Mucosal immunization with a low-energy electron inactivated respiratory syncytial virus vaccine protects mice without Th2 immune bias.

The respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections associated with numerous hospitalizations. Recently, intramuscular (i.m.) vaccines against RSV have been approved for elderly and pregnant women. Noninvasive mucosal vaccination, e.g., by inhalation, offers an alternative against respiratory pathogens like RSV. Effective mucosal vaccines induce local immune responses, potentially resulting in the efficient and fast elimination of respiratory viruses after natural infection. To investigate this immune response to an RSV challenge, low-energy electron inactivated RSV (LEEI-RSV) was formulated with phosphatidylcholine-liposomes (PC-LEEI-RSV) or 1,2-dioleoyl-3-trimethylammonium-propane and 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DD-LEEI-RSV) for vaccination of mice intranasally. As controls, LEEI-RSV and formalin-inactivated-RSV (FI-RSV) were used via i.m. vaccination. The RSV-specific immunogenicity of the different vaccines and their protective efficacy were analyzed. RSV-specific IgA antibodies and a statistically significant reduction in viral load upon challenge were detected in mucosal DD-LEEI-RSV-vaccinated animals. Alhydrogel-adjuvanted LEEI-RSV i.m. showed a Th2-bias with enhanced IgE, eosinophils, and lung histopathology comparable to FI-RSV. These effects were absent when applying the mucosal vaccines highlighting the potential of DD-LEEI-RSV as an RSV vaccine candidate and the improved performance of this mucosal vaccine candidate.

Mucosal Application of a Low-Energy Electron Inactivated Respiratory Syncytial Virus Vaccine Shows Protective Efficacy in an Animal Model.

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections in the elderly and in children, associated with pediatric hospitalizations. Recently, first vaccines have been approved for people over 60 years of age applied by intramuscular injection. However, a vaccination route via mucosal application holds great potential in the protection against respiratory pathogens like RSV. Mucosal vaccines induce local immune responses, resulting in a fast and efficient elimination of respiratory viruses after natural infection. Therefore, a low-energy electron irradiated RSV (LEEI-RSV) formulated with phosphatidylcholine-liposomes (PC-LEEI-RSV) was tested ex vivo in precision cut lung slices (PCLSs) for adverse effects. The immunogenicity and protective efficacy in vivo were analyzed in an RSV challenge model after intranasal vaccination using a homologous prime-boost immunization regimen. No side effects of PC-LEEI-RSV in PCLS and an efficient antibody induction in vivo could be observed. In contrast to unformulated LEEI-RSV, the mucosal vaccination of mice with PC formulated LEEI-RSV showed a statistically significant reduction in viral load after challenge. These results are a proof-of-principle for the use of LEEI-inactivated viruses formulated with liposomes to be administered intranasally to induce a mucosal immunity that could also be adapted for other respiratory viruses.

Apicomplexan parasites are attenuated by low-energy electron irradiation in an automated microfluidic system and protect against infection with Toxoplasma gondii.

Radiation-attenuated intracellular parasites are promising immunization strategies. The irradiated parasites are able to invade host cells but fail to fully replicate, which allows for the generation of an efficient immune response. Available radiation technologies such as gamma rays require complex shielding constructions and are difficult to be integrated into pharmaceutical production processes. In this study, we evaluated for the first time low-energy electron irradiation (LEEI) as a method to generate replication-deficient Toxoplasma gondii and Cryptosporidium parvum. Similar to other radiation technologies, LEEI mainly damages nucleic acids; however, it is applicable in standard laboratories. By using a novel, continuous, and microfluidic-based LEEI process, tachyzoites of T. gondii and oocysts of C. parvum were irradiated and subsequently analyzed in vitro. The LEEI-treated parasites invaded host cells but were arrested in intracellular replication. Antibody-based analysis of surface proteins revealed no significant structural damage due to LEEI. Similarly, excystation rates of sporozoites from irradiated C. parvum oocysts were similar to those from untreated controls. Upon immunization of mice, LEEI-attenuated T. gondii tachyzoites induced high levels of antibodies and protected the animals from acute infection. These results suggest that LEEI is a useful technology for the generation of attenuated Apicomplexan parasites and has potential for the development of anti-parasitic vaccines.

Clinical Outcomes after Mitral Valve Surgery in Failed MitraClip Procedures.

BACKGROUND: We retrospectively evaluated in-hospital and overall outcome of patients who received mitral valve replacement (MVR) after failed MitraClip procedure. METHODS: A total of 26 out of 740 patients received MVR after treatment with MitraClip between June 2010 and December 2020. We analyzed in-hospital mortality and overall mortality during the median follow-up period of 72 days after MVR. RESULTS: The median age in the entire cohort was 77.5 years. In-hospital mortality was 15.4% (n = 4) and the overall mortality during the follow-up period was 27% (n = 7). The median time between the MitraClip procedure and surgery was 34.5 days. The main reasons for surgery were mitral stenosis (23.1%), persistent prolapse of the mitral valve leaflets (42.3%), and persistent tethering of the mitral valve leaflets (34.6%). At the time of surgery all of the patients presented with New York Heart Association 3 and above. The underlying mitral valve pathology was mainly secondary 61.5% (n = 16). Median left ventricular end-diastolic diameter was 60 mm. Preoperative ejection fraction was 40% and above in 73% of the cohort. In addition to the mitral valve procedure, 57.7% of patients received either concomitant tricuspid annuloplasty, aortic valve surgery, ascending aortic replacement, or coronary artery bypass grafting. CONCLUSION: The need for MVR for failed MitraClip repair is low and the results are acceptable. However, remaining options for reconstruction are usually limited and MVR is often needed. Anticipating success or failure according to the underlying pathology more than according to concomitant risk factors should form the basis in decision making for the treatment modality of first choice.

Low-Energy Electron Irradiation of Tick-Borne Encephalitis Virus Provides a Protective Inactivated Vaccine.

Tick-borne encephalitis virus (TBEV) is a zoonotic flavivirus which is endemic in many European and Asian countries. Humans can get infected with TBEV usually via ticks, and possible symptoms of the infection range from fever to severe neurological complications such as encephalitis. Vaccines to protect against TBEV-induced disease are widely used and most of them consist of whole viruses, which are inactivated by formaldehyde. Although this production process is well established, it has several drawbacks, including the usage of hazardous chemicals, the long inactivation times required and the potential modification of antigens by formaldehyde. As an alternative to chemical treatment, low-energy electron irradiation (LEEI) is known to efficiently inactivate pathogens by predominantly damaging nucleic acids. In contrast to other methods of ionizing radiation, LEEI does not require substantial shielding constructions and can be used in standard laboratories. Here, we have analyzed the potential of LEEI to generate a TBEV vaccine and immunized mice with three doses of irradiated or chemically inactivated TBEV. LEEI-inactivated TBEV induced binding antibodies of higher titer compared to the formaldehyde-inactivated virus. This was also observed for the avidity of the antibodies measured after the second dose. After viral challenge, the mice immunized with LEEI- or formaldehyde-inactivated TBEV were completely protected from disease and had no detectable virus in the central nervous system. Taken together, the results indicate that LEEI could be an alternative to chemical inactivation for the production of a TBEV vaccine.

Low-Energy Electron Irradiation (LEEI) for the Generation of Inactivated Bacterial Vaccines.

Vaccines consisting of whole inactivated bacteria (bacterins) are generated by incubation of the pathogen with chemicals. This is a time-consuming procedure which may lead to less immunogenic material, as critical antigenic structures can be altered by chemical modification. A promising alternative approach is low-energy electron irradiation (LEEI). Like other types of ionizing radiation, it mainly acts by destroying nucleic acids but causes less damage to structural components like proteins. As the electrons have a limited penetration depth, LEEI is currently used for sterilization of surfaces. The inactivation of pathogens in liquids requires irradiation of the culture in a thin film to ensure complete penetration. Here, we describe two approaches for the irradiation of bacterial suspensions in a research scale. After confirmation of inactivation, the material can be directly used for vaccination, without any purification steps.

Low Energy Electron Irradiation Is a Potent Alternative to Gamma Irradiation for the Inactivation of (CAR-)NK-92 Cells in ATMP Manufacturing.

Background: With increasing clinical use of NK-92 cells and their CAR-modified derivatives in cancer immunotherapy, there is a growing demand for efficient production processes of these "off-the-shelf" therapeutics. In order to ensure safety and prevent the occurrence of secondary tumors, (CAR-)NK-92 cell proliferation has to be inactivated before transfusion. This is commonly achieved by gamma irradiation. Recently, we showed proof of concept that low energy electron irradiation (LEEI) is a new method for NK-92 inactivation. LEEI has several advantages over gamma irradiation, including a faster reaction time, a more reproducible dose rate and much less requirements on radiation shielding. Here, LEEI was further evaluated as a promising alternative to gamma irradiation yielding cells with highly maintained cytotoxic effector function. Methods: Effectiveness and efficiency of LEEI and gamma irradiation were analyzed using NK-92 and CD123-directed CAR-NK-92 cells. LEE-irradiated cells were extensively characterized and compared to gamma-irradiated cells via flow cytometry, cytotoxicity assays, and comet assays, amongst others. Results: Our results show that both irradiation methods caused a progressive decrease in cell viability and are, therefore, suitable for inhibition of cell proliferation. Notably, the NK-mediated specific lysis of tumor cells was maintained at stable levels for three days post-irradiation, with a trend towards higher activities after LEEI treatment as compared to gamma irradiation. Both gamma irradiation as well as LEEI led to substantial DNA damage and an accumulation of irradiated cells in the G2/M cell cycle phases. In addition, transcriptomic analysis of irradiated cells revealed approximately 12-fold more differentially expressed genes two hours after gamma irradiation, compared to LEEI. Analysis of surface molecules revealed an irradiation-induced decrease in surface expression of CD56, but no changes in the levels of the activating receptors NKp46, NKG2D, or NKp30. Conclusions: The presented data show that LEEI inactivates (CAR-)NK-92 cells as efficiently as gamma irradiation, but with less impact on the overall gene expression. Due to logistic advantages, LEEI might provide a superior alternative for the manufacture of (CAR-)NK-92 cells for clinical application.

[Predictors of the Utilization and Waiting Period Before Starting an Oncological Rehabilitation after Breast Cancer]. / Prädiktoren der Inanspruchnahme und des Beginns einer onkologischen Rehabilitation nach Brustkrebs.

PURPOSE: This study explores the sociodemographic, medical and work-related factors leading to a participation in an in-house rehabilitation measure after primary treatment for breast cancer. METHODS: The prospective multi-center study is based on a written survey with employed breast cancer patients who were recruited at 11 breast cancer centers in Lower Saxony, Germany. Predictors of participation were examined by logistic regression, predictors of the time period before starting the rehabilitation by linear regression. RESULTS: 409 patients returned their questionnaires at all three time-points. Response rates were 80,1% 3 weeks after surgery (t0), 95,2% 6 months after surgery (t1) and 89,9% one year after surgery (t2). Altogether, 294 patients (72%) participated in the rehabilitation measure. Respondents, 90% of whom participated in rehabilitation before returning to work, began their rehabilitation on average 21 weeks after primary surgery. They showed an increased probability of participation if they had indicated the need to clarify their job situation (OR=2,74, p<0,01), or if their answers displayed a detrimental relation between effort and reward at work (OR=3,89, p<0,05). At the same time, higher age, a higher level of school education (OR=4,23) and reduced physical health (OR=0,94, p<0,01) increased the chance for breast cancer patients to take part in oncological rehabilitation. The starting point of rehabilitation was only predictable by medical treatments: adjuvant chemotherapy (ß=0,492, p≤0,001), additional surgery (ß=0,112, p<0,05), and radiation therapy within the second half year after primary surgery (ß=0,20; p<0,001) led to a postponement. CONCLUSION: This study shows that an increased need of breast cancer patients for medical and socio-psychological support leads to their participation in an in-house rehabilitation and thus underlines the necessity of these institutions. Women with an impaired psychological health should be given extra attention.

Impact of DAA/water composition on PFSA ionomer conformation.

Performance of a proton exchange membrane fuel cell (PEMFC) is significantly determined by the structure and composition of the electrode layer. Electrode layers are formed from inks consisting of platinum-doped carbon black particles, perfluorosulfonic acid (PFSA) ionomer and a dispersing solvent. Interaction between these materials mainly influences suspension stability, ionomer conformation and therewith layer morphology. We characterize the interplay between a short sidechain (SSC) PFSA ionomer (Aquivion® D79-25BS) and a solvent mixture (diacetone alcohol (DAA) and water with different weight ratios) by using Hansen solubility/dispersibility parameters (HSP) and by experimental tests. It was found that HSPs are well suitable to describe the ionomer/solvent interactions. In particular, the HSP difference in terms of the hydrogen bonds is responsible for the poor affinity between ionomer and solvent at low DAA concentrations. With increasing DAA content the affinity between ionomer and solvent increases as indicated by better matching HSPs. For an ionomer concentration of 4 wt%, Aquivion always forms molecular solutions for all DAA-in-water mixing ratios. Self-organization of the ionomer molecules changes from densely packed/collapsed molecules with highly deprotonated sulfonic acid side groups at low DAA concentrations to unfolded Aquivion molecules with a low dissociation degree of the sulfonic acid groups at high DAA concentrations.

Publisher Correction: Automated application of low energy electron irradiation enables inactivation of pathogen- and cell-containing liquids in biomedical research and production facilities.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Automated application of low energy electron irradiation enables inactivation of pathogen- and cell-containing liquids in biomedical research and production facilities.

Ionizing radiation is widely used to inactivate pathogens. It mainly acts by destroying nucleic acids but causes less damage to structural components like proteins. It is therefore highly suited for the sterilization of biological samples or the generation of inactivated vaccines. However, inactivation of viruses or bacteria requires relatively high doses and substantial amounts of radiation energy. Consequently, irradiation is restricted to shielded facilities-protecting personnel and the environment. We have previously shown that low energy electron irradiation (LEEI) has the same capacity to inactivate pathogens in liquids as current irradiation methods, but generates much less secondary X-ray radiation, which enables the use in normal laboratories by self-shielded irradiation equipment. Here, we present concepts for automated LEEI of liquids, in disposable bags or as a continuous process. As the electrons have a limited penetration depth, the liquid is transformed into a thin film. High concentrations of viruses (Influenza, Zika virus and Respiratory Syncytial Virus), bacteria (E. coli, B. cereus) and eukaryotic cells (NK-92 cell line) are efficiently inactivated by LEEI in a throughput suitable for various applications such as sterilization, vaccine manufacturing or cell therapy. Our results validate the premise that for pathogen and cell inactivation in liquids, LEEI represents a suitable and versatile irradiation method for standard biological research and production laboratories.

Low-Energy Electron Irradiation Efficiently Inactivates the Gram-Negative Pathogen Rodentibacter pneumotropicus-A New Method for the Generation of Bacterial Vaccines with Increased Efficacy.

Bacterial pathogens cause severe infections worldwide in livestock and in humans, and antibiotic resistance further increases the importance of prophylactic vaccines. Inactivated bacterial vaccines (bacterins) are usually produced via incubation of the pathogen with chemicals such as formaldehyde, which is time consuming and may cause loss of immunogenicity due to the modification of structural components. We evaluated low-energy electron irradiation (LEEI) as an alternative method to generate a bacterin. Rodentibacter pneumotropicus, an invasive Gram-negative murine pathogen, was inactivated with LEEI and formaldehyde. LEEI resulted in high antigen conservation, and LPS activity was significantly better maintained when compared with formaldehyde treatment. Immunization of mice with LEEI-inactivated R. pneumotropicus elicited a strong immune response with no detectable bacterial burden upon sublethal challenge. The results of this study suggest the inactivation of bacteria with LEEI as an alternative, fast and efficient method to generate bacterial vaccines with increased efficacy.

Automated microfluidic cell culture of stem cell derived dopaminergic neurons.

Parkinson's disease is a slowly progressive neurodegenerative disease characterised by dysfunction and death of selectively vulnerable midbrain dopaminergic neurons and the development of human in vitro cellular models of the disease is a major challenge in Parkinson's disease research. We constructed an automated cell culture platform optimised for long-term maintenance and monitoring of different cells in three dimensional microfluidic cell culture devices. The system can be flexibly adapted to various experimental protocols and features time-lapse imaging microscopy for quality control and electrophysiology monitoring to assess cellular activity. Using this system, we continuously monitored the differentiation of Parkinson's disease patient derived human neuroepithelial stem cells into midbrain specific dopaminergic neurons. Calcium imaging confirmed the electrophysiological activity of differentiated neurons and immunostaining confirmed the efficiency of the differentiation protocol. This system is the first example of an automated Organ-on-a-Chip culture and has the potential to enable a versatile array of in vitro experiments for patient-specific disease modelling.

Simple and Reliable Method for Studying the Adsorption Behavior of Aquivion Ionomers on Carbon Black Surfaces.

A better understanding of the interactions of carbon black and perfluorinated sulfonic acid (PFSA) ionomer helps to improve the effectiveness of polymer electrolyte membrane fuel cells. We present a simple and fast method for quantitative PFSA ionomer analysis based on suspension density measurements. After validation of the reliability of our method by thermogravimetric analysis and isothermal titration calorimetry (ITC), we investigate the adsorption equilibrium of short-side-chain PFSA ionomers of different equivalent weights (EW) and polarities on carbon black. The measured adsorption isotherms exhibit a plateau in the ionomer surface concentration for ionomer equilibrium concentrations ≤2 g/L. In this concentration range, the adsorption isotherms are described by the Langmuir model, whereby the surface concentrations in the plateau region are between 0.041 and 0.070 g/g. The plateau value of the ionomer surface concentration increases with EW and therefore with decreasing number of side chains with terminal sulfonic acid group per ionomer molecule, while the amount of adsorbed sulfonic acid groups remains constant for all investigated ionomers, resulting in similar ζ-potentials and sedimentation stability of the suspensions. The free energies of adsorption Δ G calculated from the association constants of the adsorption isotherms agree well with Δ G values obtained by isothermal titration calorimetry (ITC) and thus validate the adsorption isotherm measurement method. From the values of adsorption enthalpy Δ H ((-7.3 ± 0.8) kJ/mol) and entropy Δ S (ca. 100 J/(mol K)), which were extracted from ITC, we conclude that the ionomer adsorption on carbon black is a spontaneous physisorption process.

Ionomer and protein size analysis by analytical ultracentrifugation and electrospray scanning mobility particle sizer.

By combining analytical ultracentrifugation (AUC) in liquid phase and scanning mobility particle sizer (SMPS) in the gas phase, additional information on the particle size and morphology has been obtained for rigid particles. In this paper, we transfer this concept to soft particles, allowing us to analyze the size and molar mass of the short side chain perfluorosulfonic acid ionomer Aquivion® in a dilute aqueous suspension. The determination of the primary size and exact molar mass of this class of polymers is challenging since they are optically transparent and due to the formation of different aggregate structures depending on the concentration and solvent properties. First, validation of AUC and SMPS measurements was carried out using the well-defined biopolymers bovine serum albumin (BSA) and lysozyme (LYZ) to confirm the reliability of the results of the two unique and independent classifying methods. Then, the ionomer Aquivion® was studied using both techniques. From the mean molar mass of 185 ± 14 kDa obtained by AUC, a mean hydrodynamic diameter of 7.6 ± 0.5 nm was calculated. The particle size obtained from SMPS (7.1 nm) agrees very well with the results from AUC showing that the molecule was transferred into the gas phase without significantly changing its structure. In conclusion, the Aquivion® is molecularly dispersed in the used aqueous buffer solution without any aggregate formation in the investigated concentration range (< 2 g l-1).

Pathogens Inactivated by Low-Energy-Electron Irradiation Maintain Antigenic Properties and Induce Protective Immune Responses.

Inactivated vaccines are commonly produced by incubating pathogens with chemicals such as formaldehyde or ß-propiolactone. This is a time-consuming process, the inactivation efficiency displays high variability and extensive downstream procedures are often required. Moreover, application of chemicals alters the antigenic components of the viruses or bacteria, resulting in reduced antibody specificity and therefore stimulation of a less effective immune response. An alternative method for inactivation of pathogens is ionizing radiation. It acts very fast and predominantly damages nucleic acids, conserving most of the antigenic structures. However, currently used irradiation technologies (mostly gamma-rays and high energy electrons) require large and complex shielding constructions to protect the environment from radioactivity or X-rays generated during the process. This excludes them from direct integration into biological production facilities. Here, low-energy electron irradiation (LEEI) is presented as an alternative inactivation method for pathogens in liquid solutions. LEEI can be used in normal laboratories, including good manufacturing practice (GMP)- or high biosafety level (BSL)-environments, as only minor shielding is necessary. We show that LEEI efficiently inactivates different viruses (influenza A (H3N8), porcine reproductive and respiratory syndrome virus (PRRSV), equine herpesvirus 1 (EHV-1)) and bacteria (Escherichia coli) and maintains their antigenicity. Moreover, LEEI-inactivated influenza A viruses elicit protective immune responses in animals, as analyzed by virus neutralization assays and viral load determination upon challenge. These results have implications for novel ways of developing and manufacturing inactivated vaccines with improved efficacy.

Unilateral pulmonary oedema after minimally invasive cardiac surgery via right anterolateral minithoracotomy.

OBJECTIVES: To investigate the incidence of unilateral pulmonary oedema after minimally invasive cardiac surgery (MICS) requiring unilateral lung collapse has been unknown until now. METHODS: We analysed the data of 484 consecutive patients undergoing minimally invasive cardiac surgery with unilateral lung collapse between January 2008 and December 2013. The clinical regimen was changed in 2010 to a single dose of dexamethasone (approximately 1 mg/kg body weight) administered after anaesthesia induction. RESULTS: Thirty-eight patients developed a radiographically evident unilateral pulmonary oedema within 24 h after surgery. Dexamethasone significantly reduced the incidence of this event [4.0 vs 12.9%; unadjusted odds ratio (OR) 0.28, 95% confidence interval (CI) 0.14-0.58, P < 0.001]. One patient with and six patients without dexamethasone were clinically symptomatic (P = 0.001). Logistic regression analysis identified four variables significantly associated with the development of a unilateral lung oedema: dexamethasone (OR 0.28, 95% CI 0.13-0.58, P = 0.001), diabetes mellitus (OR 3.17, 95% CI 1.04-9.63, P = 0.04), the level of mean pulmonary arterial pressure (OR 1.05 per mmHg, 95% CI 1.004-1.09, P = 0.03) and transfusion of fresh frozen plasma (OR 2.31, 95% CI 1.02-5.25, P = 0.045). CONCLUSIONS: Our data revealed a 7.9% incidence of radiographically evident unilateral pulmonary oedema after MICS with intraoperative collapse of a lung. Of the total number of patients, 1.5% simultaneously developed clinical symptoms. The influence of corticosteroids, as well as the contribution of possible risk factors, needs further evaluation.

Pulmonary artery vs. transpulmonary thermodilution for the assessment of cardiac output in mitral regurgitation: a prospective observational study.

CONTEXT: With increasing prevalence of mitral regurgitation, even noncardiac anaesthesiologists will be confronted by this disorder and will need to be familiar with the extended haemodynamic monitoring required. The assessment of cardiac output (CO) measured by transpulmonary thermodilution (COTP) has become an accepted alternative to the CO measured by thermodilution via pulmonary artery catheter (COPAC). However, the integrity of COTP in severe mitral regurgitation requires systematic evaluation. OBJECTIVE: This study was designed to test the hypothesis that transpulmonary thermodilution is compromised by severe mitral regurgitation. DESIGN: Prospective method comparison study. SETTING: Single university-affiliated hospital. PARTICIPANTS: Thirty patients with mitral regurgitation undergoing elective mitral valve repair. MAIN OUTCOME MEASURE: COTP and COPAC were determined in triplicate after induction of anaesthesia, and at the end of surgery after closure of the chest. The methods were compared using bias and precision statistics. RESULTS: Echocardiography revealed severe mitral regurgitation in most patients (n  =  27) after induction of anaesthesia. The least significant change in COTP (the minimum change in COTP required to detect a real change with a probability of 95%) was increased under the condition of mitral regurgitation (15.4  ±  10.2% after anaesthesia induction vs. 9.3  ±  5.9% after valve repair, P = 0.008), whereas it remained constant in COPAC (9.6  ±  5.4 vs. 8.5  ±  7.2%, P = 0.55). There was no significant bias between COTP and COPAC after anaesthesia induction [mean CO, 4.03 ±â€Š0.92 l  min; bias 0.12 l  min (95% confidence interval, CI, -0.073 to 0.311)], and after valve repair [mean CO 7.47  ±â€Š 1.44 l  min; bias 0.045 l  min (95% CI, -0.147 to 0.237)]. The percentage error was 28.4 and 13.6%, respectively. CONCLUSION: The results suggest that even severe mitral regurgitation has no significant impact on the accuracy of COTP. The precision of COTP was reduced under the condition of mitral regurgitation.

Chemoradiotherapy with gemcitabine and continuous 5-FU in patients with primary inoperable pancreatic cancer.

CONTEXT: Gemcitabine and 5-fluorouracil (5-FU) sensitize tumor cells to radiation. Furthermore, 5-FU enhances the cytotoxic effect of gemcitabine. OBJECTIVE: We report the efficacy and the toxicity of concurrent chemoradiation with gemcitabine and 5-FU in the treatment of patients with locally advanced, unresectable pancreatic cancer. PATIENTS: Thirty-two patients (20 men, 12 women; median age 69.9 years) with histologically proven advanced pancreatic carcinoma were included in the study. INTERVENTIONS: The patients received chemotherapy with gemcitabine 300 mg/m2 on days 1, 15, 29 and 5-FU as continuous infusion 350 mg/m2/day of radiation while concurrent radiation (45-50 Gy) was given to the tumor and regional lymph nodes (1.8-2.0 Gy/fraction on 5 days/week). Subsequent to chemoradiotherapy, the treatment was continued with an additional two cycles of gemcitabine (1,000 mg/m2) and cisplatin (50 mg/m2) applied on days 1 and 15 of a four-week cycle. MAIN OUTCOME MEASURES: Patient survival, time to progression, and toxicity of chemoradiation. Tumor responses (complete resolution; partial response; stable disease, and progressive disease) were also evaluated. RESULTS: After the completion of chemoradiotherapy, 2 patients (6.3%) achieved complete resolution and 18 patients (56.3%) a partial response, for an overall response rate of 62.5%. Twelve patients (37.5%) were considered resectable and 9 underwent laparotomy, 7 of whom had definitive pancreatic resection. Four patients had negative surgical margins. With a median follow-up of 49.7 months (95% CI: 48.6-60.8 months) after the completion of chemoradiation, distant metastasis occurred in 25 patients (78.1%) while local recurrence was seen only in 4 of 32 patients (12.5%). Median time to progression was 9.2 months (95% CI: 8.2-10.2 months). Median survival amounted to 13.6 months (95% CI: 12.7-14.6 months) for all patients while it was prolonged to 16.4 months (95% CI: 13.4-19.4 months) for those undergoing secondary resection. In addition, performance status proved to be another prognostic factor for overall survival. The main toxicity of chemoradiation included grade 3-4 leukopenia in 18 patients (56.3%) and thrombocytopenia in 8 patients (25.0%). Episodes of cholangitis were observed in 7 patients (21.9%). CONCLUSION: Gemcitabine and 5-FU can safely be combined with external beam radiation. This preoperative treatment approach is highly effective and appears to improve survival in patients with good performance status and in those who are eligible for a secondary resection.