Multiple Injection Sites Research Articles

ARViS: a bleed-free multi-site automated injection robot for accurate, fast, and dense delivery of virus to mouse and marmoset cerebral cortex

Genetically encoded fluorescent sensors continue to be developed and improved. If they could be expressed across multiple cortical areas in non-human primates, it would be possible to measure a variety of spatiotemporal dynamics of primate-specific cortical activity. Here, we develop an Automated Robotic Virus injection System (ARViS) for broad expression of a biosensor. ARViS consists of two technologies: image recognition of vasculature structures on the cortical surface to determine multiple injection sites without hitting them, and robotic control of micropipette insertion perpendicular to the cortical surface with 50 μm precision. In mouse cortex, ARViS sequentially injected virus solution into 100 sites over a duration of 100 min with a bleeding probability of only 0.1% per site. Furthermore, ARViS successfully achieved 266-site injections over the frontoparietal cortex of a female common marmoset. We demonstrate one-photon and two-photon calcium imaging in the marmoset frontoparietal cortex, illustrating the effective expression of biosensors delivered by ARViS.

Intratumoral Chemotherapy: The Effects of Drug Concentration and Dose Apportioning on Tumor Cell Injury.

The addition of intravenous (i.v.) chemotherapy to i.v. immunotherapy for patients with lung cancer results in improved overall survival but is limited by synergistic side effects and an unknown, highly variable final cytotoxic dose within the tumor. The synergy between i.v. chemo- and immunotherapies is hypothesized to occur as a result of cell injury caused by chemotherapy, a mechanism demonstrated to drive antigen presentation within the tumor microenvironment. Intratumoral delivery of chemotherapy may thus be optimized to maximize tumor cell injury. To assess the balance between the damage versus the death of tumor cells, we developed a computational model of intratumoral dynamics within a lung cancer tumor for three different chemotherapy agents following direct injection as a function of location and number of injection sites. We based the model on the morphology of a lung tumor obtained from a thoracic CT scan. We found no meaningful difference in the extent of tumor cell damage between a centrally injected versus peripherally injected agent, but there were significant differences between a single injection versus when the total dose was apportioned between multiple injection sites. Importantly, we also found that the standard chemotherapeutic concentrations used for intravenous administration were effective at causing cell death but were too high to generate significant cell injury. This suggests that to induce maximal tumor cell injury, the optimal concentration should be several orders of magnitude lower than those typically used for intravenous therapy.

The Non-Affected Muscle Volume Compensates for the Partial Loss of Strength after Injection of Botulinum Toxin A.

Local botulinum toxin (BTX-A, Botox®) injection in overactive muscles is a standard treatment in patients with cerebral palsy. The effect is markedly reduced in children above the age of 6 to 7. One possible reason for this is the muscle volume affected by the drug. Nine patients (aged 11.5; 8.7-14.5 years) with cerebral palsy GMFCS I were treated with BTX-A for equinus gait at the gastrocnemii and soleus muscles. BTX-A was administered at one or two injection sites per muscle belly and with a maximum of 50 U per injection site. Physical examination, instrumented gait analysis, and musculoskeletal modelling were used to assess standard muscle parameters, kinematics, and kinetics during gait. Magnetic resonance imaging (MRI) was used to detect the affected muscle volume. All the measurements were carried out pre-, 6 weeks post-, and 12 weeks post-BTX-A. Between 9 and 15% of the muscle volume was affected by BTX-A. There was no effect on gait kinematics and kinetics after BTX-A injection, indicating that the overall kinetic demand placed on the plantar flexor muscles remained unchanged. BTX-A is an effective drug for inducing muscle weakness. However, in our patient cohort, the volume of the affected muscle section was limited, and the remaining non-affected parts were able to compensate for the weakened part of the muscle by taking over the kinetic demands associated with gait, thus not enabling a net functional effect in older children. We recommend distributing the drug over the whole muscle belly through multiple injection sites.

Modified technique for proximal subclavicular brachial plexus block: study on unfixed cadavers

BACKGROUND: The proximal subclavian brachial plexus block is performed deep and posterior to the midpoint of the clavicle. Only a few studies evaluated the spread of local anesthetic when using a proximal subclavian approach to the brachial plexus. We performed a cadaveric study to evaluate the spread of the injection after performing proximal subclavian brachial plexus block using ultrasound navigation.
 AIM: To examine the spread of the stained solution in unfixed corpses, when it is administered using a modified technique of proximal subclavian access to the brachial plexus using ultrasound navigation.
 MATERIALS AND METHODS: Six ultrasound-guided injections were performed on three unfixed cadavers using 20 ml of a colored solution. The brachial plexus and its branches were distinguished from the level of the midpoint of the clavicle to the upper third of the shoulder. The boundaries of ink distribution in relation to the bundles and terminal branches of the brachial plexus from the intersection of the upper edge of the clavicle to the upper parts of the axillary region were assessed.
 RESULTS: In all cases of dye spread, the lateral, posterior, and medial bundles of the brachial plexus were stained. Terminal branch staining varied and was limited to the proximal portions of these nerves. The dye spread to the interstellar space in 2 (33%) out of 6 (100%) injections and to the level of the upper edge of the clavicle in 4 (67%) injections. The axillary and radial nerves were stained in all injections, and the ulnar nerve was stained in 4 (67%) of 6 (100%) injections. The musculocutaneous and median nerves were stained in only 2 (33%) of 6 (100%) injections. No phrenic nerve staining was observed in any case.
 CONCLUSIONS: On the basis of experiment results on unfixed cadavers, injection using a modified ultrasound-guided proximal subclavian approach can fill the fascial sheath surrounding the brachial plexus with the injection material, thus causing the dye to spread around all bundles of the brachial plexus to supraclavicular space. Additional research is needed to assess whether high injection volumes or multiple injection sites can affect distribution.

Changes in Scleral Thickness Following Repeated Anti-vascular Endothelial Growth Factor Injections.

PurposeThis cross-sectional study aimed to compare changes in scleral thickness between eyes injected with repeated anti-vascular endothelial growth factor (anti-VEGF) drugs and fellow injection naive eyes using optical coherence tomography (OCT).MethodsA total of 79 patients treated with three intravitreal anti-VEGF injections in one eye versus no injections in the fellow eye were included.Anterior segment-OCT measured scleral thickness in the inferotemporal quadrant 4 mm away from the limbus.Results Injected eyes had a mean scleral thickness of 588 95 μm versus 618 85 μm in fellow naïve eyes (P 0.001). Comparing injected eyes to fellow naïve eyes stratified by injection number showed a mean scleral thickness of 585 93 μm versus 615 83 μm in eyes with 3–10 injections (n = 32, P = 0.042); 606 90 μm versus 636 79 μm in eyes with 11–20 injections (n = 24, P = 0.017); and 573 104 μm versus 604 93 μm in eyes with 20 injections (n = 23, P = 0.041). There was no significant correlation between injection number and scleral thickness change (r = –0.07, P = 0.26). When stratified by indication, subjects with retinal vein occlusions showed a statistically significant difference in scleral thickness between injected and fellow naïve eyes (535 94 μm and 598 101 μm, respectively, P = 0.001).ConclusionCompared to injection naive eyes,multiple intravitreal injections at the repeated scleral quadrant results in scleral thinning. Consideration of multiple injection sites should be considered to avoid these changes.

Upper Extremity Infection Related to Intravenous Drug Use: Considering the True Cost of the COVID-19 Pandemic and Lockdown.

The COVID-19 pandemic caused significant morbidity and mortality in people who inject drugs (PWID). Upper extremity soft tissue infections are frequently associated with intravenous drug use (IVDU) due to poor compliance with aseptic technique. In Canada, multiple safe injection sites providing clean injection supplies closed, leaving many PWID with no alternatives to inject safely. It was hypothesized that these closures will correspond with increased morbidity and mortality among PWID. The main objective of this study was to determine the effect of the COVID-19 pandemic on the incidence of upper extremity infections in PWID. This was a retrospective chart review study. The primary outcome of interest was the frequency of upper extremity infections in PWID. Data were filtered to include only those patients presenting to the emergency department between March to June of 2019 and 2020. Chi-squared analysis was used to compare the number of IVDU patients among patients with upper extremity skin infections between these time periods. The number of IVDU patients treated for upper extremity infections in Hamilton significantly increased during the pandemic, relative risk = 2.0 (95% confidence interval [CI]: 1.3-2.9, P = .0012,) while total upper extremity infections numbers have decreased overall. During the pandemic, PWID made up a larger proportion of upper extremity infections (χ2 = 10.444, P = .00123). Demographic data such as age and sex of IVDU patients presenting with upper extremity infection was not significantly affected by the pandemic. The effect of the pandemic on accessing harm reduction services has led to evident increases in morbidity as described by this study. Further research on the impact of closures in PWID is needed to quantify these harms and work toward mitigation strategies.

Impact of injection sites on clinical pharmacokinetics of subcutaneously administered peptides and proteins

For most approved subcutaneously (SC) administered drug products in the US, the recommended injection sites (i.e., abdomen, thigh, and upper arm) are usually based on experience from phase 3 trials. Relative bioavailability data directly comparing the pharmacokinetics (PK) of different SC injection sites are often not available and the underlying mechanisms that may affect SC absorption have not been systematically investigated. In this study, we surveyed clinical PK data (AUC, Cmax, and Tmax) for SC administered drug products including therapeutic proteins and peptides based on literature and FDA database. The PK data after abdominal injection was used as a reference to determine the relative bioavailability of SC injections to the arm and thigh. The survey retrieved 19 immunoglobulin G (IgGs), 18 peptides/small proteins (molecular weight < 16 kDa), and 8 non-IgG proteins that had available clinical PK data from multiple SC injection sites. Among these, 5 (26%) IgGs, 9 (50%) peptides/small proteins, and 3 (38%) non-IgG proteins, exhibited injection site-dependent PK (i.e. PK differed by injection sites). Correlation analyses revealed that the PK of peptides/small proteins undergoing rapid SC absorption (Tmax ≤ 2 h), elimination (CL/F ≥ 39 L/h) or low plasma protein binding were more sensitive to injection sites. Similarly, non-IgG proteins (molecular weight ≥ 16 kDa) with high CL/F and low Tmax are associated with high risk of injection site-dependent SC absorption. IgGs with T1/2 < 15 days or Tmax < 5 days are more likely to show injection site-dependent SC absorption. Positive charge of the drug molecule (isoelectric point ≥8) may reduce SC absorption from all three injection sites but is not associated with high risk of injection site-dependent SC absorption. In summary, the results suggested that regional differences in pre-systemic catabolism and local SC blood flow potentially contribute injection site-dependent SC absorption of peptides/small proteins while local lymphatic flow and FcRn binding likely contribute to site-dependent SC absorption of IgGs.

Facilitated Subcutaneous Immunoglobulin (fSCIG) Administration in Secondary Immune Deficiency (SID) Due to Hematological Malignancies. Efficacy and Safety Real-World Data from a Single-Center in Greece

Intoduction Hematological malignancies are often complicated by secondary immunodeficiency (SID), namely hypogammaglobulinemia, the cause of common and opportunistic infections, which represent the major morbidity aitiology for hematological patients (pts)(Friman V, et al. Hematol Oncol 34: 121-132, 2016). Immunoglobulin replacement with intravenous gamma globulin (IVIg) reduces the number of infections, antibiotics' need and hospitalization days (Raanani P, et al. Leuk Lymphoma 50(5): 764-772, 2009). The subcutaneous (sc) route of IgG although equally effective, presents certain constraints (reduced bioavailability, multiple injection sites, and frequent infusions). The facilitated subcutaneous immunoglobulin (fSCIg) method exploits the pharmacologic properties of recombinant human hyaluronidase (rHuPH20) and has been studied in primary immune deficiency (PID) syndromes with similar efficacy to IVIG (Wasserman RL. Immunotherapy 6(5): 553-567, 2014). fSCIg has demonstrated several advantages; self-administration, same bioavailability, long infusion intervals, few adverse drug reactions-ADRs. However, fSCIg has been less extensively studied in SID. Aim We present our single-center real-world data from fSCIg administration in hematological pts with SID, focusing on safety and efficacy issues. Patients and Methods Since 14-Oct- 2015 fSCIg has been used as the primary immunoglobulin reconstitution treatment (IgRT) in our department for hematological pts fulfilling the ESMO 2015 guidelines (Eichhorst B, et al. Ann Oncol 26(5): v78-v84, 2015): hypogammaglobulinemia with recurrent bacterial infections. No PSAF (proven specific antibody failure) is performed before IgRT initiation. Treatment goal is IgG trough levels around 600 mg/dL. The fSCIg(10% IgG) dosage is 0.4-0.8 g/Kg/month. Treatment modifications are made according to infection occurrence. fSCIg is administered with a variable rate portable pump and a sc 24G needle . First, pts receive rHuPH20 (1-2 ml/min). Ten min after rHuPH20, fSCIg(10%) is infused through the same sc needle, at the same injection site. The rate of the 1st fSCIg infusion is gradually increased from 10ml/h to 300 ml/h. If well tolerated, pts are treated with the final rate of 300 ml/h for subsequent infusions. The first 5 infusions take place at our department and the pts/relatives are instructed how to use the pump. The subsequent infusions take place outside hospital facilities. IgRT is given indefinitely to this pt population. Results Between mid-October 2015 and mid-July 2019, 45 hematological pts have been treated with fSCIg(10%) at our department according to ESMO 2015 guidelines. Baseline pts' characteristics are shown in table 1. Nine hundred sixty-two (962) infusions were administered, with median number of infusions per pt 19(3-48), median time on treatment 23.5 months(1-44.8) and median follow up 23.9 months (1.4-44.8). Thirty-nine (39) pts (86.7%) were able either to self-administer the formulation or to be treated by the aid of a relative after the 5th training session. More than 700 infusions were performed outside hospital's facilities. Thirty-nine (39) pts (86.7%) had no adverse drug reaction- ADR-, except mild edema at the site of injection for 8-24 hours after the infusion. Six patients (13.3 %) presented at least one type of ADR (table 2). In 11 pts (24.4%) at least 1 infection episode was noticed. All cases were grade 2, except an appendicitis case (grade 3) that it was surgically managed. There were 4 cases of upper respiratory tract infection, 3 cases with lower respiratory tract infections, 2 dermal infections and 1 viral gastroenteritis. fSCIg dose modification was done in 3 pts. During the follow up period 37 pts (82.2%) are ongoing and 8 pts (17.8%) have discontinued fSCIg: 6 due to death from underlying malignancy and 2 (4.4%) due to ADRs (1 with grade 3 rash and 1 with grade 3 fever and rigor). Surprisingly, there was no death from infectious complication. Conclusions Our single-center real-world data from fSCIg administration in hematological patients with hypogammaglobulinemia and recurrent infections shows that this method is very effective in reducing infections, with few ADRs. These findings compare favorably to those observed with IVIg (Raanani P, et al. Leuk Lymphoma 50(5): 764-772, 2009). Finally, fSCIg reduces the nursing staff workload in hematology wards and is preferred by the vast majority of the patients. Disclosures Panayiotidis: Bayer: Other: Support of clinical trial.

The Error in Using Superposition to Estimate Pressure During Multisite Subsurface CO2Storage

AbstractAnalytic pressure estimates for multisite CO2injection are typically performed through the superposition of single‐site injection models. This is theoretically invalid for multiphase flow because of its nonlinearity. We quantify the error associated with the application of superposition in scenarios with sites located in a rectangular grid geometry. We show that the use of superposition results in overestimates of the pressure buildup, because it neglects the presence of multiple CO2plumes, which increase the reservoir fluid mobility. The adoption of a dimensionless time scaled to the geometric average between the advective and diffusive characteristic times allows us to define a general model for the maximum error, which may be used to evaluate the validity of using superposition, or to correct the pressure estimates when errors are significant. This procedure can be applied to any analytical solution and advances the extension of single‐well models to scenarios of multiple injection sites.

Maximizing botulinum toxin injections for cosmetic and therapeutic applications with a single use, disposable, exact dose injection assist device.

BackgroundAlthough freehand injection of botulinum toxin remains the status quo, it is an inaccurate technique for delivering precise amounts of neurotoxin at multiple injection sites with expediency. We developed an inexpensive, ergonomic, single-use, disposable exostructure device that rapidly converts a standard syringe into a highly accurate injection instrument.Materials and methodsBased on the results of two independent injectors, we determined the comparative delivery dose accuracy, precision, and amount of product waste associated with a standard syringe using the freehand injection technique vs a prototype injection assist device. Fifteen experienced injectors were also surveyed regarding their satisfaction using the device in a controlled research setting.ResultsThe average percentage difference from the expected dose value was <1% (0.00024 mL) for 1-unit doses (ie, 0.025 mL) with the injection assist device. In contrast, accuracy values with the freehand method were more than 10 times worse (ie, >10% or 0.0025 mL). Accuracy estimates were also superior with the device over freehand for 2- and 4-unit doses. Precision estimates favored the device for all comparisons and all dosing regimens. The magnitude of variability around the average difference ranged from 2.2 to 5.4 times worse for the freehand method compared to the device. The overall percentage of product waste was substantial with the freehand method (>10%) compared to the device (4.3%) (P=0.04) for 1-unit injections. The percentage of injections showing measurable product waste was also significantly lower with the device (78% vs 25%, P=0.01). Fourteen of 15 (93%) injectors surveyed would use the device in daily practice if it were included complimentary with the neurotoxin.ConclusionThe injection assist device offered superior accuracy and precision compared to the freehand method across the entire injection regimen. The ancillary finding of a significant reduction in product waste with the device was particularly notable.

Modeling Commercial-Scale CO2 Injection in Mt. Simon Sandstone Near Decatur, IL Storage Sites

Advancing carbon capture and storage (CCS) to commercialization necessitates exploiting CO2 storage resources efficiently, which likely will involve multiple injection sites (or entire projects) accessing the same regional storage complex. This situation is presently occurring in central Illinois, where a series of three U.S. Department of Energy-sponsored storage projects are utilizing the Cambrian Mt. Simon Sandstone storage complex near Decatur, Illinois. From 2011 to 2014, the Illinois Basin – Decatur Project (IBDP) injected CO2 at a rate of 0.33 million tonnes per year (Mt/yr), and in 2017, the Illinois Industrial CCS Project (IL-ICCS) began injecting approximately 1 Mt/yr (planned rate) in a well 1.6 km apart. Recently, the CarbonSAFE Illinois – Macon County Project began investigating whether more than 50 Mt of CO2 can be injected into the Mt. Simon Sandstone over several decades (a target rate of 2 Mt/yr) located at a site about 5 km northwest of the other injection locations. As evaluated for this study, the Macon County well would be within the Forsyth Oil Field and drilled to access the same interval of the Mt. Simon storage complex as used by the other injection projects, namely the lower Mt Simon Sandstone. The intent of this paper is to assess the feasibility of the Forsyth site for commercial CO2 storage to further develop the storage resource by evaluating whether the target rate can be achieved, designing an injector to meet the target rate, and describing the potential contact of subsurface plumes resulting from these separate but proximal central Illinois projects. This entails modelling the behaviour of the injected CO2 and evaluating the well perforated intervals, plume sizes, pressure responses, and contact with existing CO2 plumes at the Decatur sites. To understand the interaction of three subsurface plumes, a static geologic model was generated to encompass the proposed Forsyth site (CarbonSAFE project) and the existing Decatur sites (IBDP and IL-ICCS projects), an area 22.5  22.5 km2 and a vertical section of 664 m. The static model was developed to represent the geological architecture and heterogeneity of the Mt. Simon storage complex at the Forsyth and Decatur sites through regional correlations based on geophysical data from wells at the Decatur sites. A dynamic model with integrated fluid and rock–fluid properties was constructed from the static model. The primary CO2 storage mechanisms modeled were structural and stratigraphic trapping, residual gas trapping, and solubility trapping. Mineral trapping resulting from geochemical reactions among CO2, rock, and formation water were considered negligible because the target formation is quartz sandstone.

Updated NACI recommendations for measles post-exposure prophylaxis.

Human immune globulin (Ig) products are currently recommended as post-exposure prophylaxis (PEP) for measles in certain susceptible groups. However, successful measles vaccination programs in North America have led to low circulation of measles virus and most blood donors now have vaccine-derived immunity. Concurrently, the concentrations of anti-measles antibodies in human Ig products have shown trends of gradual decline and previously recommended doses and routes of administration may no longer be optimally protective. To review the literature and update recommendations on post-exposure prophylaxis for measles, including dosing and route of administration, for measles Ig PEP in susceptible infants and in individuals who are immunocompromised or pregnant, in order to prevent severe disease. The National Advisory Committee on Immunization (NACI) Measles, Mumps, Rubella, Varicella Working Group reviewed key literature, international practices, and product information for current Ig products pertaining to the optimal dosage and routes of Ig administration for measles PEP. It then proposed evidence-based changes to the PEP recommendations that were considered and approved by NACI. NACI continues to recommend that susceptible immunocompetent individuals six months of age and older, who are exposed to measles and who have no contraindications be given measles-mumps-rubella (MMR) vaccine within 72 hours of the exposure. NACI recommends that for susceptible infants younger than six months of age, if injection volume is not a major concern, intramuscular immunoglobulin (IMIg) should be provided at a concentration of 0.5 mL/kg, to a maximum dose of 15 mL administered over multiple injection sites. Susceptible infants six to 12 months old who are identified after 72 hours and within six days of measles exposure should receive IMIg (0.5 mL/kg) if injection volume is not a major concern. For susceptible contacts who are pregnant or immunocompromised, if injection volume is not a concern, IMIg can be provided at a concentration of 0.5 mL/kg understanding that recipients 30 kg or more will not receive the measles antibody concentrations that are considered to be fully protective. Alternatively, in cases where injection volume is a major concern or for recipients 30 kg or more, intravenous immunoglobulin (IVIg) can be provided at a dose of 400 mg/kg.NACI does not recommend that susceptible immunocompetent individuals older than 12 months of age receive Ig PEP for measles exposure due to the low risk of disease complications and the practical challenges of administration for case and contact management. NACI has updated the recommendations for measles PEP to reflect current evidence and best practices in order to prevent severe disease in Canada. Consistent with recommendations in other countries, this includes consideration of off-label use of IVIg in some instances.

Models and simulations of surfactant-driven fracture in particle rafts

A continuum-based model for the surfactant-driven fracture of closely-packed particle rafts is extended to examine the influence of micro-scale density variability. The model treats the particle monolayer as an elastic sheet endowed with a critical fracture energy that can be reduced through interaction with a flowing surfactant. In addition to the displacement of the monolayer, the model employs a surfactant damage field that serves as both an indicator function for the surfactant concentration as well as the damage to the monolayer. Spatial variability in the particle packing is incorporated in the model through a continuum mapping approach. The formulation gives rise to a coupled system of nonlinear partial differential equations with an irreversibility constraint. The evolution equations are recast in variational form and discretized with an adaptive finite element method. Simulations are provided to demonstrate convergence of the model, illustrate the sensitivity of the fracture process to variations in the initial packing fraction field, and make comparisons with experimental observations. The results indicate that crack bifurcations can occur in regions with spatially uniform packing as well as spatially variable packing, suggesting that both the macro-scale mechanics and the random aspects of the packing contribute to these instabilities. The model is also used to predict the response of these systems to multiple injection sources and obstacles in the domains. Finally, the model is extended to non-planar surfaces as a means to study systems in which confinement and jamming can only occur due to multiple injection sites.

Effects of hypertonic dextrose injection on chronic supraspinatus tendinopathy: A pilot study of randomized controlled trial

Rotator cuff lesions are common causes of shoulder pain. Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory symptoms. Hypertonic dextrose prolotherapy (DPT) may be another treatment choice for these refractory symptoms. However, conventional prolotherapy injection is complicated with multiple injection sites. Thus, we considered it necessary to design a rigorous trial to specifically evaluate the effectiveness of DPT injection for the supraspinatus tendon, which is mostly involved in rotator cuff tendinopathy. This double-blind, randomized, controlled study will recruit patients with chronic shoulder pain diagnosed as chronic supraspinatus tendinopathy. We recruit 20 participants, with a total of 10 participants in each treatment arm. The hypertonic DPT group will receive 5 mL of 20% glucose water prolotherapy injection, and the control group will receive normal saline by using the same injection protocol as that used for the study group. Demographic data will be recorded at baseline. Visual analog scale, Shoulder Pain and Disability Index, range of motion, ultrasound will be recorded at baseline, after intervention (week 2, and week 6). Descriptive statistics will be calculated for feasibility outcomes, and measures of clinical effectiveness will be explored using repeated measures analysis of variance. Prolotherapy injection group presented improved of VAS, SPADI, and range of motion after 2 weeks of injection with comparing baseline. However, the effect was not maintained to 6 weeks after injection. There was no difference of histogram changes before and after prolotherapy injection. With comparing control group, improved VAS and SPADI was better among study group at 2 weeks after injection but no difference at 6 weeks after injection. Our pilot study demonstrated that hypertonic dextrose prolotherapy injection can improve pain and function of chronic rotator cuff tendinosis patients in short-term period.

High-Yield Purification, Preservation, and Serial Transplantation of Human Satellite Cells.

SummaryInvestigation of human muscle regeneration requires robust methods to purify and transplant muscle stem and progenitor cells that collectively constitute the human satellite cell (HuSC) pool. Existing approaches have yet to make HuSCs widely accessible for researchers, and as a result human muscle stem cell research has advanced slowly. Here, we describe a robust and predictable HuSC purification process that is effective for each human skeletal muscle tested and the development of storage protocols and transplantation models in dystrophin-deficient and wild-type recipients. Enzymatic digestion, magnetic column depletion, and 6-marker flow-cytometric purification enable separation of 104 highly enriched HuSCs per gram of muscle. Cryostorage of HuSCs preserves viability, phenotype, and transplantation potential. Development of enhanced and species-specific transplantation protocols enabled serial HuSC xenotransplantation and recovery. These protocols and models provide an accessible system for basic and translational investigation and clinical development of HuSCs.

Adipose tissue: a new target for electroporation-enhanced DNA vaccines

DNA vaccines delivered using electroporation (EP) have had clinical success, but these EP methods generally utilize invasive needle electrodes. Here, we demonstrate the delivery and immunogenicity of a DNA vaccine into subcutaneous adipose tissue cells using noninvasive EP. Using finite element analysis, we predicted that plate electrodes, when oriented properly, could effectively concentrate the electric field within adipose tissue. In practice, these electrodes generated widespread gene expression persisting for at least 60 days in vivo within interscapular subcutaneous fat pads of guinea pigs. We then applied this adipose-EP protocol to deliver a DNA vaccine coding for an influenza antigen into guinea pigs. The resulting host immune responses elicited were of a similar magnitude to those achieved by skin delivery with EP. The onset of the humoral immune response was more rapid when the DNA dose was spread over multiple injection sites, and increasing the voltage of the EP device increased the magnitude of the immune response. This study supports further development of EP protocols delivering gene-based therapies to subcutaneous fat.

The impact of energy systems demands on pressure limited CO2 storage in the Bunter Sandstone of the UK Southern North Sea

National techno-economic pathways to reduce carbon emissions are required for the United Kingdom to meet its decarbonisation obligations as mandated by the Paris Agreement. Analysis using energy systems models indicate that carbon capture and storage is a key technology for the UK to achieve its mitigation targets at lowest cost. There is potential to significantly improve upon the representation of the CO2 storage systems used in these models, but sensitivities of a given reservoir system to future development pathways must be evaluated. To investigate this we generate a range of numerical simulations of CO2 injection into the Bunter Sandstone of the UK Southern North Sea, considered to be one of the most important regional aquifers for CO2 storage. The scenarios investigate the sensitivity of CO2 storage to characteristics of regional development including number of injection sites and target rates of CO2 injection. This enables an evaluation of the impact of a range of deployment possibilities reflecting the range of scenarios that may be explored in an energy system analysis. The results show that limitations in achieving target injection rates are encountered at rates greater than 2 MtCO2/year-site due to local pressure buildup. The areal location of injection sites has minimal impact on the results because the Bunter Sandstone model has good regional connectivity. Rather, the depth of the site is the most important factor controlling limits on CO2 injection due to the relationship between the limiting pressure and the lithostatic pressure gradient. The potential for model simplification is explored by comparison of reservoir simulation with analytical models of average reservoir pressure and near-site pressure. The numerical simulations match average pressure buildup estimated with the “closed-box” analytical model of Zhou et al. (2008) over a 50year injection period. The pressure buildup at individual sites is estimated using the Mathias et al. (2011) formulation and compared to the simulation response. Discrepancies in the match are mostly due to the interaction of signals from multiple injection sites and heterogeneous permeability in the numerical simulations. These issues should be the focus of further development of simplified models for CO2 storage in an energy systems analysis framework.

Enhancing Immune Responses to Cancer Vaccines Using Multi-Site Injections

For a vaccine to be effective it must induce a sufficiently robust and specific immune response. Multi-site injection protocols can increase the titers of rabies virus-neutralizing antibodies. Hypothetically, spreading a vaccine dose across multiple lymphatic drainage regions could also potentiate T cell responses. We used a replication-deficient adenovirus serotype 5-vectored cancer vaccine targeting the melanoma-associated antigen dopachrome tautomerase. Clinically, high numbers of tumor-infiltrating CD8+ T cells are a positive prognostic indicator. As such, there is interest in maximizing tumor-specific T cell responses. Our findings confirm a positive correlation between the number of tumor-specific T cells and survival. More importantly, we show for the first time that using multiple injection sites could increase the number of vaccine-induced CD8+ T cells specific for a self-tumor antigen. Further, the number of tumor antigen-specific antibodies, as well CD8+ T cells specific for a foreign antigen could also be enhanced. Our results show that multi-site vaccination induces higher magnitude immune responses than a single-bolus injection. This provides a very simple and almost cost-free strategy to potentially improve the efficacy of any current and future vaccine. Broader clinical adoption of multi-site vaccination protocols for the treatment of cancers and infectious diseases should be given serious consideration.

Screening the geomechanical stability (thermal and mechanical) of shared multi-user CO2 storage assets: A simple effective tool applied to the Captain Sandstone Aquifer

Multi-user storage systems are anticipated in the near future to permanently store CO2 captured at industrial sources to meet emissions reductions targets. Multiple storage permit applications will be required to exploit the immense potential capacity within extensive CO2 storage assets. To retain 99% of the injected CO2 for 1000 years the geomechanical stability of the sealing strata above the pressurised storage reservoir is a key factor which needs to be included in the geo-engineering design of shared storage assets The potential for interaction of increased pressure at multiple injection sites needs to be predicted and assessed at a regional scale to assure the integrity at all existing sites before a storage permit is granted. Geomechanical models coupled with the expected fluid pressure response predict the stability of the storage asset during and after injection of CO2 at multiple injection sites, and can be used as a tool to ensure efficient utilisation of the storage capacity. The geomechanical analysis of the thermal stress as well as local and regional fluid pressure changes requires a detailed numerical evaluation, often at a resolution significantly higher than the data available. Coupling of regional-scale static geological models, dynamic multi-phase flow models and detailed geomechanical models requires extensive computational resources. Such models often produce seemingly detailed results, but are usually only one or two realisations of a system populated by a statistically generated parameter set. Limits on time and computational resources prevent more simulations within fixed time and financial budgets. To enable a more time and cost efficient methodology of assessing the geomechanical stability of potential storage sites we present a four-tier modelling approach with increasing complexity that allows an in-depth evaluation of the geomechanical stability at a regional scale of a multi-user storage asset taking into account the fluid pressure increase and the thermal stress impact on the stability of the strata sealing the CO2 store. The tiers include: (1) development of a geo-mechanical facies model of the storage system, (2) development of an analytical geomechanical model for the storage site static stress conditions, (3) fitting an empirical multivariable polynomial function to the analytical modal, and (4) conditioning the empirical function using coupled numerical THM modelling for dynamic stress conditions. The result is look up function which gives the maximum possible fluid pressure as a function of location. This approach significantly simplifies the computational requirements and time for the prediction of geomechanical behaviour. In addition to presenting this methodology, using the Captain Sandstone of the North Sea as an example, three key findings are further examined. Firstly, detailed analysis of the stress changes as a result of cold fluid injection suggests that the redistribution of thermal stress can, in some cases, be beneficial to the storage system depending on the stress bridging which occurs. Secondly, pressure plume migration over time in dipping strata, from deeper injection sites to shallower sites, needs to be taken into account. Thirdly, the nature of the strata underlying the storage formation is critical to the pressure increase in response to the fluid injection. The methodology developed in this paper enables a rapid and efficient screening of the dynamic geomechanical stability and facilitates an efficient coupling to diverse discrete multiphase fluid flow models using commonly available computational resources.

Intravenous and Intramuscular Administration of Asparaginase in Pediatric Patients with Acute Lymphoblastic Leukemia: Treatment Patterns and Perceptions

Background: Asparaginase is an important component of therapy for acute lymphoblastic leukemia (ALL). In the United States, asparaginase may be administered as a course of intramuscular (IM) injections. These injections can be painful and may cause anxiety in children undergoing chemotherapy treatment for ALL [August KJ, et al. J Pediatr Hematol Oncol. 2013;35(7):e283-e286]. Intravenous (IV) administration of asparaginase may offer a less painful therapeutic option for patients; however, there exist concerns over an increased incidence of infusion-related reactions associated with this administration method compared with IM delivery. The goal of this study was to assess the practices and attitudes of physicians regarding their treatment of pediatric patients with ALL, including the route of administration of asparaginase.Method: This study consisted of a 30-minute, online, quantitative survey targeting board-certified physicians with 2-30 years in practice. Inclusion criteria required that physicians have spent ≥75% of their time in direct patient care, treat ≥5 pediatric patients with ALL (aged ≤21 years) in a typical month, and have treated at least 80% of patients with ALL with a Children's Oncology Group, Dana Farber, or St Jude protocol in the past year.Results: Data regarding route of administration were available from 67 of 74 participating physicians; 63 reported this information for PEG-asparaginase and 67 for asparaginase Erwinia chrysanthemi. Responses included some data not aligned with the product label. IV administration was the standard route of administration for 86% (54/63) of physicians using PEG-asparaginase and for 37% (25/67) of physicians using asparaginase Erwinia chrysanthemi. Five percent (3/63) of PEG-asparaginase users and 15% (10/67) of those using asparaginase Erwinia chrysanthemi reported that the route of administration was determined by patient characteristics and situation. Among physicians who preferred IM administration of asparaginase Erwinia chrysanthemi, the most commonly cited reason was standard of practice or protocol (38%, 12/32). Ease of administration (68%, 17/25) was the most commonly reported reason for physicians using IV administration of asparaginase Erwinia chrysanthemi. Of 15 physician responders who have used IV administration of asparaginase Erwinia chrysanthemi for 6 or more months, 67% (10/15) adhered to a 60-minute infusion duration, whereas 27% (4/15) reported using an infusion duration of ≥90 minutes, which is not aligned with the product label. Of those who administered asparaginase for ≥90 minutes, 1 physician reported that this practice reduced the risk of an infusion reaction, 1 reported that it was due to patient preference, and 1 reported that it was the standard infusion time at their institution. Additionally, 1 physician erroneously reported that the infusion time of ≥90 minutes was in line with the product label for asparaginase Erwinia chrysanthemi. Regarding the rate of infusion, 40% (6/15) of physicians reported that they typically start the infusion gradually (at a lower drug delivery rate) before ramping up the infusion speed for the remaining dose; 1 respondent stated that this infusion method was hospital policy, while the other 5 physicians stated that this method improved patient tolerance/less reactions or the ability to better monitor the patients for side effects.Conclusion: The majority of physicians using asparaginase Erwinia chrysanthemi preferred using IM administration to treat pediatric patients with ALL. Institutional preferences and standard of practice were the most common responses given for using IM administration. Infusion reactions that may occur with IV administration may be attenuated by prolonging the duration of the infusion, which was reported by a number of physicians experienced with IV asparaginase Erwinia chrysanthemi administration.Support: This study was funded by Jazz Pharmaceuticals. DisclosuresBernard:Jazz Pharmaceuticals: Employment, Equity Ownership. Off Label Use: Asparaginase Erwinia chrysanthemi is indicated as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with ALL who have developed hypersensitivity to E. coli-derived asparaginase. It can be administered by intramuscular injection or by intravenous infusion. For intramuscular use, limit the volume of reconstituted asparaginase Erwinia chrysanthemi at a single injection site to 2 mL; if reconstituted dose to be administered is greater than 2 mL, use multiple injection sites. For intravenous use, infuse asparaginase Erwinia chrysanthemi in 100 mL of normal saline over 1 hour.. Hall:Jazz Pharmaceuticals: Employment, Equity Ownership. Doede:Jazz Pharmaceuticals: Employment, Equity Ownership.