Combined Infusion Research Articles

Comparison of Intrahepatic and Pancreatic Perfusion on Fusion Images Using a Combined SPECT/CT System and Assessment of Efficacy of Combined Continuous Arterial Infusion and Systemic Chemotherapy in Advanced Pancreatic Carcinoma

The purpose of this study was to compare intrahepatic and pancreatic perfusion on fusion images using a combined single-photon emission computed tomography (SPECT)/CT system and to evaluate the efficacy of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in the treatment of advanced pancreatic carcinoma. CTAI was performed in 33 patients (22 men, 11 women; age range, 35-77 years; mean age, 60 years) with stage IV pancreatic cancer with liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. In all patients we obtained fusion images using a combined SPECT/CT system. Pancreatic perfusion on fusion images was classified as perfusion presence or as perfusion absent in the pancreatic cancer. Using WHO criteria we recorded the tumor response after 3 months on multislice helical CT scans. Treatment effects were evaluated based on the pancreatic cancer, liver metastasis, and factors such as intrahepatic and pancreatic perfusion on fusion images. For statistical analysis we used the chi-square test; survival was evaluated by the Kaplan Meier method (log-rank test). On fusion images, pancreatic and intrahepatic perfusion was recorded as hot spot and as homogeneous distribution, respectively, in 18 patients (55%) and as cold spot and heterogeneous distribution, respectively, in 15 (45%). Patients with hot spot in the pancreatic tumor and homogeneous distribution in the liver manifested better treatment results (p < 0.05 and p < 0.01, respectively). Patients with hot spot both in the pancreatic cancer and in the liver survived longer than those with cold spot in the pancreatic cancer and heterogeneous distribution in the liver (median +/- SD, 16.0 +/- 3.7 vs. 8.0 +/- 1.4 months; p < 0.05). We conclude that in patients with advanced pancreatic cancer, CTAI with systemic chemotherapy appeared to be effective and may prolong their survival. The development of a reservoir port system allowing for the homogeneous distribution of anticancer drugs is necessary to improve the prognosis of patients with advanced pancreatic cancer.

Combined NT–pro-BNP and CW-Doppler ultrasound cardiac output monitoring (USCOM) in epirubicin and liposomal doxorubicin therapy

Background Chemotherapy with epirubicin is approved in women with breast cancer and is associated with a certain degree of cardiotoxicity. Hypothesis Epirubicin changes stroke volume, cardiac output and systemic vascular resistance, while liposomal doxorubicin does not. Methods 75 patients with HER-2-positive metastatic breast cancer were continuously measured with CW-Doppler ultrasound for stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR) before, during and after drug infusion in combination with NT–pro-BNP before and 10 min after drug infusion. Results Epirubicin infusion increased stroke volume significantly in low-level NT–pro-BNP (62 ± 23 ml vs. 74 ± 29 ml, p = 0.004) and high-level NT–pro-BNP (48 ± 5 ml vs. 64 ± 20 ml, p = 0.131), while liposomal doxorubicin infusion increased stroke volume significantly in low-level NT–pro-BNP (54 ± 16 ml vs. 67 ± 22 ml, p = 0.001) and high-level NT–pro-BNP (65 ± 22 ml vs. 82 ± 27 ml, p = 0.001). Cardiac output was significantly increased in epirubicin ( p = 0.004) by 20% (NT–pro-BNP < 125 pg/ml) and not significantly 38% (NT–pro-BNP > 125 pg/ml; p = 0.144), while in liposomal doxorubicin cardiac output was significantly increased by 23% (NT–pro-BNP < 125 pg/ml; p = 0.023) and 33% (NT–pro-BNP > 125 pg/ml; p = 0.001). In liposomal doxorubicin cardiac index was significantly increased by 26% (NT–pro-BNP < 125 pg/ml; p = 0.021) and 33% (NT–pro-BNP > 125 pg/ml; p = 0.0001). SVR was significantly reduced during and after epirubicin therapy. Conclusion Using the CW-Doppler USCOM a different hemodynamic response to epirubicin vs. liposomal doxorubicin is evident. Epirubicin leads to a significant upregulation of stroke volume and cardiac output, which is even more pronounced in the high-level NT–pro-BNP group, while liposomal doxorubicin does not change immediate hemodynamics. No deterioration of cardiac function using the real-time CW-Doppler ultrasound USCOM or an increase in NT–pro-BNP levels was evident during epirubicin or liposomal doxorubicin therapy.

P2-295: Phase II trial a 2-h infusion of Gemcitabine-carboplatin combination as first-line therapy for stage IIIB or IV non-small cell lung cancer

P2-295: Phase II trial a 2-h infusion of Gemcitabine-carboplatin combination as first-line therapy for stage IIIB or IV non-small cell lung cancer

Modified FOLFOX in combination with docetaxel for patients with metastatic adenocarcinoma of the stomach or gastroesophageal junction: A multicenter phase II study of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

4545 Background: The combination of docetaxel, cisplatin, and fluorouracil (DCF) is clearly superior to CF in the treatment of patients (pts) with advanced gastric cancer (AGC). DCF is, however, associated with significant toxicity, including neutropenia, febrile neutropenia, diarrhea and mucositis. This study evaluated a biweekly, oxaliplatin-based modification of DCF. Methods: Pts with measurable, locally advanced or metastatic adenocarcinoma of the stomach or GE-junction and no prior chemotherapy received mFOLFOX (oxaliplatin 85 mg/sqm, leucovorin 200 mg/sqm, and fluorouracil 2.6 g/sqm via 24hr infusion) in combination with docetaxel 50 mg/sqm on day 1 every 2 weeks (FLOT-regimen). Prophylactic G-CSF was not administered. Overall response rate (RR) was the primary endpoint (power 80% to detect a RR of &gt;40%) and toxicity profile the main secondary endpoint. The study was externally monitored according to GCP and data were reviewed by an independent safety board. Results: 59 pts (male, 41; female, 18) were enrolled. At the time of analysis, 53 pts were evaluable for toxicity and 51 pts for response. Median age was 60 (range, 29–76), median ECOG PS was 1, and almost all (93%) pts had metastatic disease. Of 51 pts, 2 had a CR and 25 pts attained a PR, adding to an overall RR of 53% (ITT-analysis). Stable disease was observed in 12 (23.5%) and progressive disease in 6 (11.8%) pts. Six (11.8%) pts were not evaluable for response. NCI-CTC grade 3 or 4 hematologic toxicity included leukopenia in 12 (22.6%), neutropenia in 23 (43%), and anemia in 2 (3.8%) pts. Febrile neutropenia was observed in 1 (1.9%) pt only. Other grade 3 or 4 toxicities included peripheral neuropathy in 4 (7.5%), nausea in 3 (5.7%), vomiting in 2 (3.8%) as well as diarrhea and fatigue in 5 (9.4%) pts each. No treatment related deaths were observed. Conclusions: FLOT is active and has a favorable toxicity profile in the treatment of pts with AGC. It may show activity also in perioperative treatment settings and may be considered as a useful treatment option for elderly pts. Survival data will be presented at the meeting. [Table: see text]

Addressing resistance evolution in Pseudomonas aeruginosa using pharmacodynamic modelling: application to meropenem dosage and combination therapy

Isolates of Pseudomonas aeruginosa (n = 208) were collected from an 810-bed hospital in Connecticut, USA. A model employing the pharmacokinetic properties of meropenem, susceptibility results and Monte Carlo simulation was used to analyse four different dosing regimens of meropenem at pharmacodynamic endpoints. Cumulative fraction of response (CFR) was assessed at bacteriostatic and bactericidal endpoints for the entire population of isolates, as well as for isolates from principal anatomical sites. CFR was also evaluated at endpoints shown to suppress emergence of resistance in 'susceptible'P. aeruginosa with either monotherapy or combination therapy. The bacteriostatic/bactericidal CFR of meropenem 1 g every 8 h (q8h), 2 g q8h, 1 g q8h infused over 3 h (3-h INF), and 2 g q8h 3-h INF were 76%/73%, 80%/76%, 77%/75% and 79%/78%, respectively. At the monotherapeutic suppressive endpoint, CFRs against susceptible isolates were 21%, 35%, 32% and 50%, respectively. When combination therapy with an aminoglycoside was simulated, the CFRs for the same regimens were 50%, 64%, 65% and 79%, respectively. Bactericidal CFRs for all regimens against wound isolates were significantly higher (p <0.03 for each regimen) than CFRs for the entire population. Meropenem 2 g q8h with a 3-h infusion in combination with an aminoglycoside provides the greatest likelihood of P. aeruginosa coverage, and may help to prevent development of resistance, although local MIC data are essential to inform therapeutic decisions.

Le morte du tumour: Histological features of tumor destruction in chemo-resistant cancers following intravenous infusions of pathotropic nanoparticles bearing therapeutic genes

The pathotropic targeting of therapeutic nanoparticles to cancerous lesions is an innovative concept that has recently been reduced to practice in clinical trials for the treatment of metastatic cancer. Previously, we reported that intravenous infusions of Rexin-G, a pathotropic nanoparticle (or vector) bearing a cyto-ablative construct, induced tumor regression, reduced tumor burden, and improved survival, while enhancing the overall quality-of-life of patients with otherwise intractable chemotherapy-resistant cancers. In this report, we describe the major histopathological and radiologic features that are characteristic of solid tumors under the destructive influences of Rexin-G administered as a single therapeutic agent. To further promote tumor eradication and enhance cancer survival, we explored the potential of an auxiliary gene transfer strategy, specifically intended to induce a localized cancer auto-immunization in addition to assisting in acute tumor destruction. This immunization strategy uses Rexin-G in combination with Reximmune-C, a tumor targeted expression vector bearing a granulocyte macrophage-colony stimulating factor (GM-CSF) gene. Intravenous infusions of Rexin-G were given first to induce apoptosis and necrosis in the metastatic tumor nodules, thus exposing tumor neo-antigens, followed by Reximmune-C infusions, intended to recruit immune cells discretely into the same compartments (or lesions). The intent of this two-step approach is to bring a complement of cells involved in humoral and cell-mediated immunity in close proximity to the immunizing tumor antigens in a concerted effort to assist in tumor eradication and to promote a cancer vaccination in situ. Herein, we also describe the distinctive histopathologic and immunocytochemical features of tumors in terminal cancer patients who received Rexin-G infusions in combination with Reximmune-C. In addition to documenting the first histological indications of clinical efficacy achieved by this novel personalized approach to cancer vaccination, we discuss new methods and strategies for advancing its therapeutic utility. Taken together with the clinical data, these histological studies serve as valuable landmarks for medical oncology, and as definitive benchmarks for the emerging field of cancer gene therapy.

The effects of chronic estradiol treatment on working memory deficits induced by combined infusion of β-amyloid (1–42) and ibotenic acid

Estrogen limits in vitro neuron death induced by application of β-amyloid, the cytotoxic peptide linked to Alzheimer's disease. However, the ability of estrogen to protect neurons and preserve cognitive function in vivo following exposure to β-amyloid has not been demonstrated. Our objective was to evaluate the potential of estrogen to reduce spatial working memory deficits in female rats induced by administration of a neurotoxic form of β-amyloid in combination with the excitotoxin, ibotenic acid. The interaction of β-amyloid with excitotoxic factors may underlie cognitive deficits associated with Alzheimer's disease. Therefore, to create an experimental model typical of early Alzheimer's disease a low dose of ibotenic acid was administered with β-amyloid into the dorsal hippocampus. Ovariectomized rats were implanted subcutaneously with Silastic capsules that produce physiological levels of 17β-estradiol 10 days before bilateral intrahippocampal injections of aggregated β-amyloid (1–42) and ibotenic acid. Capsules remained in situ throughout behavioral testing. When tested 3–10 weeks after neurotoxin treatment, females without estrogen capsules exhibited delay-dependent impairments in working memory performance on a water maze and a radial arm maze. Females treated with estrogen and combined neurotoxins displayed working memory performance comparable to unlesioned females on both tasks. Neurotoxin treatment increased immunoreactivity for glial fibrillary acidic protein but this measure was unaffected by estradiol treatment indicating that estrogen did not limit glial proliferation. Results indicate that estrogen prevented deficits in spatial working memory induced by neurotoxin treatments intended to mimic the pathology of early Alzheimer's disease.

Simultaneous hemodynamic and serological cardiotoxicity monitoring during immunotherapy with trastuzumab

Background Immunotherapy with trastuzumab (Herceptin), a selective HER-2(ErbB2)-antibody, is associated with a certain degree of cardiotoxicity. This study sought to evaluate the immediate hemodynamic response to trastuzumab with real-time CW-Doppler depending on the level of nt-pro-BNP (brain natriuretic peptide) as a possible marker of cardiotoxicity. Methods 48 patients with HER-2-positive metastatic breast cancer were continuously measured with CW-Doppler ultrasound for cardiac output (CO) and systemic vascular resistance (SVR) before, during and after drug infusion in combination with nt-pro-BNP before and 10 min after drug infusion. Depending on the nt-pro-BNP-levels < 125 pg/ml (group A, n = 34, 51 ± 11 years) vs. nt-pro-BNP > 125 pg/ml (group B, n = 14, 63 ± 7 years) two groups have been defined. Results Trastuzumab therapy did not change nt-pro-BNP immediately before (44 ± 29 pg/ml) vs. after the infusion (45 ± 32 pg/ml, n.s.) in the low-level as in the high level nt-pro-BNP group (231 ± 356 pg/ml prior and 240 ± 377 pg/ml, n.s.). Cardiac output remained stable during trastuzumab infusion, however cardiac output was significantly increased following the end of the infusion stronger in the high-level nt-pro-BNP group. Systemic vascular resistance prior to the trastuzumab infusion was higher in the high-level nt-pro-BNP group with significant decrement during and after the infusion. Conclusion Combining real-time CW-Doppler ultrasound and nt-pro-BNP monitoring is feasible to monitor the immediate hemodynamic changes during and after trastuzumab infusion.

Roles of nitric oxide and angiotensin II in the impaired baroreflex gain of pregnancy

The present study tested the hypothesis that nitric oxide (NO) contributes to impaired baroreflex gain of pregnancy and that this action is enhanced by angiotensin II. To test these hypotheses, we quantified baroreflex control of heart rate in nonpregnant and pregnant conscious rabbits before and after: 1) blockade of NO synthase (NOS) with Nomega-nitro-L-arginine (20 mg/kg iv); 2) blockade of the angiotensin II AT1 receptor with L-158,809 (5 microg x kg(-1) x min(-1) iv); 3) infusion of angiotensin II (1 ng x kg(-1) x min(-1) nonpregnant, 1.6-4 ng x kg(-1) x min(-1) pregnant iv); 4) combined blockade of angiotensin II AT(1) receptors and NOS; and 5) combined infusion of angiotensin II and blockade of NOS. To determine the potential role of brain neuronal NOS (nNOS), mRNA and protein levels were measured in the paraventricular nucleus, nucleus of the solitary tract, caudal ventrolateral medulla, and rostral ventrolateral medulla in pregnant and nonpregnant rabbits. The decrease in baroreflex gain observed in pregnant rabbits (from 23.3 +/- 3.6 to 7.1 +/- 0.9 beats x min(-1) x mmHg(-1), P < 0.05) was not reversed by NOS blockade (to 8.3 +/- 2.5 beats x min(-1) x mmHg(-1)), angiotensin II blockade (to 5.0 +/- 1.1 beats x min(-1) x mmHg(-1)), or combined blockade (to 12.3 +/- 4.8 beats x min(-1) x mmHg(-1)). Angiotensin II infusion with (to 5.7 +/- 1.0 beats x min(-1) x mmHg(-1)) or without (to 8.4 +/- 2.4 beats x min(-1) x mmHg(-1)) NOS blockade also failed to improve baroreflex gain in pregnant or nonpregnant rabbits. In addition, nNOS mRNA and protein levels in cardiovascular brain regions were not different between nonpregnant and pregnant rabbits. Therefore, we conclude that NO, either alone or via an interaction with angiotensin II, is not responsible for decrease in baroreflex gain during pregnancy.

Endogenous Endothelin in Human Coronary Vascular Function

Endothelin 1 mediates coronary vasoconstriction and endothelial dysfunction via endothelin receptor type A (ET(A)) activation. However, the effects of selective endothelin receptor type B (ET(B)) and combined ET(A+B) receptor blockade on coronary vasomotion are unknown. We measured coronary vascular tone and endothelium-dependent and -independent vasomotor function before and after selective infusion of BQ-788 (an ET(B) receptor antagonist) or combined infusion of BQ-788+BQ-123 (an ET(A) antagonist) into unobstructed coronary arteries of 39 patients with coronary atherosclerosis or risk factors undergoing cardiac catheterization. BQ-788 did not affect epicardial diameter but constricted the microcirculation (P<0.0001), increased coronary sinus endothelin, and reduced nitrogen oxide levels. In contrast, BQ-123+BQ-788 dilated epicardial (P<0.0001) and resistance (P=0.022) arteries. Responses to acetylcholine and sodium nitroprusside were unaffected by BQ-788 alone. Epicardial endothelial dysfunction improved after BQ-123+BQ-788 (P=0.007). Coronary microvascular responses to acetylcholine and sodium nitroprusside were unaffected by BQ-123+BQ-788. We conclude that selective ET(B) receptor antagonism causes coronary microvascular constriction, without affecting epicardial tone or endothelial function, via reduced endothelin clearance and NO availability. Combined ET(A+B) blockade dilates coronary conduit and resistance vessels and improves endothelial dysfunction of the epicardial coronary arteries. Thus, endogenous endothelin, predominantly via ET(A) receptor stimulation, contributes to basal constrictor tone and endothelial dysfunction, whereas ET(B) activation mediates vasodilation in human coronaries. Our data suggest that selective ET(A) blockade may have greater therapeutic potential than nonselective agents, particularly for treatment of endothelial dysfunction in atherosclerosis.

Blockade of GABA A receptors within the extended amygdala attenuates D 2 regulation of alcohol-motivated behaviors in the ventral tegmental area of alcohol-preferring (P) rats

The dopamine (DA) mesolimbic pathway, which originates from DA cell bodies within the ventral tegmental area (VTA), has been shown by various studies to play a role in the mediation of various drugs of abuse including alcohol (EtOH). It has been suggested that the VTA's control of EtOH reward is mediated in part by the D2 receptors within the VTA. These receptors may be under the regulation of reciprocal GABAergic inputs from forebrain components of the mesolimbic path such as the nucleus accumbens (NAcc), a classic EtOH reward substrate, and the bed nucleus of the stria terminalis, a substrate recently implicated in EtOH reinforcement, forming a self-regulating feedback loop. To test this hypothesis, D2 regulation of EtOH self-administration (SA) was evaluated by the microinfusion of the D2 antagonist eticlopride into the VTA of P rats, which produced profound reductions in EtOH SA in the highest (20.0 and 40.0 μg) doses tested in both BST/VTA and NAcc/VTA implanted P rats. To determine the role of GABA in the mediation of EtOH SA, a 32.0 ng dose the non-selective GABA antagonist SR 95531 was microinfused into the BST producing no effect on responding for EtOH and into the NAcc which lead to a reduction in EtOH responding. Finally, the hypothesis that GABA innervation of the VTA from the mesolimbic forebrain may influence EtOH SA was examined by the simultaneous infusion of eticlopride (40.0 μg) into the VTA and SR 95531 (32.0 ng) into either the BST or NAcc. This combination infusion completely attenuated the reduction in EtOH SA observed with the 40.0 μg dose of eticlopride alone in both groups of animals. These results suggest that while the D2 receptors within the VTA regulate EtOH-motivated behaviors, this is modulated by GABAergic input from the mesolimbic forebrain, specifically from the BST and NAcc.

Interaction of AT1 receptors and V1a receptors-mediated effects in the central cardiovascular control during the post-infarct state

Experimental objectives. Because myocardial infarct is associated with overactivation of brain angiotensin II (ANG II) and vasopressin (AVP) V1a receptors we decided to determine whether AT1 and V1a receptors-mediated effects of ANG II and AVP interact in central cardiovascular control during the post-infarct state. Four groups of infarcted and four groups of sham-operated conscious rats entered the study. Results. In the infarcted rats cerebroventricular infusion of AT1 (AT1ANT, losartan) and V1a antagonist {V1aANT,d(CH 2) 5[Tyr(Me) 2Ala-NH 2 9]VP} and combined infusion of both these compounds performed 4 weeks after induction of the infarct significantly and comparably reduced mean arterial blood pressure (MABP) in comparison to control experiments (artificial cerebrospinal fluid infusion). In the sham rats MABP was not affected by any of the infusions. In control experiments MABP and HR responses to an alarming air jet stress were significantly higher in the infarcted than in the sham rats. Both responses were normalized with the same effectiveness by administration of AT1ANT, V1aANT and AT1ANT+V1aANT. In the sham rats administration of these compounds did not affect MABP and HR responses to stress. Conclusion: The results provide evidence for interaction of AT1 and V1a receptors-mediated effects of ANG II and AVP in the central cardiovascular control during the post-infarct state.

Anesthetic and Cardiopulmonary Effects of Total Intravenous Anesthesia Using a Midazolam, Ketamine and Medetomidine Drug Combination in Horses

The anesthetic and cardiopulmonary effects of midazolam, ketamine and medetomidine for total intravenous anesthesia (MKM-TIVA) were evaluated in 14 horses. Horses were administered medetomidine 5 microg/kg intravenously as pre-anesthetic medication and anesthetized with an intravenous injection of ketamine 2.5 mg/kg and midazolam 0.04 mg/kg followed by the infusion of MKM-drug combination (midazolam 0.8 mg/ml-ketamine 40 mg/ml-medetomidine 0.1 mg/ml). Nine stallions (3 thoroughbred and 6 draft horses) were castrated during infusion of MKM-drug combination. The average duration of anesthesia was 38 +/- 8 min and infusion rate of MKM-drug combination was 0.091 +/- 0.021 ml/kg/hr. Time to standing after discontinuing MKM-TIVA was 33 +/- 13 min. The quality of recovery from anesthesia was satisfactory in 3 horses and good in 6 horses. An additional 5 healthy thoroughbred horses were anesthetized with MKM- TIVA in order to assess cardiopulmonary effects. These 5 horses were anesthetized for 60 min and administered MKM-drug combination at 0.1 ml/kg/hr. Cardiac output and cardiac index decreased to 70-80%, stroke volume increased to 110% and systemic vascular resistance increased to 130% of baseline value. The partial pressure of arterial blood carbon dioxide was maintained at approximately 50 mmHg while the arterial partial pressure of oxygen pressure decreased to 50-60 mmHg. MKM-TIVA provides clinically acceptable general anesthesia with mild cardiopulmonary depression in horses. Inspired air should be supplemented with oxygen to prevent hypoxemia during MKM-TIVA.

Phase I Trial of Fixed Dose Rate Infusion Gemcitabine with Gefitinib in Patients with Pancreatic Carcinoma

Purpose: To determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of gemcitabine using a fixed dose rate infusion (FDRI) in combination with gefitinib in patients (pts) with pancreatic adenocarcinoma (PCa). Patients and methods: Patients with advanced PCa were given gemcitabine at the FDRI of 10 mg/m2/min IV on Days 1, 8, and 15 of a 28-day cycle. Dose levels of 1000, 1200, and 1500 mg/m2 were evaluated. Oral gefitinib 250 mg was given daily. DLTs were defined as 2 instances of Grade 3 hematologic or 4 nonhematologic or any Grade 4 hematologic toxicity. At least 4 patients were treated at each dose level. Dose escalation occurred in the absence of DLTs. Results: Five women and 8 men were enrolled. Median age was 59 and performance status 1. All had metastatic disease. Four patients received prior adjuvant chemoradiation for PCa, and one chemotherapy for lung cancer. Median cycles were 4 per patient. The MTD was 1,200 mg/m2. Toxicity was predominantly hematologic. At 1,500 mg/m2, 1 patient had Grade 4 granulocytopenia and 3 patients Grade 3 granulocytopenia. Overall, 8 patients (60 percent) developed Grade 1 or 2 acneiform rashes. One patient had Grade 3 vomiting; no significant diarrhea or liver toxicity was seen. There were no objective responses seen. Median time to progression and overall survival were 4.57 months and 7.13 months, respectively. Conclusion: Combining FDRI gemcitabine with gefitinib is feasible and tolerable. The recommended dose of gemcitabine is 1,200 mg/m2 when used with gefitinib 250 mg daily.

Phase I/II feasibility study evaluating the generation of leukemia-reactive cytotoxic T lymphocyte lines for treatment of patients with relapsed leukemia after allogeneic stem cell transplantation

Graft-versus-host-disease may be avoided and the likelihood of a graft-versus-leukemia reaction increased by infusion of in vitro generated, leukemia-reactive, cytotoxic T lymphocyte (CTL) lines as treatment for patients with relapsed leukemia after allogeneic stem cell transplantation, instead of donor lymphocyte infusion. The aim of this study phase I/II study was to assess the feasibility of large-scale in vitro generation of leukemia-reactive CTL for clinical use. Using a modified limiting dilution culture system donor T cells were stimulated with HLA-identical leukemic antigen presenting cells. Feasibility experiments demonstrated that in 16 of 27 donor-recipient pairs tested a CTL line could be generated. Twelve of these 16 patients developed a relapse and for 11 of these 12 patients a CTL line was generated under Good Manufacturing Practice conditions. The CTL lines showed moderate to high cytotoxic activity against original recipient leukemic cells in vitro. Eight patients with a relapse received from one to seven CTL lines. One patient entered a complete remission after CTL infusion only, one entered a complete remission after combined CTL infusion and donor lymphocyte infusion, two patients had temporarily stable disease, and in four patients no response was observed. Although the current procedure to generate these CTL lines is feasible, the strategy is logistically complex and time-consuming, and needs further improvement. Key words: cellular immunotherapy, CTL, leukemia, allogeneic stem cell transplantation.

The Effects of Midazolam or Propofol Combined with Remifentanil Infusion for Central Venous Catheterization in Children

Background: Midazolam or propofol has been used for the procedural sedation in children. However, the combined use of remifentanil have not been widely investigated. The purpose of this study was to evaluate the effectiveness and safety of remifentanil infusion with intravenous anesthetics during the central venous catheterization in children. Methods: After institutional review board approval and written informed consent from patients` parent, 20 children planned central venous catheterization for chemotherapy were randomly assigned into two groups. All patients were infused with remifentanil 0.1μg/kg/min. In M group, 0.3 mg/kg of midazolam bolus was injected and 0.1 mg/kg bolus were injected intermittently if the sedation was inadequate. In P group, 1.0 mg/kg of propofol bolus and 150μg/kg/min were infused. 0.5 mg/kg of propofol was given intermittently if the sedation was inadequate. Hemodynamic variables, end-tidal CO2 (EtCO2), bispectral index score (BIS) were monitored throughout the procedure. Results: There were no significant differences in hemodynamic variables, sedation and recovery times. Oxygen saturation (SpO2) in P group was significantly lower than that of M group at 15 min after the start of infusion. EtCO2 in P group was significantly higher than that of M group at 10 min after the start of infusion. Hypoxemia (SpO2＜90%) were occurred in three patients of P group. There was no significant difference in BIS among the groups. Conclusions: The combined infusion of remifentanil 0.1μg/kg/min with midazolam provided successful sedation without airway assistance during the central venous catheterization in children. (Korean J Anesthesiol 2007; 52: 669~74)

RESISTANT OEDEMA IN NEPHROTICS

Introduction: Hypoalbuminemic nephrotics often have sufficient fluid accumulation to mandatediuretic therapy but are often resistant to diuresis. Furosemide is one of the most effective and least toxic diuretics usedin pediatric practice. In children with different diseases who received orally or intravenously 1 to 2 mg/kg doses offurosemide. In a country like Pakistan, such a treatment is not always afforded, albumin being quite costly. Objective:To compare the efficacy of albumin furosemide combination infusion to the infusion of furosemide alone in patients ofnephrotic syndrome with resistance oedema. Study design: Two way crossover study. Setting: Paediatric Medicine,Nishtar Medical College, Multan. Duration: From January 2004 to June 2005. Patients and Methods:10 children.Results: There was marked improvement in the symptoms like respiratory distress and oedema in both the groups.Urine output was markedly increased without any significant changes in the BUN, serum creatinine, serum electrolytesand serum calcium. These values were slightly higher in group-I but not statistically significant. No adverse effects likedrowziness confusion, hypotension and seizures were observed in any group. Conclusion: During the clinicalmanagement of resistant oedema in nephrotics, furosemide infusion alone is as efficacious in reducing the oedemaas albumin furosemide mixtures without any adverse effects and is much more economical.

Dopamine activity in the nucleus accumbens modulates blocking in fear conditioning

Associative learning depends on the discrepancy between actual and predicted outcomes. The neurochemical mechanisms involved in regulating this discrepancy in Pavlovian fear conditioning in rats are unknown. We employed the blocking paradigm to show that this learning discrepancy is decreased by heightened activation of dopamine following an accumbal infusion of d-amphetamine, and increased by dopaminegic blockade following an accumbal infusion of cis-(z)-flupenthixol or by combined infusions of the D1 (SCH23390) and D2 (sulpiride) antagonists but not by infusion of either alone.

Alloreactive Natural Killer Cells Reduce Graft-Versus-Host Disease and Enhance Engraftment in Mice Bone Marrow Transplantation Model.

Bone marrow transplantation (BMT) has become an important approach to cure many hematological malignancies. Unfortunately, graft-versus-host disease (GVHD) and graft rejection are still the major drawbacks of allogeneic BMT. GVHD fundamentally depends on the interaction of donor T cells with antigen-presenting-cells (APC) and it subsequently effect T cells activation and proliferation. Natural killer (NK) cells exert a variety of immunological functions and accommodation capacity to alter the course of GVHD and graft rejection. In this study, we established a mice GVHD model and with this model explored whether NK cells could reduce GVHD and enhance engraftment.Methods:C57BL/6(H-2b) mice were as bone marrow cells donors, and BALB/c (H-2d) mice as recipients. NK cells from donors and recipients were enriched with anti-CD49b immuno-magnetic microbeads and MiniMACS separator respectively, and been reactive by culture in complete DMEM medium supplemented with recombinant human IL-2(rhIL-2). The recipients were divided into four groups: Control group 1 was treated with nothing, Control group 2 with BMT alone, Experiment group 1 with BMT plus autoreactive NK cells, and Experiment group 2 with BMT plus alloreactive NK cells. Each recipient mouse received 1×107 donor bone marrow cells and 1×107 spleen cells combination infusion after 7Gy 60Co total-body irradiation, and in Experiment groups, each mouse was infused 5×105 autoreactive NK cells (group 1)or donor activated NK cells (group 2).Results: The survival time in groups of the BMT alone, the BMT with alloreactive NK cells, and the BMT with syngeneic NK cells were 25.6±1.2 days, 33.7±1.5 days, and 19.4±1.8 days; the mortality of these three groups at Day +30 were 100%, 20%, and 100%, and the chimerism of donor cells were 51.9±3.3%, 72.9±2.47%, and 41.8±2.19% respectively. Histopathological study in liver, small intestine, and skin of the recipients received BMT alone and BMT with syngeneic NK cells showed extensive infiltration of inflammatory lymphocytes associated with cellular necrosis, and a GVHD score was 7.6±0.47 and 8.6±0.47 respectively at 4 weeks after BMT. However, the mice received BMT with alloreactive NK cells showed little infiltration of inflammatory cells with normal structure of liver, small intestine, and skin, and a GVHD scores was 2.4±0.53(P <0.01). When allogeneic NK cells reduced GVHD and enhanced engraftment, the content of host APC or DCs and host mature APC or DCs were decreased and serum TGF-β1 level were increased, and when syngeneic NK cells aggravated GVHD and reduced engraftment, the contents of host APC or DCs were not changed and host mature APC or DCs were increased and the TGF-β1 level were decreased.Conclusions:Our study suggested that alloreactive NK cells can reduce GVHD and enhance engraftment; and syngeneic reactive NK cells can aggravate GVHD and reduce engraftment. The mechanism of allogeneic NK cells reducing GVHD and enhancing engraftment is related to decreasing of host APC or DCs, and to increasing of TGF-β1 level, and in the other hand, the mechanism of syngeneic NK cells aggravating GVHD and reducing engraftment is related to increasing of host APC or DCs, and to decreasing of TGF-β1 level. Our results provide a theoretic proof of NK cells reducing GVHD and graft rejection in allogeneic BMT, especially in unrelated donor BMT, and may be related to the mismatch of Ly49-MHCIantigen.

Prolonged Attenuation of Amygdla Kindled Seizures by Local Delivery of Large Molecular Weight Therapeutic Agents by Convection-Enhanced Delivery in Rats

Many patients with temporal lobe epilepsy (TLE) respond inadequately to antiepileptic drugs, necessitating resective surgery as a last resort. An alternative less invasive approach is site-specific delivery of therapeutic agents into the epileptic focus. However, conventional intraparenchymal injection produces localized tissue damage and there is poor control over the drug distribution. Convection-enhanced delivery (CED) is an alternative infusion technique that allows for the nondestructive and well-controlled localized delivery of solutes, including high molecular weight agents (e.g., peptides, proteins, and even viral vectors). The present study examined whether long-term changes in amygdala-kindled seizure susceptibility can be produced by a one-time CED infusion into the amygdala. Agents selected for study were presynaptic neurotoxins capable of producing long-term attenuation of neurotransmitter release either by inhibiting N-type calcium channels (i.e., ω-conotoxins GVIA and MVIIA) or cleaving intracellular proteins involved in exocytosis (i.e., botulinum toxins type A and B). A conventional, small-molecule antiepileptic drug, carbamazepine, was used for comparison. Each rat was implanted with a combination infusion cannula and stimulation electrode into the right basolateral amygdala. Daily stimulations were carried out until the animals were fully kindled (stage 5 seizures for at least five consecutive days). Then, the rats received infusions of vehicle alone or ω-conotoxins (5-500 pmol), botulinum toxins (7-67 fmol), or carbamazepine (500 nmol) through the cannula whose tip was adjacent to the stimulation site. Each dose was delivered in a volume of 5 μL at a rate of 0.25 μL/min. Electrophysiological (afterdischarge threshold and duration) and behavioral (seizure stage and duration) measures of amygdala-kindled seizures were recorded daily for up to 64 days after the infusion. There were no changes in any of the kindling parameters in rats that had received vehicle infusions. In contrast, infusions of ω-conotoxins and botulinum toxins resulted in a dose- and time-dependent increase in the afterdischarge threshold and a decrease in seizure stage and duration, indicting an inhibitory effect on kindled seizure expression. The protective effects of ω-conotoxins reached a maximum at 48 h postinfusion and then gradually dissipated within the next five days; in contrast, effects of botulinum toxins lasted for several weeks. Infusions of each toxin appeared well tolerated and devoid of any immediate or long-term side effects. In marked contrast to the long-lasting effects produced by ω-conotoxins and botulinum toxins, attenuation of seizures produced by carbamazepine lasted only a few hours after the infusion. These results indicate that local CED-mediated delivery of high molecular weight presynaptic toxins can produce long-lasting anticonvulsant effects that persist for weeks. Whether this approach will be useful in the treatment of human epilepsy or other brain disorders requires further investigation.