Hypofractionated Stereotactic Radiotherapy vs. Single Fraction Stereotactic Radiosurgery to the Resection Cavity of Brain Metastases after Surgical Resection (SATURNUS trial): A Prospective, Randomized Phase III Trial

PURPOSE/OBJECTIVE(S)

The brain is a common site for metastases. Resection of large or symptomatic metastases is followed by stereotactic radiotherapy to prevent local recurrence. The optimal fractionation scheme is subject of ongoing research. Supported by emerging retrospective data, we hypothesize that hypofractionated stereotactic radiotherapy (HFSRT) is superior to single-fraction stereotactic radiosurgery (SRS) in terms of local control (LC). We designed the SATURNUS trial to prospectively demonstrate the superiority of HFSRT over SRS after resection of brain metastases in terms of LC.

MATERIALS/METHODS

The SATURNUS trial is a prospective, randomized phase III trial, currently recruiting patients at a single institution. Patients are 1:1 allocated to HFSRT or SRS using permuted block randomization. Affiliation to the treatment arm is solely blinded to the neuroradiologist assessing therapy response. HFSRT will be delivered with 6 - 7 x 5 Gy and SRS with 1 x 12-20 Gy, prescribed to the surrounding isodose, depending on cavity size and proximity to structures at risk. For SRS, doses do not exceed the maximum doses according to RTOG 90-05. Case number calculation was based on own institutional data on HFSRT (mean LC rate of 88% at 12 months) and data from large phase III trials on SRS (pooled mean LC rate of 66% at 12 months). Using a Chi-squared test of equal proportions (odds ratio = 1), setting test significance level (α) to 0.05, and allocating an equal number of patients to both treatment arms, 114 patients are needed to detect the superiority of HFSRT in terms of LC at 12 months (primary endpoint) with a power of at least 80%. Estimating a dropout rate of 10%, the case number was set to 126. The trial was registered with clinicaltrials.gov (NCT05160818). The first patient was enrolled in May 2021 and recruitment is ongoing. Patients with up to three resected brain metastases are considered for study participation. Further eligibility criteria are histologically confirmed solid tumor disease, resection cavity diameter ≤ 4 cm, consent to perform adjuvant radiotherapy by an interdisciplinary tumor board, completed wound healing, resection within the last six weeks at the time of study inclusion, age ≥ 18 years, KPS ≥ 60%, adequate contraceptive measures for fertile women / men and written informed consent. Patients are followed up clinically and with MRI at 6 weeks and 3, 6, 9 and 12 months after treatment. LC is assessed according to RANO-BM. Toxicity (CTCAE v4.03) is assessed as a secondary endpoint. The rather broad dose corridors allowed within the trial do justice to clinical reality, however, may represent a limitation of the trial. They are therefore addressed with a predefined subgroup analysis, as will be cavity size, among others. Participation of further study centers is desired. To the best of our knowledge, the SATURNUS trial is the only randomized phase III trial adequately powered to detect the superiority of HFSRT over SRS with regard to LC for resected brain metastases.

RESULTS

To be determined.

CONCLUSION

To be determined.

THE COMPARISON OF DUAL TASK TIME AMONG APOE CARRIERS AGAINST NON-APOE CARRIERS IN AGING ADULTS

No single variable has been identified as the sole factor for predicting an individuals’ declining health status. In order to predict mental or physical decline in older adults, researchers have designed tasks that include both a physical and mental or cognitive demand known as dual task (DT). The purpose of implementing dual task is to assess the possible changes in accuracy when a second task gets compounded with a given single task. Our study consists of males and females aged from 45 to 75 years who have risk factors for dementia. Each subject was randomly assigned to either a health coaching (HC), or health education (HE) control group. The HC group received coaching to address the lifestyle areas known to be linked to AD risk, such as diet, exercise, sleep, stress, cognitive training, and social interaction. Blood markers of each individual have been assessed to determine carrier status of Apolipoprotein E 4 (APOE4) due to the correlation between the allele and increased risk of Alzheimer’s. To be included in the study, the participants must have at least 2 positive risk factors for AD as determined by the Australian National University-Alzheimer Disease Risk Index (ANU-ADRI). Among non-APOE carriers, a 2x3 (group x time) mixed ANOVA revealed a significant interaction effect wherein the HC group improved DTC score more than the HE group from time 1 to time 3, F (2, 362) =1.253, P=0.017. No significant interaction was noted for APOE carriers.

Effect of White Willow Bark on Delayed Onset Muscle Soreness Following Resistance Training: A Pilot Study

OBJECTIVES Delayed onset muscle soreness (DOMS) is discomfort that occurs within 8-24hrs following an unaccustomed bout of physical activity that peaks within 24-27hrs and slowly resolves on its own. White willow bark (WWB) is a nutritional supplement that is believed to have anti-inflammatory and analgesic properties like aspirin but without the risk of GI adverse effects. The purpose of this investigation is to determine the effectiveness of WWB on alleviating the symptoms of DOMS following exercise.METHODS Twenty-five individuals volunteered to participate and were randomly assigned to take WWB (798mg salicin) or placebo for 5 days following a lower body resistance training session which consisted of 5X10 lunges at 40% body weight (BW) and 3X fatigue leg press at 75%BW. Test procedures included visual analog scale (VAS), mid-thigh circumference and pressure pain threshold. VAS was measured pre, all five days of the supplementation period and day 6 (post-supplementation). All other variables were measured at pre, immediate, day 3(72hrs), and day 6 (post-supplementation).RESULTS No condition X time interaction was observed (p > 0.05) for any variable. However, VAS scores were lower in the WWB compared to the placebo for all time frames. There was a significant main effect of time for VAS scores indicating muscle soreness for hamstrings (p < 0.001), gluteal (p < 0.001), gastrocnemius (p < 0.001) and quadriceps (p < 0.001). In addition, there was a significant main effect of time for right midthigh pressure pain threshold (p = 0.02), mid-right (p < 0.001) and mid-left (p < 0.001) thigh circumference.CONCLUSIONS WWB may reduce subjective feelings of muscle soreness and appears to have analgesic properties.

Outcomes after stereotactic radiosurgery of brain metastases in patients with malignant melanoma and validation of the melanoma molGPA

INTRODUCTION

Malignant melanoma is the third most common primary in the diagnosis of brain metastases. Stereotactic radiosurgery (SRS) is a well-established treatment option in limited brain disease. We analyzed outcomes of SRS with a particular focus on the graded prognostic assessment (GPA, melanoma molGPA), prognostic factors, and toxicity.

METHODS

We evaluated 173 brain metastases in 83 patients with malignant melanoma. All were treated with SRS median dose of 20 Gy prescribed to the 80 or 100% isodose line between 2002 and 2019. All patients were followed-up regularly, including contrast-enhanced brain imaging as well as clinical examination, initially 6 weeks after treatment, then in quarterly follow-up.

RESULTS

The median age was 61 years (range 27-80); 36 female and 47 male patients were treated. After a median follow-up of 5.7 months, median OS (overall survival) was 9.7 months 95%-KI 4.7-14.7). LC (local control) at 6 months, 12, 24 months was 89%, 86%, and 72%, respectively (median was not reached). Median DBC (distant brain control) was 8.2 months (95%-KI 4.7-11.7). For OS, a KPS ≥ 80%, a positive BRAF mutation status, a small PTV (planning target volume), the absence of extracranial metastases, as well as a GPA and melanoma molGPA > 2 were prognostic factors. In the MVA, a small PTV and a melanoma molGPA > 2 remained significant.

CONCLUSION

The present survival outcomes support the use of the disease-specific melanoma molGPA as reliable prognostic score. Favorable outcomes for SRS compared to other studies were observed. In the treatment of brain metastases of malignant melanoma patients, a multidisciplinary approach consisting of surgery, SRS, chemotherapy, and immunotherapy should be considered.

Heart Rate Responses during Simulated Fire Ground Scenarios among Full-Time Firefighters

Simulated fire ground scenarios (SFGS) provide firefighters with an opportunity to maintain skills, receive feedback, and optimize performance. Although there is extensive research on heart rate (HR) changes in the firefighter population, few examine the differences between positions. Firefighters are primarily responsible for fire suppression and control (23), officers for emergency operations and organizational management, paramedics for providing on-scene emergency medical care, and drivers are responsible for driving the fire apparatus. Utilizing HR analysis to quantify the physical demands of SFGS among firefighting crews by position. Sixty-seven male (age: 38.97 ± 9.17; ht: 177.99 ± 6.45 cm. wt: 88.83 ± 13.55 kg) firefighters (FF) participated in this investigation. FF crews performed two SFGS involving the suppression and control of a structural fire. Participants were outfitted with heart rate (HR) monitors and average heart rate (HRavg) and maximum heart rate (HRmax) data were collected for each of the two SFGS. Significant differences were observed for Age (P = 0.01), APMHR (P = 0.01), HRmax1 (P = 0.04), and HRmax2 (P = 0.04) in which firefighters had higher values for Age-predicted maximal heart rate (APMHR), HRmax1, HRmax2 compared to the officers. SFGS can be very physically demanding events that may elicit maximal or near maximal HR responses regardless of position. Based on the metabolic demands of these events and the individual firefighter's capabilities, this information can be used to develop resistance training and conditioning programs that optimize performance at maximal or near maximal heart rates.

Publisher Correction: Oxidized phospholipids are proinflammatory and proatherogenic in hypercholesterolaemic mice

In this Letter, affiliation number 1 was originally missing from the HTML; the affiliations were missing for author Ming-Yow Hung in the HTML; and the Fig. 4 legend erroneously referred to panels a-h, instead of a-g. These errors have been corrected online.

Oxidized phospholipids are proinflammatory and proatherogenic in hypercholesterolaemic mice

Oxidized phospholipids (OxPL) are ubiquitous, are formed in many inflammatory tissues, including atherosclerotic lesions, and frequently mediate proinflammatory changes ¹ . Because OxPL are mostly the products of non-enzymatic lipid peroxidation, mechanisms to specifically neutralize them are unavailable and their roles in vivo are largely unknown. We previously cloned the IgM natural antibody E06, which binds to the phosphocholine headgroup of OxPL, and blocks the uptake of oxidized low-density lipoprotein (OxLDL) by macrophages and inhibits the proinflammatory properties of OxPL^2-4. Here, to determine the role of OxPL in vivo in the context of atherogenesis, we generated transgenic mice in the Ldlr^-/- background that expressed a single-chain variable fragment of E06 (E06-scFv) using the Apoe promoter. E06-scFv was secreted into the plasma from the liver and macrophages, and achieved sufficient plasma levels to inhibit in vivo macrophage uptake of OxLDL and to prevent OxPL-induced inflammatory signalling. Compared to Ldlr^-/- mice, Ldlr ^-/- E06-scFv mice had 57-28% less atherosclerosis after 4, 7 and even 12 months of 1% high-cholesterol diet. Echocardiographic and histologic evaluation of the aortic valves demonstrated that E06-scFv ameliorated the development of aortic valve gradients and decreased aortic valve calcification. Both cholesterol accumulation and in vivo uptake of OxLDL were decreased in peritoneal macrophages, and both peritoneal and aortic macrophages had a decreased inflammatory phenotype. Serum amyloid A was decreased by 32%, indicating decreased systemic inflammation, and hepatic steatosis and inflammation were also decreased. Finally, the E06-scFv prolonged life as measured over 15 months. Because the E06-scFv lacks the functional effects of an intact antibody other than the ability to bind OxPL and inhibit OxLDL uptake in macrophages, these data support a major proatherogenic role of OxLDL and demonstrate that OxPL are proinflammatory and proatherogenic, which E06 counteracts in vivo. These studies suggest that therapies inactivating OxPL may be beneficial for reducing generalized inflammation, including the progression of atherosclerosis, aortic stenosis and hepatic steatosis.

Psychosocial problems in traumatized refugee families: overview of risks and some recommendations for support services

This article is an abridged version of a report by an advisory council to the German government on the psychosocial problems facing refugee families from war zones who have settled in Germany. It omits the detailed information contained in the report about matters that are specific to the German health system and asylum laws, and includes just those insights and strategies that may be applicable to assisting refugees in other host countries as well. The focus is on understanding the developmental risks faced by refugee children when they or family members are suffering from trauma-related psychological disorders, and on identifying measures that can be taken to address these risks. The following recommendations are made: recognizing the high level of psychosocial problems present in these families, providing family-friendly living accommodations, teaching positive parenting skills, initiating culture-sensitive interventions, establishing training programs to support those who work with refugees, expanding the availability of trained interpreters, facilitating access to education and health care, and identifying intervention requirements through screening and other measures.

Getting personal: Endogenous adenosine receptor signaling in lymphoblastoid cell lines

Genetic differences between individuals that affect drug action form a challenge in drug therapy. Many drugs target G protein-coupled receptors (GPCRs), and a number of receptor variants have been noted to impact drug efficacy. This, however, has never been addressed in a systematic way, and, hence, we studied real-life genetic variation of receptor function in personalized cell lines. As a showcase we studied adenosine A2A receptor (A2AR) signaling in lymphoblastoid cell lines (LCLs) derived from a family of four from the Netherlands Twin Register (NTR), using a non-invasive label-free cellular assay. The potency of a partial agonist differed significantly for one individual. Genotype comparison revealed differences in two intron SNPs including rs2236624, which has been associated with caffeine-induced sleep disorders. While further validation is needed to confirm genotype-specific effects, this set-up clearly demonstrated that LCLs are a suitable model system to study genetic influences on A2AR response in particular and GPCR responses in general.

Abstract 30: Localized Immune Response to Oxidized Lipids in ABCG1-/- Mice: A New Model for Lipid-Driven Autoimmunity

Many metabolic diseases, including atherosclerosis, type 2 diabetes, pulmonary alveolar proteinosis (PAP), and obesity, have a chronic inflammatory component involving both innate and adaptive immunity. Mice lacking the ATP binding cassette (ABC) transporter ABCG1, develop chronic inflammation in the lungs, associated with lipid accumulation (cholesterol, cholesterol ester, phospholipid, oxidized lipids) and cholesterol crystal deposition, characteristic of atherosclerotic lesions and PAP. Here we demonstrate that specific lipids, likely oxidized (Ox) phospholipids and/or sterols, elicit a lung-specific immune response in Abcg1-/- mice. Loss of ABCG1 results in increased levels of specific oxysterols, phosphatidylcholines and oxidized phospholipids, including 1-palmitoyl-2-(5’-oxovaleroyl)-sn-glycero-3-phosphocholine (POVPC), in the lungs. Further, we identify a niche-specific increase in natural antibody (NAb)-secreting B-1 B cells in response to this lipid accumulation that is paralleled by increased titers of IgM, IgA and IgG against oxidation specific epitopes such as those on OxLDL and malondialdehyde-modified LDL (MDA-LDL). Finally, we identify a cytokine/chemokine signature in the lungs of Abcg1-/- mice reflective of increased B cell activation, antibody secretion and homing. Collectively, these data demonstrate that the accumulation of lipids in Abcg1-/- mice induces the specific expansion and localization of B-1 B cells, which secrete NAbs that may help protect against the development of atherosclerosis. Indeed, despite chronic lipid accumulation and inflammation, hyperlipidemic mice lacking ABCG1 develop smaller atherosclerotic lesions compared to controls. These data also suggest that Abcg1-/- mice may represent a new model in which to study the protective functions of B-1 B cells/NAbs, and may provide novel targets for pharmacologic intervention and treatment of disease.

Transcriptomic and cistromic comparison of the effects of glucocorticoid receptor activation in B-1 and B-2 cells. (P1118)

Glucocorticoids are widely used clinically to potently modulate the activity of many immune cells. They bind to the glucocorticoid receptor, which functions as a ligand inducible transcription factor capable of either transactivation or trans-repression of target genes. Surprisingly, little is known regarding the molecular mechanisms by which glucocorticoids modulate B cells in general and B-1 cells in particular. We have previously reported that the glucocorticoid receptor is prominently expressed in both mouse B-1 and B-2 cells. Ex-vivo treatment of primary B-1 cells with dexamethasone inhibits proliferation and antibody secretion as well as strongly induces apoptosis. Utilizing RNA- sequencing the effect of glucocorticoid receptor activation on genome-wide mRNA transcript levels was analyzed and compared in quiescent and activated primary B-1 and B-2 cells. Furthermore, the genome-wide binding of glucocorticoid receptor was analyzed in B-1 and B-2 cells using chromatin immunoprecipitation and deep sequencing. While in general the dexamethasone dependent changes in glucocorticoid receptor binding and mRNA levels were similar between B-1 and B-2 cells, reflecting B cell specific effects, there were notable differences as well, possibly reflecting lineage specific differences between B-1 and B-2 cells. Current work is exploring the reasons for these differential responses in B-1 and B-2 cells to glucocorticoid receptor ligation, and the consequences to B cell function.

Abstract 21: Loss of Abcg1 Drives the Site-selective Expansion of B-1 B Cells and Secretion of Atheroprotective Natural Antibodies, in Response to Local Accumulation of Specific Oxidized Lipids

The oxidation of LDL, a key event in the pathogenesis of atherosclerosis, generates multiple oxidation-specific neo-epitopes (OSE). These epitopes are recognized by natural germ line IgM antibodies that are secreted by B-1 B cells. Mice lacking the ATP binding cassette (ABC) transporter, ABCG1, develop chronic inflammation in the lungs, associated with the accumulation of lipid (cholesterol, cholesterol ester, phospholipid)-filled cells and cholesterol crystal deposition, which are also characteristic of atherosclerotic lesions. However, hyperlipidemic mice lacking ABCG1 develop smaller atherosclerotic lesions compared to controls. We previously attributed this decrease to increased apoptosis of macrophages within the atherosclerotic lesions of mice lacking ABCG1. We now demonstrate that the lungs of Abcg1-/- mice have increased levels of specific oxidized phospholipids species. Here we show that there is a significant increase in B cell number in the lungs, but not the spleens, of Abcg1-/- mice. Subsequent comparison of B cell subtypes revealed that B-1 B cells, which secrete natural antibodies (NAbs), are significantly expanded in the pleural cavity of Abcg1-/- mice, compared to wild type mice. In addition, we show that the lungs and plasma of Abcg1-/- mice have increased titers of NAbs to OSE, and increased mRNA transcript levels for the known hypervariable (VH) CDR3 region of the atheroprotective EO6/T15 NAb. These data are consistent with an antigen-specific enhanced local production of NAbs in the pleural cavity. These findings suggest that the accumulation of lipids resulting from loss of ABCG1 induces the specific expansion of B-1 B cells, which secrete NAbs that may help protect against the development of atherosclerosis. These data also suggest that Abcg1-/- mice may represent a new model in which to study the protective functions of B-1 B cells/NAbs, and may provide novel targets for pharmacologic intervention and treatment of disease.

Oxidation-specific epitopes are an important target of innate immunity (P4261)

Oxidation of LDL is important in atherosclerosis and generates oxidation-specific epitopes, which are proinflammatory and immunogenic. We showed that oxidation specific epitopes are recognized by innate immunity, including Natural Ab’s, scavenger receptors and innate proteins. In addition, many of these epitopes are also found on apoptotic cells and are share molecular mimicry with pathogens. For example, the NAb E06, scavenger receptor CD36 and CRP, all bind to PC on oxidized LDL, but also bind to the PC on apoptotic cells and on S. pneumonia. To determine if other oxidation specific epitopes share molecular mimicry with pathogens, we screened a pathogen library with oxidation specific epitopes NAbs. We found that the NAb E014, specific for malondialdehyde also bound to Streptococcus group A, demonstrating molecular mimicry between the two. I showed that E014 specifically binds to the M protein of Streptococcus group A. Using synthetic peptide arrays I narrowed the binding site on M protein to a 24AA section. I am currently studying the immunological consequences of molecular mimicry between peptides from M protein and the ubiquitous malondialdehyde. These data support the hypothesis that oxidation-specific epitopes are an important target of innate immunity and both oxidative events and pathogens have contributed to the natural selection of shared and potent innate immune responses to oxidative specific epitopes.

The Bcl6-SMRT/NCoR cistrome represses inflammation to attenuate atherosclerosis

Chronic inflammation is a hallmark of atherosclerosis, but its transcriptional underpinnings are poorly understood. We show that the transcriptional repressor Bcl6 is an anti-inflammatory regulator whose loss in bone marrow of Ldlr(-/-) mice results in severe atherosclerosis and xanthomatous tendonitis, a virtually pathognomonic complication in patients with familial hypercholesterolemia. Disruption of the interaction between Bcl6 and SMRT or NCoR with a peptide inhibitor in vitro recapitulated atherogenic gene changes in mice transplanted with Bcl6-deficient bone marrow, pointing to these cofactors as key mediators of Bcl6 inflammatory suppression. Using ChIP-seq, we reveal the SMRT and NCoR corepressor cistromes, each consisting of over 30,000 binding sites with a nearly 50% overlap. While the complete cistromes identify a diversity of signaling pathways, the Bcl6-bound subcistromes for each corepressor are highly enriched for NF-κB-driven inflammatory and tissue remodeling genes. These results reveal that Bcl6-SMRT/NCoR complexes constrain immune responses and contribute to the prevention of atherosclerosis.

Ion optical design of a collinear laser-negative ion beam apparatus

An apparatus for photodetachment studies on atomic and molecular negative ions of medium up to heavy mass (M ≃ 500) has been designed and constructed. Laser and ion beams are merged in the apparatus in a collinear geometry and atoms, neutral molecules and negative ions are detected in the forward direction. The ion optical design and the components used to optimize the mass resolution and the transmission through the extended field-free interaction region are described. A 90° sector field magnet with 50 cm bending radius in combination with two slits is used for mass dispersion providing a resolution of M∕ΔM≅800 for molecular ions and M∕ΔM≅400 for atomic ions. The difference in mass resolution for atomic and molecular ions is attributed to different energy distributions of the sputtered ions. With 1 mm slits, transmission from the source through the interaction region to the final ion detector was determined to be about 0.14%.

Standardization across multiple sites

Standardizing products, procedures, and processes in clinical departments across multiple sites has significant potential for improving clinical outcomes, enhancing financial savings, and simplifying management processes. This is true whether a network of owned hospitals is working toward a full-scale clinical integration or a group of community hospitals is collaborating to gain cost efficiencies. By developing a functional team and designing a relatively simple program, the results can be very rewarding. The author describes some of the basic principles in designing a standardization program and cites some examples of successful programs as well as listing some pitfalls to be avoided along the way.

Local and systemic delivery of low molecular weight heparin following PTCA: acute results and 6-month follow-up of the initial clinical experience with the porous balloon (PILOT-study). Preliminary Investigation of Local Therapy Using Porous PTCA Balloons

The purpose of this study was to assess safety and feasibility of intracoronary delivery of reviparin using a porous balloon following percutaneous transluminal coronary angioplasty. The 2.7 mm porous balloon used in this study had 35 holes arranged in a spiral pattern. Eighteen patients (male n = 10, female n = 8, age 63 +/- 9 years) undergoing successful PTCA in coronary arteries with a vessel diameter of 2.5 to 3.0 mm determined by online QCA (LAD = 11, RCX = 3, RCA = 4) were included. They received a bolus of 7,000 anti-Xa-IU reviparin followed by local delivery of 1,500 anti-Xa-IU in 4 ml with an injection pressure of 2 atm. The patients received additionally 10500 anti-Xa-units intravenously during the following 24 hours and a daily dose of 7000 anti-Xa-units reviparin subcutaneously for the following 28 days. Angiograms were obtained before and after PTCA, directly after local delivery, at 24 hours postintervention and after 6 months. The primary success rate was 100%. Quantitative coronary angiography showed a minimum luminal diameter of 0.42 +/- 0.14 mm before PTCA, 1.87 +/- 0.45 after PTCA, 1.67 +/- 0.43 after LDD, 1.63 +/- 0.46 after 24 hours, and 1.06 +/- 0.6 after 6 months. Angiographic follow-up was obtained in all patients. No major complications occurred during the 6-month follow-up period. The angiographic restenosis rate was 28% (5/18) at follow-up. This study demonstrates safety and feasibility of local intracoronary delivery of reviparin with a porous balloon following PTCA even in smaller diameter coronary arteries.

Long-term preservation of islets of Langerhans in hydrophilic macrobeads

Several obstacles have hindered the successful transplantation of islets of Langerhans to human patients in efforts to cure type I diabetes mellitus. One problem is the necessity for short- and long-term storage of islets after isolation and before transplantation. Current long-term storage methods, such as incubation in a physiological medium and cryopreservation, are suboptimal, resulting in significant loss of viable islet mass or function. Better storage methods are needed. In this study we examined the long-term storage of rat islets in macrobeads composed of agarose and collagen. Islets isolated from Wistar-Furth rats were placed into macrobeads (1000 islets/macrobead) and maintained in culture for periods of up to 189 days at 37 degrees C. Insulin released from the cultured macrobeads remained constant for periods of at least 154 days. In one group, insulin release was 1050 mU/24 hr/4 beads on day 3 and 1040 mU/24 hr/4 beads on day 154. In another group, insuling release was 1305 Xenotransplantation of Wistar Furth islet macrobeads, stored for 10 to 112 days at 37 degrees C, degrees C into 42 B6AF/1 mice with streptozotocin-induced diabetes resulted in a return to euglycemia in the recipients within 24 hr. Thereafter, euglycemia was maintained for more than 100 days in 32/42 of the recipients, and removal of the macrobeads caused a return to hyperglycemia within 48 hr in all animals. In addition, a group of 7 mice receiving macrobeads containing 1000 islets stored for 84 days had normal glucose tolerance tests (compared with those of 7 nontreated, nontransplanted mice with streptozotocin-induced diabetes and 7 normal mice), demonstrating that the islets in the macrobeads were functioning as they would in an intact pancreas. Finally, 5 macrobeads transplanted after initial storage of 112 days, removed from the first recipient after 100 days or more, stored again for 4 days in vitro, and retransplanted into 5 other diabetic mice also restored and maintained euglycemia for at least 45 days. Our results indicate that collagen-agarose macrobeads are capable of preserving rat pancreatic islets for extended periods without loss of in vitro insulin release capability or ability to achieve and maintain euglycemia in vivo. As such they should be useful for human islet transplantation efforts.

Retrievable, replaceable, macroencapsulated pancreatic islet xenografts. Long-term engraftment without immunosuppression

Prevention of rejection and prolongation of graft survival are critical to achieving successful islet cell transplantation. Various techniques have been utilized to prolong graft survival. Recently, protection of pancreatic islets from host immune mechanisms by isolating the islets in artificial membranes has emerged as an attractive alternative to the use of immunosuppression. In this Rapid Communication, we describe a novel method for macroencapsulation of rat islets in hydrophilic macrobeads made with various combinations of agarose, collagen, and Gelfoam. Encapsulated xenotypic islets were placed intraperitoneally in mice in which diabetes was induced by streptozotocin. The encapsulated xenografts maintained normoglycemia > 170 days. Recipients mice had normal glucose tolerance tests, which indicates that the islets in the macrobeads were functioning as they would in an intact pancreas. Macrobeads retrieved up to 103 days after transplantation showed no evidence of tissue reaction or local inflammation. These retrieved macrobeads could also be retransplanted and replaced. Our studies indicate that the agarose-collagen/Gelfoam macrobeads we have developed serve both to protect islet xenografts from rejection and to provide a microenvironment in which the islets maintain and support their normal function in vivo. Because they may be retrieved after implantation and replaced, these macrobeads may be suitable for human clinical islet cell xenotransplantation.

The brain-dead pregnant woman: finding meaning to help cope

Caring for brain-dead pregnant women is a new critical care challenge. Rather than the usual life/death situations involving catastrophic events, critical care nurses have the added burden of caring for a life in suspension to maintain the viability of the fetus. Nurses struggle with keeping the brain-dead patient alive and yet know that as soon as the infant is delivered the mother will be allowed to die. These authors use interviews with clinical nurses to show how they used the coping strategy of creating meaning to successfully cope with this difficult situation.