (KEOMT) spine advanced course [16].

The number of physical therapy sessions and study length for both the RCT group and the case study group was about equal, with an average of 10.7 and 10.4 manual therapy sessions. The number of weeks over which the sessions occurred was also very similar, with an average of 7.2 weeks for the RCT group and 7.3 weeks for the case study group. There was greater variance between studies, however, with most studies either lasting one month or about 3 months. The shorter, one month time frame is more likely to be clinically realistic. As far as number of sessions goes, a Dutch study of 41 PT practices found that there was an average of 9.9 treatment sessions among patients with a diagnosis of low back pain [21]. Therefore, having an average of 10.5 treatment sessions for the studies listed here is not unrealistic, but this number could vary depending on the laws in the particular country of treatment.

In an assessment of the outcome measures used to measure the postural improvements, each of the randomized trials utilized highly reliable measurement tools. The distance from the posterior border of the acromion to the table used by Wong et al was shown to have a reliability of 0.88–0.94, and this measurement is also easy to learn and replicate [22]. The spinal mouse used by Bautmanns et al and the Debrunner kyphometer used by Widberg et al were both shown to have a both a very high inter-rater and intra-rater reliability [23]. The rotation angle to measure cervical posture used by Gong et al and Lee et al was also shown to have a high Interclass Correlation Coefficient (ICC) [24]. And finally, the thoracic index (measured using a flexible ruler) used by Sandsund et al had an ICC of 0.94. The validity of the measurement tools used in these studies further increases the evidence that posture can be improved by manual therapy techniques.

Table 2. RCT: Study Characteristics

Author, Year

MT Approach

Other Treatment

Patient Population

Mean age

Study Size

Treatment Length

Outcome Measures

Results

Wong et al, 2009

Pectoralis minor STM and self-stretching

Yes – stretching

Healthy patients with rounded shoulder posture (RSP);40% female

25.5

n = 56; 31 experimental, 25 control

1 session with 2 week follow-up

RSP measuring distance from acromion to exam table

One session of pec minor STM and self-stretching significantly reduced RSP for up to 2 weeks

Bautmans et al, 2010

Thoracic spine manual mobilizations

Yes – taping, exercise

Elderly postmenopausal patients with osteoporosis; 100% female

76

n = 38; 21 experimental, 16 control

18 sessions over 12 weeks

Thoracic kyphosis using Spinal Mouse (hand-held inclinometer)

Thoracic kyphosis improved significantly

Widberg et al, 2008

Self and manual soft tissue mobilizations

No

Patients with ankylosing spondylosis; 100% male

35.8

n = 32; 16 experimental, 16 control

8 weeks; 1 hr 2x/week + HEP

Pair of compasses and a ruler (cervical); Debrunner’s kyphometer (thoracic & lumbar)

Improved sagittal plane posture in c-spine; improved posture in neutral position at t-spine

Gong et al, 2015

Passive motion analysis vs. regular cervical joint mobilization

No

University students with postural deficits

22.4

n = 40; 20 experimental, 20 control

3x/week for 4 weeks

Absolute rotation angle – cervical lordosis

Decreased forward head posture and improved cervical lordosis and ROM

Sandsund et al, 2011

Mobilizations of rib cage and t-spine; myofascial release

Yes – Alexander technique, regular PT

Patients with CF; 50% female

27

n = 20; 10 experimental, 10 control

12 weeks; 6 weekly visits

Thoracic index – thoracic curve in sagittal plane using flexible ruler

Thoracic index decreased, showing improvement

Lee et al, 2012

Cervical and thoracic mobilization vs cervical mobilization only (control)

No

Patients with neck pain and forward head posture

Adults

n = 30; 15 experimental, 15 control

15 min 3x/week for 4 weeks

Cranial vertical angle (CVA) and cranial rotation angle (CRA)

CVA increased and CRA decreased. Cervical + thoracic mobilizations are more effective than cervical alone.

Bennell et al, 2010

Soft tissue massage, thoracic mobilizations

Yes – taping, exercise

Patients with osteoporotic vertebral fracture; 85% female

66.2

n = 20; 11 experimental, 9 control

10 weeks; 1x/week + HEP

Thoracic kyphosis using Dualer Electric Inclinometer

No difference between groups

Table 3. Case Study: Study Characteristics

Author

MT Approach

Other Treatment

Patient Characteristics

Treatment Length

Outcome Measures

Results

Roehrig, 2006

Neurodevelopmental treatment-cervical and scapular mobilization

Yes – breathing, exercise

78 year old female with kyphosis and osteoporosis

11 visits over 4 weeks; mobilizations began at visit 4

Visual assessment; goniometric measure

Posture improved

LeBauer et al, 2008

Myofascial release

No

18 year old female with idiopathic scoliosis

6 weeks; 1 hr 2x/week

Visual assessment via grid photography

Posture improved

Staes et al, 2011

Lumbosacral manual therapy

Yes – exercise

26 year old female

9 30 min. sessions over 4 months

Forward head posture and shoulder position via video screening

Postural alignment improved

Park et al, 2014

Kaltenborn-Evjenth orthopedic manual therapy (lumbar)

Yes – PNF

29 year old female with chronic LBP and lumbar transitional vertebra

4 weeks 40 min. 3x/week

Angle of spinal curvature

Spinal curvature and ROM  increased

*Lewis et al, 2014

ATM2 using Mulligan’s mobilization-with-movement (thoracic and lumbar)

No

43 patients aged 14–63 with mild-to-moderate scoliosis; 86% female; mean age 43.5

 4 week intervention 2x/week + HEP

Visual assessment via photography

Posture improved

*Not a case study but a preliminary trial

In the RCT by Bennell et al, while no change was shown in posture, other outcome measures such as pain, physical function, and back and shoulder muscle endurance showed significant positive changes [5]. This finding leads to the hypothesis that other outcome measures can be used to measure change in studies involving MT techniques. Of the 7 RCTs presented here, 4 used some subjective measure of quality of life or function [5, 10–12]. These outcome measures are important because they measure changes that the patient cares more about. Two of the studies also measured lung expansion, which can be an indicator of whether or not a patient is able to breathe easily [10, 11].

Future studies are needed to demonstrate the effectiveness of MT techniques for improvement of posture specifically in older adults (over age 60). Only 2 of the randomized controlled trials had a mean age over 60 [5, 12], and one of these did not find a significant change in posture after intervention. Just one out of 4 of the case studies were performed on an older adult. Therefore, it is not clear if the positive effects of manual therapy on posture are equally as significant in older populations, where the change in kyphosis is more pronounced.

Conclusion

This review found promising evidence for the use of manual therapy as a means to improve posture in adults. 11 of the 12 studies measuring postural improvement as an outcome measure showed a significant positive change in patients receiving manual therapy. The one RCT that did not find an improvement in posture over the control group did show significant changes in other outcome measures, including decreases in pain, improvement in physical function, and improvement in quality of life in the experimental group [5]. Outcome measures that may also be appropriate to show change include subjective measures of quality of life and physical functioning as well as lung function tests. These results demonstrate that even when postural gains are not made due to the use of manual therapy, other positive outcomes can still be seen that warrant the therapy. For the clinician seeking to help a patient improve their posture, manual therapy techniques can be an effective intervention that may also help improve their quality of life and physical functioning.

References

  1. Kado DM (2009) The rehabilitation of hyperkyphotic posture in the elderly. European Journal of Physical and Rehabilitation Medicine 45: 583–593.
  2. Staff MC Kyphosis. 2014 5 June 2014 20 September 2015]; Available from: http://www.mayoclinic.org/diseases-conditions/kyphosis/basics/definition/con-20026732.
  3. Fon GT, Pitt MJ, Cole Thies JA (1980) Thoracic kyphosis: range in normal subjects. American Journal of Radiology 134: 979–963.
  4. Wendy B, Katzman P, DPTSc (2010) Age-related hyperkyphosis: its causes, consequences, and management. Journal of Orthopedic Sports Physical Therapy 40: 352–360.
  5. Bennell KL (2010) Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Muscluoskeletal Disorders 11: 36.
  6. Page MJ, Green S, Kramer S, Johnston RV, McBain B, et al. (2014) Manual therapy and exercise for adhesive capsulitis (frozen shoulder) (Review). Cochrane Database of Systematic Reviews (8): CD011275.
  7. Gebremariam L (2014) Subacromial impingement syndrome_effectiveness of physiotherapy and manual therapy. British Journal of Sports Medicine 48: 1202–1208.
  8. French HP, Brennan A, White B, Cusack T (2011) Manual therapy for osteoarthritis of the hip or knee – a systematic review. Man Ther 16: 109–117. [crossref]
  9. Christopher Kevin Wong P, OCS (2010) The effects of manual treatment on rounded-shoulder posture, and associated muscle strength. Journal of Bodywork & Movement Therapies 14: 326–333.
  10. Widberg K, Karimi H, Hafstrom I (2009) Self-and manual mobilization improves spine mobility in men with ankylosing spondylitis – a randomized study. Clinical Rehabilitation 23:  599–608.
  11. Sandsund CA (2011) Musculoskeletal techniques for clinically stable adults with cystic fibrosis: a preliminary randomized controlled trial. Physiotherapy 97: 209–217.
  12. Ivan Bautmans P (2010) Rehabilitation using manual mobilization for thoracic kyphosis in elderly posmenopausal patients with osteoporosis. Journal of Rehabilitation Medicine 42: 129–135.
  13. Jaehong Lee P (2013) The Effects of Cervical Mobilization Combined with Thoracic Mobilization on Forward Head Posture of Neck Pain Patients. Journal of Physical Therapy Science 25: 7–9.
  14. Wontae Gong P (2015) The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. Journal of Physical Therapy Science 27: 1609–1611.
  15. Susan M, Roehrig P (2006) Use of neurodevelopmental treatment techniques in a client with kyphosis: A case report. Physiotherapy Theory and Practice 22: 337–343.
  16. Si-Eun Park P, Joong-San Wang P (2015) Effect of joint mobilization using KEOMT and PNF on a patient with CLBP and a lumbar transitional vertebra: a case study. Journal of Physical Therapy Science 27: 1629–1632.
  17. Staes FF (2009) Physical therapy as a means to optimize posture and voice parameters in student classical singers: A case report. Journal of Voice 23: 91–101.
  18. Aaron LeBauer L, SDPT, Robert Brtalik S, Katherine Stowe S (2008) The effect of myofascial release (MFR) on an adult with idiopathic scoliosis. Journal of Bodywork & Movement Therapies 12: 356–363.
  19. Clare Lewis D, PsyD (2014) A preliminary study to evaluate postural improvement in subjects with scoliosis: active therapeutic movement version 2 device and home exercises using the Mulligan’s mobilization-with-movement concept. Journal of Manipulative Physiol Ther 27: 502–509.
  20. Sran MM, K.M. Khan (2006) Is spinal mobilization safe in severe secondary osteoporosis? – a case report. Manual Thearpy 11: 344–351.
  21. Swinkels IC (2005) What factors explain the number of physical therapy treatment sessions in patients referred with low back pain; a multilevel analysis. BMC Health Services Research 5.
  22. Struyf F, Nijs J, Mottram S, Roussel NA, Cools AM, et al. (2014) Clinical assessment of the scapula: a review of the literature. Br J Sports Med 48: 883–890. [crossref]
  23. Barrett E, McCreesh K, J Lewis (2013) Intrarater and interrater reliability of the flexicurve index, flexicurve angle, and manual inclinometer for the measurement of thoracic kyphosis. Rehabilitation Research and Practice 2013: 7.
  24. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, et al (2000) Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. SPINE 25: 2072–2078.