A quantitative evaluation of aerosol generation during cardiopulmonary resuscitation.

It is unclear if cardiopulmonary resuscitation is an aerosol-generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out-of-hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time-series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546-59,209 [1523-242,648]) particles.l-1 , which were 24-fold greater than in control participants under general anaesthesia (744 (309-2106 [23-9099]) particles.l-1 , p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time-averaged aerosol concentrations during ventilation were approximately 270-fold higher than before cardiac arrest (19,410 (2307-41,017 [104-136,025]) vs. 72 (41-136 [23-268]) particles.l-1 , p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high-risk pathogens, until the airway is secured with an airway device and breathing system with a filter.

Efficacy and safety of fumaric acid esters in young patients aged 10-17 years with moderate-to-severe plaque psoriasis: a randomized, double-blinded, placebo-controlled trial.

BACKGROUND: Apart from biologics, no systemic drugs are approved in Europe for children with moderate-to-severe psoriasis. Retrospective observational studies have shown promising results for fumaric acid esters (FAE) in this setting. OBJECTIVES: To show superiority of FAE over placebo in terms of treatment response after 20 weeks in children and adolescents aged 10-17 years. METHODS: In a multicentre, randomized, double-blind, placebo-controlled phase IIIb study, patients aged 10-17 years with moderate-to-severe plaque psoriasis requiring systemic therapy were randomized 2 : 1 to receive FAE (n = 91) or placebo (n = 43) over 20 weeks, followed by an open-label FAE treatment phase. The coprimary endpoints were ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) and Physician's Global Assessment (PGA) score of 0 or 1 (clear or almost clear) at week 20. The study was registered with EudraCT number 2012-000035-82. RESULTS: At week 20, 55% [95% confidence interval (CI) 0·44-0·65] of FAE-treated patients achieved a PASI 75 response vs. 19% (95% CI 0·08-0·33) in the placebo group (absolute difference 36%, 95% CI 0·20-0·53; P < 0·001). In total, 42% (95% CI 0·32-0·53) in the FAE group vs. 7% (95% CI 0·01-0·19) in the placebo group achieved a PGA score of 0 or 1 at week 20 (absolute difference 35%, 95% CI 0·21-0·49; P < 0·001). During the double-blind period, drug-related adverse events occurred more frequently in patients receiving FAE compared with placebo (76% vs. 47%). Gastrointestinal disorders were the most common adverse events. CONCLUSIONS: FAE administered over a period of 20 weeks demonstrated a better response than placebo; the difference was statistically significant and clinically meaningful. Application up to 40 weeks was generally well tolerated. However, further studies are required.

Development of a multi-component lifestyle intervention for preventing type 2 diabetes and cardiovascular risk factors in adults with intellectual disabilities.

Background: We report on the development of the 'STOP Diabetes' education programme, a multi-component lifestyle behaviour change intervention for the prevention of type 2 diabetes and cardiovascular risk factors in adults with intellectual disabilities (ID). Methods: We combined qualitative stakeholder interviews with evidence reviews to develop the intervention, guided by the MRC Framework and informed by intervention mapping and two existing diabetes prevention programmes. We conducted two pilot cycles drawing on additional stakeholder interviews to inform and refine the intervention. Results: The STOP Diabetes education programme employed a theoretical framework, using sound learning and behavioural principles and concrete kinaesthetic methods, to provide the grounding for innovative games and activities to promote health behaviour change in adults with ID. Qualitative data also suggested that two educators and one support person delivering a programme of one carer session followed by seven 2.5-h sessions over 7 weeks was acceptable to service users, carers and educators and appeared to benefit the participants. Conclusions: The STOP Diabetes education programme was successfully developed and is suitable for a definitive randomized controlled trial.

Paediatric x-ray radiation dose reduction and image quality analysis.

Collaboration of multiple staff groups has resulted in significant reduction in the risk of radiation-induced cancer from radiographic x-ray exposure during childhood. In this study at an acute NHS hospital trust, a preliminary audit identified initial exposure factors. These were compared with European and UK guidance, leading to the introduction of new factors that were in compliance with European guidance on x-ray tube potentials. Image quality was assessed using standard anatomical criteria scoring, and visual grading characteristics analysis assessed the impact on image quality of changes in exposure factors. This analysis determined the acceptability of gradual radiation dose reduction below the European and UK guidance levels. Chest and pelvis exposures were optimised, achieving dose reduction for each age group, with 7%-55% decrease in critical organ dose. Clinicians confirmed diagnostic image quality throughout the iterative process. Analysis of images acquired with preliminary and final exposure factors indicated an average visual grading analysis result of 0.5, demonstrating equivalent image quality. The optimisation process and final radiation doses are reported for Carestream computed radiography to aid other hospitals in minimising radiation risks to children.

Transmembrane segment 5 of the Glut1 glucose transporter is an amphipathic helix that forms part of the sugar permeation pathway.

Transmembrane segment 5 of the Glut1 glucose transporter has been proposed to form an amphipathic transmembrane helix that lines the substrate translocation pathway (Mueckler, M., Caruso, C., Baldwin, S. A., Panico, M., Blench, I., Morris, H. R., Allard, W. J., Lienhard, G. E., and Lodish, H. F. (1985) Science 229, 941-945). This hypothesis was tested using cysteine-scanning mutagenesis in conjunction with the membrane-impermeant, sulfhydryl-specific reagent, p-chloromercuribenzenesulfonate (pCMBS). A series of 21 mutants was created from a fully functional, cysteine-less, parental Glut1 molecule by changing each residue within putative transmembrane segment 5 to cysteine. Each mutant was then expressed in Xenopus oocytes and its steady-state protein level, 2-deoxyglucose uptake activity, and sensitivity to pCMBS were measured. All 21 mutants exhibited measurable transport activity, although several of the mutants exhibited reduced activity due to a corresponding reduction in steady-state protein. Six of the amino acid side chains within transmembrane segment 5 were clearly accessible to pCMBS in the external medium, as determined by inhibition of transport activity, and a 7th residue showed inhibition that lacked statistical significance because of the extremely low transport activity of the corresponding mutant. All 7 of these residues were clustered along one face of a putative alpha-helix, proximal to the exoplasmic surface of the plasma membrane. These results comprise the first experimental evidence for the existence of an amphipathic transmembrane alpha-helix in a glucose transporter molecule and strongly suggest that transmembrane segment 5 of Glut1 forms part of the sugar permeation pathway.

Identification of an amino acid residue that lies between the exofacial vestibule and exofacial substrate-binding site of the Glut1 sugar permeation pathway.

A valine-to-isoleucine mutation at amino acid residue 197 of Glut2 or the equivalent residue 165 of Glut1 has been shown to impair glucose transport activity. This mutation was originally discovered in the Glut2 gene of a patient with type 2 diabetes. We investigated the mechanism of the effect of this mutation on transport activity via the analysis of Glut1 mutants expressed in Xenopus oocytes combined with cysteine substitution mutagenesis and the use of cysteine-reactive chemical probes. Aliphatic side chain substitutions at position 165 that were bulkier than the native valine residue inhibited glucose transport activity, whereas substitutions of less bulky side chains had little effect on transport, suggesting a role for steric hindrance. A cysteine residue was introduced at position 165 of a functional, cysteine-less Glut1 construct, and this mutant was then tested for inhibition of transport activity by a membrane-impermeant sulfhydryl-specific reagent (p-chloromercuribenzenesulfonate). p-Chloromercuribenzenesulfonate inhibited activity of the Cys165 mutant when it was added to the external buffer but not when it was injected directly into oocytes, indicating that this residue is accessible from the external solvent but not from the cytoplasm. Competition experiments indicated that Cys165 lies near the exofacial substrate-binding site or directly in the sugar permeation pathway. These data provide evidence that the side chain of Val165, which resides in the middle of transmembrane helix 5, juts into the aqueous permeation pathway of Glut1, probably between the exofacial substrate-binding site and the outer vestibule of the pathway.

Radiosensitization of hypoxic tumor cells in vitro by nitric oxide.

PURPOSE: The effects of nitric oxide (NO) on the radiosensitivity of SCK tumor cells in oxic and hypoxic environments in vitro were studied. METHODS AND MATERIALS: NO was delivered to cell suspensions using the NO donors 2,2-diethyl-1-nitroso-oxyhydrazine sodium salt (DEA/NO), and a spermine/nitric oxide complex (SPER/NO), which release NO at half-lives of 2.1 min and 39 min at pH 7.4, respectively. The cells were suspended in media containing DEA/NO or SPER/NO for varying lengths of time under oxic or hypoxic conditions, irradiated, and the clonogenicity determined. RESULTS: Both compounds markedly radiosensitized the hypoxic cells. The drug enhancement ratios (DER) for 0.1, 1.0, and 2.0 mM DEA/NO were 2.0, 2.3 and 3.0, respectively, and those for 0.1, 1.0, and 2.0 mM SPER/NO were 1.6, 2.3, and 2.8, respectively. Aerobic cells were not radiosensitized by DEA/NO or SPER/NO. When DEA/ NO and SPER/NO were incubated in solution overnight to allow release of NO, they were found to have no radiosensitizing effect under hypoxic or oxic conditions indicating the sensitization by the NO donors was due to the NO molecule released from these drugs. At the higher concentrations, SPER/NO was found to be cytotoxic in aerobic conditions but not in hypoxic conditions. DEA/NO was only slightly toxic to the cells in both aerobic and hypoxic conditions. CONCLUSIONS: NO released from NO donors DEA/NO and SPER/NO is as effective as oxygen to radiosensitize hypoxic cells in vitro. Its application to the radiosensitization of hypoxic cells in solid tumors remains to be investigated.

Tumour pO2 can be increased markedly by mild hyperthermia.

We have studied the feasibility of improving tumour oxygenation with hyperthermia at modest temperatures which are achievable with the use of presently available clinical hyperthermia machines. FSaII tumours grown s.c. in the leg of C3H mice and R3230 AC tumours grown s.c. in the leg of Fischer rats were heated with a water bath and the tumour pO2 was determined with an Eppendorf pO2 histograph. The median pO2 in 7-8 mm diameter control FSaII tumours was 6.5 +/- 0.5 mmHg and it increased to 16.6 +/- 1.1 mmHg when the tumours were heated at 41.5 degrees C for 1 h. The median pO2 in 10 mm diameter control R3230 AC tumours was 3.7 +/- 0.3 mmHg. Heating at 42.5 degrees C for 30 min increased the median pO2 in the R3230 AC tumours to 12.2 +/- 1.8 mmHg. The pO2 in FSaII tumours measured 24 h after heating at 41.5 degrees C for 1 h was still higher than the pO2 before heating. The % frequency of pO2 values lower than 5 mmHg decreased markedly when the tumours were heated at the modest temperatures mentioned above. Modest temperature hyperthermia (MTH) may be an efficient and useful means to improve the oxygenation of human tumours.

Effect of intracellular acidity and ionomycin on apoptosis in HL-60 cells.

The aim was to investigate in detail the influence of intracellular pH (pHi) and intracellular Ca2+ concentration ([Ca2+]i) on apoptosis in HL-60 human promyelocytic leukaemia cells. The pHi was controlled by changing the pH of media as well as by interfering with the pHi regulatory mechanisms with 3-amino-6-chloro-5-(1-homopiperidyl)-N-(diaminomethylene) pyrazincarboxamide (HMA; an inhibitor of Na+/H+ antiport), 4-diiosothiocyanatostilbene-2,2'disulfonic acid, (DIDS; an inhibitor of Na(+)-dependent HCO3-/Cl- exchange) and nigericin (a K+ ionophore). The [Ca2+]i was increased with ionomycin, a Ca2+ ionophore. The apoptosis of HL-60 cells was measured with conventional agarose gel electrophoresis for DNA fragmentation and also with the release of 3H from 3H-thymidine-labelled DNA. Based on the magnitude of DNA fragmentation and 3H release at different pHi, it was shown that apoptosis occurred in HL-60 cells when the pHi was lowered from normal pHi of 7.4 to about 7.2-6.7 with a peak increase at pHi 6.8-6.9. Addition of 4 microM ionomycin to RPMI 1640 medium, which contained 615 microM Ca2+, elevated the apoptosis in the cells. Such an increase in apoptosis by ionomycin in HL-60 cells appeared to result from both an increase in [Ca2+]i and from a decline in pHi. The results indicate that the acidic intratumour environment may greatly affect the response of neoplastic tissues to hyperthermia, radiation and chemotherapeutic drugs which cause apoptosis.

Thermosensitization by increasing intracellular acidity with amiloride and its analogs.

PURPOSE: The major mechanisms that regulate the intracellular acidity of pHi in mammalian cells are the Na+/H+ exchange and HCO3-/Cl- exchange through the plasma membrane. The purpose of this study was to investigate the feasibility of increasing the thermosensitivity of tumors by increasing intracellular acidity with the use of drugs that inhibit the pHi regulatory mechanisms. METHODS AND MATERIALS: The pHi of SCK tumor cells in vitro was determined with the fluorescence spectroscopy method. The thermosensitizing effects of the drugs on the cells in neutral (pH 7.2-7.5) and acidic (pH 6.6) media were determined by clonogenic assay. The thermosensitization of SCK tumors in vivo by the drugs was determined with the tumor growth delay and the in vivo-in vitro assay for clonogenic cells. RESULTS: The pHi of SCK tumor cells in pH 7.2-7.5 media was similar to the media pH, while the pHi of the cells in pH 6.6 media was about 7.0. The pHi declined and the thermosensitivity of the tumor cells increased when the Na+/H+ exchange was inhibited with amiloride (3,5 diamino-6-chloro-N-(diaminomethylene) pyrazinecarboxamide) and its analogs, HMA (3-amino-6-chloro-5-(1-homopiperidyl)-N-(diaminomethylene) pyrazinecarboxamide) or EIPA (3-amino-6-chloro-5-(N-ethyl-N-isopropylamino)-N-diaminomethylene) pyrazinecarboxamide), especially in acidic medium. The potencies of HMA and EIPA to decrease the pHi and increase the thermosensitivity in vitro were more than 50 times greater than that of amiloride. DIDS (4,4-diiosothiocyanatostilbene-2,2'-disulfonic acid), an inhibitor of the Na(+)-dependent HCO3-/Cl- exchange, exerted little effect on the pHi and thermosensitivity of SCK cells in vitro, but it enhanced the effects of amiloride and its analogs. Amiloride and HMA also significantly enhanced the thermal effect on tumors in vivo, as judged by the tumor growth delay and also by the in vitro-in vivo assay for clonogenic cells. Combinations of DIDS with amiloride or HMA were more effective than either of them alone in increasing the thermal damage in vivo. As in vitro, HMA was far more potent than amiloride in increasing the thermosensitivity of tumor cells in vivo. However, EIPA was not effective in vivo, probably due to a rapid metabolic breakdown of the drug. CONCLUSION: The drugs that interfere with the pHi regulatory mechanism significantly thermosensitized the tumor cells in vitro, particularly those in acidic media. The drugs were also effective in increasing the thermosensitivity of tumors. Because the interstitial environment in tumors is acidic relative to that in normal tissues, the thermosensitization by the drugs may be greater in tumors than that in normal tissues.

Effects of HMA, an analog of amiloride, on the thermosensitivity of tumors in vivo.

PURPOSE: The effects of HMA (3-amino-6-chloro-5-(1-homopiperidyl)-N- (diaminomethylene)pyrazinecarboxamide), an analog of amiloride, on the intracellular pH (pHi) of SCK tumor cells in vitro and on the thermosensitivity of tumors in vivo were investigated. METHODS AND MATERIALS: The pHi of SCK tumor cells in vitro was measured with the BCEC fluorescence spectroscopy method. The effect of HMA on the thermosensitivity of SCK tumors grown SC in the legs of A/J mice was assessed by the tumor growth delay method and the in vivo-in vitro excision assay method. RESULTS: The pHi of SCK tumor cells in pH 7.5 and 6.6 medium was about 7.50 and 7.15, respectively. The presence of 10-50 microM of HMA lowered the pHi by 0.1-0.2 pH units both in pH 7.5 and 6.6 medium. Heating at 43 degrees C 120 min lowered the pHi by 0.2 and 0.3 pH units in pH 7.5 and 6.6 medium, respectively. When the cells were heated in the presence of 10-50 microM HMA, a marked decline in pHi occurred and and the decline in pHi resulting from the combination of heat and HMA was more pronounced in pH 6.6 medium than in pH 7.5 medium. Heating the SCK tumors grown SC in the legs of A/J mice at 43.5 degrees C for 1 h resulted in a growth delay of 3.7 days. When the host mice were i.v. injected with 0.1 mg/kg of HMA and the tumors were heated heated 20 min later, the tumor growth was delayed by 8.2 days, which was 4.5 days longer than that by heating alone. Heating the SCK tumor at 42.5 degrees C for 1 h caused a tumor growth delay of 0.9 days. An i.v. injection of 1 mg/kg or 10 mg/kg of HMA prior to heating at 42.5 degrees C for 1 h caused a tumor growth delay 2.1 and 3.1 days longer, respectively, than that by heating alone. Such an enhancement of heat-induced tumor growth delay by HMA was due to increased cell killing, as determined with the in vivo-in vitro excision assay of clonogenic cells in the tumors. CONCLUSION: HMA is a potent thermosensitizer, particularly in an acidic environment. Thermosensitization by HMA may occur preferentially in tumors relative to normal tissues since the intratumor environment is acidic.

Increase in tumor blood flow by pentoxifylline.

PURPOSE: The effect of pentoxifylline (PTX) on the blood flow in experimental rodent tumors was investigated. METHODS AND MATERIALS: When the R3230 AC adenocarcinoma implanted in the leg of Fischer 344 rats grew to about 1 g, the effect of PTX on the blood flow in the tumor and in the skin and muscle was determined with the microsphere method using 85Sr labelled 25 microns diameter microspheres. The SCK mammary carcinoma was induced subcutaneously in the leg or foot of A/J mice and the effect of PTX on the tumors was investigated: the blood perfusion in the leg tumors (7 mm in diameter) was determined with the 86Rb uptake method and that in the foot tumors (5 mm diameter) was determined with the laser Doppler flow (LDF) method. RESULTS: The blood flow in the R3230 AC adenocarcinoma significantly increased when measured 30 min after an IP injection of 50 mg/kg PTX while the blood flow in the normal skin and muscle remained unchanged. The 86Rb uptake in the SCK tumor slightly increased 30 min after an IP injection of 50 mg/kg PTX. The LDF in the SCK tumors grown in the foot began to increase 5-10 min after an injection of 25 mg/kg PTX reaching 1.5-2.0 times in 20-30 min and it returned to the original level at 60 min. CONCLUSION: The results in the present study together with our previous observation that PTX increases the tumor pO2 in rodent tumors strongly suggest that PTX may be useful for increasing the radiosensitivity of human tumors.

Thermosensitization by lowering intracellular pH with 5-(N-ethyl-N-isopropyl) amiloride.

It has previously been reported that amiloride, a diuretic drug, sensitizes cells to hyperthermia by inhibiting the Na+/H+ exchange through the plasma membrane and thus decreasing the intracellular pH (pHi), particularly in a low extracellular pH (pHe) environment. In the present study, the efficacy of 5-(N-ethyl-N-isopropyl) amiloride (EIPA), an analog of amiloride, to lower the pHi and sensitize tumor cells to hyperthermia was investigated. It was observed that 10 microM EIPA was as effective as 500 microM amiloride to lower the pHi and to increase the thermal sensitivity of SCK tumor cells in vitro. The fact that lowering the pHi and increasing thermal sensitivity of tumor cells by EIPA are more pronounced in acidic medium suggests that the acidic intratumor environment may be exploited to selectively increase the thermal damage in tumors relative to normal tissues by EIPA or its analogs.

Increase in thermosensitivity of tumor cells by lowering intracellular pH.

We previously reported that the thermosensitivity of tumor cells can be increased when the intracellular pH is lowered by inhibiting Na+/H+ exchange through the plasma membrane with amiloride (3,5-diamino-6-chloro-N-(diamino methylene)pyrazinecarboxamide) or its analogues and HCO3-/Cl-exchange with 4,4-diiothiocyanato-stilbene-2,2'-disulfonic acid. In this study, we investigated the effects of (3-amino-6-chloro-5- (1-homopiperidyl)-N-(diaminomethylene)pyrazine-carboxamide) (HMA), an analogue of amiloride and a potent inhibitor of Na+/H+ exchange, and R(+)-[(5,6-dichloro-2,3,9,9a-tetrahydro-3-oxo-9a-propyl-1H-fluoren -7- yl)oxy]acetic acid [B-3(+)], a potent inhibitor of HCO3-/Cl- exchange, on the thermosensitivity of SCK tumor cells in vitro. We observed that 10 microM of HMA could effectively increase the cell death by heating at 43 degrees in pH 6.6 medium but not in pH 7.5 medium. The B-3(+) at 50 microM alone had no effect on the thermosensitivity of cells, but it increased the thermosensitizing effect of HMA in acidic medium. Our results strongly suggested that a combination of HMA and B-3(+) may preferentially thermosensitize tumors in vivo since the interstitial environment in tumors is acidic relative to that in normal tissues.