IL-1ß as mucosal vaccine adjuvant: the specific induction of tissue-resident memory T cells improves the heterosubtypic immunity against influenza A viruses.

A universal influenza vaccine must provide protection against antigenically divergent influenza viruses either through broadly neutralizing antibodies or cross-reactive T cells. Here, intranasal immunizations with recombinant adenoviral vectors (rAd) encoding hemagglutinin (HA) and nucleoprotein (NP) in combination with rAd-Interleukin-(IL)-1ß or rAd-IL-18 were evaluated for their efficacy in BALB/c mice. Mucosal delivery of rAd-IL-1ß enhanced HA-specific antibody responses including strain-specific neutralizing antibodies. Nevertheless, the beneficial effects on the local T cell responses were much more impressive reflected by increased numbers of CD103+CD69+ tissue-resident memory T cells (TRM). This increased immunogenicity translated into superior protection against infections with homologous and heterologous strains including H1N1, pH1N1, H3N2, and H7N7. Inhibition of the egress of circulating T cells out of the lymph nodes during the heterologous infection had no impact on the degree of protection underscoring the unique potential of TRM for the local containment of mucosal infections. The local co-expression of IL-1ß and antigen lead to the activation of critical checkpoints in the formation of TRM including activation of epithelial cells, expression of chemokines and adhesion molecules, recruitment of lung-derived CD103+ DCs, and finally local TRM imprinting. Given the importance of TRM-mediated protection at mucosal barriers, this study has major implications for vaccine development.

Synergy between expression of fusogenic membrane proteins, chemotherapy and facultative virotherapy in colorectal cancer.

Using Chou-Talalay median effect analysis, we demonstrated in permanent and short-term cultures of colorectal cancer cells that the expression of measles virus fusogenic membrane glycoproteins (FMGs) in combination with chemotherapy often causes over most of the cytotoxic dose range synergistic cell killing. In this combined treatment, we observed strongly enhanced annexin V binding and caspase-3/7 activity when compared to single-agent treatment. Furthermore, we showed increased expression of heat-shock protein (Hsp)70 and Hsp90alpha, but not of Hsp60. In a subcutaneous HT-29 colorectal xenograft model, we demonstrated that the administration of a replication-defective adenoviral or herpes simplex virus (HSV) amplicon vector (Ad.H/F or HSV.H/F) encoding tumor-restricted FMG in combination with FOLFOX significantly enhanced treatment outcome when compared to treatment with each compound individually. To increase the fraction of tumor cells expressing the FMG, we trans-complemented the Ad.H/F and HSV.H/F vector with the respective oncolytic replication-restricted adenovirus Ad.COXDeltaMK or HSV-1 G47Delta vector. At the end of the observation period (day 100), eight out of 10 animals that received G47Delta, HSV.H/F and FOLFOX were alive and tumor free. Administration of the analogous adenovirus-based regimen resulted in four out of 10 long-term survivors. We demonstrated that the expression of FMG in combination with chemotherapy can significantly enhance treatment outcome, which is further enhanced by combination with trans-complementing oncolytic vectors.

Patients and community together. A family medicine community-oriented primary care project in an urban private practice.

BACKGROUND: There has been considerable discussion in the literature regarding the value and feasibility of community-oriented primary care (COPC), but relatively few published real-world examples. OBJECTIVE: To examine the effect of a practice-based COPC project on rates of preventive health interventions within an inner-city family medicine practice. METHODS: A newly created community advisory board called Patients and Community Together (PACT) and the medical director of the practice in Rochester, NY, collaborated on all phases of the COPC project. Papanicolaou smear and mammography screening, childhood immunizations, diabetes control, and smoking cessation were targeted for intervention. A practice/community awareness campaign was instituted and individual and group incentives were developed. Progress was monitored through a computerized medical record that included all active patients in the practice. RESULTS: Rates of annual Papanicolaou smears increased from 46% to 71%; annual mammography for women older than age 50 years, from 56% to 86%; completed childhood immunizations when younger than 6 years, from 78% to 97%; and performance of semiannual glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated hemoglobin values under 10% improved from 56% to 77%. There were 5 smokers who successfully quit. CONCLUSION: This project illustrates how practice-based COPC can be successfully implemented within a private practice setting. It also shows how COPC principles can be used to achieve the goals for Healthy People 2000 within inner-city practices.

Autologous tumor cell vaccination combined with adoptive cellular immunotherapy in patients with grade III/IV astrocytoma.

Brain tumors are highly resistant to treatment. Their diffuse infiltrative nature and the relative inaccessibility of the brain to blood and lymph are barriers to surgical and cytotoxic treatments alike. Preclinical animal studies demonstrated that intravenously administered tumor antigen-specific T lymphocytes will reject tumors growing in the brain. Specifically activated effector T lymphocytes may be generated by in vivo immunization followed by restimulation of antigen-primed T cells with autologous tumor cells in vitro. In order to apply these findings to humans, feasibility studies of combined active immunization and specific adoptive cellular immunotherapy were performed on fifteen patients with recurrent astrocytoma. The objective was to determine whether; 1) T cells could be grown from peripheral blood of patients immunized with autologous tumor cells, and 2) whether stimulated cells could be safely readministered to patients. Patients were immunized with a combination of their own irradiated tumor cells and Bacillus of Calmette and Guerin. Two weeks later a mononuclear cell-rich fraction of blood was obtained by leukapheresis. Mononuclear cells were cultured with irradiated autologous tumor cells and interleukin-2. Selective expansion of CD4+ and CD8+ T lymphocytes occurred. Intravenous transfer of stimulated cells to the fifteen patients on twenty-four separate occasions with or without systemic administration of interleukin-2 was tolerated with limited toxicity. The studies established the feasibility of conducting controlled studies of the anti-tumor effects of tumor antigen-specific cellular immunotherapy.

Effect of fine needle aspiration biopsy on the histology of thyroid neoplasms.

We evaluated the effect of fine needle aspiration biopsy (FNAB) upon the histology of thyroid adenoma and differentiated thyroid carcinoma. When surgery was performed within three months of FNAB, infarction was found histologically in 8/82 (9.8%) of the tumors. It was extensive in four patients, with one patient having no residual neoplastic cells identifiable within the nodule. No infarction was seen in the histologic specimens from patients with similar pathology whose surgery was performed without prior FNAB. These findings confirm previous reports that infarction may be caused by FNAB and can be so extensive as to interfere with the histologic diagnosis.

The effect of fine-needle aspiration biopsy on the thyroid scan.

Fine-needle aspiration biopsy (FNAB) is the most sensitive and specific procedure in diagnosing benign from malignant thyroid nodular disease. The effects of a FNAB on the thyroid scan, however, have never been studied. This assumes importance because a hot nodule on scan has been advocated as useful to differentiate certain benign from malignant follicular neoplasms. Thyroid scans were performed before and after FNAB on 11 patients with nodular thyroid disease and an area of normal or increased uptake either in the nodule or in a contralateral enlarged lobe to determine if the biopsy changed the pattern of isotope uptake. For this study, biopsies were done in the area of normal or increased uptake. In two patients, there was a reduction in isotope concentration in three nodules after FNAB, whereas no change was demonstrable in nine other patients. Review of the literature revealed a number of prior reports of hemorrhage, necrosis, or infarction of thyroid nodules after FNAB. Based on these data and the demonstration of a change in scan pattern in a patient following FNAB, it is concluded that FNAB may decrease the isotope uptake in thyroid nodules; therefore, the concept of clinical judgments being based on the scan pattern after FNAB should be reevaluated.

Use of blood components in cancer patients with bleeding.

The need for blood components for oncology patients is small compared with the need for patients with hematologic malignancies. The subject is important because use of these valuable components is dependent on a limited supply and availability. Agreement on when to use components is extremely important. In fact, at the time of this writing, the Transfusion Practices Committee of the American Association of Blood Banks is conducting an extensive survey on the use of platelets in oncology and hematology cancer patients (Questionnaire on Institutional Policy on Platelet Transfusion Practice for Hematology/Oncology Patients). The results will, we hope, provide a consensus on the proper times and counts that require prophylactic use of components for these patients. Because these patients use the vast majority of components (see Table 15), their proper use is imperative to maintaining an adequate platelet and frozen plasma supply. Transfusion support in cancer patients is vital for their survival. Platelets, in particular, are necessary to prevent serious bleeding. The risks from transfusion must always be considered. Fortunately, with increased monitoring of the blood supply, they have been reduced. As with any therapeutic regimen, these risks must be weighed against the benefit the patient may gain. Transfusion should always be used prudently.

Use of platelets and other transfusion products in patients with malignancy.

The need for blood components for oncology patients is small compared with the need for patients with hematologic malignancies. Appropriate use of blood components is necessary, not only medically, but also because of limited supply and availability. Agreement on when to use components is extremely important. In fact, at the time of this writing, the Transfusion Practices Committee of the AABB is conducting an extensive survey on the use of platelets in the oncology and hematology cancer patients (Questionnaire on Institutional Policy on Platelet Transfusion Practice for Hematology/Oncology Patients). The results will, it is hoped, provide a consensus on the proper times and counts that require prophylactic use of components for these patients. Since these patients use the vast majority of components (see Table 15), their proper use is imperative to maintaining an adequate platelet and frozen plasma supply. Transfusion support in cancer patients is vital for their survival. Platelets, in particular, are necessary to prevent serious bleeding. However, refractoriness to platelet transfusions can develop. It must be appreciated that refractoriness is not a general problem and need not require the expensiveness of a universal decision for handling all platelet transfusions in the same manner. Total refractoriness probably occurs in 15 to 20% of patients frequently transfused. In patients in whom frequent platelet transfusion is anticipated, that is, bone marrow transplantation, the development of platelet refractoriness may be reduced by using SDPC and administering them through leukocyte filters. Patients who become refractory to either random or SDPC can either be cross-matched for single-donor platelets that are compatible or can be given HLA-A,B matched platelets. Certainly, the success of platelet transfusion in leukemic patients cannot be denied, since only a small number of these patients now die because of bleeding due to platelet refractoriness. Most of the serious bleeding still seen is associated with sepsis. The risks from transfusion must always be considered. Fortunately, with increased monitoring of the blood supply, they have been reduced. As with any therapeutic regimen, these risks must be weighed against the benefit the patient may gain. Transfusion should always be used prudently.

Serum selenium levels in patients with malignant melanoma.

The incidence of malignant melanoma of the skin has increased rapidly among white people during the last decade. Although the pathogenesis of malignant melanoma is not clear, epidemiologic data and experimental work indicates that ultraviolet (UV) radiation plays a critical role in tumorigenesis. Recent data implicate peroxidative reactions in UV-carcinogenesis and clearly demonstrate that selenium (Se) confers protection, in part by inducing cellular-free radical scavenging systems and by enhancing peroxide breakdown, thus enhancing the capacity of the cell to cope with oxidant stress. With this in mind, we investigated the Se status of 101 patients with malignant melanoma. Our study revealed significantly lower Se levels in the sera of melanoma patients than of controls. Although patients in all clinical stages had lower Se levels than the controls, patients in stage III (disseminated melanoma) had the lowest levels. Separate analysis of histogenetic subtypes of melanoma revealed that lentigo maligna melanoma (LMM) and superficial spreading melanoma (SSM) had the strongest association with depressed Se serum levels. Our results, showing for the first time that malignant melanoma is associated with low Se concentrations, are consistent with results of epidemiologic studies showing an inverse correlation between serum Se levels and certain cancers.

Use of capillary blood for the evaluation of iron status.

The accuracy and precision of measurements of iron status made on the capillary blood from a single 75 X 1-mm microhematocrit tube were evaluated in 301 normal volunteers. After recording the hematocrit value, a hematofluorometer was used to assay erythrocyte protoporphyrin directly on the packed red cell fraction. Values in the low normal range were 50-100% higher than assays by an extraction technique in simultaneously collected venous blood. However, measurements in the iron deficient range were only 12% greater. Plasma ferritin concentration was determined by using an enzyme-linked immunoassay on 10-microliters plasma retrieved after measuring the hematocrit. Capillary values were approximately 7% higher than venous concentrations, the proportional difference being consistent throughout the measured range. When the individual measurements were combined to calculate the iron storage status of each individual, the frequency distribution of iron stores in 141 female volunteers between 18 and 36 years of age was approximately Gaussian and paralleled that calculated for women aged 18-44 years in NHANES II. These studies demonstrate that iron status can be determined accurately from the measurement of hematocrit, erythrocyte protoporphyrin, and ferritin on a single microhematocrit tube of capillary blood.

AIDS retrovirus antibodies in hemophiliacs treated with factor VIII or factor IX concentrates, cryoprecipitate, or fresh frozen plasma: prevalence, seroconversion rate, and clinical correlations.

Antibodies to the AIDS retrovirus, specifically to human T cell lymphotropic virus, type III, and AIDS-associated retrovirus, were detected with increasing prevalence in a population of 190 hemophiliacs from western Pennsylvania between 1981 and 1984: 7.7% in 1981, 20.0% in 1982, 45.5% in 1983, and 62.5% in 1984. The seropositive included approximately three fourths of those receiving factor VIII concentrate, nearly one third of those receiving factor IX concentrate, nearly one fifth of those receiving cryoprecipitate, and none of those receiving fresh frozen plasma. The seroconversion rate, determined on 43 seropositive hemophiliacs from this group who were serially sampled, was 0% in 1977, 4.7% in 1978, 4.9% in 1979, 2.6% in 1980, 10.5% in 1981, 52.9% in 1982, 87.5% in 1983, and 100% in 1984. Of 27 seropositive for three or more years (since 1982 or before), four (15%) have developed AIDS and seven (26%), diffuse lymphadenopathy (ARC); of 16 seropositive for less than three years, none has developed AIDS and three (19%) have developed ARC. The mean time from seroconversion to onset of ARC, 0.8 +/- 0.2 years (SEM), was shorter (P less than .001) than the time to onset of AIDS, 4.1 +/- 0.6 years. These findings confirm the widespread presence of AIDS retrovirus and support the association of these retroviruses with the acquired immunodeficiency syndrome and related conditions.

Relation of titers of antibodies to CMV in blood donors to the transmission of cytomegalovirus infection.

Titers of antibody to cytomegalovirus (CMV) of 529 persons whose blood had been supplied to 51 selected patients who underwent open-heart surgery were determined by indirect hemagglutination (IHA) and IgM-specific indirect immunofluorescence (IFA). Twenty-eight patients showed evidence of active CMV infection after transfusion (seroconversion or a fourfold rise in titer by IHA), whereas 23 showed no serological change. Patients with active CMV infections had received, on average, a greater number of blood units (12.9 vs. 7.9), of which more were seropositive (6.9 vs. 3.5), than did patients who showed no serological change. Those seropositive units of blood that had been transfused into the group that showed evidence of active infection, however, had a lower geometric mean titer than did those transfused into the group that showed no serological change (1:654 vs. 1:1,360). Seven (1.3%) of the 529 blood donors had CMV-specific IgM titers (by IFA) of greater than or equal to 1:16; each of the seven recipients of their blood subsequently showed evidence of active CMV infection. This study suggests that donor blood with high IHA titers may prevent transmission of CMV infection, whereas blood from donors with IgM antibody to CMV may transmit CMV.

Hyperthermia-induced intracellular ionic level changes in tumor cells.

The intracellular content of potassium (K) ions in P815 cells decreases when the media pH is lowered, and it increases when media pH is raised. The determination of the ion content therefore requires accurate control of the medium pH. The K ion content measured both by the flame emission method and by the K analog. 86Rb, exhibits a decline when the cells are incubated at 43 degrees C at a fixed pH chosen between 7.4 and 6.7. The chloride content also decreases while the sodium content does not change by a significant amount. Under the same hyperthermic conditions the intracellular pH decreases by a fraction of a pH unit. Simultaneously, the cell water volume increases by 20%, as measured by tritiated water. In the final analysis, hyperthermia produces an apparent deficit in the cellular osmolarity. A possible explanation is given.

The use of blood and blood components in 1,769 patients undergoing open-heart surgery.

There has been a decrease in the use of whole blood and red cell transfusions during and after open-heart operations in the greater Kansas City area from an average of slightly more than 9 units per patient from 1969 through 1971, to just over 3 units per patient from 1975 through 1977. In 1977, 1,256 patients, or 71% of 1,769 patients, underwent coronary artery bypass exclusively and had an average transfusion utilization of 2.6 units. All other open-heart operations averaged 4.7 units per patient. Hemodilution and the acceptance of hematocrits between 25 and 30% in open-heart operations are probably the main factors responsible for lower transfusion use per patient, while the increased proportion of patients undergoing coronary artery bypass accounts for a further decrease in the average amount of blood used per patient. It is of note that blood transfused to patients having an open-heart operation was not significantly fresher than blood for routine use, yet hemostasis was not a problem as evidenced by the small use of fresh-frozen plasma in 67 patients (3.8%) and platelet concentrates in 42 patients (2.4%).

Effect of hydroxyethyl starch on platelet function following granulocyte collection using the continuous flow cell separator.

Hydroxyethyl starch (HES) was used as sedimenting agent in the course of granulocyte collection on seventeen normal donors, using the continuous flow cell separator (CFCS). No clinical bleeding was noted in any of the donors. In spite of a 21 per cent mean reduction in postcollection platelet count, all donors had platelet counts within normal limits precollection and postcollection. Postcollection platelet adhesiveness increased in five donors, remained the same in one donor and declined in ten donors. Except in one donor there was no change in previously normal platelet aggregation to adenosine diphosphate or collagen. In the dose used, 500 ml, the infusion of 6% hydroxyethyl starch as an adjunct to granulocyte separation using the continuous flow cell separator does not appear to adversely affect platelet number and function.

Plasma exchange with plasma protein fraction and lactated Ringer's solution using the continuous flow cell separator.

Ten patients underwent 50-70 percent plasma exchanges using the continuous flow cell separator. The exchange material consisted of Plasma Protein Fraction (PPF) and Lactated Ringer's Solution (LRS) instead of fresh frozen, modified or lyophilized plasma. No bleeding or other complications were encountered. The coagulation factor activity after exchange was above that required for hemostasis. The procedure is safe, expeditious and efficient.