Cost benefit for assessment of intermediate coronary stenosis with fractional flow reserve in public and private sectors in australia.

BACKGROUND: Fractional Flow Reserve (FFR) is a proven technology for guiding percutaneous coronary intervention (PCI), but is not reimbursed despite the fact that it is frequently used to defer PCI. METHODS: Costs incurred with use of FFR were compared in both the public and private sectors with the costs that would have been incurred if the technology was not available using consecutive cases over a two year period in a public teaching hospital and its co-located private hospital. RESULTS: FFR was performed on 143 lesions in 120 patients. FFR was < 0.80 in 37 lesions in 34 patients and 25 underwent PCI while 11 had CABG. It was estimated that without FFR 78 lesions in 70 patients would have had PCI with 17 patients having CABG with 35 additional functional tests. Despite a cost of $A1200 per wire, FFR actually saved money. Mean savings in the public sector were $1200 per patient while in the private sector the savings were $5000 per patient. CONCLUSIONS: FFR use saves money for the Federal Government in the public sector and for the Private Health Funds in the private sector. These financial benefits are seen in addition to the improved outcomes seen with this technology.

Purification of plasmid DNA using selective precipitation by compaction agents.

A scaleable method for the liquid-phase separation of plasmid DNA from RNA.

Development of an effective gene delivery system: a study of complexes composed of a peptide-based amphiphilic DNA compaction agent and phospholipid.

We recently described a basic technology to efficiently combine compacted DNA with phospholipids and hydrophobic peptides, to produce homogenous complexes that are completely resistant to nuclease. We have developed this technology further to form gene delivery complexes that transfect cells effectively in vitro. In addition to plasmid DNA, the complexes contained two basic components: (i) a DNA compacting peptide (-CGKKKFKLKH), either conjugated to lipid or extended to contain (WLPLPWGW-) and (ii) either phosphatidylethanolamine or phosphatidylcholine. Complexes containing a 5.5-fold charge equivalence (peptide charge/DNA charge) of WLPLPWGWCGKKKFKLKH and 5 nmol dimyristoleoylphosphatidylethanolamine/microg DNA produced the highest luciferase gene expression, exceeding 1 x 10(9) relative light units/s/mg protein (>3 microg luciferase per mg protein). These complexes transfected OVCAR-3, COS-7 and HeLa cells at either similar or superior levels when compared to polyethylenimine or lipofectamine complexes. With green fluorescent protein reporter gene, >50% of HeLa cells were positive 30 h after addition of these complexes. Furthermore, these optimal complexes were the least sensitive to pre-treatment of cells with chloroquine, indicating efficient endosomal escape. Our results indicated that self-assembling complexes of plasmid DNA, amphiphilic peptide and phosphatidylethanolamine are highly effective non-viral gene delivery systems.

A single-chain immunotoxin against carcinoembryonic antigen that suppresses growth of colorectal carcinoma cells.

We have engineered an anti-carcinoembryonic antigen (CEA) single-chain immunotoxin derived from humanized anti-CEA antibody (hMN14) and a truncated Pseudomonas exotoxin (PE), PE40. The purified anti-CEA immunotoxin (hMN14(Fv)-PE40) was first measured for binding affinity against a CEA-positive colorectal carcinoma cell line and compared with its parental IgG and the monovalent Fab fragment. The Ka of sFv-PE40, Fab, and IgG were 5 x 10(7), 6 x 10(7), and 3 x 10(8) M(-1), respectively. There was no significant affinity loss by conversion of Fab to the single-chain Fv, but these monovalent forms were 5-6-fold reduced in affinity compared with the parental IgG. In cytotoxicity assays, the hMN14(Fv)-PE40 showed specific growth suppression of CEA-expressing colon cancer cell lines MIP-CEA (high CEA) and LS174T (moderate CEA) with IC50s of 12 ng/ml (0.2 nM) and 69 ng/ml (1.1 nM). These IC50s correlated inversely with the surface expression of CEA, such that 50% killing was equivalent for each cell type when expressed in toxin molecules bound/cell (3000-5000). The presence of soluble CEA up to 1000 ng/ml did not affect the cytotoxicity against CEA-expressing cells, with 50% suppression only at 4000 ng/ml that correlated with the binding Kd of the single-chain Fv. The stability of the hMN14(Fv)-PE40 molecule at 37 degrees C was confirmed by bioassay and by lack of aggregation. Our hMN14(Fv)-PE40 may be clinically useful for tumors with high CEA expression without affecting normal tissues with low or absent CEA, even in patients with high soluble antigen levels.

Bypassing immunization: optimized design of "designer T cells" against carcinoembryonic antigen (CEA)-expressing tumors, and lack of suppression by soluble CEA.

Tumor-associated antigens are typically nonimmunogenic in cancer patients, "immune surveillance" having manifestly failed. The fact that most tumor antigens are normal human proteins presents significant obstacles to current cancer immunization approaches that researchers are presently striving to overcome. An alternative strategy bypasses immunization altogether by direct genetic alteration of autologous patient T cells, to create "designer T cells" specific to a particular antigen. Chimeric immunoglobulin-T cell receptors (IgTCR) with a specificity for carcinoembryonic antigen (CEA) were created to evaluate the optimal IgTCR structure for cancer therapy. Antigen-binding domains of a humanized antibody were combined with TCR signaling chains to yield four different chimeric IgTCR: single chain Fv fragment (sFv)-zeta, fragment antigen-binding (Fab)-zeta, sFv-epsilon, and Fab-epsilon. All of the IgTCR were well expressed on T cells, and all showed specific binding and activation, as demonstrated by IL-2 production on contact with immobilized or cellular CEA, excepting sFv-epsilon alone which was inert solely against cellular targets for steric reasons unique to this construct. In contrast to prior studies of isolated TCR chains that related increased tyrosine-based activation motifs in zeta as a reason for superior signaling potency, these tests are the first to show that epsilon and zeta are indistinguishable for T cell signaling when assayed in the context of the intact TCR complex. Further, Fab was equivalent to sFv as an IgTCR component for expression and antigen binding, establishing an important alternative for IgTCR antigen recognition because sFvs may often lose antigen affinity. When IgTCR was expressed on normal human T cells, cytotoxic potency was demonstrated at low E:T ratios, with T cell recycling and progressive tumor cell destruction. Contrary to recent speculations, these observations prove that high affinity TCR interactions are not an impediment to serial target engagement and disengagement by cytotoxic T cells. The multivalent intercellular interactions of target cell binding, activation, and cytotoxicity were resistant to inhibition by soluble CEA. These studies establish a potentially important new immunotherapeutic modality for the treatment of CEA-expressing tumors.

Comparison of morning or bedtime insulin with and without glyburide in secondary sulfonylurea failure.

OBJECTIVES: New treatment options are needed for glycemic control in NIDDM. We evaluated the effects of bedtime or morning insulin treatment, combined with daytime glyburide or given alone. RESEARCH DESIGN AND METHODS: Twenty-nine male patients with NIDDM, mean age 63 +/- 1.7 yr, body weight 124 +/- 2.98% of DBW, received a maximum glyburide dose (20 mg/day) for a minimum of 6 wk, to confirm sulfonylurea failure. Human lente insulin was added for 12 wk either AM (n = 14) or HS (n = 15) and adjusted to obtain fasting euglycemia (FPG; combination treatment phase). Glyburide was then stopped, and insulin was continued for 6 wk, aiming for normal FPG (insulin phase). RESULTS: After combination treatment phase, FPG decreased (P < 0.02) from 12.43 +/- 0.68 to 5.73 +/- 0.65 mM (AM) and from 12.68 +/- 0.76 to 5.51 +/- 0.48 mM (HS) (AM vs. HS, NS). Postbreakfast, presupper, and 0200 AM plasma glucose levels fell equally (P < 0.02) except for 1-h postprandial (AM 12.46 +/- 0.51 mM, HS 10.88 +/- 0.62 mM, AM vs. HS, P < 0.1). Mean HBA1c fell similarly in both AM and HS groups. At 2 wk of the insulin phase, FPG was higher in AM than HS, 9.8 +/- 0.76 vs. 7.56 +/- 0.7 mM (P < 0.1). At the end of insulin phase, plasma glucose levels were similar to the end of combination treatment phase, but the insulin dose had to be raised in AM by 39% (P < 0.02) and HS by 30% (P < 0.05). After the combination treatment phase, fasting C-peptide was significantly suppressed in HS group only, from 1.22 +/- 0.12 to 0.82 +/- 0.09 nM (P < 0.02). At the end of insulin phase, fasting C-peptide was further suppressed in both groups, but 2-h postprandial C-peptide levels decreased significantly in AM group only, from 1.85 +/- 0.23 to 1.42 +/- 0.13 nM (P < 0.02). Triglycerides and total and HDL cholesterol did not change significantly after either combination treatment phase or insulin phase. Mean weight gain was 6.5 lb during combination treatment phase (NS from baseline), without further change during insulin phase. Hypoglycemic reactions, all mild, were recorded at a rate of 1.35/patient in the AM group and 0.4/patient in the HS group (P < 0.025). CONCLUSIONS: Normal fasting glycemia and near-normal postprandial glucose profile could be obtained with combination therapy in NIDDM. Results were similar if insulin, alone or in combination with glyburide, was given before breakfast or at bedtime, but hypoglycemic reactions were more common with conventional morning insulin injections.

Immunologic studies of poisonous Anacardiaceae: oral desensitization to poison ivy and oak urushiols in guinea pigs.

Poison ivy and oak urushiols or their components were compared with the respective esterified derivatives for efficacy in oral desensitization of Hartley guinea pigs sensitized to urushiols. The esterified derivatives produced a significantly greater degree of hyposensitization than did free urushiol counterparts. Suppression produced by esterified urushiols was of longer duration than that produced by free urushiols. Groups of sensitized guinea pigs were given high (100 mg/kg) or low (10 mg/kg) doses of a mixture of acetylated, saturated urushiol congeners over a 1-, 2-, or 3-week period. High doses produced a greater degree of hyposensitization regardless of the dosage schedule used. Low doses did not produce significant hyposensitization unless given over a shorter (1 week) schedule. Large single booster doses (33 mg/kg/week) of the acetate derivatives produced a rebound in responsiveness when given, 2 weeks following the last dose of the initial series, to animals hyposensitized with 10 mg/kg. No such rebound in sensitivity occurred in animals given a series of high initial doses.

Immunologic studies of poisonous Anacardiaceae: I. Production of tolerance and desensitization to poison Ivy and oak urushiols using esterified urushiol derivatives in guinea pigs.

The development of contact sensitivity to poison ivy urushiol in Hartley guinea pigs was inhibited by i.v. injection of the diacetate esters of poison ivy and oak urushiols into guinea pigs 2 weeks prior to attempted sensitization with homologous antigen. Immune tolerance to urushiols of poison ivy and oak developed in 80% or more of the treated animals and persisted for the duration of the study, 8 weeks. The tolerance was immunologically specific for urushiols since the tolerant animals were sensitizable to the unrelated sensitizer 2, 4-dinitrochlorobenzene. Guinea pigs already sensitive to urushiol were also desensitized or hyposensitizied by i.v. injection of urushiol acetates in successively increasing doses. After receiving the equivalent of 16 mg of poison ivy and oak urushiols in the acetate form over a period of 12 weeks, 54% of a group of guinea pigs were desensitized to poison ivy. all of the remaining 46% of the guinea pigs still sensitive to poison ivy were substantially hyposensitized (no longer responded to 1.5 or 0.80 microgram test doses of PDC). A control group of guinea pigs was not hyposensitized by injection of vehicle, and remained highly sensitive throughout the 15 week study. The majority of treated animals (less than 80%) were also hyposensitized to poison sumac and cashew nut shell liquid allergens.

Single-step immunization using a controlled release, biodegradable polymer with sustained adjuvant activity.

The use of a biodegradable polymer for antigen delivery based on poly(CTTH-iminocarbonate) (IUPAC nomenclature: poly[oxyimidocarbonyloxy-p-phenylene [2-(hexyloxycarbonyl)ethylene]imino[2-[1-(benzyloxy)formamido]- 1-oxotrimethylene]-p-phenylene]) was investigated. This polymer was selected since its primary degradation product, N-benzyloxycarbonyl-L-tyrosyl-L-tyrosine hexyl ester (CTTH) was found to be as potent an adjuvant as complete Freund's adjuvant and muramyl dipeptide, when measuring the serum antibody response to bovine serum albumin (BSA) in male CD-1 mice over 56 weeks. BSA released from subcutaneously implanted polymeric antigen delivery devices made of poly(CTTH-iminocarbonate) resulted in significantly higher (P less than 0.006) anti-BSA antibody titers than devices made of poly(bisphenol A-iminocarbonate).

3-Aryl- and 3-hydroxy-3-aryloctahydropyrido[2,1-c][1,4]oxazines. Synthesis, stereochemistry, and central nervous system pharmacological actions.

A series of substituted 3-aryl- and hydroxy-3-aryloctahydropyrido[2,1-c][1,4]oxazines has been synthesized for purposes of investigating potentially useful CNS pharmacological actions of this novel heterocyclic system. The preferred conformation of the bicyclic system of the parent compounds, 1 and 2, has been shown to be trans with equatorial orientation of the 3-phenyl substituent in each compound. The various substituted aryl analogues of this series are depressants of motor activity in mice, and certain analogues exhibit significant anticonvulsant and appetite suppressant activity in test animals.

Cannabinoids in glaucoma: a primary screening procedure.

A procedure was developed for screening of cannabinoids for their ability to reduce intraocular pressure (IOP) using normal rabbits. Eight animals per group were used for statistical significance of data. A negative control group was used for every screen as well as a positive control with 1.5 mg/kg delta 9-THC given intravenously (I.V.). All compounds were tested by I.V. injection and IOP measurements were taken periodically for 5 hours. Data were analyzed by a computer program which takes into account the change in IOP of the control group. Following this procedure we found that delta 8-THC, delta 9-THC, cannabinol, and nabilone were active while cannabidiol was inactive.

Conformational aspects of the antifibrillatory activity of procaine.

The effects of procaine and four semi-rigid conformational analogs (compounds 1,2,3 and 4) were tested and compared on isolated rabbit atria. Procaine and the four analogs produced positive inotropic effects at all dose levels tested. The antifibrillatory activity of procaine and its analogs arranged in decreasing order of activity was compound 4 greater than 3 greater than 2 greater than 1 greater than procaine. The antifibrillatory activity of the compounds correlated to the distance between the ring nitrogen and the ester oxygen; that is, as the N-O distance increased the concentration required to reduce the following frequency decreased. However, the compound became more toxic as the N-O distance increased. Our data do not confirm the commonly regarded direct relationship between local anesthetic activity and antifibrillatory activity of procaine. Differences in activity displayed by the isomers of procaine could reflect differences in the ability of these analogs to bind to receptors responsible for the respective actions.

Toxicological evaluation of poison oak urushiol and its esterified derivative.

Poison oak urushiol was compared with its esterified derivative for toxicity after oral administration to rats and guinea pigs. No hematological or pathological changes were noted and there were no differences seen in clinical chemistry measurements when compared to clinical biochemical and hematological reference values of normal experimental animals. Comparative LD50 studies in mice and tissue reactivity studies in rabbits indicated that acetylated urushiols were substantially less toxic than free urushiols. However, neither poison oak urushiol or poison oak urushiol acetate appeared to produce any tissue toxicity not related to a direct irritant effect. The free urushiol produced a much greater degree of skin irritation than did the urushiol acetate. Whether or not an animal had been sensitized to urushiol apparently had no effect on organ toxicity.

Ocular irritancy responses to various pHs of acids and bases with and without irrigation.

Acids and alkalies were instilled into the eyes of 2 groups of rabbits; the eyes of one group were washed with tap water 30 s after exposure. Damage seen in washed and unwashed eyes was not always related to pH. Some strong acids with greater acidity than pH 2.5 produced opacities while 0.3% hydrochloric acid with a pH of 1.28 produced no ocular damage. Phenol (5%) and acetic acid (5%) with pHs greater than 2.5 produced damage equivalent to or greater than that produced by equal concentrations (w/v) of the mineral acids. All alkalies with pHs ranging from 11.5 to 13.5 produced opacities and other ocular damage of different degrees depending upon the alkali and its concentration. For example, low concentrations of some alkalies in the pH range from 11.3 to 12.8 produced no ocular changes. The duration of the corneal opacities produced by phenol, 1% sodium hydroxide, acetic acid and anhydrous sodium carbonate and the onset of corneal opacity produced by 5% sulfuric acid, the weak acids and 1% sodium hydroxide were reduced as a result of washing the test eyes 30 s after instillation of the test material. These data suggest that acidity and alkalinity of the test material are not the only factors to be considered in relation to a substances' capacity to produce severe ocular injury. The concentration of the test chemical and its period of contact with the eye prior to washing are also important.

Cutaneous irritation in the topical application of 30 antineoplastic agents to New Zealand white rabbits.

Of 30 antineoplastic agents studied for their primary irritation potential in rabbits, 9 showed some potential for irritation. Five of these 9 agents produced a significant dermal irritation. None of the irritation observed was considered to be irreversible skin damage. The study further showed a strong correlation between irritation observed by the Draize method and acute inflammation evaluated histopathologically. There was a tendency toward increased epidermal thickness of irritated skin sites. None of the agents produced gross or microscopically visible lesions in the internal organs observed.

Total hip arthroplasty for congenital dysplasia or dislocation of the hip. Survivorship analysis and long-term results.

Two hundred and thirty-two total hip replacements with cement were performed between 1965 and 1987 in 190 patients who had osteoarthrosis secondary to acetabular dysplasia resulting from congenital dysplasia or dislocation of the hip. Forty-nine patients (fifty hips) who died or who did not have at least three years of clinical and radiographic follow-up were excluded; therefore, the study comprised 141 patients (182 hips), 125 of whom were women and sixteen of whom were men. The mean age at the time of the operation was 42.5 years (range, 19.5 to 76.5 years), and the mean duration of follow-up was 9.9 years (range, 3.1 to 22.8 years). A Charnley low-friction prosthesis with a 22.25-millimeter femoral head was used in all hips. A trochanteric osteotomy was performed in 164 hips. A direct lateral approach was used only when there was a limb-length discrepancy of less than two centimeters. Bulk autogenous graft was not used to augment the fixation of the acetabular component. The hips were divided into two groups on the basis of the degree of subluxation or dislocation according to the classification of Crowe et al. One hundred and thirty-six hips were grade I, II, or III (indicating subluxation) (Group S), and forty-six hips were grade IV (indicating dislocation) (Group D). At the most recent follow-up evaluation, 128 (94 per cent) of the 136 hips in Group S and forty-four (96 per cent) of the forty-six hips in Group D caused no or only slight pain (a score of 6 or 5 points, respectively, according to the system of Merle d'Aubigné and Postel). Nineteen cups (10 per cent) and five stems (3 per cent) failed and were revised. The rate of revision for loosening of the femoral component in Group D (2 per cent [one stem]) was similar to that in Group S (3 per cent [four stems]). In comparison, the rate of revision of the acetabular component in Group D (15 per cent [seven cups]) was almost twice that in Group S (9 per cent [twelve cups]). This study demonstrated satisfactory clinical results at a mean of nearly ten years. The fixation of the femoral components appeared to be satisfactory; however, the failure of the fixation of the acetabular components in Group D (the dislocated hips) is a cause for concern.

Allergenic properties of naturally occurring cannabinoids.

The guinea pig maximization test was used to determine the potential of seven cannabinoids to produce allergic contact dermatitis. delta 9-Tetrahydrocannabinol and cannabinol were found to be extreme (Grade V) sensitizers. Cannabidiol, delta 8-tetrahydrocannabinol, and cannabichromene were moderate (Grade III) sensitizers. Cannabigerol and cannabinol methyl ether were not sensitizers. Most of the cannabinoids were found to be allergenically cross-reactive. Additionally, it was shown that the presence of a free 1'-hydroxyl group was required for sensitization, but not to elicit a response in sensitive animals.

Synthesis of 5,6-benzo-2-azabicyclo[2.2.2]octane derivatives as potential benzomorphan-type analgesic agents.

The synthesis of two N-substituted 5,6-benzo-2-azabicyclo[2.2.2]octane analogs of benzomorphan-type analgesics via benzyne addition to appropriate N-substituted N-alkyl-2-pyridones is described. Neither derivative possessed observable analgesic activity at the doses tested.

Biological effects of nonalkaloid-containing fractions of Erythroxylon coca.

Water soluble nonalkaloid fractions of Erythroxylon coca were screened in mice for their effects on oxygen utilization and central nervous system (CNS) activity. The fractions were screened in dogs for cardiovascular, blood glucose, and respiratory changes. No CNS effects were demonstrated in mice; however, there was a reduction in the oxygen utilization rate. Intravenous administration of the extract to dogs produced hyperglycemia, a reduction in heart rate, and a decrease in blood pressure. No substantial change in the respiratory rate and tidal or minute volumes were observed.

Immunological studies of poisonous anacardiaceae: production of tolerance in guinea pigs using 3-n-pentadecylcatechol-"modified" autologous blood cells.

The development of contact sensitivity to poison ivy urushiol in guinea pigs was prevented by intravenous injection of 3-n-pentadecylcatechol (I) coupled to autologous blood cells. Hartley, line-bred, guinea pigs were treated with pentadecylcatechol-"modified" blood cells or sham-treated blood cells 2 weeks prior to attempted topical sensitization with I. Skin testing of all guinea pigs with 3-, 1-, and 0.3-microgram doses of I applied in 5 microliter of acetone to abdominal skin sites was begun 2 weeks after attempted sensitization and repeated at 2- or 4-week intervals thereafter for 6 months or until study termination. Profound tolerance to I was observed at all skin testing intervals in the group receiving haptenated red cells and did not weaken with time. Contact sensitivity to I in control animals, however, waned with time; the study was terminated at 6 months because of the low sensitivity level of the control animals at that period. Complete or partial tolerance was induced in approximately 80% of the treated animals. The immune tolerance obtained by the single injection of pentadecylcatechol-associated red blood cells was of long duration and urushiol specific. This treatment also conferred tolerance to three unsaturated congeners of I. The allergenic potencies of the pentadecylcatechols declined with increasing saturation of the alkyl side chain. Binding studies using tritiated pentadecylcatechol showed that 81% of the activity incorporated into the red cell was membrane associated and that 19% was cell sap associated.