Intradermal immunization with novel plasmid DNA-coated nanoparticles via a needle-free injection device

A high population of dendritic cells in the skin makes intradermal (ID) immunization an attractive route. We sought to further enhance immune responses from a previously reported novel nanoparticle-based DNA vaccine delivery system by administering the system intradermally into mouse skin using Biojector 2000, a needle-free jet injection device. Two mouse studies were carried out. Balb/C mice (n=5-6) were immunized on day 0, 7, and 14 by subcutaneous injection or via the Biojector 2000 with pDNA alone (CMV-beta-galactosidase, 5 micro g), pDNA-coated nanoparticles, or beta-galactosidase protein (10 micro g) adjuvanted with 'Alum' (15 micro g). On day 28, mice were sacrificed and specific serum IgG and IgA titer, in vitro cytokine release, and cell proliferation of isolated splenocytes were determined. Similar to previous reports, in both mouse studies, SC immunization with pDNA-coated nanoparticles led to over a log increase in specific serum IgG titer as compared to immunization with pDNA alone. For pDNA alone, jet and SC injection did not result in significant differences in IgG titer. In contrast, for pDNA-coated nanoparticles, jet injection led to as high as a 20-fold enhancement in IgG titer over SC injection. In addition, jet injection of pDNA-coated nanoparticles enhanced the IgG titer by more than 200-fold over jet injection of pDNA alone. Also, jet injection of pDNA-coated nanoparticles resulted in significantly enhanced specific serum IgA titer. For in vitro cytokine release, immunization with pDNA-coated nanoparticles by jet injection enhanced IFN-gamma and IL-4 release over pDNA alone by 6- and 5-fold, respectively. SC injection of pDNA-coated nanoparticles also resulted in enhanced IFN-gamma and IL-4 release over pDNA alone although with less magnitude. Finally, immunization with pDNA-coated nanoparticles, by both jet injection and SC injection, led to improved splenocyte proliferation over pDNA alone. In conclusion, a combination of a novel cationic nanoparticle-based DNA delivery system with ID jet injection led to enhanced antibody production, Th-1/Th-2 balanced cytokine release, and enhanced splenocyte proliferation.

A nationwide study of continuous subcutaneous insulin infusion (CSII) in Denmark

AIMS

To record the number of patients treated with continuous subcutaneous insulin infusion (CSII), the attitude to CSII treatment among diabetes care providers and the characteristics of pump users in Denmark.

METHODS

A questionnaire was mailed to all departments of endocrinology, internal medicine and paediatrics in Denmark (n = 73) to determine the number of diabetic patients treated with CSII and the attitudes of chief consultants to it. All patients using CSII were identified and data from their records collected.

RESULTS

Primarily Type 1 diabetic patients (n = 142) were treated with CSII, approx. 0.5% of patients in Denmark. The explanations given for this low frequency varied for non-CSII and CSII-using diabetologists. Both found lack of funding important. In addition, the non-CSII-using group had a perception that CSII was dangerous. The CSII-using diabetologists found that no more patients were interested and that it did not significantly improve metabolic control. The mean age of pump users was 48.1 +/- 10.5 years and the mean time wearing a pump 14.1 +/- 6.3 years. Mean HbA1c was 7.9 +/- 1.2% during CSII, with a significant difference among the 15 centres (P < 0.05) and a tendency to be lower in females (P = 0.07).

CONCLUSIONS

CSII is infrequently used in Denmark despite pump users showing reasonably good metabolic control. The most common explanations for these low figures are lack of expertise and funding for CSII. If more patients in Denmark were to be offered pumps, education of healthcare providers would be needed and the funding would have to be clarified.

Will subareolar injection be a standard technique for sentinel lymph node biopsy?

BACKGROUND

Controversy surrounds the correct injection site of radioisotope (RI) and blue dye for sentinel node biopsy (SNB) in breast cancer, and there have been some reports on the advantages of subareolar (SA) injection. We carried out a study to assess whether SA injection is useful for all patients undergoing SNB.

METHODS

In this prospective study, 20 patients with T1 or T2 tumors clinically node negative, were enrolled. Injection of 99mTc-phytate (0.5 mCi) was performed two times (3 to 5 days before surgery and the day of surgery) for each patient. The first RI injection was SA, and the second RI injection was subdermal (SD). The location and number of hot nodes were assessed by lymphoscintigraphy (LSG) and hand-held gamma probe.

RESULTS

There were no patients in whom hot nodes on LSG were visualized in clearly different locations between the SA and SD injection sites. However, there were 2 patients in whom hot nodes were identified at different locations with a gamma probe. Seven patients had more hot nodes on LSG with SD injection than SA injection. Eight patients had a higher RI count of hot nodes by SD injection than SA injection. The mean RI count of hot nodes by SA injection was higher than that after SD injection.

CONCLUSION

SA and SD lymphatic flow run into the same node in most patients, however, SD injection is more useful than SA injection in some patients. Though SA injection is a useful technique, it may not identify sentinel lymph nodes correctly in patients with multiple lesions or tumors in the upper outer quadrant.

Misadventures in insulin therapy: are you at risk?

About dollar 1 out of every dollar 7 spent on health care is related to diabetes mellitus, a leading cause of blindness and kidney failure and a strong risk factor for heart disease. Prevalence of the disease has increased by a third among adults in general in the last decade, but intensive therapy has been shown to delay the onset and slow the progression of diabetes-related complications. While insulin therapy remains key in the management of type 1 diabetes, many patients with type 2, or insulin-resistant, diabetes encounter insulin administration errors that compromise the quality of insulin delivery. Insulin errors are a major, but modifiable, barrier to dosing accuracy and optimal diabetes control for many patients. Future trends to combat the problem include increased use of insulin inhalers and smaller doses of rapid- or short-acting insulin to supplement longer-acting injections.

Treatment with intravenous insulin followed by continuous subcutaneous insulin infusion improves glycaemic control in severely resistant Type 2 diabetic patients

AIMS

Despite high-dose s.c. insulin therapy, some Type 2 diabetes mellitus (DM) patients remain in poor metabolic control. We investigated whether a period of euglycaemia using i.v. insulin, followed by continuous subcutaneous insulin infusion (CSII), would ameliorate the deleterious effects of hyperglycaemia on insulin sensitivity and result in sustained, improved metabolic control.

METHODS

In a prospective observational study, eight Type 2 DM patients with severe insulin resistance (insulin dose 1.92 +/- 0.66 U/kg per day (mean +/-sd)), in poor metabolic control (HbA(1c) 12.0 +/- 1.7%), were treated with i.v. insulin for 31 +/- 10 days aimed at euglycaemia, followed by CSII therapy for 12 months, using insulin lispro. Before and after 28 +/- 6 days of i.v. insulin treatment, insulin sensitivity was measured by a hyperinsulinaemic euglycaemic clamp.

RESULTS

Euglycaemia was reached after 12 +/- 6 days of i.v. insulin treatment. Subsequently, the i.v. insulin dose required to maintain euglycaemia decreased from 1.7 +/- 0.9 to 1.1 +/- 0.6 U/kg per day (P < 0.005). Whole body glucose uptake increased from 12.7 +/- 5.7 to 22.4 +/- 8.8 micromol/kg per min (P < 0.0005). HbA(1c) decreased to 8.9 +/- 1.2% after 28 +/- 6 days, to 7.1 +/- 0.6% after 6 months and to 8.3 +/- 1.4% after 12 months (P < 0.001 vs. pretreatment, for all). Lipid profile improved and plasminogen activator inhibitor type 1 levels decreased significantly. Mean body weight did not change.

CONCLUSIONS

In Type 2 diabetic patients, who are poorly controlled despite high-dose s.c. insulin treatment, a period of 2 weeks of euglycaemia achieved by i.v. insulin reverses hyperglycaemia-induced insulin resistance and substantially improves metabolic control. Subsequent CSII treatment, using insulin analogues, appears to maintain improved metabolic control for at least 1 year. This approach is promising but needs further evaluation.

Administration of recombinant human FSH (solution in cartridge) with a pen device in women undergoing ovarian stimulation

This study evaluated the first multiple-use pen device for the self-administration of recombinant FSH. The pen device is used for the subcutaneous injection of a pre-mixed ready-to-use solution of follitropin beta from a multiple-dose cartridge, and has flexible dosing capabilities. In the ease-of-use questionnaire, 90% of subjects rated the overall experience of self-injecting follitropin beta using the pen device as 'very good' (on day 6). The comprehension questionnaire revealed that prior to the first injection and during the second injection, the follitropin beta cartridge was properly loaded into the pen device by 96.7 and 100% of the subjects respectively. The questionnaire also showed that the correct dose was selected and self-administered by 98.3 and 100% of the subjects respectively. Biochemical and ongoing pregnancy rates per attempt were 56.7 and 45.0% respectively. The pen device is safe, effective, and easy to use for self-administering recombinant FSH during ovarian stimulation.

Subareolar injection for sentinel lymph node location in breast cancer

AIM

Several different injection techniques are currently used for sentinel node (SN) identification in patients with breast cancer. Some studies suggest that the subareolar plexus drains lymph from the whole breast to the same axillary SN. In order to test this hypothesis, we ascertained whether subareolar blue dye injection and subdermal radioisotope injection close to the tumour identify the same axillary nodes.

METHODS

One day prior to surgery, 50 patients with breast cancer underwent subdermal injection of 30-40MBq of 99m-Tc colloidal albumin (Nanocoll) at the site of the cutaneous projection of the tumour. Ten minutes before surgery, each patient received a subareolar injection of 2-3cc of patent blue. All axillary radioactive nodes and blue-stained nodes were excised and a histologic examination was made.

RESULTS

Radioisotope marked the SNs in 47/50 (94%) cases, and the blue dye in 43/50 cases (86%). In three cases, SNs were not identified with either method. Of the 43 cases in which both the tracers reached the axilla, in 40 (93%) the SN was hot and blue-stained, while in 3 cases the two tracers identified different nodes.

CONCLUSIONS

Our findings suggest that subareolar injection and subdermal injection elsewhere in the breast usually identify the same SN. Subareolar injection appears to be particularly valuable in patients with multicentric or deep non-palpable breast tumours.

[Evaluation of the technique of subcutaneous administration of heparin in the development of hematomas]

This study identified and evaluated the presence and extent of hematomas, pain and other complications after the administration of low-dose subcutaneous heparin. It compared applications using the conventional technique and applications with modified techniques in 60 patients hospitalized in an University Hospital in the interior of São Paulo State-Brazil. Each patient received four heparin injections, that is, two injections of each of the techniques mentioned. The site was observed after 24 hours. Results showed that hematomas were observed after the application of 83.7% of the injections. The thigh was the site with the highest incidence of hematomas, followed by the arm and the abdomen. There were no significant differences in the formation of hematomas caused by the two techniques. It was concluded that the techniques used for heparin application were probably not related to the formation of hematomas.

[Factors that enable the patients to live their life till death at home by controlling cancer-pains with continuous subcutaneous injection of opioids-case reports of 3 patients with a terminal cancer]

Recently, it is gradually getting easier to change a life-style of the patients with cancer-pains from the conventional hospitalized way to the home healthcare system, because of the progress in technique of reducing pains and symptoms and because of prevalence of visiting nurse system. Home healthcare system or hospice is aimed at the improvement of the quality of life (QOL) of the patients. We had 3 patients who died at home after home healthcare service and whose cancer-pains were well controlled till their death at home by continuous subcutaneous injections of opioids (painkiller) when these patients could not take oral medications any more. Therefore, in order to determine the factors that enable the patients to live the terminal stage of their life at home until death by controlling their cancer-pain with continuous subcutaneous injections of opioid, we examined 3 patients who died of cancer at home under a good pain control. The subjects of the present study were 3 patients, who initially had oral or rectal medication of opioid for their pain control, eventually switched to subcutaneous injection of opioid and then died at home under a good pain control between April 1998 and December 2000. We collected all the information through nursing diaries, regarding painkiller care, and interaction of the patients, their family members and other people, and discussed the factors which enabled to maintain a good pain control in these patients at home by continuous subcutaneous injection of painkiller (opioid). As a result, the following 7 items were notified as the factors common in these 3 patients. 1) The patients themselves understood the diagnosis of their diseases and symptoms and could openly discuss the issues such as "how the patient and his/her family would like to live his/her life from now on" among family members, and also between family and medical associates. 2). The patients received detailed explanation of continuous subcutaneous injection at the time of admission to the hospital and chose to receive the continuous subcutaneous injection with their own will. 3) The patients had no other painful symptoms except cancer pains or had them well controlled if they had any, and had much stronger desire to live their life at home than above all. The family member agreed with the patients and respected their choice. 4) The family members had enough nursing capability, so they could properly handle medications and medical equipment as well as they could take care of the patients. 5) Both primary care physicians and visiting nurses had enough knowledge of home healthcare service for painkiller, and were able to frequently interact with the patients and their family in order to reduce their pains. 6) Visiting nurses supported the family by 24 hr-system and assisted the family in nursing the patients at home without worry. 7) Pharmacists also participated in the home healthcare system, thus, they could smoothly provide and manage opioids without any trouble.

Optimization of cottontail rabbit papilloma virus challenge technique

Disease induced by Cottontail Rabbit Papilloma Virus (CRPV) scarification in domestic rabbits shares many attributes with disease induced by human papilloma virus (HPV). CRPV induces squamous papillomas in domestic rabbits, of which approximately 70% transform into invasive carcinomas. In advanced tumors, virus is often undetectable, and occasionally, some rabbits undergo spontaneous regression of papillomas. Techniques utilized to scarify rabbit skin are diverse, often labor intensive and time consuming with the possibility for significant variability. Using four unique infection techniques, resultant papilloma incidence, time to onset, and total papilloma volumes were compared to determine an optimal challenge method. Five rabbits were each infected with CRPV via a tattoo gun with and without ink, an intradermal injection, manual use of a tattoo needle, or a sterile blade followed by manual use of a tattoo needle. Papilloma formation was monitored weekly after inoculation for 6 weeks. CRPV papillomas began as pinpoint foci at 3 weeks post challenge and grew exponentially throughout the course of measurement. Individual foci coalesced rapidly to form larger papilloma aggregates. Although intradermal injection was well tolerated and easily performed, it was the worst method of papilloma production (2.2 mm(3) at 6 weeks). The best method, a sterile blade followed by manual use of a tattoo needle, produced significantly larger papillomas over all time periods (>1100 mm(3) at 6 weeks, P<0.01). Inoculation of CRPV using this method produces highly repeatable papillomas beginning 3 weeks post-infection.

[Puntino and the injections of Popeye]

Subcutaneous injection of active principles must be performed through a short and thin needle and an insuline syringe (because of the few quantity of drug to administrate). In our Centre, to prevent preterm chronic anemia wc practice subcutaneous therapy with recombinant human erythropoietin. 300 UI three times a week, to all the newborns weighing < 1500 g at birth. Injections to the newborns are performed in correspondence of their gluteal and deltoid muscles, and in the outer part of their thigh. To prevent atrophy, it is important to change every time the site of Injection. For this goal, we have created the shape of a newborn, nained Puntino, and we have located 24 points on it. Each point has received a number between 0 and 23. During the treatment we have followed the guide of Puntino to locate each time the correct site of injection. Thanks to Puntino's aid, there were no cases of skin adverse reaction and atrophy, even in newborns weighing < 1000 g.

Safety, pharmacokinetics and pharmacodynamics of recombinant human tumour necrosis factor-binding protein-1 (Onercept) injected by intravenous, intramuscular and subcutaneous routes into healthy volunteers

The safety, pharmacokinetics and pharmacodynamics of recombinant human tumour necrosis factor-binding protein-1 (r-hTBP-1, Onercept) were investigated after intravascular and extravascular injection, in three studies in healthy volunteers. Subjects received Onercept as single intravenous doses of 5, 15, 50 and 150 mg, or single IV, IM, SC injection of 50 mg, or six repeated SC injections of 50 mg. Based on vital signs, hematology and blood chemistry, antibodies to study drug and local tolerability, r-hTBP-1 exhibited a remarkably safe profile. There was no evidence of alteration of hepatic oxidative metabolism. Recombinant-hTBP-1 showed linear pharmacokinetics that could be described by a triexponential model, and exhibited an initial half-life of 30 min, an intermediate half-life of 4 hours and a terminal elimination half-life of about 15 hours, although it was prolonged to 21 hours after repeated SC injections. The total clearance was estimated at 4 l/h. The initial (Vc) and steady state (Vss) volumes of distribution were approximately 4 l and 10 l, respectively. Renal clearance was minimal, representing around 2.5% of the total clearance, and remained constant after increasing doses of r-hTBP-1. The absorption was slow and biphasic. The immunoactivity of r-hTBP-1 was closely related to its biological activity, although the assessment was limited to only some of the samples. As anticipated in normal healthy volunteers, the pharmacodynamic response was generally not different from placebo. Total TNF-alpha serum levels increased slightly, 1 hour following IV administration of 50 mg and 150 mg r-hTBP-1. However, no major increase in the active entity levels (free TNF-alpha) was observed. In addition, no TNF-alpha-driven biological response was observed, i.e. C-reactive protein, IL-6 and fibrinogen remained almost constant, as did transferrin and albumin. Its safety profile and pharmacokinetic characteristics make Onercept a candidate drug suitable for antagonising pathologically high levels of TNF-alpha as reported in inflammatory, immune and cardiovascular diseases.

Dose accuracy testing of the humalog/ humulin insulin pen device

The primary purpose of the study was to determine whether pen users would challenge the insufficient remaining dose (IRD) stop mechanism with sufficient force to affect the dose accuracy of the final dose. The secondary purpose was to determine the participant's positive and negative impressions of the Humalog/Humulin pen and the likelihood of using the new prefilled pen. Three different modifications to the prefilled pen's IRD stop feature were made. These three pen models then underwent environmental dose accuracy testing at various temperatures and humidities, and user dose accuracy testing by 64 patients with diabetes. Evaluation also involved challenging the IRD stop at various dialing torques. Thirty pens from each model were tested to failure of the IRD stop. A model of the prefilled pen was selected for commercialization that met the dose accuracy targets of +/- 1 unit (U) for insulin doses less than 20 U and +/- 5% of dose volume for doses equal to or over 20 U. The selected pen model was superior at the minimum (1 unit), median (30 unit) and maximum (60 unit) dose volumes. Also 92% (n = 59) of patients interviewed felt that the stop mechanism for the final dose was clear. Extensive testing in the development of a prefilled insulin delivery device demonstrates an accurate and reliable medical device.