Efficacy and safety of iota-carrageenan nasal spray versus placebo in early treatment of the common cold in adults: the ICICC trial.

UNLABELLED: Iota-carrageenan (I-C) is active against respiratory viruses in vitro and was effective as nasal spray in three previous clinical trials. The current trial served to further investigate I-C in patients with early common cold symptoms. METHODS: This randomized, placebo-controlled, double-blind phase IV trial was conducted in 200 adult patients with self-diagnosed colds of <48 h' duration that were confirmed by baseline cold symptom scores. Patients were to self-administer 0.12 % I-C or placebo spray (NaCl 0.5 %) four times daily for four to ten days and record symptom information for ten days. Common respiratory viruses were quantified by RT-PCR during pretreatment and on Day 3 or 4. The primary endpoint was the mean total symptom score (TSS) of eight cold symptoms on Days 2-4 (TSS2-4). RESULTS: Patients in both treatment groups had similar baseline TSSs (mean TSS: 6.75 for I-C and 6.79 for placebo). Viruses were detected in baseline samples from 53 of 98 I-C patients (54.1 %) and 54 of 97 placebo patients (55.7 %). Mean ± SE for TSS2-4 was 5.78 ± 0.25 for I-C patients and 6.39 ± 0.25 for placebo (p = 0.0895). Exploratory analyses after unblinding (TSS2-4 excluding a patient with aberrantly high symptom scores [TSS2-4, ex 1pt]; mean of TSS over Days 1-4 [TSS1-4]; change in TSS1-4 relative to baseline [TSS1-4, rel]) demonstrated treatment differences in favor of I-C (p = 0.0364, p = 0.0495 and p = 0.0421, respectively). For patients with quantifiable rhinovirus/enterovirus at baseline, there was a trend towards greater reduction of virus load at Day 3 or 4 (p = 0.0958; I-C: 90.2 % reduction in viral load; placebo: 72.0 %). Treatments were well tolerated with no differences in adverse event rates. CONCLUSIONS: The primary endpoint did not demonstrate a statistically significant difference between I-C and placebo but showed a trend towards I-C benefit. Exploratory analyses indicated significant reduction of cold symptoms in the I-C group relative to placebo during the first four days when symptoms were most severe, and also substantiated I-C's activity against rhinovirus/enterovirus. TRIAL REGISTRATION: NCT01944631 (clinicaltrials.gov).

Persistent and therapeutic concentrations of human factor IX in mice after hepatic gene transfer of recombinant AAV vectors.

Haemophilia B, or factor IX deficiency, is a X-linked recessive disorder that occurs in about one in 25,000 males, and severely affected people are at risk for spontaneous bleeding into numerous organs. Bleeding can be life-threatening or lead to chronic disabilities with haemophilic arthropathy. The severity of the bleeding tendency varies among patients and is related to the concentration of functional plasma factor IX. Patients with 5-30% of the normal factor IX have mild haemophilia that may not be recognized until adulthood or after heavy trauma or surgery. Therapy for acute bleeding consists of the transfusion of clotting-factor concentrates prepared from human blood and recombinant clotting factors that are currently in clinical trials. Both recombinant retroviral and adenoviral vectors have successfully transferred factor IX cDNA into the livers of dogs with haemophilia B. Recombinant retroviral-mediated gene transfer results in persistent yet subtherapeutic concentrations of factor IX and requires the stimulation of hepatocyte replication before vector administration. Recombinant adenoviral vectors can temporarily cure the coagulation defect in the canine haemophilia B model; however, an immune response directed against viral gene products made by the vector results in toxicity and limited gene expression. The use of recombinant adeno-associated virus (rAAV) vectors is promising because the vector contains no viral genes and can transduce non-dividing cells. The efficacy of in vivo transduction of non-dividing cells has been demonstrated in a wide variety of tissues. In this report, we describe the successful transduction of the liver in vivo using r-AAV vectors delivered as a single administration to mice and demonstrate that persistent, curative concentrations of functional human factor IX can be achieved using wild-type-free and adenovirus-free rAAV vectors. This demonstrates the potential of treating haemophilia B by gene therapy at the natural site of factor IX production.

Rhinovirus contamination of surfaces in homes of adults with natural colds: transfer of virus to fingertips during normal daily activities.

Multiple surfaces contaminated with rhinovirus were detected in hotel rooms by reverse transcriptase-polymerase chain reaction (RT-PCR) following occupancy by a cold sufferer. Whether infectious rhinovirus contaminates surfaces in homes and is transferred from surfaces to fingertips through normal activities is not known. Nasal secretions from 30 subjects with new colds were tested for rhinovirus genome by RT-PCR; infectious rhinovirus was sought with tissue cultures. Each subject identified 10 sites in their home touched during the preceding 24 hr. Samples from sites were tested for rhinovirus by RT-PCR and cell culture. Later, each subject's mucus (stored at -70°C) was deposited on surfaces for testing transfer to fingertips through daily life activities such as flipping a light switch, touching the telephone keypad, and holding the telephone handset. Nasal secretions from 16/30 subjects were positive for rhinovirus by RT-PCR; 66 (41%) of 160 surfaces in homes were positive. Contaminated surfaces included doorknobs (6 positive/18 tested), refrigerator door handles (8/14), TV remote controls (5/10), and bathroom faucets (8/10). Five (19%) of 26 RT-PCR positive sites from culture positive subjects were positive in cell culture. Nasal mucus from six culture positive subjects was deposited on objects. Infectious rhinovirus was detected on 22% of fingertips following contact with objects contaminated for 1 hr; transfer dropped to 3% after 24 hr of contamination, and 0% after 48 hr. Infectious rhinovirus found on surfaces in homes of people with colds can be transferred to fingertips, but infectivity of virus in mucus declines by 24 hr after deposition.

Radiopaque contrast dye in nasopharynx reaches the middle ear during swallowing and/or yawning.

CONCLUSION: Contrast dye in the nasopharynx reaches the middle ear during swallowing and yawning in normal adults. This suggests that displacement of bacteria in nasopharyngeal secretion to the middle ear may occur frequently during sleep. OBJECTIVE: The middle ear is sterile under normal conditions. The purpose of this study was to examine by means of CT whether radiopaque contrast dye in the nasopharynx would reflux into the middle ear of normal adults during swallowing and/or yawning. MATERIAL AND METHODS: Six normal adult volunteers were studied. Contrast dye was kept at the orifices of the Eustachian tube during swallowing and/or yawning by placing volunteers in either a head-down or lateral decubitus position. Reflux was determined by the presence of contrast dye in the middle ear on CT scanning of the temporal bone. RESULTS: Two of the three volunteers in each group (four out of six in total) had contrast material detected in one or both middle ear cavities.

Effect of live and inactivated Lactobacillus rhamnosus GG on experimentally induced rhinovirus colds: randomised, double blind, placebo-controlled pilot trial.

The aim of this work was to investigate the usability of an experimental rhinovirus model in probiotic trials aiming to assess effectiveness in viral infections, and to provide preliminary data of live and inactivated probiotic Lactobacillus rhamnosus GG for larger-scale trials utilising the model. 59 subjects were randomised to receive 100 ml of fruit juice supplemented with 10(9) cfu of live or heat-inactivated (by spray-drying) L. rhamnosus GG or control juice daily for six weeks. After three weeks subjects were intranasally inoculated with experimental rhinovirus. Infection rate (at least one positive culture for challenge virus on five days following inoculation or at least four-fold rise in antibody response to challenge virus) was 14/19 in the group receiving live probiotic strain and 18/20 both in the group receiving heat-inactivated probiotic strain and in the control group (P=0.36). The occurrence and severity of cold symptoms on the five days following the inoculation was lowest in the group receiving live probiotic strain (P=0.45). This trial was the first one dedicated to the investigation of the effect of probiotics using the experimental rhinovirus model. The model showed potential for demonstration of efficacy of probiotics in controlled respiratory viral infections. Occurrence and severity of cold symptoms and number of subjects with rhinovirus infection was lowest in the group receiving live L. rhamnosus GG, but differences were not statistically significant. Further large-scale studies are needed to demonstrate the efficacy of L. rhamnosus GG in respiratory infections.

High-efficiency retrovirus-mediated gene transfer into the livers of mice.

Recombinant retroviral vectors represent an attractive means of transferring genes into the liver because they integrate in the host cell genome and result in permanent gene expression. However, efficient gene transfer is limited by the requirement of active cell division for integration. Surgical partial hepatectomy has been the traditional method of inducing hepatocellular proliferation, but this invasive approach would be difficult to justify in clinical gene therapy. As an alternative, we used a recombinant adenovirus expressing a nonsecreted form of urokinase plaminogen activator (Ad.PGKmuPA), which results in liver regeneration over a period of 8 days. When a high-titer retroviral vector was continuously infused into the portal vein of mice during this period of hepatocyte proliferation, 33.5% of hepatocytes were stably transduced. In addition, high-level expression of a secreted transgene reporter was sustained for at least 48 weeks (length of experiment). We investigated the influence of vector titer on the in vivo transduction efficiency in our system, and found that the total number of infectious retroviral particles delivered per target cell is a critical factor. The results presented here demonstrate the ability to obtain a high gene transfer efficiency and long-term gene expression in hepatocytes in vivo without the need for surgical hepatectomy. The two-vector system described here may be of clinical relevance, as the level of hepatic gene transfer achieved has potential to be curative for a large number of genetic liver diseases.

The human adenoid. A morphologic study.

OBJECTIVE: We examined the route by which antigen on the surface of the adenoid may be brought into contact with the lymphoid follicles in the submucosa of the adenoid. DESIGN: We studied under light and electron microscopy 13 adenoids from children undergoing elective surgery. Portions of all of the specimens were fixed in formalin and embedded in paraffin and plastic for hematoxylin-eosin and periodic acid-Schiff staining. Portions of four adenoids were fixed in glutaraldehyde for electron microscopy. RESULTS: Two major types of epithelium were evident by light microscopy: a ciliated or squamous epithelium containing few lymphocytes and a nonciliated-flat epithelium with a heavy infiltration of lymphocytes ("lymphoepithelium"). Scanning microscopy showed the surface of this lymphoepithelium to be composed largely of cells with multiple microfolds known as M-cells. Freeze-fracture technique showed many lymphocytes under the M-cells. Transmission electron microscopy showed the lymphocytes to be located in compartments formed by the epithelial cells. Light microscopy study of 50 serial sections embedded in plastic suggested that the compartments communicated to form intraepithelial channels for the lymphocytes. CONCLUSION: The epithelium of the adenoid has areas with ciliated epithelium adjacent to areas with epithelium containing M-cells and intraepithelial lymphatic channels. HYPOTHESIS: The lymphoepithelium of the adenoid is a mechanism for transporting antigen via the M-cells to the underlying lymphoid follicles.

Cold air-induced rhinorrhea and high-dose ipratropium.

A high dose of the cholinoceptor antagonist ipratropium bromide, in the form of a nasal spray, was tested on cold air- and hot soup-induced rhinorrhea in order to determine to what extent these types of rhinorrhea are reflex-mediated hypersecretions from nasal glands. Fourteen normal volunteers were examined in a placebo-controlled study. A single dose of ipratropium bromide (400 micrograms) caused a 73% reduction of cold air-induced rhinorrhea and a 66% reduction of hot soup-induced rhinorrhea. It is concluded that a major part of the nasal discharge induced by these stimuli is reflex-mediated, and consequently may be treated by a cholinoceptor antagonist, such as ipratropium.

Lymphocyte subsets in normal airway mucosa of the human nose.

The distribution and number of lymphocytes, monocytes/macrophages, and cells expressing HLA-DR antigen were studied in frozen biopsy sections of nasal mucosa from 40 healthy adults, using monoclonal antibody avidin-biotin immunoperoxidase techniques. The lymphocyte to monocyte/macrophage ratio was estimated to be 10:1; the T cell to B cell ratio was 3:1; and the T helper/inducer cell to T suppressor/cytotoxic cell ratio averaged 2.5:1. Regional differences were observed with a relatively increased number of T suppressor/cytotoxic cells around submucosal glands, and a relatively large number of B cells in lymphocyte aggregates in the lamina propria. The HLA-DR antigen was expressed in epithelial cells, suggesting involvement of surface epithelium of human airway in local immune responses.

Therapeutic approach to sinusitis: antiinfectious therapy as the baseline of management.

Although acute sinusitis is an infectious disease in which several bacterial species play a major etiologic role, there is an important interaction between the respiratory viruses (common cold viruses) and the bacteria in the pathogenesis of acute community-acquired sinusitis. The relative inaccessibility of the sinus cavities makes special techniques of sampling necessary to acquire specimens that accurately reflect disease conditions in the sinuses. Bacterial etiology of sinus infection has therefore been determined by sinus puncture studies, chiefly of the maxillary sinus, several of which are reviewed here. Because the bacteria causing acute sinusitis have not changed in many years, puncture is not often necessary for clinical diagnosis. Patients with acute, community-acquired sinusitis can usually be treated empirically, on the basis of previous studies, unless complications are suspected. In that case, and in other patients with hospital-acquired sinusitis, puncture of the involved sinus and aspiration of sinus fluid for Gram's staining and quantitative microbial cultures and sensitivities are required for appropriate antimicrobial management.

Computed tomography imaging of the maxillary and ethmoid sinuses in children with short-duration purulent rhinorrhea.

INTRODUCTION: Adults with a common cold often have paranasal sinus effusions detected by computed tomographic (CT) scans. There are no comparable data for children. The purpose of this study was to document the sinus CT findings in children with short-duration purulent rhinorrhea. DESIGN: Thirty children, 3 to 12 years of age (median age, 7 years), with purulent rhinorrhea for a mean duration of 5 days (and always less than 9 days) were enrolled in the study. The children were otherwise well. Institutional Review Board (IRB)-approval was obtained before enrollment of the first patient. Informed written consent was obtained from each child's parent. CT imaging of the maxillary and ethmoid sinuses was obtained on the day of the initial visit (occasionally, the following day). Follow-up CT scans were obtained from cooperative children/parents, 3 to 4 weeks later. RESULTS: Opacification or an air/fluid level in the maxillary sinuses was seen in 27 (90%) of 30 study children at study entry. Ethmoid sinuses were not opacified without opacification of a maxillary sinus. Three weeks later, 24 of 27 study children, who had positive CT scans on study entry, improved clinically. Of 17 follow-up CT scans, 10 (58%) normalized, 4 had improvement of bilateral disease, and 3 improved with unilateral disease. None appeared worse than baseline. CONCLUSIONS: Pansinus opacification (ethmoid and maxillary sinuses), on CT scans in children with short-duration purulent nasal drainage was seen in 70% of children. An additional 20% had isolated maxillary sinus effusions (10% had no effusion). Three-week follow-up CT scans on 17 children were normal in 60% and improved (partial clearance) in 40%. In this patient population, the decision to treat with antibiotics should be made on clinical grounds alone.

Immunological barriers in the nose and paranasal sinuses.

This review deals mainly with lymphocyte subsets in the human nasal mucosa, and with the common cold. Lymphocytes have recently been characterized in biopsy specimens by an immuno-histochemical method (the avidin-biotin, monoclonal antibody peroxidase technique). In summary, the overall T:B cell ratio was 3:1 and that of T helper cells to T suppressor was 2.5:1; topographical differences within the nasal mucosa were identified. Non-specific defence systems, such as interferon, provide some protection against rhinovirus infection, but most important is the presence of specific antibodies against a given antigenic type of virus. Recent results have suggested that a rhinovirus infection does not cause a marked destruction of the epithelial lining, that it is spotty in the nasal mucosa, and that it is most prominent in the nasopharynx. Increased knowledge about the site of infection and how symptoms are produced is essential for a rational approach to the development of anti-viral therapy.

Light and scanning electron microscopy of nasal biopsy material from patients with naturally acquired common colds.

As our knowledge of the histopathology of common colds is very limited, we have undertaken a blind quantitative examination by scanning electron microscopy and light microscopy of 56 nasal biopsies, taken from 29 volunteers with naturally acquired colds. In agreement with earlier reports we found evidence of sloughing of epithelial cells, but in contrast to in vitro experiments, this did not result in a destruction of the epithelial lining, which by and large remained continuous, with structurally normal cell borders. There was a significant increase in the number of neutrophils, both in epithelium and in lamina propria, already on the 2nd day of the disease, and the hypothesis is advanced that the virus infection itself is the cause of the local neutrophilia. The only other abnormality demonstrated was an increased number of extracellular erythrocytes in the acute stage. The histological picture was not suggestive of an involvement of epithelial mast cells in the inflammation.

Study of bacteria in the nasal cavity and nasopharynx during naturally acquired common colds.

It was the purpose of this study to examine whether the number of bacteria in the nose and nasopharynx changes during a common cold. Samples for bacteriological culture were taken from the nasal cavity of 29 and from the nasopharynx of 26 adult patients with naturally acquired colds. The bacteriological samples were taken on days 2, 4, 8 16, 32 and 64 after the first nasal symptoms. The results showed that there were few pathogenic bacteria in the nasal cavity and nasopharynx. There was no tendency to an increase in the number of positive cultures during the cold, although most patients had macroscopically purulent discharge on days 3-5. In conclusion, the study indicates that during an uncomplicated common cold, a bacterial infection is not responsible for the occurrence of purulent nasal discharge which may be a direct consequence of the viral infection.

Common cold and high-dose ipratropium bromide: use of anticholinergic medication as an indicator of reflex-mediated hypersecretion.

UNLABELLED: It was our aim to study the role played by parasympathetic reflexes for the amount and physical characteristics of nasal discharge during a common cold, and to define the maximum anti-rhinorrhoea effect obtainable with anticholinergic medication. Fifty adults with naturally acquired colds were treated with a very high dose of the topically active cholinoceptor-antagonists ipratropium bromide in a randomized, double-blind, placebo-controlled study of parallel groups. A dosage of 400 micrograms was given 4 times daily for 3 days, using a specially manufactured high-dosed pressurized aerosol. This treatment resulted in a 56% reduction in the number of nose blowings (p < 0.01) and a 58% reduction in the weight of blown secretions (p < 0.01). Assessment of the "pourability" of the nasal discharge indicated that ipratropium bromide mainly reduces the watery secretions but not the mucopurulent secretions. The high dose of ipratropium bromide caused nose- and mouth-dryness in a considerable number of the patients. IN CONCLUSION: (1) during the first days of a common cold about 60% of the nasal discharge is a reflex-mediated product from nasal glands; (2) this type of secretion is predominantly watery; and (3) ipratropium bromide can reduce watery rhinorrhoea in the common cold, but a lower dose is required in order to avoid side effects.

Effects of oral norephedrine on common cold symptoms.

The aim of the trial was to examine the effectiveness of an oral decongestant in common cold. Thirty subjects with naturally acquired colds got a 100 mg sustained release tablet containing norephedrine on one day and a placebo tablet on another day in double blind design. Changes in nasal patency were assessed by rhinomanometry, measurement of nasal expiratory peak flow, and a self-assessment test, and the number of sneezes and of nose blowings were recorded in a 10 hours period after medication. Rhinomanometry, but not peak flow measurements showed a significant difference (p less than 0.02) two hours after medication, and the self-assessment of nasal blockage showed that the effect lasted for the entire 10 hours observation period (p less than 0.01). Nasal respiration was reestablished in half of the blocked noses. There was no effect on number of sneezes and nose blowings. In conclusion, oral norephedrine has a moderate decongestant effect, which may justify its use in adults with common colds. This symptom amelioration must be balanced against cost of therapy and risk of side effects. A prevention of otitis media and of sinusitis has not been documented in the literature.

Effects on the nasal mucosa of upper respiratory viruses (common cold).

Delineation of the pathogenesis of symptoms during common colds is the overall aim of this work. The studies included in this thesis have focused on the histopathologic changes in the nasal mucosa produced by infection with respiratory viruses. The accepted concept when these studies were undertaken was that cold symptoms were caused by destruction of nasal epithelium by virus and that epithelial damage sometimes led to secondary bacterial infection evidenced by purulent nasal secretions. The pathogenesis of cold symptoms has been reviewed in this thesis based on investigations by others and my own research. Chapter 1 described the clinical design of a naturally acquired cold model and an experimental rhinovirus cold model which were used. The advantages of the experimental model over the natural cold model are that the viral etiology is known and that volunteers can be studied beginning at viral inoculation rather than onset of symptoms. Unfortunately, the experimental model is very expensive. Chapter 2 reviewed the histopathology of the nasal mucosa during colds. The degree of destruction of the mucosa during naturally acquired colds reported in the literature has varied. We did not detect any discernible damage of the epithelium by light and scanning electron microscopy in naturally acquired colds. We repeated the study in volunteers with rhinovirus colds and again did not find any damage to the surface epithelium (light microscopy). Although different viruses may cause epithelial damage in naturally acquired colds, in rhinovirus colds the epithelium of the anterior part of the inferior turbinate is not destroyed. There was an early influx of neutrophils into the nasal mucosa in patients both with naturally acquired colds (day 2 after onset) and with experimental rhinovirus colds. This discovery in combination with the minimal damage of the nasal epithelium led to formulation of a new hypothesis of how cold symptoms may be produced. The influx of neutrophils might be a direct response to viral infection and/or may reflect the release of a cascade of inflammatory mediators which are responsible in part for the symptoms. Naclerio et al (1988) has since shown that the number of neutrophils in nasal secretions increases early in rhinovirus colds. This increase correlated nicely with the symptoms. In addition, Turner (1988) demonstrated the elaboration of a chemoattractant factor for neutrophils by cell cultures infected with rhinovirus type 39. Chapter 3 focused on the location of rhinovirus replication in the nose and nasopharynx. The entire mucosal lining of the nasal cavities was not infected during the first week of a rhinovirus colds.(ABSTRACT TRUNCATED AT 400 WORDS)

Light- and scanning electron-microscopy of the nasal mucosa.

The article is a short review of some aspects of the surface structure of the human nose. It deals with the morphology of the surface epithelium in nasal allergy, viral and bacterial infection. Kartagener's triad and in rhinitis patients continuously treated with topically active steroids.