In-Use Stability of SB12 (Eculizumab, Soliris Biosimilar) Diluted in Saline and Dextrose Infusion Solution after an Extended Storage Period.

INTRODUCTION: SB12 is a biosimilar to eculizumab reference product [SolirisTM (Soliris is a trademark of Alexion Pharmaceuticals, Inc.)] that acts as a C5 complement protein inhibitor. The infusion stability of in-use (diluted) SB12 outside the conditions stated in the reference product's label is unknown. OBJECTIVE: The objective of this study was to assess the stability of SB12 after extended storage in conditions not claimed in the originator label. METHODS: Infusion stability was assessed in SB12 samples (diluted in 0.9% NaCl, 0.45% NaCl, and 5% dextrose, final concentration of 5 mg/mL per clinical trial protocol and the reference product's label) kept at 5 ± 3 °C for up to 3 months, then 30 ± 2 °C/65 ± 5% relative humidity (RH) for 72 h. The product was stored in different containers [polyolefin (PO) bags, glass bottles and syringes], and the protocol followed International Conference on Harmonisation (ICH) and European Medicines Agency (EMA) requirements for stability evaluation of biological products. Stability was evaluated using complementary assays, including pH, protein concentration (A280), purity (size exclusion-high-performance liquid chromatography, capillary electrophoresis-sodium dodecyl sulfate, and imaged capillary isoelectric focusing), biological activity (C5 binding and inhibition), and safety (subvisible particles). RESULTS: Except for charge variants in SB12 diluted in 5% dextrose, all results met the stability acceptance criteria. There were no major changes in terms of physicochemical stability, biological activity, and subvisible particles. CONCLUSIONS: The infusion stability of SB12 after extended storage (5 ± 3 °C for up to 3 months, then 30 ± 2 °C/65 ± 5% RH for 72 h) was demonstrated for longer periods and at higher temperatures than what is stated in the EU and US labels of the reference product. The physicochemical properties, biological activity, and subvisible particles of in-use SB12 diluted in 0.9% NaCl and 0.45% NaCl were maintained under the described conditions and for all tested containers. However, instability was observed for the diluted SB12 in 5% dextrose. These results may reduce the workload of clinical staff and minimize drug waste from treatment delays without any loss in product quality and biological activity.

The state of anesthesia in South Korea: a national survey of the status of anesthetic service activity in 2014-2016.

BACKGROUND: Because the quality of anesthesia affects the surgical outcome, the aim of this study was to investigate the current status of anesthetic services performed by anesthesiologists and non-anesthesiologists in South Korea from 2014 to 2016 and to compare the results with data from 2011 to 2013. METHODS: The claimed anesthesia services at medical institutions with employed anesthesiologists and the claims for an invitation fee for an anesthesiologist at medical institutions without employed anesthesiologists were regarded as anesthetic services performed by an anesthesiologist. From 2014 to 2016, the employment of anesthesiologists according to the type of medical institution, the status of anesthetic services according to the presence or absence of employed anesthesiologists, and status of anesthetic services at medical institutions without employed anesthesiologists were analyzed. RESULTS: The proportion of medical institutions that employed anesthesiologists slightly increased from 27.8% in 2014 to 28.8% in 2016. General anesthesia was more concentrated at higher medical institutions, and most anesthesias were performed by an anesthesiologist. The proportion of spinal anesthesia, epidural anesthesia, and brachial plexus performed by non-anesthesiologists was 11%, 15%, and 16.5%, respectively. Intravenous anesthesia performed by non-anesthesiologists was 58% and has increased compared to the past. CONCLUSIONS: The employment of anesthesiologists has increased with time, and general anesthesiology was mostly performed by anesthesiologists. However, since the proportion of anesthetic services performed by non-anesthesiologists in regional anesthesia and intravenous anesthesia was maintained high, it is necessary to find ways to expand the safety of anesthetic services.

Effects of Combined Remote Ischemic Pre-and Post-Conditioning on Neurologic Complications in Moyamoya Disease Patients Undergoing Superficial Temporal Artery-Middle Cerebral Artery Anastomosis.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the most commonly used treatment for Moyamoya disease. During the perioperative period, however, these patients are vulnerable to ischemic injury or hyperperfusion syndrome. This study investigated the ability of combined remote ischemic pre-conditioning (RIPC) and remote ischemic post-conditioning (RIPostC) to reduce the occurrence of major neurologic complications in Moyamoya patients undergoing STA-MCA anastomosis. The 108 patients were randomly assigned to a RIPC with RIPostC group (n = 54) or a control group (n = 54). Patients in the RIPC with RIPostC group were treated with four cycles of 5-min ischemia and 5-min reperfusion before craniotomy and after STA-MCA anastomosis (RIPostC). The incidence of postoperative neurologic complications and the duration of hospital stay were determined. The overall incidence of neurologic complication was significantly higher in the control group than in the RIPC with RIPostC group (13 vs. 3, p = 0.013). The duration of hospital stay was significantly longer in the control group than in the RIPC with RIPostC group (17.8 (11.3) vs. 13.8 (5.9) days, p = 0.023). Combined remote ischemic pre- and post-conditioning can be effective in reducing neurologic complications and the duration of hospitalization in Moyamoya patients undergoing STA-MCA anastomosis.

Relationship between the muscle relaxation effect and body muscle mass measured using bioelectrical impedance analysis: A nonrandomized controlled trial.

OBJECTIVE: The dose of neuromuscular blocking drugs is commonly based on body weight, but using muscle mass might be more effective. This study investigated the relationship between the effect of neuromuscular blocking drugs and muscle mass measured using bioelectrical impedance analysis. METHODS: Patients who were scheduled for elective surgery using a muscle relaxant were screened for inclusion in this study. Under intravenous anaesthesia, 12 mg or 9 mg of rocuronium was administered to males and females, respectively; and the maximal relaxation effect of T1 was measured using a TOF-Watch-SX® acceleromyograph. RESULTS: This study enrolled 40 patients; 20 males and 20 females. For both sexes, the maximal relaxation effect of T1 did not correlate with the body weight-based dose of neuromuscular blocking drugs (males, r2 = 0.12; females, r2 = 0.26). Instead, it correlated with the dose based on bioelectrical impedance analysis-measured muscle mass when injected with the same dose of rocuronium (males, r2 = 0.78, female, r2 = 0.82). CONCLUSIONS: This study showed that the muscle relaxation effect of rocuronium was correlated with muscle mass and did not correlate with body weight when using the same dose. Therefore, a muscle mass-based dose of neuromuscular blocking drugs is recommended.

Correlation between regional tissue perfusion saturation and lactate level during cardiopulmonary bypass.

BACKGROUND: Cardiopulmonary bypass (CPB) can cause systemic hypoperfusion, which remains undetected by routine monitoring of physiological parameters. Noninvasive tissue perfusion monitoring offers a clinical benefit by detecting low systemic perfusion. In this study, we tried to evaluate whether regional tissue perfusion saturation reflects systemic hypoperfusion during CPB. METHODS: This retrospective study included 29 patients with American Society of Anesthesiologists physical status II-III, who required cardiac surgery with CPB. We evaluated the correlations of serum lactate and delivery oxygen with organ perfusion values of peripheral tissue oxygen saturation and cerebral oxygen saturation. Data were recorded at different stages of CPB: T1 (pre-CPB), T2 (cooling), T3 (hypothermia), T4 (rewarming), and T5 (post-CPB). RESULTS: Lactate levels were elevated after CPB and up to weaning (P < 0.05). The levels of peripheral and tissue oxygen saturation decreased after the start of CPB (P < 0.05). Lactate levels were negatively correlated with peripheral tissue oxygen saturation levels at T4 (R = -0.384) and T5 (R = -0.370) and positively correlated with cerebral oxygen saturation at T3 (R = 0.445). Additionally, delivery oxygen was positively correlated with peripheral tissue oxygen saturation at T4 (R = 0.466). CONCLUSIONS: In this study, we demonstrated that peripheral tissue oxygen saturation can be a reliable tool for monitoring systemic hypoperfusion during CPB period. We also believe that peripheral tissue oxygen saturation is a valuable marker for detecting early stages of hypoperfusion during cardiac surgery.

Amelioration of sepsis by TIE2 activation-induced vascular protection.

Protection of endothelial integrity has been recognized as a frontline approach to alleviating sepsis progression, yet no effective agent for preserving endothelial integrity is available. Using an unusual anti-angiopoietin 2 (ANG2) antibody, ABTAA (ANG2-binding and TIE2-activating antibody), we show that activation of the endothelial receptor TIE2 protects the vasculature from septic damage and provides survival benefit in three sepsis mouse models. Upon binding to ANG2, ABTAA triggers clustering of ANG2, assembling an ABTAA/ANG2 complex that can subsequently bind and activate TIE2. Compared with a conventional ANG2-blocking antibody, ABTAA was highly effective in augmenting survival from sepsis by strengthening the endothelial glycocalyx, reducing cytokine storms, vascular leakage, and rarefaction, and mitigating organ damage. Together, our data advance the role of TIE2 activation in ameliorating sepsis progression and open a potential therapeutic avenue for sepsis to address the lack of sepsis-specific treatment.

A multimeric carcinoembryonic antigen signal inhibits the activation of human T cells by a SHP-independent mechanism: a potential mechanism for tumor-mediated suppression of T-cell immunity.

Carcinoembryonic antigen (CEA) is a well-known tumor antigen that is found in the serum of patients with various cancers and is correlated with an increased risk of cancer recurrence and metastasis. To understand the tumor environment and to develop antitumor therapies, CEA has been studied as an antigen to activate/tolerate specific T cells. In this study, we show that CEA can function as a coinhibitory molecule and can inhibit the activation of human peripheral blood mononucleated cell-derived T cells. The addition of CEA-overexpressing tumor cells or immobilized CEA dampened both cell proliferation and the expression of IL-2 and CD69 expression in T cells after TCR stimulation. The phosphorylation of ERK and translocation of NFAT were hampered in these cells, whereas the phosphorylation of proximal TCR signaling molecules such as ZAP70 and phospholipase Cγ was not affected by immobilized CEA. To determine the relevance of carcinoembryonic antigen-related cell adhesion molecule-1 and Src homology region 2 domain-containing phosphatase (SHP) molecules to CEA-mediated suppression, we tested the effect of the SHP inhibitor, NSC-87877, on CEA-mediated suppression of T cells; however, it did not reverse the effect of CEA. Collectively, these results indicate that CEA can function as a modulator of T-cell responses suggesting a novel mechanism of tumor evasion.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report.

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Gln-362 of angiopoietin-2 mediates migration of tumor and endothelial cells through association with α5ß1 integrin.

Angiopoietin-2 (Ang-2) not only regulates angiogenesis by binding to its well known receptor Tie2 on endothelial cells but also controls sprouting of Tie2-negative angiogenic endothelial cells and invasion of Tie2-negative non-endothelial cells by binding to integrins. However, the molecular mechanism of the Ang-2/integrin association has been unclear. In this study, we found that the Gln-362 residue of Ang-2 was essential for binding to α5ß1 integrin. A Q362E Ang-2 mutant, which still bound to Tie2, failed to associate with α5ß1 integrin and was unable to activate the integrin downstream signaling of focal adhesion kinase. In addition, unlike wild-type Ang-2, the Q362E Ang-2 mutant was defective in mediating invasion of Tie2-negative glioma or Tie2-positive endothelial cells. Furthermore, the tailpiece domain of the α5 subunit in α5ß1 integrin was critical for binding to Ang-2. Taken together, these results provide a novel insight into the mechanism of integrin regulation by Ang-2, which contributes to tumor invasion and endothelial cell migration in a Tie2-independent manner.

Design and Evaluation of ω-Hydroxy Fatty Acids Containing α-GalCer Analogues for CD1d-Mediated NKT Cell Activation.

CD1d molecules recognize glycolipid antigens with straight chain fatty acid moieties. Although most of the residues in the CD1d binding groove are hydrophobic, some of the amino acids can form hydrogen bonds. Consequently, we have designed ω-hydroxy fatty acid-containing glycolipid derivatives of the prototypical CD1d ligand α-GalCer. The potency of the ω-hydroxy analogues of the proper length is comparable to that of α-GalCer. We propose, based on the biological results and molecular modeling studies, that a hydrogen bonding interaction is involved between the ω-hydroxy group and a polar amino acid residue in the hydrophobic binding groove.

Effects of cranial electrotherapy stimulation on preoperative anxiety, pain and endocrine response.

OBJECTIVES: Cranial electrotherapy stimulation (CES) is used as a treatment for depression and anxiety, and as an adjunctive intervention for pain management. This prospective study investigated whether CES could decrease preoperative anxiety, the injection pain of rocuronium, postoperative pain and stress hormone levels. METHODS: Female patients undergoing thyroidectomy were randomly assigned to two groups, to receive either no pretreatment (control group) or CES pretreatment. Anxiety score, withdrawal response on rocuronium injection, and pain scores at 1, 4, 12 and 24 h post surgery were evaluated. Adrenocorticotrophic hormone (ACTH), cortisol and glucose levels were measured. Patients were blinded to the treatment condition. RESULTS: Fifty patients entered the study (n = 25 per group). Anxiety score and withdrawal responses during rocuronium injection were significantly reduced in the CES group compared with the control group. Pain score was significantly lower in the CES group than in the control group, 1 h and 4 h post surgery. There were no significant differences in ACTH, cortisol and glucose levels. CONCLUSIONS: CES pretreatment appears to reduce the level of preoperative anxiety, injection pain of rocuronium and postoperative pain. However, CES pretreatment did not affect stress hormone responses.

The Wnt inhibitor secreted Frizzled-Related Protein 1 (sFRP1) promotes human Th17 differentiation.

Wnt/ß-catenin signaling plays a crucial role during embryogenesis and tumorigenesis, and in T cells, promotes the differentiation of Th2 cells. However, the role of Wnt signals in the differentiation and maintenance of human Th17 cells remains poorly understood. We found that the higher levels of IL-17 in the synovial fluid of rheumatoid arthritis (RA) patients compared with that of osteoarthritis (OA) patients were associated with a higher concentration of sFRP1 (secreted Frizzled-Related Protein 1), an inhibitor of the Wnt/ß-catenin pathway. The addition of sFRP1 during TCR-mediated stimulation induced a significant increase in IL-17 production by both naïve and memory CD4(+) T cells. Moreover, under Th17-differentiation conditions, the addition of sFRP1 significantly reduced the requirement for TGF-ß. Mechanistically, we observed that sFRP1 significantly enhanced the phosphorylation of Smad2/3 in CD4(+) T cells upon TGF-ß stimulation and that blocking TGF-ß signaling abolished the Th17-promoting activity of sFRP1. Our findings reveal a novel function for sFRP1 as a potent inducer of human Th17-cell differentiation. Consequently, sFRP1 may represent a promising target for the treatment of Th17-mediated disease in humans.

Retinoic acid alleviates Con A-induced hepatitis and differentially regulates effector production in NKT cells.

Retinoic acid (RA) is a diverse regulator of immune responses. Although RA promotes natural killer T (NKT) cell activation in vitro by increasing CD1d expression on antigen-presenting cells (APCs), the direct effects of RA on NKT-cell responses in vivo are not known. In the present study, we demonstrated the effect of RA on the severity of Con A-induced hepatitis and molecular changes of NKT cells. First, we demonstrated that Con A-induced liver damage was ameliorated by RA. In correlation with cytokine levels in serum, RA regulated the production of IFN-γ and IL-4 but not TNF-α by NKT cells without influencing the NKT-cell activation status. However, RA did not alleviate α-GalCer-induced liver injury, even though it reduced IFN-γ and IL-4 but not TNF-α levels in serum. This regulation was also detected when liver mononuclear cells (MNCs) or NKT hybridoma cells were treated with RA in vitro. The regulatory effect of RA on NKT cells was mediated by RAR-α, and RA reduced the phosphorylation of MAPK. These results suggest that RA differentially modulates the production of effector cytokines by NKT cells in hepatitis, and the suppressive effect of RA on hepatitis varies with the pathogenic mechanism of liver injury.

Intrathecal hydromorphone added to hyperbaric bupivacaine for postoperative pain relief after knee arthroscopic surgery: a prospective, randomised, controlled trial.

BACKGROUND AND OBJECTIVE: Adding opioid to spinal anaesthetic provides additional analgesia during the postoperative period. The purpose of this study was to determine the dose of intrathecal hydromorphone necessary to achieve postoperative pain relief after arthroscopic knee surgery. METHODS: In a prospective, double-blinded parallel, placebo-controlled manner, 60 patients who were undergoing unilateral knee arthroscopy randomly received unilateral spinal anaesthesia with 0.5% hyperbaric bupivacaine 6 mg combined with 0.0, 2.5, 5.0 or 10.0 µg per 0.05 ml hydromorphone. Fifteen patients were assigned to receive each dose. The visual analogue pain scores (VAPSs) were measured at 30 min and 2, 4, 6, 12 and 24 h postoperatively, and the side-effects of hydromorphone were recorded. RESULTS: The postoperative VAPSs at 4, 6 and 12 h for the 5 and 10 µg hydromorphone groups were significantly decreased, compared to the control group. The 2.5 µg hydromorphone group had lower VAPS only at 4 and 6 h postoperatively. Nausea was significantly increased in the 10 µg hydromorphone group (46.6%). CONCLUSION: The analgesic effects of 5 and 10 µg intrathecal hydromorphone provided satisfactory pain relief for 12 h postoperatively and nausea increased significantly in a dose-dependent manner.

Morphine attenuates endothelial cell adhesion molecules induced by the supernatant of LPS-stimulated colon cancer cells.

A large reservoir of bacterial lipopolysaccharide (LPS) is available in the colon and this could promote colon cancer metastasis by enhancing tumor cell adhesion, intravasation, and extravasation. Furthermore, adhesion molecules like ICAM-1, VCAM-1, and E-selectin play important roles in the adhesion of tumor cells to endothelium. This study was designed to determine whether morphine can attenuate the expressions of adhesion molecules up-regulated by the supernatant of LPS-stimulated HCT 116 colon cancer cells (LPS-Sup). In this study, we divided to three groups by cell-growth medium of human umbilical vascular endothelial cells (HUVECs): the control group was incubated in growth factor-free endothelial medium, the Sup group was incubated in the supernatant of HCT 116 cells (Sup), and the LPS-Sup group was incubated in LPS-Sup. To observe effect of morphine to the adhesion molecules expressions in the LPS-Sup group, we co-treated morphine with LPS or added it to LPS-Sup. Adhesion molecule expressions on HUVECs in all three groups were measured during incubation period. Consquentially, ICAM-1, VCAM-1, and E-selectin expressions on HUVECs were significantly lower when morphine was co-treated with LPS than not co-treated. Thus, we suggest that morphine affects the expressions of adhesion molecules primarily by attenuating LPS stimuli on tumor cells.

Anesthetic experience using total intra-venous anesthesia for a patient with Wolf-Hirschhorn syndrome -A case report-.

We present here the case of a 33-month-old male patient with Wolf-Hirschhorn syndrome (WHS) and who underwent tympanoplasty and myringotomy. WHS is caused by a rare chromosomal abnormality, which is the deletion of the short arm of chromosome number 4. The typical craniofacial features of WHS patients such as micrognathia, microcephaly and the muscular weakness can make using neuromuscular blocking agents and performing intubation difficult. Moreover, there are a few previous case reports showing that malignant hyperthermia occurred during and after an operation in which the anesthesia was done with inhalation agents, so special anesthetic care is needed when operating on a WHS patient. By carefully intubating the patient and using total intravenous anesthesia, we performed successful anesthesia without any complications. We describe here the anesthetic management of a WHS patient and we review the relevant literature.

Morphine postconditioning attenuates ICAM-1 expression on endothelial cells.

The purpose of this study is to determine 1) whether morphine post condition (MPostC) can attenuate the intercellular adhesion molecules-1 (ICAM-1) expression after reoxygenation injury and 2) the subtype(s) of the opioid receptors (ORs) that are involved with MPostC. Human umbilical vein endothelial cells (HUVECs) were subjected to 6 hr anoxia followed by 12 hr reoxygenation. Three morphine concentrations (0.3, 3, 30 µM) were used to evaluate the protective effect of MPostC. We also investigated blockading the OR subtypes' effects on MPostC by using three antagonists (a µ-OR antagonist naloxone, a κ-OR antagonist nor-binaltorphimine, and a δ-OR antagonist naltrindole) and the inhibitor of protein kinase C (PKC) chelerythrine. As results, the ICAM-1 expression was significantly reduced in the MPostC (3, 30 µM) groups compared to the control group at 1, 6, 9, and 12 hours reoxygenation time. As a consequence, neutrophil adhesion was also decreased after MPostC. These effects were abolished by co administering chelerythrine, nor-binaltorphimine or naltrindole, but not with naloxone. In conclusion, it is assumed that MPostC could attenuate the expression of ICAM-1 on endothelial cells during reoxygenation via the κ and δ-OR (opioid receptor)-specific pathway, and this also involves a PKC-dependent pathway.

An α-GalCer analogue with branched acyl chain enhances protective immune responses in a nasal influenza vaccine.

α-Galactosylceramide (α-GalCer) is a safe and effective adjuvant for nasal vaccines and induces protective immune responses against tumors and viral infections. In our previous study, the fatty acyl chains of α-GalCer were modified based on the CD1d/glycolipid structure to generate α-GalCer analogues with branched acyl chains. In this study, two α-GalCer analogues, KBC-007 and KBC-009, that have different branched chain lengths were prepared and evaluated for their efficacy as nasal influenza vaccine adjuvants. These analogues displayed improved solubility over α-GalCer and potently stimulated NKT cells in both murine and in vitro human systems. Examination of serum cytokines in vivo revealed that these analogues elicited different cytokine release profiles compared to α-GalCer. KBC-009 induced both Th1/Th2 cytokines, whereas KBC-007 induced a more Th2-polarized cytokine response with diminished IFN-γ production. We found that a single immunization of inactivated influenza virus A/PR/8/34 (PR8) combined with α-GalCer analogues enhanced PR8-specific humoral and cellular immune responses in both systemic and mucosal compartments. Notably, KBC-009 exhibited potent adjuvant effects, inducing significantly higher systemic IgG and mucosal IgA antibody titers and enhancing cytotoxic T lymphocyte generation when compared to immunization with inactivated PR8 alone. In contrast, addition of KBC-007 to inactivated PR8 only marginally increased PR8-specific immune responses. The protective effect of KBC-009 against challenge infection was comparable to the effect produced by α-GalCer. These results suggest that an α-GalCer analogue with a branched acyl chain could be used as an effective mucosal adjuvant for the induction of protective immune responses against influenza virus infection.

Anaphylaxis with angioedema by rocuronium during induction of general anesthesia -A case report-.

Perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestations. Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anesthesiologist. A 34-year-old woman was scheduled to undergo endo venous laser therapy of varicose veins. She had no history of allergies and had never undergone general anesthesia. General anesthesia was induced with propofol and rocuronium bromide. Approximately three minutes after rocuronium administration, hypotension and tachycardia developed and angioedema around the eyelids and skin rashes and urticaria appeared. The patient received ephedrine and hydrocortisone with hydration. After achieving stable vital signs and symptom relief, surgery was performed without complications. A postoperative skin dermal test performed to identify the agent responsible revealed a positive skin test for rocuronium.