A universal virus inactivant for decontaminating blood and biopharmaceutical products

Removal of virus infectivity from blood and biopharmaceutical products prepared from blood is an issue of considerable importance. For biopharmaceutical products, removal can usually be achieved by a series of fractionation steps or by inactivation with a suitable reagent. Irrespective of the methods that are chosen it is vital that the biological activity of the product is not impaired. For blood and unfractionated plasma or serum, the problem is even more challenging. Selective inactivation of the genome is the key step in the preparation of killed virus vaccines. Viruses belonging to all the recognised families can be inactivated by imines. In this paper it is shown that the biological properties of several proteins, including the cell growth-promoting factors in calf serum, are not impaired using conditions which ensure the inactivation of > 10(15) infectious units of poliovirus and foot-and-mouth disease virus (FMDV). Also shown is that both viruses can be inactivated by imines at 4 degrees C, thus providing a method for removing infectivity from protein preparations which are unstable at higher temperatures. The RNA extracted from FMDV inactivated at 4 degrees C was not degraded and contained no hidden breaks but nevertheless was non-infectious. However, it could be amplified by PCR using primers corresponding to the gene coding for a portion of the viral RNA polymerase, but not from that coding for VP1, one of the structural proteins, showing that alteration of a base or bases had occurred in that region. Surprisingly, it could be translated in the rabbit reticulocyte system although some of the products were different from those obtained with unmodified RNA.

Peripheral neuropathy and testosterone

A 265 lb. (body mass index, 38.1) male elite bodybuilder suffered focal muscle atrophy that developed in his right vastus lateralis muscle within a month following a painful self-administered injection of testosterone. The subject did not lose any sensory or motor function immediately after the injection; however after several days to weeks, muscle atrophy and paresthesia ensued. The subject had an obvious atrophic zone in the right vastus lateralis muscle with approximately 40% loss of strength when compared to the left leg. In our view, the neuropraxia developed from direct neurotoxic effect of androgens or pressure exerted upon the nerve following injection of a bolus of liquid. This report is indicative of the many potential dangers associated with unsupervised androgen use which may include androgens as potential neurotoxins.

Paediatric life support. An advisory statement by the Paediatric Life Support Working Group of the International Liaison Committee on Resuscitation

This document reflects the deliberations of ILCOR. The epidemiology and outcome of paediatric cardiopulmonary arrest and the priorities, techniques and sequence of paediatric resuscitation assessments and interventions differ from those of adults. The working group identified areas of conflict and controversy in current paediatric basic and advanced life support guidelines, outlined solutions considered and made recommendations by consensus. The working group was surprised by the degree of conformity already existing in current guidelines advocated by the American Heart Association (AHA), the Heart and Stroke Foundation of Canada (HSFC), the European Resuscitation Council (ERC), the Australian Resuscitation Council (ARC), and the Resuscitation Council of Southern Africa (RCSA). Differences are currently based upon local and regional preferences, training networks and customs, rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted. This document does not include a complete list of guidelines for which there is no perceived controversy and the algorithm/decision tree figures presented attempt to follow a common flow of assessments and interventions, in coordination with their adult counterparts. Survival following paediatric prehospital cardiopulmonary arrest occurs in only approximately 3-17% and survivors are often neurologically devastated. Most paediatric resuscitation reports have been retrospective in design and plagued with inconsistent resuscitation definitions and patient inclusion criteria. Careful and thoughtful application of uniform guidelines for reporting outcomes of advanced life support interventions using large, randomized, multicenter and multinational clinical trials are clearly needed. Paediatric advisory statements from ILCOR will, by necessity, be vibrant and evolving guidelines fostered by national and international organizations intent on improving the outcome of resuscitation for infants and children worldwide.

Favourable glycaemic effects of a new balanced liquid diet for enteral nutrition — Results of a short-term study in 30 type II diabetic patients

A new fibre enriched (15 g/l soy polysaccharides) balanced liquid diet was developed containing 53% (of energy) as carbohydrate, 32% fat and 15% protein. 71% of carbohydrates in this formula consist of modified starch, 29% of fructose. The glycaemic response to this diabetes adapted diet (DD) was compared with an isoenergetic standard diet (SD) containing maltodextrins and sucrose and a typical continental breakfast (CB). 30 type II diabetics orally ingested isoenergetic amounts of these test diets in randomised order. Each diet contained 48 g carbohydrates. The 4 h postprandial (p.p.) observation period was characterised by a markedly improved response of blood glucose following ingestion of DD. This effect was seen as significantly reduced p.p. peaks (p < 0.00001 vs SD; p = 0.00001 vs CB) as well as diminished areas under the curve. (p < 0.00001 vs SD; p = 0.00001 vs CB). Similar results were obtained by evaluation of the corresponding insulin levels. The differences between the test diets were greater in insulin treated patients than in diabetics on sulfonylureas or a dietary regimen only. We conclude that this new balanced liquid diet can be helpful in maintaining a good glycaemic control in diabetics receiving artificial enteral nutrition and may be administered in a similar way to normal foods without changes in the patients antidiabetic therapy.

Passively transferred African swine fever virus antibodies protect swine against lethal infection

The role of anti-viral antibodies in homologous protective immunity to a virulent African swine fever virus (ASFV) strain E75 was examined by passive transfer experiments in swine. Eighty-five percent of animals (n = 14) that received anti-ASFV immunoglobulin (Ig) survived challenge infection, while 100% mortality was observed in control group animals (n = 28) that received anti-pseudorabies virus Ig, normal swine Ig, or phosphate-buffered saline. With the exception of a significantly delayed and transient fever response, anti-ASFV Ig group animals remained clinically normal following challenge, whereas control group animals presented with clinical ASF on Day 4 postchallenge. Additionally a significant 3 day delay in onset of viremia and a 10,000-fold reduction in both mean and maximum virus titers were observed for animals given anti-ASFV Ig. These results indicate that anti-ASFV Ig alone will protect swine from lethal infection with virulent ASFV. Further, they support the view that the antibody-mediated protective effect is an early event that effectively delays disease onset.

NR-LU-10 monoclonal antibody scanning. A helpful new adjunct to computed tomography in evaluating non-small-cell lung cancer

Computed tomographic scanning has improved the noninvasive staging of lung cancer but has the deficiency of not distinguishing benign from malignant lesions. This prospective trial evaluated the usefulness of a new radiolabeled monoclonal antibody, NR-LU-10, as an adjunct to computed tomography by assessing its clinical applicability and accuracy in detecting malignancy in primary lung tumors and mediastinal nodes. NR-LU-10 is a technetium 99m-labeled Fab fragment of a murine immunoglobulin G2b monoclonal antibody that recognizes a 40 kD glycoprotein expressed in lung and other epithelial cancers.

METHODS

(1) Patients with potentially resectable non-small-cell lung cancer were eligible; (2) all patients had computed tomographic scans of the chest; (3) whole body and single photon emission computed tomographic imaging were performed 14 to 17 hours after intravenous infusion of 20 to 30 mCi of NR-LU-10; (4) subsequent mediastinoscopy or thoracotomy with complete mediastinal nodal mapping provided pathologic correlation.

RESULTS

Twenty-four patients were entered, 14 men and 10 women. No allergic reactions or other adverse effects were seen. Interference from a prior ventilation-perfusion scan precluded adequate imaging in 1 patient, but high-quality images were obtained in the other 23 patients. The 22 primary malignant tumors all had uptake and there was no uptake in 1 lung nodule found to be benign. In 21 patients who had surgical correlation of mediastinal nodal involvement, NR-LU-10 was false-positive in 5 and false-negative in 1; results of computed tomography were false-positive in 6 and false-negative in 1. In this preliminary study, NR-LU-10 antibody scanning was safe and easily performed, it produced high-quality images of the lung and mediastinum, and it was accurate in detecting primary non-small-cell lung cancers. Further evaluation of its value in staging the mediastinum is needed, in particular, its role as an adjunct to computed tomography to help distinguish benign from malignant lesions.

Rochester, New York: a model for health reform

The 50-year-old health care experiment conducted in Rochester, New York, has yielded encouraging results. The policies implemented there include coverage by a single payer, community rating, a spending cap, encouraged use of HMOs, and general cooperation among providers, employers, insurers, and the area's one million residents. Surveys of those residents and local employers indicate that they are more satisfied with Rochester's health system than the rest of Americans are with the U.S. system.

Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device

We present a case of cutaneous recurrence from an adenocarcinoma of the rectum, which was diagnosed 7 months after anterior resection of the primary tumour had been performed using the EEA stapling device to fashion the anastomosis. We propose that the recurrence was caused by the seeding of exfoliated tumour cells into an area of perianal skin which was abraded during the introduction of the stapling gun.

The state of quality management in HMOs

Interest in total quality management (TQM) in health care is increasing rapidly as leaders search for positive strategies to deal with both costs and quality. We conducted a national telephone survey of 200 HMO medical directors, 451 physicians affiliated with managed care organizations, and 550 corporate health benefits officers to obtain their reports of the potential contributions, the current interest in, and the degree of implementation of TQM activities in their own managed care systems. A large majority of all respondents felt that TQM could help greatly in health care, as it has in other industries. Among HMO medical directors, 81% claimed that their organizations placed "a great deal of emphasis" on TQM, while only 34% of physicians and 35% of benefits officers agreed. Areas of implementation claimed by the HMOs tended to involve abstract matters such as mission statements and leadership commitment, while technical components of TQM, including data systems, training, and supplier management, appeared much less well-developed. The managed care organizations surveyed seem to be in the early phases of commitment to TQM. To achieve the results seen in other industries, these organizations will need much deeper levels of investment, understanding, and deployment of TQM than this survey reveals.

ICRF-187 permits longer treatment with doxorubicin in women with breast cancer

PURPOSE

To test potential protection by ICRF-187 against cumulative doxorubicin-dose-related cardiac toxicity, we conducted a randomized clinical trial in 150 women with advanced breast cancer.

PATIENTS AND METHODS

Patients received fluorouracil (5FU) 500 mg/m2, doxorubicin 50 mg/m2, and cyclophosphamide 500 mg/m2 every 21 days intravenously (IV) (control regimen, 74 patients), or the same regimen preceded by ICRF-187 1,000 mg/m2 IV (experimental regimen, 76 patients).

RESULTS

We previously reported that ICRF-187 in this dose and schedule provides cardiac protection and does not substantially alter the noncardiac toxicity or antitumor efficacy of the control regimen. In this updated analysis of the entire patient cohort, we provide additional support for these findings and demonstrate that patients in the ICRF-187 group received more cycles (median, 11) and higher cumulative doses (median, 500 mg/m2) of doxorubicin than patients in the control group (median, nine cycles, P less than .01; and 441 mg/m2, P less than .05). Twenty-six patients in the ICRF-187 group received doxorubicin doses of at least 700 mg/m2, and among them, 11 patients received 1,000 mg/m2 or more. Only three patients in the control group received doxorubicin doses of 700 mg/m2; the maximum dose administered to one patient in this group was 950 mg/m2. ICRF-187 cardiac protection was demonstrated by difference in incidence of clinical congestive heart failure (CHF; two patients in the ICRF-187 group v 20 in the control group; P less than .0001) and by differences in resting left ventricular ejection fraction (LVEF) determined by multigated radionuclide (MUGA) scan from baselines and that required patient removal from study (five patients in the ICRF-187 group had a decrease in LVEF to less than 0.45 or a decrease from the baseline LVEF of 0.20 or more v 32 in the control group; P less than .000001). Among the 30 patients who had an assessable endomyocardial biopsy at cumulative doxorubicin 450 mg/m2, none of 16 in the ICRF-187 group and six of 14 in the control group had a score of 2 (P less than .05). ICRF-187 cardiac protection was observed in patients with and without prior chest-wall radiation or other risk factors for developing doxorubicin cardiac toxicity.

CONCLUSION

By protecting against cumulative doxorubicin-induced cardiac toxicity, ICRF-187 permits significantly greater doses of doxorubicin to be administered to patients with greater safety.

High-dose multi-agent chemotherapy followed by bone marrow 'rescue' for malignant astrocytomas of childhood and adolescence

Between April 1986 and March 1989, ten patients under 21 years of age with histologically confirmed malignant astrocytoma, received marrow-ablative chemotherapy with either thiotepa and Etoposide (five patients) or thiotepa, Etoposide and BCNU (five patients), followed by bone marrow 'rescue'. Nine patients had glioblastoma multiforme (GBM), and one patient had an intrinsic brain stem anaplastic astrocytoma (AA). Seven patients were treated for recurrent tumor. Two patients who developed GBM as second malignancies were treated directly following surgical resection. One patient had received irradiation only for recently diagnosed cervical spinal cord GBM. Thiotepa was administered at a total dose of 600-900 mg/M2 over three days, Etoposide was administered at a total dose of 1500 mg/M2 over three days, and BCNU was administered at a total dose of 600 mg/M2 over four days. Non-hematopoietic toxicities have been mainly transient, predictable and acceptable, consisting of oropharyngeal mucositis, cutaneous hyperpigmentation, erythema and desquamation. Four patients achieved complete responses (CR), as determined by radiographic evaluation (CT and/or MRI) on day 28 post-marrow infusion. The mean remission duration of those with CR is 290+ days; two patients presently remain in remission. Two patients achieved partial responses (PR, greater than 50% tumor shrinkage) by day 28 post-marrow infusion; both developed disease progression, at day 61 and 94 post-marrow infusion, respectively. One patient, with a brain stem AA, had stable disease maintained for 13 months post-marrow infusion. With a total (CR + PR) response rate of 60%, these regimens merit evaluation in broader categories of recurrent brain tumor patients, as well as in patients with newly-diagnosed GBM.

Pharmacologic treatment of noncognitive behavioral disturbances in elderly demented patients

Fifty-nine elderly residents of long-term care facilities who had DSM-III diagnoses of dementia were studied in an 8-week randomized, double-blind comparison trial of haloperidol, oxazepam, and diphenhydramine to test the efficacy of these agents in the treatment of clinically significant behavioral disturbances in patients with dementia. All three agents demonstrated modest but significant efficacy as measured by clinician ratings of agitated behavior and activities of daily living. The absolute magnitude of improvement was greater for haloperidol and diphenhydramine than for oxazepam, but differences among groups did not approach statistical significance. Frequencies of acute adverse events during the trial were similar across the drug treatment groups. Although these drugs may differ in terms of long-term safety and efficacy, they appear to be equivalent for short-term management of agitated behavior in severely demented patients.

Importance of heterosexual activity in the transmission of hepatitis B and non-A, non-B hepatitis

To identify previously unrecognized sources for acquiring acute hepatitis B and non-A, non-B (NANB) hepatitis, we interviewed patients with these types of hepatitis who were reported to two county health departments in the United States and matched control subjects for known and potential risk factors for acquiring hepatitis. Of 218 patients with hepatitis B and 140 patients with NANB hepatitis, 46% and 53%, respectively, had no commonly recognized source for infection. When these patients were compared with control subjects, significantly more patients with hepatitis B had multiple heterosexual partners, accounting for 14% of all hepatitis B infections; more patients with NANB hepatitis either had sexual or household contact with a person who had hepatitis in the past or had multiple heterosexual partners, accounting for 11% of all NANB infections. This is the first study to suggest that heterosexual transmission may play an important role in the spread of NANB hepatitis.