Intrathecal injection of helper-dependent adenoviral vectors results in long-term transgene expression in neuroependymal cells and neurons

Helper-dependent adenoviral (HDAd) vectors are devoid of all viral genes and result in long-term transgene expression in the absence of chronic toxicity. Because of their ability to infect post-mitotic cells, including cells of the central nervous system, HDAd vectors are particularly attractive for brain-directed gene therapy. In this study, we show that intrathecal injection of HDAd results in extensive transduction of ependymal cells and sustained expression of the transgene up to 1 year post-administration. We also demonstrate, for the first time, the ability of HDAd injected by this route of delivery to transduce neuronal cells. The transduced neuroepithelial cells can be potentially used to secrete therapeutic proteins into the cerebrospinal fluid and provide them via cross-correction to nontransduced cells. Targeting of neuronal cells and long-term transgene expression make this approach attractive for the treatment of several neurologic diseases.

Fabrication of CdZnTe Strip Detectors for Large Area Arrays

A CdZnTe strip detector large area array (∼ 60 cm2 with 36 detectors) with capabilities for high resolution imaging and spectroscopy has been built as a prototype for a space flight gamma ray burst instrument. The detector array also has applications in nuclear medical imaging. Two dimensional orthogonal strip detectors with 100 μm pitch have been fabricated and tested. Details for the array design, fabrication and evaluation of the detectors will be presented.

Aligned Carbon Nanotubes Via Microwave Plasma Enhanced Chemical Vapor Deposition

Aligned multi-wall carbon nanotubes have been grown on silicon substrates by microwave plasma enhanced chemical vapor deposition using methane/ammonia mixtures. The concentration ratio of methane/ammonia in addition to substrate temperature was varied. The morphology, structure and alignment of carbon nanotubes were studied by scanning electron microscopy and transmission electron microscopy. Both concentric hollow and bamboo-type multi-wall carbon nanotubes were observed. Growth rate, size distribution, alignment, morphology, and structure of carbon nanotubes changed with methane/ammonia ratio and growth temperature. Preliminary results on field emission properties are also presented.

Incorporating patient reported outcome measures in clinical practice: development and validation of a questionnaire for inflammatory arthritis

BACKGROUND

Rheumatology is embarking on a fundamental redesign of rheumatic disease care. It has become mandatory not only to recognise disease activity core set data, but also the risks for other co-morbidities associated with inflammatory arthritis. Measurement of patient reported outcomes have become critical in both standard clinical practice and long term observational studies.

OBJECTIVES

To assess validity, reliability and responsiveness to change of a patient self-reported questionnaire which can assess construct outcome measures of patients with inflammatory arthritis.

METHODS

Four hundred and sixty-two patients with inflammatory arthritis were included in this work. The questionnaire was developed by integrating information obtained from patients suffering from inflammatory arthritis based on the Rasch model for ordered response options. The questionnaire includes assessment for functional disability, quality of life, VAS for joint pain, global status, fatigue, duration of morning stiffness, review of the systems, falls and cardiovascular risks, self-helplessness, as well as self reported joint pain.

RESULTS

The questionnaire was reliable as demonstrated by a high-standardised alpha (0.891-0.992). The questionnaire items correlated significantly (p<0.01) with clinical parameters of disease activity. RA patient reported tender joints correlated significantly with the physician's scores (0.842). Changes in functional disability, quality of life as well as self-helplessness scores showed significant (p<0.01) variation with disease activity status. The PROMs questionnaire also showed a high degree of comprehensibility.(9.4).

CONCLUSIONS

Integrating patient reported outcome measures into standard clinical practice is feasible and applicable. This version of a multidimensional questionnaire was found to be valid and reliable. It provides informative quantitative measures for the disease activity core set data, and in the mean time, facilitates assessing the patients' health related quality of life measure, cardiovascular and falls risks on an individual basis.

A novel bicistronic high-capacity gutless adenovirus vector that drives constitutive expression of herpes simplex virus type 1 thymidine kinase and tet-inducible expression of Flt3L for glioma therapeutics

Glioblastoma multiforme (GBM) is a deadly primary brain tumor. Conditional cytotoxic/immune-stimulatory gene therapy (Ad-TK and Ad-Flt3L) elicits tumor regression and immunological memory in rodent GBM models. Since the majority of patients enrolled in clinical trials would exhibit adenovirus immunity, which could curtail transgene expression and therapeutic efficacy, we used high-capacity adenovirus vectors (HC-Ads) as a gene delivery platform. Herein, we describe for the first time a novel bicistronic HC-Ad driving constitutive expression of herpes simplex virus type 1 thymidine kinase (HSV1-TK) and inducible Tet-mediated expression of Flt3L within a single-vector platform. We achieved anti-GBM therapeutic efficacy with no overt toxicities using this bicistronic HC-Ad even in the presence of systemic Ad immunity. The bicistronic HC-Ad-TK/TetOn-Flt3L was delivered into intracranial gliomas in rats. Survival, vector biodistribution, neuropathology, systemic toxicity, and neurobehavioral deficits were assessed for up to 1 year posttreatment. Therapeutic efficacy was also assessed in animals preimmunized against Ads. We demonstrate therapeutic efficacy, with vector genomes being restricted to the brain injection site and an absence of overt toxicities. Importantly, antiadenoviral immunity did not inhibit therapeutic efficacy. These data represent the first report of a bicistronic vector platform driving the expression of two therapeutic transgenes, i.e., constitutive HSV1-TK and inducible Flt3L genes. Further, our data demonstrate no promoter interference and optimum gene delivery and expression from within this single-vector platform. Analysis of the efficacy, safety, and toxicity of this bicistronic HC-Ad vector in an animal model of GBM strongly supports further preclinical testing and downstream process development of HC-Ad-TK/TetOn-Flt3L for a future phase I clinical trial for GBM.

Bioengineered factor IX molecules with increased catalytic activity improve the therapeutic index of gene therapy vectors for hemophilia B

Although the desire to develop gene therapy for hemophilia B is high, safety remains a concern. Therefore, improving the therapeutic index of gene therapy vectors is an important goal. Thus, we evaluated the use of three bioengineered factor IX (FIX) variants with improved catalytic activity in the context of the helper-dependent adenoviral vector. The first vector expressed R338A-FIX, an FIX variant with the arginine at position 338 changed to an alanine, which resulted in a 2.9-fold higher specific activity (IU/mg) compared with the wild-type FIX. The second vector expressed FIX(VIIEGF1), a variant with the EGF-1 domain replaced with the EGF-1 domain from FVII, which resulted in a 3.4-fold increase in specific activity. The third expressed R338A + FIX(VIIEGF1), a novel variant containing both aforementioned modifications, which resulted in a 12.6-fold increase in specific activity. High-level, long-term, and stable expression of these three variants was observed in hemophilia B mice with no evidence of increased thrombogenicity compared with wild-type FIX. Thus, these bioengineered FIX variants can increase the therapeutic index of gene therapy vectors by permitting administration of lower doses to achieve the same therapeutic outcome. Furthermore, these variants may also be valuable for recombinant FIX protein replacement therapy.

Protection against Mucosal SHIV Challenge by Peptide and Helper-Dependent Adenovirus Vaccines

Groups of rhesus macaques that had previously been immunized with HIV-1 envelope (env) peptides and first generation adenovirus serotype 5 (FG-Ad5) vaccines expressing the same peptides were immunized intramuscularly three times with helper-dependent adenovirus (HD-Ad) vaccines expressing only the HIV-1 envelope from JRFL. No gag, pol, or other SHIV genes were used for vaccination. One group of the FG-Ad5-immune animals was immunized three times with HD-Ad5 expressing env. One group was immunized by serotype-switching with HD-Ad6, HD-Ad1, and HD-Ad2 expressing env. Previous work demonstrated that serum antibody levels against env were significantly higher in the serotype-switched group than in the HD-Ad5 group. In this study, neutralizing antibody and T cell responses were compared between the groups before and after rectal challenge with CCR5-tropic SHIV-SF162P3. When serum samples were assayed for neutralizing antibodies, only weak activity was observed. T cell responses against env epitopes were higher in the serotype-switched group. When these animals were challenged rectally with SHIV-SF162P3, both the Ad5 and serotype-switch groups significantly reduced peak viral loads 2 to 10-fold 2 weeks after infection. Peak viral loads were significantly lower for the serotype-switched group as compared to the HD-Ad5-immunized group. Viral loads declined over 18 weeks after infection with some animals viremia reducing nearly 4 logs from the peak. These data demonstrate significant mucosal vaccine effects after immunization with only env antigens. These data also demonstrate HD-Ad vectors are a robust platform for vaccination.

Retrospective review of prognostic factors, including 1p19q deletion, in low-grade oligodendrogliomas and a review of recent published works

The purpose of the present study was to investigate potential prognostic factors in low-grade oligodendrogliomas (LGOs), particularly 1p19q deletion, due to its proven prognostic significance in anaplastic oligodendrogliomas. We carried out a retrospective review of patients with a histological diagnosis of LGO between 1990 and 2000 in Auckland and Wellington, New Zealand. All cases underwent central histopathological review and FISH testing for 1p19q status. Univariate analysis of potential prognostic factors including 1p19q status, age, tumour size, tumour crossing midline, tumour enhancement, extent of surgery and seizures at diagnosis was carried out. Thirty-one patients were eligible and FISH testing was successful in 28 specimens (90%). Twenty-three specimens (82%) had 1p19q deletion; four (14%) had no 1p19q deletion; and one (4%) had 1p deletion alone. At a median follow-up of 87 months (0-147 months), median survival had not been reached and no significant difference in overall survival (OS) based on 1p19q status was detected (1p19q deletion OS 56%; 1p19q intact OS 0%; 1p deletion alone 100% (P = 0.38)). None of the other prognostic factors investigated reached statistical significance. We confirmed the high incidence (82%) of combined 1p19q deletion in LGOs and the feasibility of successful FISH testing in paraffin embedded specimens up to 10-years-old. Analysis of potential prognostic factors was limited by the lack of events during the follow-up period.

A randomized controlled trial of treatment options for troublesome uterine bleeding in Implanon users

BACKGROUND

Pilot data have indicated that both doxycycline alone and mifepristone combined with ethinyl estradiol (EE) are effective in stopping episodes of bleeding in Implanon users with troublesome bleeding. We compared four treatments against a placebo in Implanon users and tested whether repeated treatment improved subsequent bleeding patterns.

METHOD

Implanon users aged 18-45 years were randomized to treatment with (i) mifepristone 25 mg given twice on day 1 followed by 4 days of EE 20 microg; (ii) doxycycline 100 mg twice daily for 5 days; (iii) mifepristone 25 mg given twice on day 1 plus doxycycline 100 mg twice daily for 5 days; (iv) doxycycline 100 mg twice daily with EE 20 microg daily; and (v) placebo twice daily for 5 days. The primary end-point was the number of days of bleeding/spotting immediately following initiation of the first 5-day course of each therapy, compared with placebo.

RESULTS

There were 204 women assigned to treatment. Mifepristone in combination with either EE or doxycycline was significantly more effective in stopping an episode of bleeding (mean 4.0 days (CI 3.5-4.6) and 4.4 days (CI 3.8-5.2), respectively) than doxycycline alone or in combination with EE, or placebo (6.4 days (CI 4.4-9.2), 6.4 days (CI 4.8-8.6) and 6.4 days (CL 5.1-8.0), respectively).

CONCLUSION

Mifepristone combined with either EE or doxycycline was significantly more effective than placebo in terminating an episode of bleeding in Implanon users. However there was no improvement in subsequent bleeding patterns.

TRIAL REGISTRATION NUMBER

ACTR # 012605000206628.

Comparison of replication-competent, first generation, and helper-dependent adenoviral vaccines

All studies using human serotype 5 Adenovirus (Ad) vectors must address two major obstacles: safety and the presence of pre-existing neutralizing antibodies. Helper-Dependent (HD) Ads have been proposed as alternative vectors for gene therapy and vaccine development because they have an improved safety profile. To evaluate the potential of HD-Ad vaccines, we compared replication-competent (RC), first-generation (FG) and HD vectors for their ability to induce immune responses in mice. We show that RC-Ad5 and HD-Ad5 vectors generate stronger immune responses than FG-Ad5 vectors. HD-Ad5 vectors gave lower side effects than RC or FG-Ad, producing lower levels of tissue damage and anti-Ad T cell responses. Also, HD vectors have the benefit of being packaged by all subgroup C serotype helper viruses. We found that HD serotypes 1, 2, 5, and 6 induce anti-HIV responses equivalently. By using these HD serotypes in heterologous succession we showed that HD vectors can be used to significantly boost anti-HIV immune responses in mice and in FG-Ad5-immune macaques. Since HD vectors have been show to have an increased safety profile, do not possess any Ad genes, can be packaged by multiple serotype helper viruses, and elicit strong anti-HIV immune responses, they warrant further investigation as alternatives to FG vectors as gene-based vaccines.

Search for gravitational-wave bursts from soft gamma repeaters

We present a LIGO search for short-duration gravitational waves (GWs) associated with soft gamma ray repeater (SGR) bursts. This is the first search sensitive to neutron star f modes, usually considered the most efficient GW emitting modes. We find no evidence of GWs associated with any SGR burst in a sample consisting of the 27 Dec. 2004 giant flare from SGR 1806-20 and 190 lesser events from SGR 1806-20 and SGR 1900+14. The unprecedented sensitivity of the detectors allows us to set the most stringent limits on transient GW amplitudes published to date. We find upper limit estimates on the model-dependent isotropic GW emission energies (at a nominal distance of 10 kpc) between 3x10;{45} and 9x10;{52} erg depending on waveform type, detector antenna factors and noise characteristics at the time of the burst. These upper limits are within the theoretically predicted range of some SGR models.

Misinterpreting emotional expressions in attention-deficit/hyperactivity disorder: evidence for a neural marker and stimulant effects

BACKGROUND

In addition to cognitive impairment, there are disruptions to mood and emotion processing in attention-deficit/hyperactivity disorder (ADHD) but little is known about their neural basis. We examined ADHD disturbances in mood and emotion recognition and underlying neural systems before and after treatment with stimulant medication.

METHODS

Participants were 51 unmedicated ADHD adolescents and 51 matched healthy control subjects rated for depressed and anxious mood and accuracy for identifying facial expressions of basic emotion. Brain function was recorded using event-related potentials (ERPs) while subjects viewed these expressions. ADHD subjects were retested after 4 weeks, following treatment with methylphenidate (MPH).

RESULTS

ADHD subjects showed a profile of emotion-related impairment: higher depression and anxiety, deficits in identifying threat-related emotional expressions in particular, and alterations in ERPs. There was a pronounced reduction in occipital activity during the early perceptual analysis of emotional expression (within 120 msec), followed by an exaggeration of activity associated with structural encoding (120-220 msec) and subsequent reduction and slowing of temporal brain activity subserving context processing (300-400 msec). Methylphenidate normalized neural activity and produced some improvement of emotion recognition but had no impact on negative mood. Improvements in neural activity with MPH were consistent predictors of improvement in clinical features of emotional lability and hyperactivity.

CONCLUSIONS

Objective behavioral and brain function measures of emotion processing may provide a valuable addition to the clinical armamentarium for assessing emotional disturbances in ADHD and the efficacy of stimulants for treating these disturbances.

One-year expression from high-capacity adenoviral vectors in the brains of animals with pre-existing anti-adenoviral immunity: clinical implications

The main challenge of gene therapy is to provide long-term, efficient transgene expression. Long-term transgene expression from first generation adenoviral vectors (Advs) delivered to the central nervous system (CNS) is elicited in animals not previously exposed to adenovirus (Ad). However, upon systemic immunization against Ad, transgene expression from a first generation Adv is abolished. High-capacity Advs (HC-Advs) provide sustained very long-term transgene expression in the brain, even in animals pre-immunized against Ad. In this study, we tested the hypothesis that a HC-Adv in the brain would allow for long-term transgene expression, for up to 1 year, in the brain of mice immunized against Ad prior to delivery of the vector to the striatum. In naïve animals, the expression of beta-galactosidase from Adv or HC-Adv was sustained for 1 year. In animals immunized prior to vector delivery, expression from a first generation Adv was abolished. These results point to a very long-term HC-Adv-mediated transgene expression in the brain, even in animals that had been immunized systemically against Ad before the delivery of HC-Adv into the brain. This study therefore indicates the utility of HC-Adv as a powerful gene therapy vector for chronic neurological disorders, even in patients who had been pre-exposed to Ad prior to gene therapy.

Optimization of adenoviral vector-mediated transgene expression in the canine brain in vivo, and in canine glioma cells in vitro

Expression of the immune-stimulatory molecule Fms-like tyrosine kinase 3 ligand (Flt3L) and the conditional cytotoxic enzyme herpes simplex virus type 1 thymidine kinase (HSV1-TK) provides long-term immune-mediated survival of large glioblastoma multiforme (GBM) models in rodents. A limitation for predictive testing of novel antiglioma therapies has been the lack of a glioma model in a large animal. Dogs bearing spontaneous GBM may constitute an attractive large-animal model for GBM, which so far has remained underappreciated. In preparation for a clinical trial in dogs bearing spontaneous GBMs, we tested and optimized adenovirus-mediated transgene expression with negligible toxicity in the dog brain in vivo and in canine J3T glioma cells. Expression of the marker gene beta-galactosidase (beta-Gal) was higher when driven by the murine (m) than the human (h) cytomegalovirus (CMV) promoter in the dog brain in vivo, without enhanced inflammation. In the canine brain, beta-Gal was expressed mostly in astrocytes. beta-Gal activity in J3T cells was also higher with the mCMV than the hCMV promoter driving tetracycline-dependent (TetON) transgene expression within high-capacity adenovirus vectors (HC-Ads). Dog glioma cells were efficiently transduced by HC-Ads expressing mCMV-driven HSV1-TK, which induced 90% reduction in cell viability in the presence of ganciclovir. J3T cells were also effectively transduced with HC-Ads expressing Flt3L under the control of the regulatable TetON promoter system, and as predicted, Flt3L release was stringently inducer dependent. HC-Ads encoding therapeutic transgenes under the control of regulatory sequences driven by the mCMV promoter are excellent vectors for the treatment of spontaneous GBM in dogs, which constitute an ideal preclinical animal model.

Regulatable gutless adenovirus vectors sustain inducible transgene expression in the brain in the presence of an immune response against adenoviruses

In view of recent serious adverse events and advances in gene therapy technologies, the use of regulatable expression systems is becoming recognized as indispensable adjuncts to successful clinical gene therapy. In the present work we optimized high-capacity adenoviral (HC-Ad) vectors encoding the novel tetracycline-dependent (TetOn)-regulatory elements for efficient and regulatable gene expression in the rat brain in vivo. We constructed two HC-Ad vectors encoding beta-galactosidase (beta-gal) driven by a TetOn system containing the rtTAS(s)M2 transactivator and the tTS(Kid) repressor under the control of the murine cytomegalovirus (mCMV) (HC-Ad-mTetON-beta-Gal) or the human CMV (hCMV) promoter (HC-Ad-hTetON-beta-Gal). Expression was tightly regulatable by doxycycline (Dox), reaching maximum expression in vivo at 6 days and returning to basal levels at 10 days following the addition or removal of Dox, respectively. Both vectors achieved higher transgene expression levels compared to the expression from vectors encoding the constitutive mCMV or hCMV promoter. HC-Ad-mTetON-beta-Gal yielded the highest transgene expression levels and expressed in both neurons and astrocytes. Antivector immune responses continue to limit the clinical use of vectors. We thus tested the inducibility and longevity of HC-Ad-mediated transgene expression in the brain of rats immunized against adenovirus by prior intradermal injections of RAds. Regulated transgene expression from HC-Ad-mTetON-beta-Gal remained active even in the presence of a significant systemic immune response. Therefore, these vectors display two coveted characteristics of clinically useful vectors, namely their regulation and effectiveness even in the presence of prior immunization against adenovirus.

52. THE AUSTRALIAN WOMEN'S HEALTH SURVEY: ASSESSING THE PSYCHOSOCIAL BURDEN OF HPV RELATED ILLNESS AND PREVENTIVE INTERVENTIONS

There is increasing recognition of the psychosocial impact of cervical cytology screening programs as well as of the treatment of screening-detected human papillomavirus (HPV) - related disease. The HPV Impact Profile (HIP) includes 29 items with standard response categories representing nine psychosocial impact domains: 'worries and concerns, emotional impact, sexual impact, self image, health perception, cognition, partner and social relations, interaction with doctors and sleep'. Higher scores (0-100) are associated with higher disease burden. The HIP and other generic quality of life instruments such as the Sheehan Disability Scale were administered to women who had experienced and were aware of an HPV related diagnosis in the past 3 months (total n�=�333): 103 women with normal Pap test results (N. Pap), 111 with abnormal Pap tests (58 low grade squamous intraepithelial lesions (LSIL) and 53 high grade SIL (HSIL)), 80 women with biopsy confirmed cervical intraepithelial neoplasia (CIN) (36 CIN1 and 44 CIN 2/3) and 39 women with external genital warts (EGW). In univariate analysis, estimated HIP scores (95% CI) were lower for N.Pap than for all other groups (p�<�0.0001), N. Pap: 25.8 (22.6-29.0); LSIL: 38.8 (34.6-43.1); HSIL: 41.7 (37.2-46.2); CIN1: 41.7 (36.3-47.1); CIN 2/3: 46.6 (41.6-51.5) (p�=�0.013 vs LSIL); EGW: 44.6 (39.4-49.8). The effect was maintained after adjusting for age, race and occupation. On the Sheehan scale, CIN 2/3 and EGW demonstrated increased interference with work and social activities. Results demonstrate: a) HPV infection and disease are associated with significantly increased psychosocial burden, beyond that of the Pap test experience; b) The HIP instrument can adequately distinguish between different HPV conditions; c) Despite their non life threatening nature, the psychosocial impact of genital warts is similar to that of potentially life threatening high grade cervical lesions.

The mellow years?: neural basis of improving emotional stability over age

Contrary to the pervasive negative stereotypes of human aging, emotional functions may improve with advancing age. However, the brain mechanisms underlying changes in emotional function over age remain unknown. Here, we demonstrate that emotional stability improves linearly over seven decades (12-79 years) of the human lifespan. We used both functional magnetic resonance imaging and event-related potential recording to examine the neural basis of this improvement. With these multimodal techniques, we show that better stability is predicted by a shift toward greater medial prefrontal control over negative emotional input associated with increased activity later in the processing sequence (beyond 200 ms after stimulus) and less control over positive input, related to a decrease in early activity (within 150 ms). This shift was independent from gray matter loss, indexed by structural magnetic resonance data. We propose an integrative model in which accumulated life experience and the motivation for meaning over acquisition in older age contribute to plasticity of medial prefrontal systems, achieving a greater selective control over emotional functions.

Effective high-capacity gutless adenoviral vectors mediate transgene expression in human glioma cells

Glioblastoma multiforme (GBM) is the most common subtype of primary malignant brain tumor. Although serotype 5 adenoviral vectors (Ads) have been used successfully in clinical trials for GBM, the capacity of Ads to infect human glioma cells and the expression of adenoviral receptors in GBM cells have been challenged. In this report, we studied the expression of three molecules that have been shown to mediate adenoviral entry into cells, i.e., coxsackie and adenovirus receptor (CAR), integrin alphavbeta3 (INT), and major histocompatibility complex class I (MHCI), in rodent glioma cell lines and low-passage primary cultures and cell lines from human GBM. We correlated levels of expression of CAR, INT, and MHCI with transduction efficiency elicited by several high-capacity helper-dependent adenoviral vectors (HC-Ads). Expression levels of adenoviral receptors were variable among the different GBM cells studied. HC-Ad-mediated therapeutic gene expression was efficient, ranging between 20 and 80% of the total target cells expressing the encoded transgenes. Our results show no correlation between the levels of CAR, INT, or MHCI molecules and the levels of transgene expression or the number of GBM cells transduced. We conclude that expression levels of adenoviral receptors do not predict their transduction efficiency or biological function.

Modulation of TNFalpha, a determinant of acute toxicity associated with systemic delivery of first-generation and helper-dependent adenoviral vectors

Understanding the determinants of the host innate immune response to systemic administration of adenoviral (Ad) vectors is critical for clinical gene therapy. Acute toxicity occurs within minutes to hours after vector administration and is characterized by activation of innate immune responses. Our data indicate that in mice, indicators of vector toxicity include elevations of cytokine levels, liver transaminase levels and thrombocytopenia. To discern potential targets for blunting this host response, we evaluated genetic factors in the host response to systemically administered first-generation Ad vectors (FGV) and helper-dependent Ad vectors (HDV) containing beta-galactosidase expression cassettes. A preliminary screen for modulation of vector-induced thrombocytopenia revealed no role for interferon-gamma, mast cells or perforin. However, vector-induced thrombocytopenia and interleukin 6 (IL-6) expression are less evident in tumor necrosis factor alpha (TNFalpha)-deficient mice. Moreover, we also demonstrated that TNFalpha blockade via antibody or huTNFR:Fc pretreatment attenuates both thrombocytopenia (>40% increase in platelet count) and IL-6 expression (>80% reduction) without affecting interleukin 12 , liver enzymes, hematological indices or vector transduction in a murine model. Our data indicate that the use of HDV, in combination with clinically approved TNFalpha immunomodulation, may represent an approach for improving the therapeutic index of Ad gene therapy for human clinical trials.

Diagnosis of early arthritis: outcomes of a nurse-led clinic

Recent data suggest that early treatment of inflammatory arthritis can improve patient outcomes. While rheumatologists recognized this need for early evaluation and treatment, the current load on the rheumatology service nationwide may limit the capacity for timely evaluation. The authors developed a protocol to be applied through a specialized early arthritis clinic that is able to discriminate between different categories of early arthritis, to shortening the time taken to reach the correct diagnosis and provide the appropriate management. A total of 108 patients have been reviewed in the early arthritis clinic over 12 months. It took 3 weeks for the patients to be fully assessed in the rheumatology clinic instead of 16 weeks. Completing the clinic proforma helped the assessor to cover all causes of arthritis/arthralgia. Disease-modifying antirheumatic drug (DMARD) therapy was initiated within a few weeks (2 to 5 weeks) once diagnosis was confirmed, instead of 8 to 10 months previously. This early arthritis clinic model helped to shorten the referral lag time (duration between symptoms onset and first rheumatologist assessment) as well as lag time to DMARD therapy (duration between symptom onset and the institution of DMARD therapy).

The 'when' and 'where' of perceiving signals of threat versus non-threat

We tested the proposal that signals of potential threat are given precedence over positive and neutral signals, reflected in earlier and more pronounced changes in neural activity. The temporal sequence ('when') and source localization ('where') of event-related potentials (ERPs) elicited by fearful and happy facial expressions, compared to neutral control expressions, were examined for 219 healthy subjects. We scored ERPs over occipito-temporal sites (N80, 50-120 ms; P120, 80-180 ms; N170, 120-220 ms; P230, 180-290 ms; N250, 230-350 ms) and their polarity-reversed counterparts over medial sites (P80, 40-120 ms; N120, 80-150 ms; VPP, 120-220 ms; N200, 150-280 ms; P300, 280-450 ms). In addition to scoring peak amplitude and latency, the anatomical sources of activity were determined using low resolution brain electromagnetic tomography (LORETA). Fearful faces were distinguished by persistent increases in positivity, associated with a dynamical shift from temporo-frontal (first 120 ms) to more distributed cortical sources (120-220 ms) and back (220-450 ms). By contrast, expressions of happiness produced a discrete enhancement of negativity, later in the time course (230-350 ms) and localized to the fusiform region of the temporal cortex. In common, fear and happiness modulated the face-related N170, and produced generally greater right hemisphere activity. These findings support the proposal that fear signals are given precedence in the neural processing systems, such that processing of positive signals may be suppressed until vigilance for potential danger is completed. While fear may be processed via parallel pathways (one initiated prior to structural encoding), neural systems supporting positively valenced input may be more localized and rely on structural encoding.

Readministration of helper-dependent adenovirus to mouse lung

Adenovirus vectors (Ad) are widely used in gene therapy studies, including those aimed at treating cystic fibrosis lung disease. Various approaches have been investigated to blunt the host immune response to Ad, including development of helper-dependent (HD) Ad. The host cytotoxic T-cell response to HD-Ad is generally lower than to earlier-generation Ad. However, antibodies are formed which could inhibit the efficacy of HD-Ad readministration. In this first study of HD-Ad readministration to the lung, we found that a second administration of HD-Ad to mice was possible with minimal loss of transgene expression. In contrast, when first-generation (FG) Ad was administered initially, followed by HD-Ad or FG-Ad, transgene expression was reduced. Significantly lower concentrations of antibodies against Ad were found in lung lavage fluid and serum from mice that received two doses of HD-Ad (when the initial HD-Ad lacked a transgene), compared to mice that received FG-Ad followed by HD-Ad. These data suggest that readministration of HD-Ad for lung gene therapy may be feasible.

A pilot study to assess the effect of three short-term treatments on frequent and/or prolonged bleeding compared to placebo in women using Implanon

BACKGROUND

The major side-effect of progestogen-only contraception is disruption of menstrual bleeding patterns, which can lead to a high incidence of early discontinuation. The aim of this study was to compare three treatments with placebo on the duration and recurrence of frequent and/or prolonged bleeding in Implanon users.

METHOD

Women between the ages of 18 and 45 years, who had used Implanon for > or =3 months and were experiencing prolonged or frequent bleeding patterns, were recruited at four Australian sites. Subjects were randomized to treatment using computer-generated random number table if they met the World Health Organization criteria for prolonged and/or frequent bleeding in the previous 90 days [Belsey, E.M., Pinol, A.P.Y. and Taskforce on Long-Acting Systemic Agents for Fertility Regulation, World Health Organization (1997) Contraception 55,57-65]. Treatments were: (1) mifepristone 25 mg given twice on day 1 followed by 4 days of twice daily placebo; (2) mifepristone 25 mg given twice on day 1 followed by 4 days of ethinyl estradiol (EE) 20 microg in the morning and placebo at night; (3) doxycycline 100 mg twice daily for 5 days; and (4) placebo twice daily for 5 days. Analysis was by intention to treat. The primary endpoint was the number of days of bleeding and spotting immediately following initiation of the 5 day course of each active therapy compared with placebo.

RESULTS

A total of 179 women was assigned to treatment. Both mifepristone in combination with EE and doxycycline alone were significantly more effective in stopping an episode of bleeding {mean 4. 3 days [confidence interval (CI) 3.5-5.2], and 4.8 days (CI 3.9-5.8) respectively} than mifepristone alone or placebo [5.9 days (CI 4.8-7.2) and 7.5 days (CI 6.1-9.1) respectively]. No effect on subsequent bleeding patterns was observed in any treatment group.

CONCLUSION

Both mifepristone plus EE and doxycycline alone were significantly more effective than placebo in terminating an episode of bleeding in women with prolonged and/or frequent bleeding using Implanon. We believe that the observed reduction in the number of bleeding days by almost 50% compared to placebo in both the mifepristone combination group and the doxycycline group demonstrates a clinically significant improvement in bleeding patterns and that further trials are needed to compare different combinations of therapy as well as multiple dosing regimens in order to establish which is the most effective treatment option. The effect of repeat administration or combinations of these preparations on long-term bleeding patterns requires further investigation.

Mono- vs. bi-metallic assembly on a bulky bis(imino)terpyridine framework: a combined experimental and theoretical study

The bis(imino)terpyridine ligands, 6,6''-{(2,6-i-Pr2C6H3)N=CR}2-2,2':6',2''-C15H9N3 (R = H L1, Me L2), have been prepared in high yield from the condensation reaction of the corresponding carbonyl compound with two equivalents of 2,6-diisopropylaniline. The molecular structure of L2 reveals a transoid relationship between the imino and pyridyl nitrogen groups throughout the ligand framework. Treatment of aldimine-containing L1 with one equivalent or an excess of MX2 in n-BuOH at 110 degrees C gives the mononuclear five-coordinate complexes, [(L1)MX2] (M = Fe, X = Cl 1a; M = Ni, X = Br 1b; M = Zn, X = Cl 1c), in which the metal centre occupies the terpyridine cavity and the imino groups pendant. Conversely, reaction of ketimine-containing L2 with excess MX2 in n-BuOH at 110 degrees C affords the binuclear complexes, [(L2)M2X4] (M = Fe, X = Cl 3a; M = Ni, X = Br 3b; M = Zn, X = Cl 3c), in which one metal centre occupies a bidentate pyridylimine cavity while the other a tridentate bipyridylimine cavity. 1H NMR studies on diamagnetic 3c suggests a fluxional process is operational at ambient temperature in which the central pyridine ring undergoes an exchange between metal coordination. Under less forcing conditions (room temperature in dichloromethane), the monometallic counterpart of 1b [(L2)NiBr2] (2b) has been isolated which can be converted to 3b by addition of one equivalent of (DME)NiBr2 (DME = 1,2-dimethoxyethane) in n-BuOH at 110 degrees C. Quantum mechanical calculations (DFT) have been performed on [(L1)ZnCl2] and [(L2)ZnCl2] for different monometallic conformations and show that 1a is the energetically preferred structure for L1 while there is evidence for dynamic behaviour in L2-containing species leading to bimetallic formation. Single-crystal X-ray diffraction studies have been performed on 1a, 1b, 1c, 2b, 3a, 3b(H2O) and 3c.

A link between prompt optical and prompt γ-ray emission in γ-ray bursts

The prompt optical emission that arrives with the gamma-rays from a cosmic gamma-ray burst (GRB) is a signature of the engine powering the burst, the properties of the ultra-relativistic ejecta of the explosion, and the ejecta's interactions with the surroundings. Until now, only GRB 990123 had been detected at optical wavelengths during the burst phase. Its prompt optical emission was variable and uncorrelated with the prompt gamma-ray emission, suggesting that the optical emission was generated by a reverse shock arising from the ejecta's collision with surrounding material. Here we report prompt optical emission from GRB 041219a. It is variable and correlated with the prompt gamma-rays, indicating a common origin for the optical light and the gamma-rays. Within the context of the standard fireball model of GRBs, we attribute this new optical component to internal shocks driven into the burst ejecta by variations of the inner engine. The correlated optical emission is a direct probe of the jet isolated from the medium. The timing of the uncorrelated optical emission is strongly dependent on the nature of the medium.

An infrared flash contemporaneous with the γ-rays of GRB 041219a

The explosion that results in a cosmic gamma-ray burst (GRB) is thought to produce emission from two physical processes: the central engine gives rise to the high-energy emission of the burst through internal shocking, and the subsequent interaction of the flow with the external environment produces long-wavelength afterglows. Although observations of afterglows continue to refine our understanding of GRB progenitors and relativistic shocks, gamma-ray observations alone have not yielded a clear picture of the origin of the prompt emission nor details of the central engine. Only one concurrent visible-light transient has been found and it was associated with emission from an external shock. Here we report the discovery of infrared emission contemporaneous with a GRB, beginning 7.2 minutes after the onset of GRB 041219a (ref. 8). We acquired 21 images during the active phase of the burst, yielding early multi-colour observations. Our analysis of the initial infrared pulse suggests an origin consistent with internal shocks.

Aerosol delivery of an enhanced helper-dependent adenovirus formulation to rabbit lung using an intratracheal catheter

BACKGROUND

Poor transduction of the ciliated airway epithelium and inefficient airway delivery of viral vectors are common difficulties encountered in lung gene therapy trials with large animals and humans.

METHODS

We delivered a helper-dependent adenovirus vector, incorporating a human epithelial cell-specific expression cassette, to rabbit lung. An intratracheal device was used to aerosolize a moderate dose of virus (5 x 10(11) particles), mixed with the enhancing agent LPC (L-alpha-lysophosphatidylcholine), directly into the airways. Lung mechanics, body weight and temperature, transgene expression and histopathology were studied at day 5.

RESULTS

Transgene expression was seen in the epithelium of large and small airways, from trachea to terminal bronchioles, with a strong tendency toward the right lung. All cell types of the surface epithelium were transduced. Extensive transduction of the epithelium (66% of cells in trachea) was obtained using virus formulated in isotonic 0.1% LPC, while virus formulated in 0.01% LPC transduced fewer cells (24% in trachea). A transient decrease in dynamic lung compliance was observed immediately following aerosol delivery. Fever and mild-to-moderate patchy pneumonia without edema were also observed.

CONCLUSION

These data demonstrate a strategy for efficient and effective transduction of airway epithelium in a large animal.

Improved system for helper-dependent adenoviral vector production

Helper-dependent adenoviral vectors (HDAds) are devoid of all viral coding sequences and have demonstrated tremendous potential for gene therapy by providing increased cloning capacity (up to 37 kb) and long-term, high-level transgene expression in vivo with negligible toxicity. Currently, the most widely used method of producing HDAds is the Cre/loxP system developed by Graham and co-workers. However, two major obstacles currently hinder progress of this promising technology: (1) the difficulty of large-scale vector production and (2) helper virus (HV) contamination. We have developed an improved producer cell line, HV, and protocols that have successfully addressed these problems. With this system, >1 x 10(13) viral particles (vp) can be easily produced from 3 liters of cells within 2 weeks of vector rescue, with specific yields of >10,000 vp/cell and with exceedingly low HV contamination of 0.4-0.1% without relying on density-based vector purification and 0.02-0.01% following CsCl purification. This new system represents a major improvement over the original method in terms of simplicity, speed, vector yield, and purity, and it will significantly improve our ability to assess this promising gene therapy technology, especially in large animal models and, ultimately, for clinical applications.

Peripheral parenteral nutrition

BACKGROUND

Peripheral parenteral nutrition (PPN) currently accounts for almost 20 per cent of all parenteral nutrition administered in the UK. In the absence of consensus guidelines there is wide variation in practice. Heterogeneity of clinical trials has made direct comparisons difficult and meta-analysis impossible.

METHODS

Medline, Embase and Cochrane databases were searched for all clinical trials relating to the use of PPN in adults. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed.

RESULTS AND CONCLUSIONS

Effective PPN is possible in about 50 per cent of inpatients requiring parenteral nutrition. Evidence relating to optimal feed composition, choice of cannula, infusion technique and pharmacological manipulation is discussed, along with practical recommendations for the administration of PPN.

Automated collection of blood components: their storage and transfusion

The performance of an automated device, the Gambro TRIMA, was evaluated for component production, and an in vivo assessment of the platelets was carried out. Red cell concentrates (RCCs), platelets and plasma were collected and stored according to standard blood bank procedures and evaluated for quality by in vitro measurements. Additionally, single-donor platelets (n=10) were transfused to thrombocytopenic patients after 5 days of storage. Platelet counts were measured after 1 h and the corrected count increment (CCI) was calculated. No significant changes were seen before or after procedure in donor haemoglobin, haematocrit, coagulation factors or platelet count. Return-line samples showed no increase in the level of plasma haemoglobin. Plasma haemoglobin and potassium increased following RBC storage, but there was no change in the red cell number. Platelet aggregation decreased from 52 to 11% (adenosine diphosphate) and the Kunicki morphology score dropped from 379 to 174. Little change was seen in the hypotonic shock response (69-63%) or in the percentage of CD62 expression (4.8-19.8) over time. The CCI averaged 28+/-26 x 10(3) microL(-1) in 10 patients 1 h after transfusion. The TRIMA machine collects RCCs, platelets and plasma in a variety of combinations in one session. For autologous collection, two units of RCC plus platelets can be collected at one time, reducing administrative and testing costs. The platelets have good in vivo recovery, as shown by the CCI values. An added advantage is that the TRIMA machine can be used in hospitals to generate components in times of shortage without the need for a component's laboratory.

Emergency department triage of indigenous and non-indigenous patients in tropical Australia

OBJECTIVE

To examine the relationship between ethnicity and triage at a tertiary hospital emergency department.

METHODS

Electronic Emergency Department Information System data analysis was used to examine the relationship between ethnicity and triage allocation and process times between 1 April 1999 and 29 June 1999. Outcome measures were waiting times by triage category and admission rate by triage category.

RESULTS

There were 9614 attendances: 1949 indigenous (20.3%), 7328 non-indigenous (76.2%) and 337 (3.5%) had no ethnicity recorded. Indigenous patients were more often female (1033; 53%, CI 51-55%) than non-indigenous patients (3078; 42.0%, CI 41-43%, P < 0.001). Indigenous patients presented more often with illness (70% CI 68-72%) rather than injury (30%, CI 28-32%), compared with the non-indigenous patients, illness (64%, CI 63-65%), injury (36%, CI 35-37%, P < 0.001). Indigenous patients were more likely to be triaged to national triage scale categories 1, 2 or 3 (36%, CI 34-38%) than non-indigenous patients (32%, CI 31-33%, P = 0.011). Admission rates for indigenous patients were higher than non-indigenous patients across all urgency categories and were within national triage scale guidelines. Non-indigenous admission rates were well below national triage scale guidelines for all urgency categories. The overall admission rate for indigenous patients was double (33%, CI 31-35%) that for non-indigenous patients (16%, CI 15-17%, P < 0.001). There was no significant difference between indigenous and non-indigenous waiting times.

CONCLUSION

Indigenous patients are more likely to present with illness rather than injury and are more likely to require admission than non-indigenous patients. Indigenous patients are triaged in accordance with Australasian triage guidelines. Many non-indigenous patients should be triaged to lower urgency categories to allow resource allocation towards higher acuity indigenous and non-indigenous patients.

Virus-directed, enzyme prodrug therapy with nitroimidazole reductase: a phase I and pharmacokinetic study of its prodrug, CB1954

CB1954 [5-(aziridin-1-yl)-2,4-dinitrobenzamide] is converted by the bacterial enzyme nitroimidazole reductase (NTR) into a potent cytotoxic bifunctional alkylating agent, which can be delivered to tumors in adenoviral vectors as virus-directed, enzyme prodrug therapy. This report summarizes a Phase I and pharmacokinetic study of the prodrug, CB1954. Thirty patients, ages 23-78 years (median 62 years), with predominantly gastrointestinal malignancies were treated. CB1954 was administered by i.v. injection every 3 weeks or i.p. followed by 3-weekly i.v. injections, toward a maximum of six cycles. The dose was escalated from 3 to 37.5 mg/m2. No significant toxicity was seen until 24 mg/m2 (recommended i.v. dose). Dose-limiting toxicities (DLT) were diarrhea and hepatic toxicity, seen at 37.5 mg/m2. DLT has not been observed at the current i.p. dose of 24 mg/m2. There was no alopecia, marrow suppression, or nephrotoxicity. Clearance data suggest hepatic metabolism, and <5% of CB1954 was renally excreted. There was a nonlinear relationship between i.v. dose and area under the curve (AUC). At the recommended i.v. dose of 24 mg/m2, the AUC was 5.8 microM/h. Intraperitoneal administration (24 mg/m2) achieved an AUC of 387 microM/h, giving a considerable regional advantage. In vitro, the AUC required to achieve the IC50 for CB1954, in NTR-expressing cancer cells, ranges from 10-50 microM/h. Thus, CB1954 is well tolerated at a dose of 24 mg/m2, and sufficient serum/peritoneal levels are achieved for an enzyme-prodrug approach to be feasible. We are now conducting a Phase I trial combining adenovirus-mediated NTR and i.v. CB1954 (24 mg/m2) in patients with primary and secondary liver tumors.

Changes in BiP (GRP78) levels upon HSV-1 infection are strain dependent

BiP (grp78) is a chaperone protein which can also regulate the unfolded protein response of the cell. Levels of BiP increased in cells infected by the small plaque producing, cell associated, neuroinvasive strains of HSV-1 (SP7, 490) but decreased in cells infected with KOS, a large plaque, attenuated strain. BiP protein synthesis continued early in infection and BiP was sequestered and its degradation was limited during SP7 infection. BiP protein synthesis stopped and the protein was degraded in KOS infected cells. These viral strain dependent differences in BiP concentration may influence other aspects of the viral interaction with the target cell and its host.

Biomechanical comparison of ankle arthrodesis techniques: crossed screws vs. blade plate

Many different techniques for ankle arthrodesis have been described. Experience at our institution with crossed screws internal fixation has not met the 90+% union rate reported in the literature. A compression blade plate is one technique for ankle arthrodesis which has not been evaluated biomechanically. A biomechanical study comparing two groups of sawbone ankle fusion constructs fixed with crossed screws and compression blade plates was performed in order to evaluate the stiffness and rigidity of these two arthrodesis techniques. The crossed screws construct demonstrated superior stiffness during dorsiflexion (p < 0.001) and valgus (p < 0.001) loading. The two constructs were found to have equal strength in resisting plantarflexion, varus and torsional loads although there was a trend for greater resistance by the crossed screws construct. These findings lend biomechanical support to the use of crossed screws for tibiotalar arthrodesis.