Immunomodulatory and toxic effects of free and liposome-encapsulated tumor necrosis factor alpha in rats.

Tumor necrosis factor alpha has potent immunomodulatory and antitumor activity, but its therapeutic applications may be limited by its significant host toxicity. We showed that liposome-encapsulated recombinant human tumor necrosis factor alpha (rHuTNF-alpha) retained full anticellular activity in vitro. We then assessed the immunomodulatory and toxic effects of two different doses of i.v. free or liposome-encapsulated rHuTNF-alpha in normal rats. Both free and liposome-encapsulated rHuTNF-alpha significantly enhanced alveolar macrophage- and blood monocyte-mediated interleukin 1 release and tumor cell lysis, as well as natural killer cell cytotoxicity, when compared to buffer-treated controls. However, administration of rHuTNF-alpha in liposomes substantially reduced tumor necrosis factor alpha-mediated toxicity. Animals receiving liposome-encapsulated rHuTNF-alpha showed significantly less tissue injury, gastric retention, and circulating leukocyte shifts than animals receiving free rHuTNF-alpha. In addition, liposome-based delivery significantly increased lung and liver uptake of rHuTNF-alpha. Therefore, liposome-encapsulated rHuTNF-alpha retains immunomodulatory activity, significantly reduces toxic inflammatory effects, and may allow targeting of tumor necrosis factor alpha to selected organs after i.v. administration.

Comparison of three jet nebulizer aerosol delivery systems used to administer recombinant human DNase I to patients with cystic fibrosis. The Pulmozyme rhDNase Study Group.

STUDY OBJECTIVE: To compare the degree of improvement in pulmonary function achieved with recombinant human DNase I (rhDNase) administered by three different aerosol delivery systems: DeVilbiss Pulmo-Aide compressor with the Marquest Acorn II nebulizer, the Hudson T Up-draft nebulizer, and the Pari LC Jet Plus nebulizer with the Pari Inhalier Boy compressor. These produce similar aerosols in vitro in terms of size distribution and activity of delivered rhDNase. STUDY DESIGN: Multicenter, randomized, open-label, parallel-group comparison of changes from baseline in pulmonary function variables in each test group. Patients were treated with rhDNase (2.5 mg bid) for 15 days, administered with three different aerosol delivery systems. SETTING: Outpatient clinics at 26 sites in the United States. PATIENTS: 397 patients > 5 years of age with cystic fibrosis and baseline forced vital capacity (FVC) values between 40 and 70% of predicted values. RESULTS: All three nebulizers gave comparable improvements in pulmonary function. FEV1 increased by an average of 13.2 to 14.1%, FVC by 10.9 to 11.8% and forced midexpiratory flow (FEF25-75) by 16.5 to 17.1%. No unusual or unexpected adverse events were reported other than those that would be expected in patients with cystic fibrosis. CONCLUSIONS: Recombinant human DNase I produced a similar magnitude of improvement in the pulmonary function of patients with cystic fibrosis when the drug was administered using three different types of nebulizer systems with similar in vitro delivery and safety characteristics.

The pattern of lung injury induced after pulmonary exposure to tumor necrosis factor-alpha depends on the route of administration.

TNF-alpha is a protein elaborated by monocytes and macrophages in response to endotoxin. The in vivo consequences of TNF-alpha elaboration have been examined extensively after intravenous administration of TNF-alpha. Substantially less is known about the effects of TNF-alpha that may be generated locally by resident tissue phagocytes. We investigated the direct effects of TNF-alpha on lung tissue by administering large amounts of human TNF-alpha directly to the lung, either as an aerosol or as an intratracheal bolus. Rats were exposed to an aerosol containing several concentrations of TNF-alpha, resulting in retention of significant quantities of TNF-alpha. The histologic response to inhaled TNF-alpha was characterized by adherence of leukocytes to venular endothelium, endothelial cell disruption, and bronchovascular edema. After aerosol administration, however, there was no evidence of alveolar inflammation or edema. In contrast, intravenous administration of large amounts of human TNF-alpha, at a dose that produced a lung content of TNF-alpha similar to that produced after high-concentration aerosol exposure, resulted in severe alveolar injury and edema. Intravenous administration of TNF-alpha did not result in the bronchovascular changes seen after inhalation. To ensure that sufficient quantities of TNF-alpha were being delivered to the lung, TNF-alpha was given as an intratracheal bolus to rats. This led to measurable absorption, but the spectrum and severity of lung injury was similar to the group that received TNF-alpha as an aerosol. We conclude that in rats, the pulmonary response to the injurious effects of TNF-alpha differ, depending on whether the TNF-alpha is delivered to the air or blood side of the alveolar capillary barrier.

Assessment of various topical oral formulations by bone marrow transplant recipients.

Topical approaches to management of oral mucositis have the advantages of high local concentration and limited or no systemic absorption, reducing the risk of systemic complications. The acceptability of topical therapies in cancer patients has not been evaluated. Thirty-eight transplant patients assessed the acceptability of three formulations (rinse, thin gel, thick gel) of a new compound developed to prevent oral mucositis. The rinse was selected as the most acceptable formulation. The thick gel received the lowest rating. Consistency was a major determinant of overall acceptability. A neutral taste was desirable for most participants. Room temperature of the formulation was rated as completely acceptable. Most participants would be willing to use the rinse or thin gel several times per day, to retain each dose in the oral cavity for up to 5 min, and to swallow it. The support of caregivers may be needed to achieve compliance with such regimens.

[Thyroid hormones and thyrotropin in liver and kidney insufficiency]. / Die Schilddrüsenhormone und thyreotropes Hormon (TSH) bei Leber- und Niereninsuffizienz

In 22 patients with hepatic or renal insufficiency the serum concentrations of trijodothyronin, thyroxine and thyrotropin and also the T4-binding capacity of TBG were determined. The mean serum T3 concentration was found to be significantly lower in patients with hepatic coma when compared with euthyroid subjects. In the cases of renal insufficiency the serum T3 concentrations were in the normal range. Due to hormone loss through dialysis however, the mean value of the T3 concentrations was slightly lower than the average concentration of normal subjects. The obtained results agree with those of our earlier studies which showed that there are significant differences between liver artery and vein T3 concentrations in serum, whereas no such differences could be ascertained between serum concentrations in renal artery and vein. On the basis of these findings it is assumed that conversion of T4 into T3 occurs predominantly in the liver.

[Glaucoma blindness in Denmark]. / Glaukomblindhed i Danmark.

The prevalence and the incidence of glaucoma blindness in Denmark was evaluated by examining all registration forms of persons > or = 50 years of age admitted to the Danish Association of the Blind (DAB) between 1955 and 1987 with glaucoma as main cause of blindness. In 1987, 6.7% of DAB-members > or = 50 years suffered from blindness caused at least partially by glaucoma, equivalent to an estimated prevalence of 45 per 100,000 of the Danish population > or = 50 years. The estimated annual incidence of blindness due to glaucoma was seven per 100,000 > or = 65 years, and in an equal number of patients glaucoma was a contributory cause of blindness. The incidence of glaucoma blindness was decreasing in the younger age groups (< 65 years) throughout the study period. Glaucoma blindness seems to occur at a later age now than earlier, leaving the patients blind for a shorter time. The proportion of glaucoma blindness in the glaucoma population was estimated to be 4-5%.

[Risk of cataract surgery in patients with myopia. A prospective Danish multicenter study with special reference to a complication]. / Risiko ved operation for grå staer hos naersynede. En prospektiv dansk multicenterundersøgelse med soerligt henblik på komplikationen nethindeløsning.

A prospective Danish multicentre study was conducted to evaluate the incidence of retinal detachment after cataract extraction in myopic eyes (axial length, > or = 25.5 mm). Two hundred and forty-seven cataract extractions in myopic eyes were reported during a period of 13 months. Two hundred and forty-one eyes underwent extracapsular and six eyes intracapsular cataract extraction. The mean follow-up time for 158 eyes was seven months (ranging from 1-30 months). In five cases a retinal detachment was observed, one case was probably present preoperatively, this person had undergone intracapsular cataract extraction. The incidence of retinal detachment was thus 1.62-2.02% in the total material and 1.66% in eyes operated with extracapsular cataract extraction.

Affinity inactivation of bovine Cu,Zn superoxide dismutase by hydroperoxide anion, HO2-.

Bovine liver Cu,Zn superoxide dismutase (SOD) is inactivated by hydrogen peroxide at alkaline pH, and full inactivation correlates with the loss of 1.1 histidine/subunit. At each pH utilized, saturation of the rate of inactivation is observed. This process is characterized by a half-saturation constant for peroxide and a maximum pseudo-first-order rate constant for inactivation. At 25 degrees C, the former decreases from 15.7 to 3.2 mM as the pH is increased from 9.0 to 11.5, while the latter increases from 0.83 to 2.43 per min over the same pH range. We have previously (Arch. Biochem. Biophys. 224, 579 (1983] proposed that the true affinity reagent for the inactivation of yeast SOD is the hydroperoxide anion, and we now believe the same is true for bovine SOD. However, a subtle difference between the two enzymes exists, for while the maximum pseudo-first-order rate constant for inactivation of bovine SOD increases with increasing pH, the same parameter for the yeast enzyme is pH-independent.

Cellular influx and activation increase macrophage cytotoxicity and interleukin-1 elaboration during pulmonary inflammation in rats.

This study was undertaken to investigate the effects of pulmonary inflammation induced by bacillus Calmette-Guérin (BCG) on the density distribution of lavaged alveolar macrophages. We sought to determine macrophage cytotoxicity and interleukin-1 elaboration in density-defined subpopulations of macrophages during tissue inflammation. At all time points after intravenously administered BCG, lavaged alveolar macrophages contained increased percentages of higher density cells. Alveolar macrophage cytotoxicity against the rat sarcoma cell line XC increased maximally 2 to 6 days after intravenous administration of BCG before declining on Day 13. Macrophage interleukin-1 elaboration increased maximally 14 days after administration of BCG before declining on Day 23. Additionally, macrophage cytotoxicity and interleukin-1 elaboration were increased above normal in cells from each of five density fractions. We conclude that a subpopulation of higher density macrophages, probably recently derived from blood monocytes, accumulates in inflammatory sites. Cellular activation increases the cytotoxicity and interleukin-1 elaboration by macrophages in all density-defined subpopulations and obscures the relationship between cellular density and function that is present in normal animals.

Use of allophycocyanin allows quantitative description by flow cytometry of alveolar macrophage surface antigens present in low numbers of cells.

Autofluorescence has limited quantitative description by flow cytometry of certain alveolar macrophage surface antigens. Autofluorescence is most significant when macrophages are excited by blue light and emission is monitored in the green-yellow light range. Because of recent advances in flow cytometry and in the development of fluorescent labeling compounds, such as allophycocyanin, autofluorescence can be minimized by the use of red excitation and emission wavelengths. We have developed a three-step labeling technique that discretely identifies the minor subpopulation of normal rat alveolar macrophages that express Class II major histocompatibility (Ia) antigens. Using this technique, we observed that alveolar macrophage Ia antigen expression increases at least fourfold after intravenous administration of bacillus Calmette-Guerin to previously primed rats. Additionally, we observed that in vitro treatment of alveolar macrophages by exposure to gamma interferon results in an increase in Ia antigen expression. This new method is significant because flow cytometry is a powerful tool with which to analyze quickly, accurately, and reproducibly alveolar macrophage surface antigens.

[Haemodynamic measurements during controlled hypotension by nitroglycerin (author's transl)]. / Kreislaufuntersuchungen unter arterieller Hypotension mit Nitroglycerin.

In nine patients undergoing neurosurgical operation for cerebral aneuryms haemodynamic measurements were made before, during and after continuous intravenous administration of Nitroglycerin at a mean dose of 6.5 micrograms/kg . min. Within 15 min of the start of the infusion mean arterial pressure fell from 94.2 +/- 10.5 to 73.4 +/- 11.1 mm Hg. A further decrease of mean arterial pressure even by a substantial raising of the Nitroglycerin dose was not possible. 15 min after the discontinuation of Nitroglycerin administration mean arterial pressure rose to the preinfusion level. The decrease of stroke volume index from 40.8 +/- 9.9 to 31.0 +/- 7.3 ml/m2 was partially compensated by an increase of heart rate from 65.9 +/- 9.6 to 77.7 +/- 19.4 beats/min. Consequently cardiac index fell only slightly from 2.9 +/- 0.6 to 2.5 +/- 0.5 ml/min . m2. The right atrial pressure decreased to 3.3 +/- 2.9 mm Hg, the mean pulmonary arterial pressure to 6.3 +/- 1.9 mm Hg and the pulmonary capillary wedge pressure to 2.3 +/- 2.1 mm Hg. The significant fall of total peripheral resistance to 983 +/- 194 dyn x s/cm5 (p less than 0.05) and the decrease of left ventricular stroke work index to 34.7 +/- 11.5 g . m/m2 contributed to reduce myocardial oxygen consumption. The authors conclude that, because of its effect on blood pressure, it reversibility of action and its absence of adverse side effects Nitroglycerin is a valuable agent for controlled hypotension.

[Effect of metoprolol on the circulation after head trauma. Studies during continuous intravenous administration (author's transl)]. / Kreislaufwirkung von Metoprolol bei Schädel-Hirn-Verletzten. Untersuchungen während kontinuierlicher intravenöser Applikation.

The influence of continuous intravenous administration of metoprolol on heart rate and haemodynamics was tested in ten unconscious patients who, after sustaining a head injury, developed sinus tachycardia due to increased sympathicotonia. In preliminary studies on three patients the effective dosage for heart rate reduction was determined. Following this, seven patients received 0.15 mg/kg . h of metoprolol over 36 hours. Heart rate decreased from an average of 127.5 to 78.8/min, a statistically significant reduction. Stroke volume index significantly rose from an average of 35.5 to 52.3 ml/m2, while other haemodynamic variables were not or only slightly changed. Cardiac index fell (not significantly) from 4.51 to 3.81/min . m2, peripheral vascular resistance rose (not significantly) form 942.4 to 1061.7 dyn . s . cm-5. Arterial and pulmonary artery pressures as well as filling pressures of right and left ventricle and left ventricular work index were not altered. Total oxygen consumption and oxygen extraction rate also remained unchanged. Measurement of metoprolol plasma levels in four patients excluded the possibility of a cumulative effect.

[Multiple myeloma and terminal acute myeloid leukaemia (author's transl)]. / Plasmozytom und finale unreifzellige Leukose

A patient with multiple myeloma died of an acute myeloid leukaemia 15 years after onset of the former. At time of diagnosis the 39 year-old-patient had bone marrow infiltration of maximally 32 plasma cells/100 white bone marrow cells, a paraprotein (IgG, light-chain type lambda), osteoporosis of late onset and occasional osteolysis. The long survival time, as well as the acute myeloid leukaemia, are probably due to the effective treatment, first with cyclophosphamide (198 g over four years), later melphalan (3000 mg over eight years).

Interferon-gamma increases alveolar macrophage Ia antigen expression despite oral administration of dexamethasone to rats.

Corticosteroids have multiple effects on immune and inflammatory responses and decrease host resistance to a broad range of microorganisms. Resident tissue macrophages have been proposed as a target for the immunosuppressive effects of corticosteroids and are important in host defense against infections. During infection-induced immune responses, macrophages are activated after exposure to interferon-gamma (IFN-gamma), and class II major histocompatibility (Ia) antigens on their surface are increased. We investigated the effect of orally administered corticosteroids on alveolar macrophages, the resident macrophages of the lung parenchyma. We hypothesized that corticosteroids would inhibit the activation of alveolar macrophages and measured induction by IFN-gamma of Ia antigens as a marker of cell activation. Alveolar macrophages from normal and corticosteroid-treated rats were exposed to recombinant murine IFN-gamma (rMuIFN-gamma) in vitro and assayed for Ia transcription and surface Ia expression. Ia mRNA accumulation was induced in alveolar macrophages from normal and corticosteroid-treated rats after exposure in vitro to rMuIFN-gamma. Furthermore, rMuIFN-gamma increased surface expression of Ia proteins on alveolar macrophages from corticosteroid-treated rats, although to a lesser extent than on cells from control rats. Finally, surface Ia expression could also be increased in vivo by exposure of corticosteroid-treated rats to an aerosol containing rMuIFN-gamma. These results demonstrate that administration of oral corticosteroids, while establishing a state of immunosuppression in rats, does not abolish responsiveness of rat alveolar macrophages to rMuIFN-gamma. We speculate that IFN-gamma-induced augmentation of phagocytic cell function may constitute an important therapeutic modality to treat complications of immunodeficiency.

Effects of recombinant human DNase therapy on healthcare use and costs in patients with cystic fibrosis.

OBJECTIVE: To assess the effects of recombinant human DNase (rhDNase) therapy on the cost of treating respiratory tract infections (RTIs) in patients with cystic fibrosis. DESIGN: We prospectively documented the use of healthcare services among 968 patients with cystic fibrosis who participated in a recent Phase III double-blind, multicenter, clinical trial in which patients were assigned randomly to receive either rhDNase 2.5 mg once daily, rhDNase 2.5 mg twice daily, or placebo. All patients were followed for 24 weeks. Data from secondary sources were used to estimate a total cost of RTI-related care (excluding the cost of study therapy) for each trial participant, based on observed levels of resource use. MAIN OUTCOME MEASURES: Number of RTI-related hospital admissions, days of RTI-related outpatient antibiotic therapy (intravenous and oral), and total costs of RTI-related care (excluding the cost of study therapy). RESULTS: Patients randomized to receive rhDNase once daily averaged 0.15 fewer RTI-related hospital admissions (0.41 vs 0.56 for placebo; p < 0.05) and 1.5 fewer days of RTI-related outpatient intravenous antibiotic therapy (2.9 vs 4.4; p < 0.05). Patients randomized to receive rhDNase twice daily had 0.14 fewer hospital admissions (p < 0.01), but no reduction in outpatient intravenous antibiotic therapy. Compared with placebo, the cost of treating RTIs over 24 weeks was $814-1682 less among patients receiving rhDNase. CONCLUSIONS: rhDNase therapy reduced the costs of treating RTIs in patients with cystic fibrosis; assuming once-daily dosing, these savings would offset about one-third of the cost of such therapy.

[Comparative circulatory studies during implantation of total endoprostheses using methylmethacrylate and BDF cement]. / Vergleichende Kreislaufuntersuchungen während Implantation von Totalendoprothesen mit Palacos und BDF-Zement.

In every ten patients undergoing elective surgery for total hip prosthesis methylmethacrylate and BDF cement respectively were used for the implantation of the prosthesis. The results of the haemodynamic investigation demonstrate that improvement of the surgical procedure may reduce the incidence of haemodynamic parameters: After implantation of methylmethacrylate into the femoral shaft the arterial pressure decreased from 95.9 +/- 13 to 86 +/- 11 torr (P less than 0.05); the left ventricular stroke work index dropped from 49.9 +/- 5 to 42.1 +/- 7 g.m/m2 (P less than 0.01). While total peripheral resistance decreased slightly in the methylmethacrylate group, there was a small increase after implantation of BDF cement into the femoral shaft. In both groups, however we found a slight elevation of pulmonary vascular resistance after cement implantation into the femur. The determination of the serum concentration of the cement monomer did not yield any measurable serum concentrations. Heat production by polymerisation of BDF cement (maximum 45.8 +/- 6.5 Centigrade) was much less compared with the temperature which developed during the polymerisation of methylmethacrylate (maximum 63 +/- 16.4 Centigrade); therefore, the safety of clinical application seems to be greater with the new BDF cement.

Patient reports of complications of bone marrow transplantation.

In recent years, significant improvements have been made in the management of neutropenia and thrombocytopenia and other potentially life-threatening complications of ablative chemotherapy. While these complications are of particular concern to physicians, patients receiving ablative therapy for bone marrow or blood stem cell transplants are often troubled by other side effects such as nausea, vomiting, diarrhea and mouth sores. The purpose of the study was to gain a better understanding of patients' experiences while undergoing a transplant. The same professional medical interviewer conducted in-depth interviews with 38 subjects (10 men, 28 women; mean age 46.9 years) who had received ablative therapy for bone marrow and/or peripheral blood stem cell transplants. Participants were consecutively identified through physician and patient referrals, cancer and BMT patient support groups, and newspaper advertisements. Twenty-eight patients (74%) received autologous stem cell transplants and 10 patients (26%) received allogeneic transplants. Participants reported mouth sores, nausea and vomiting, diarrhea, and fatigue as the most troubling side effects of their transplants. Mouth sores were selected as the single most debilitating side effect (42%), followed by nausea and vomiting (13%). Many patients mentioned that mouth sores made it difficult or impossible to eat (n = 23), swallow (n = 21), drink (n = 17), and/or talk (n = 8). Twenty patients reported pain in the mouth, throat, and/or esophagus. Two-thirds (66%) of patients reported receiving opioid analgesics, most frequently morphine, to relieve oral pain. For many, opioids caused incapacitating side effects, including hallucinations, a feeling of loss of control and a decrease in mental acuity. Patients receiving ablative chemotherapy identify oral mucositis as a significant cause of suffering and morbidity. Effective interventions to alleviate this complication are urgently needed.

[Percutaneous puncture of the femoral vein for haemodialysis: report of 5000 punctures (author's transl)]. / Die perkutane Punktion der Vena femoralis zur Hämodialysebehandlung. Erfahrungen und Komplikationen bei 5000 Punktionen.

Using the Seldinger technique, a total of 5306 percutaneous femoral vein catheterisations were performed in the course of ten years. Two-catheter venovenous dialysis was performed 2357 times and single-needle technique 592 times. There were five important complications: severe retroperitoneal bleeding after perforation of the external iliac vein three times, fatal bleeding from the femoral artery once, and reversible damage to the femoral nerve once. The results indicate that for every 1000 percutaneous femoral-vein catheterisations one must expect one severe complication. However, by using the correct catheter technique, especially careful manipulation of the wire, complications can be largely avoided.