Administration of DAB389IL-2 to patients with recalcitrant psoriasis: a double-blind, phase II multicenter trial

BACKGROUND

Current therapies for recalcitrant psoriasis focus on immunoregulation and targeting of activated T-lymphocytes rather than keratinocytes. Previous studies with low doses of the lymphocyte-selective fusion protein DAB389IL-2 have shown benefit to patients with psoriasis.

OBJECTIVE

We examined the safety and efficacy of DAB389IL-2 in 41 volunteers receiving more frequent and higher doses than in a previous trial.

METHODS

Patients were randomized to receive either placebo or 5, 10, or 15 microg/kg daily of DAB389IL-2 intravenously for 3 consecutive days each week for 4 consecutive weeks with a subsequent 4-week observation period.

RESULTS

Of the placebo group, 17% (2 of 12) exhibited at least 50% improvement from baseline Psoriasis Area and Severity Index scores at the end of the study, whereas 24% of all treated patients (7 of 29) showed the same improvement. Overall, 3 of 12 (25%) patients given placebo as opposed to 12 of 29 (41%) patients treated with DAB389IL-2 improved to this same extent at some point during the study. The rate of improvement for treated patients was significantly greater than for placebo patients (p = 0.04; repeated measures ANOVA). Among treated patients, decreases in Psoriasis Area and Severity Index scores were paralleled by changes in the Physician's Global Assessment and the Dermatology Life Quality Index. Treatment in ten patients was discontinued because of adverse events. Flu-like symptoms were the most common with severity increasing at the two higher doses. Only one serious adverse event was reported. This occurred in a patient receiving 5 microg/kg daily who experienced vasospasm and a coagulopathy resulting in arterial thrombosis.

CONCLUSION

Our findings are consistent with the potential antipsoriatic activity of DAB389IL-2 demonstrated in an earlier study. However, DAB389IL-2 was less well tolerated at this dosing regimen, particularly at the highest dose, and it was too toxic at these doses and schedules to be considered in the routine treatment of psoriasis.

Microcirculation in hyperglycemic patients with IDDM without diabetic complications--effect of low-dose angiotensin-converting enzyme inhibition

In patients with insulin-dependent diabetes mellitus (IDDM) angiotensin-converting enzyme inhibitors (ACEI) have been demonstrated to have beneficial effects in the secondary prevention of microvascular complications. There are only few data available regarding the effect of ACEI on microcirculation in patients with IDDM without any microvascular complications. In addition, there is little knowledge about ACEI action during acute hyperglycemia. In a pilot study nine patients with IDDM without any clinical signs of diabetic complications (5 females, 4 males, aged 33.3 +/- 1.0 years, duration of diabetes 11.4 +/- 3.0 years, HbA1 7.2 +/- 0.2% [normal range 4.8-7.4%], BMI 21.4 +/- 0.5 [kg/m2]) received 1.25 mg of the ACEI ramipril (Delix, Hoechst Marion Roussel, Frankfurt) over 4 weeks. Nine healthy volunteers (4 females, 5 males, age 27.4 +/- 1.1 years, HbA1 5.9 +/- 0.2% (p < 0.01 vs patients), BMI 22.2 +/- 0.9 [kg/m2]) served as controls. Using nailfold capillaroscopy we determined capillary blood cell velocity (CapiFlow, Lawrenz Electronics, Sulzbach, Germany) before and during post-occlusive hyperemia (200 mmHg for 3 minutes) as a provocative test. Before and after treatment patients were studied during hyperglycemia (blood glucose 250-350 mg/dl). Treatment with low-dose ramipril resulted in a significant decrease in the time to peak capillary blood cell velocity during post-occlusive hyperemia (17.8 +/- 7.7 vs 57.4 +/- 12.8 s, p < 0.01) in hyperglycemic patients. This effect was absent in healthy volunteers. Hemodynamic and metabolic parameters remained unchanged throughout the study in both groups. These data demonstrate that low-dose therapy with the ACEI ramipril is able to improve microcirculation in hyperglycemic patients with type 1 diabetes mellitus also before microvascular complications are evident. Prospective studies are necessary to evaluate whether this effect might be clinically relevant in the primary prevention of diabetic microangiopathy.

Evaluation of hepatitis C virus envelope proteins expressed in E. coli and insect cells for use as tools for antibody screening

BACKGROUND/METHODS

The two envelope proteins of hepatitis C virus, E1 and E2, were expressed in E. coli and, as secretory proteins, in Sf9 insect cells using recombinant baculoviruses. Co-infection of insect cells with E1 and E2-recombinant baculoviruses was performed, which has been shown to result in formation of E1-E2 dimers. All envelope proteins were purified by Ni2+-NTA chromatography and used for screening of serum samples in a HCV EIA assay. Serum samples of normal blood donors, chronically HCV-infected patients, a mixed titer panel and several seroconversion panels were screened and compared to test results with Cobas Core Anti-HCV EIA.

RESULTS

Screening of the sera of chronically HCV-infected patients (100% positive in Cobas Core Anti-HCV EIA) revealed 10-40% anti-E1 positive sera using different Sf9-expressed, glycosylated proteins and 93% using E. coli-expressed, non-glycosylated E1 protein. When the same sera were tested with different E2 proteins expressed in Sf9 cells and in E. coli, about 70-73% showed anti-E2 reactivity. When the proteins from Sf9 cells co-infected with E1- and E2-recombinant baculoviruses were tested, 70-80% of the same sera showed anti-envelope reactivity.

CONCLUSIONS

Testing of these patient antisera, and those from the well-characterized mixed titer panel BBI-PHV203, showed that recombinant E1 expressed in E. coli and co-expressed E1 and E2 proteins from Sf9 cells could be used as additional tools for anti-HCV antibody screening.

Growth of molluscum contagiosum virus in a human foreskin xenograft model

Molluscum contagiosum virus (MCV) is a common pathogen causing a troublesome skin condition in many immunocompetent individuals and a widespread, disfiguring affliction in many patients with AIDS. We have successfully infected human foreskin fragments with a patient-derived isolate of MCV. This was demonstrated by exposing the foreskin pieces to a patient lesion extract and implanting the tissue under the renal capsule of athymic mice. Light and electron microscopic examination of infected implants showed the presence of cytoplasmic inclusions containing typical poxvirus particles within 2-3 weeks of implantation. Replication of MCV was established by demonstrating that viable virus was required to produce the cytopathologic effects, and viral DNA replication was demonstrated by incorporation of bromodeoxyuridine into cytoplasmic inclusions. Four additional patient extracts (representing both described MCV types) were also used to successfully infect foreskin implants. A limited number of attempts to pass virus from one infected implant to another were not successful. This system is the most rapid and reproducible for growing MCV that has been reported to date.

Effectiveness of antioxidants (vitamin C and E) with and without sunscreens as topical photoprotectants

Considerable interest has been recently generated concerning the use of natural compounds, anti-oxidants in particular, in photoprotection. Two of the best known anti-oxidants are vitamins C and E, both of which have been shown to be somewhat effective in different models of photodamage. Very little has been reported, however, on the effectiveness of a combination of the two (known to be biologically the more relevant situation); nor have there been detailed studies on the ability of these antioxidants to augment commercial sunscreen protection against UV damage. We report that (in swine skin) vitamin C is capable of additive protection against acute UVB damage (sunburn cell formation) when combined with a UVB sunscreen. A combination of both vitamins E and C provided very good protection from a UVB insult, the bulk of the protection attributable to vitamin E. However, vitamin C is significantly better than vitamin E at protecting against a UVA-mediated phototoxic insult in this animal model, while the combination is only slightly more effective than vitamin C alone. When vitamin C or a combination of vitamin C and E is formulated with a commercial UVA sunscreen (oxybenzone), an apparently greater than additive protection is noted against the phototoxic damage. These results confirm the utility of anti-oxidants as photoprotectants but suggest the importance of combining the compounds with known sunscreens to maximize photoprotection.

Specificity of antinuclear antibodies in scleroderma-like chronic graft-versus-host disease: clinical correlation and histocompatibility locus antigen association

Chronic graft-versus-host disease after bone marrow transplantation presents, in a few cases, as mild to severe scleroderma-like changes. Patients with chronic graft-versus-host disease with and without sclerodermatous skin changes were analysed for antinuclear autoantibodies (ANA) and antinucleolar autoantibodies (ANoA) and the results correlated with disease symptoms and histocompatibility locus antigen (HLA) pattern. Nineteen patients with chronic graft-versus-host disease and scleroderma-like skin changes, 18 with chronic graft-versus-host disease without scleroderma, and 17 controls on immunosuppressive treatment were screened for ANA and ANoA using enzyme-linked immunosorbent assay, immunodiffusion and immunoblot techniques. Four patients with severe scleroderma had antibodies to topoisomerase I, two had antibodies against PM-Scl, both characteristic serological findings in idiopathic systemic scleroderma. One patient had La/SSB antibodies and, in three cases, antibodies to the nucleolar antigen C23 (nucleolin) could be identified. A possible correlation between antinucleolin antibodies and disease activity was observed. HLA-A1, -B1, and -B2 were found significantly more often in patients with scleroderma-like symptoms in comparison to patients without scleroderma-like symptoms. Chronic graft-versus-host disease with scleroderma-like manifestations can be associated with the occurrence of ANA specific for idiopathic scleroderma. The development of scleroderma after bone marrow transplantation might have a HLA-linked genetic background.

[Endoscopic extraperitoneal patch-plasty of inguinal and femoral hernias without suture or staple fixation of the polypropylene patch]

The operative technique of endoscopic extraperitoneal inguinal and femoral hernia repair without fixation of the polypropylene patch is presented. The results of 725 inguinal and femoral hernia repairs are demonstrated and discussed.

Evaluation of erectile dysfunction with the sympathetic skin response in comparison to bulbocavernosus reflex and somatosensory evoked potentials of the pudendal nerve

Sympathetic skin response (SSR) was investigated in 60 normal subjects (mean age 37.7 +/- 15.9) and 30 patients (mean age 47.2 +/- 12.0) referred from the department of urology for further electrophysiological evaluation of erectile dysfunction (ED). SSR was present in all normal subjects. Mean latency in the lower extremities was 2.16 +/- 0.20 sec. The coefficient of variance for repeated measurements in individual subjects was 10%. The latencies correlated slightly positively with the height of the subjects (r = 0.271, p < 0.05), but not with age. SSR in patients was compared to the bulbocavernosus reflex (BCR) and somatosensory evoked potentials (SSEP) of the pudendal nerve. All patients had a complete urological work-up with evaluation of hormonal function, pharmacotesting and Dopplersonography, as well as pharmacocavernosography and measurement of nocturnal penile tumescence if indicated. Six patients were diagnosed to have functional impotence, 4 dysfunctions were probably of vascular origin, 5 were neurogenic and 15 of the mixed type of vascular and neurogenic origin. Diabetes mellitus was the underlying disease in 14. In the two groups with neurogenic involvement (5 neurogen, 15 mixed) 14 of 20 patients had a pathological BCR, 12 had pathological SSEP and 9 had an absent SSR. Of these 9 patients two showed normal BCR and SSEP. Sensitivity for neurogenic dysfunction was 70% for the BCR, 60% for the BCR and SSEP, but that it detects some patients with erectile dysfunction, in whom other parameters are not pathological.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laparoscopic cholecystectomy as standard intervention in symptomatic cholecystolithiasis. Experiences with 1,277 patients]

As a result of 1277 laparoscopic cholecystectomies, which were performed as a standard procedure in uncomplicated and complicated symptomatic cholecystolithiasis, the complication-rates of conventional cholecystectomy and laparoscopic cholecystectomy are compared. It can be demonstrated, that the adoption of the principles of conventional cholecystectomy into laparoscopic technique and a careful preparation can reach the same high level of safety as the so called "gold-standard".

[Sympathetic skin response--physiologic principles, normal values and clinical use]

Sympathetic skin reflex (SSR) was evaluated in the lower extremities of 60 normal volunteers aged 17 to 72 (mean age 38 +/- 16 years, 28 females, 32 males). SSR was obtainable in all volunteers and most often consisted of a biphasic wave with initial negative deflection. Mean latency was 2.16 +/- 0.20 s. Mean variation in a second repetitive measurement was 0.21 +/- 0.14 s. The SSR was not age- or sex dependent. There was a weak positive correlation of the SSR with the height of the volunteers (r = 0.271; p = 0.037). SSR was investigated in 39 patients with polyneuropathy (age 59 +/- 18). SSR was pathological in 51% on one or both legs. There was no correlation of the SSR to the aetiology nor to the type of lesion (axonal versus demyelinating polyneuropathy) nor to clinical symptoms. The applicability of the SSR is reviewed from the literature regarding polyneuropathy, erectile dysfunction, central degenerative diseases, multiple sclerosis, sympathetic reflex dystrophies, spinal and peripheral nerve lesions. SSR is briefly compared to alternative methods. SSR appears to be a reasonable method to describe a small section of the autonomic nervous system (sympathetic sudomotor function) and to calculate group differences. There appears to be no close correlation to any of the autonomic disturbances in individual patients.

Sympathetic skin response abnormalities in amyotrophic lateral sclerosis

The sympathetic skin response (SSR) was evaluated in 25 patients with amyotrophic lateral sclerosis (ALS) to assess for involvement of the autonomic nervous system. Twenty-two age-matched normals and 6 patients with muscular dystrophy served as controls. The SSR was intact in all normal volunteers and all patients with muscular dystrophy. The mean SSR latency in the ALS patients was prolonged compared to that of normals (2.29 +/- 0.28 versus 2.13 +/- 0.16 s, P < 0.05). The SSR was absent in one or both legs of 10 ALS patients (40%). Absence or abnormal latency of SSR in patients with ALS without clinical findings of autonomic failure suggests involvement of the autonomic nervous system in addition to the motor system.

Cutaneous Histoplasma capsulatum in a nonimmunocompromised patient with previously treated cutaneous Mycobacterium kansasii

This report describes a black woman with a history of cutaneous Mycobacterium kansasii responsive to antituberculous drugs. A culture several years later of cutaneous lesions was also positive for Histoplasma capsulatum. Both cutaneous diseases are rare and most often occur in immunocompromised hosts. There is no known association between these two diseases. This patient may have an as-yet unidentified immunodeficiency that predisposes her to these rare infections. Her case emphasizes the importance of repeat biopsy for atypical skin lesions.

Evaluation of protein metabolism in clinical practice

The application of stable isotopes creates further possibilities for our understanding of the metabolism. New concepts especially for non-invasive diagnostic procedures could be developed. An important step in our research program was the performing of a 1-year experiment on a volunteer. On the basis of a 10-pool model we received a lot of informations. Based on this knowledge we developed 2 simplified methods for calculating whole body protein turnover. Knowing the problems with whole body protein calculations we intensified our intentions for determining the protein enrichment in organs and isolated cells (hepatocytes), estimating at the same time the precursor pool in the cells. Of special importance was an extensive study, wherein all those 15N-estimations were performed we are able to do up to now. We calculated whole body protein, but especially we studied the enrichment of the cellular protein fractions in hepatocytes, of plasmaproteins, and of the intracellular precursor pool. This study is the base for further tracer investigations.

[15N]methacetin urine test to measure liver function: methodology for application in pediatrics

A simple, noninvasive test is proposed to measure the activity of the hepatocellular monooxygenase system in vivo. Elimination rates of the stable isotope 15N are measured in urine after an oral dose of the 15N-labeled phenacetin homologue [15N]methacetin. Different forms of obtaining and expressing results are investigated in order to determine optimum methodology and differentiation for clinical application in pediatrics. The best discriminating power and reliability of results are seen with the measurement of 15N elimination half-life. For follow-up, a more easily measured parameter--eliminated dose over 9 h--is sufficient. In the latter case, only total nitrogen and 15N contents of a collective urine sample are measured.

Endoscopic sphincterotomy and surgical approaches in the treatment of the 'sump syndrome'

The 'sump syndrome' is a rare, late complication of choledochoenterostomies. We observed 13 patients with this syndrome. The clinical features included recurrent cholangitis, liver abscesses, and recurrent pancreatitis. Five patients were treated by surgery, eight patients endoscopically. Reviewing an average follow up period of 22 months (range 6-60) after therapeutic endoscopy and 57 months (range 1-126) after different surgical procedures, we conclude that endoscopic sphincterotomy with removal of the debris is as efficient a therapy of the 'sump syndrome' as surgical sphincteroplasty and entails a smaller risk for the patient. We therefore advocate that endoscopic papillotomy should first be tried in all cases of 'sump syndrome' in the absence of suprapapillary stricture of the bile ducts.

[Changes in diagnostic imaging of non-Hodgkin's lymphoma in recent years]

The following examinations have been carried out with various methods of diagnostic imaging: 148 CT, 69 US, 56 Ly. Data on the rate of accuracy of the various methods of examination in the individual abdominal regions. CT examinations rose from 1980 to 1985 from 83 percent to 100 percent. US examinations ranged between 50 to 25%. Lymphographies dropped from 54% to 0%. Owing to the early dissemination pattern of the NHL with frequent primary extranodal involvement, lymphography is no longer indicated. In the abdominal region including the pelvis, CT is superior to US accuracy also with those abdominal findings that have been histologically verified. CT cuts show a better reproducibility and more accurate basis for therapeutic controls. The problem of the mere characteristic of the "size of the lymph node" with non-invasive diagnostic imaging will be discussed. The costs of the various methods of examination are compared with each other. The strategy of examination has changed.

Nuclear medicine liver-function tests for pregnant women and children. 2. A new test method via urine using 15N-methacetin

A simple, non-invasive, non-radioactive liver-function test is proposed. After an oral dose of 3 mg 15N-methacetin per kilogram body mass, the kinetics of 15N excretion via urine were characterized by the quotient of the amounts of 15N excreted in two successive urine samples (Q value). The stable nitrogen isotope 15N was found to be an excellent and easily detectable indicator of the sum of all methacetin metabolites present in urine. Alterations in the nature or ratio of methacetin metabolites due to liver diseases could not be found. From the investigation of 11 men, 3 pregnant women and 15 children, a clear difference was observed in Q values of healthy persons and patients suffering from liver-cell-activity diseases. The discriminating power of our new liver-function test is shown to be equivalent to that of the 14CO2 breath test.

A liver-function test using 15N-labelled ammonium chloride

Malfunction of the liver involves disturbances of urea synthesis and ammonia detoxification. These phenomena became apparent, especially during ammonia loading of patients. The functional state of the liver can be assessed by oral administration of 15NH4Cl and subsequent analysis of 15N-urea and 15N-ammonia in urine by emission spectrometry. Clinical tests based on the ratio of the excess abundances of 15N-ammonia to 15N-urea excreted in urine 3 h after oral administration gave values for patients with liver disease which differed significantly from those for healthy subjects. Absorption disturbances, which often accompany liver diseases, do not influence the effectiveness of the method.