209 NEURO-MEDICAL COMPLICATIONS OF STROKE—TRENDS OVER THE DECADES IN AN ACUTE STROKE UNIT

Background

Neuro-medical complications post-stroke are common and often serious [1]. We first described complications in our stroke cohort in 1998 and sought to assess whether the severity and the nature of neuro-medical complications may have changed over time due to changes in presentation and the processes of care [2].

Methods

Analysis of stroke service database, which captures all neuro-medical complications as part of its portal for the Irish National Audit of Stroke (INAS), was completed. The frequency of each of the 19 complications was expressed as the percentage of patients that developed each complication over a certain year and over 5 years. Historical comparison was made with dataset from 1998, which captured six complications.

Results

Data on 1,283 patients presenting over 5 years between 2015–2019 was collected. The median age of all patients was 71 years (Range 21–101). In all, 19 different post-stroke complications were recorded; 48% (n = 622) had post-stroke pain, while 23.85% (n = 306) had cognitive decline. Data on 100 patients from 1998 was compared for a number of common metrics including; 21.82% (n = 275) of patients developed an LRTI in the 2015–2019 cohort compared with 14%(n = 14) in the 1998 cohort (p = 0.09) while 16.29% (n = 209) of patients developed a swallow disorder compared to 21% (n = 21) in 1998 (p = 0.22).

Conclusion

There are high levels of neuro-medical complications in stroke patients. Twenty years has seen extensive investment in hyperacute stroke care yet post-acute care complications did not appear to reduce significantly between this time, albeit with low numbers. Direction of future funding may consider the full spectrum of stroke care.

Women's experience of stress and related use of diet and/or dietary supplements

Women's lives are negatively impacted by chronic psychological stress. Dietary supplement use to manage stress is prolific despite inadequate evidence to support supplementation. The researchers used participatory action research to examine the experience of living with stress and the role that diet and/or dietary supplements played in the self-reported ability to manage stress among community dwelling women. Convenience sampling was used to recruit eight women. Focus group sessions were held across eight consecutive weeks wherein personal experiences of stress and dietary strategies to manage stress were audio-recorded. Verbatim transcripts of the sessions, journal notes, and email correspondence were analyzed, identifying codes, categories, and six themes: "causes and effects of stress," "thinking patterns and stress," "confusion and skepticism about using dietary strategies to manage stress," "the role of relationships in experiencing stress," "the role of relationships in managing physical health and stress," and "stress-management strategies." Participants experienced habitual stress responses, skepticism about dietary stress management strategies, and long-reaching physical and psychological effects on key relationships. Health professionals may find similar perspectives influencing the choices of chronically stressed women they support.

Specific Nutrient Intake Via Diet and/or Supplementation in Relation to Female Stress: A Cross-Sectional Study

Background: Women are negatively impacted by psychological stress and despite the prolific use of dietary supplements to manage stress there is little evidence to support their use for such. This study examined the relationship between intake of specific nutrients through diet and/or dietary supplementation and level of perceived stress.

Method: In this cross-sectional study of adult Australian women (n = 74), perceived stress was measured using the Perceived Stress Scale, dietary intake was assessed using a validated Food Frequency Questionnaire, and supplement usage was recorded using a Supplement Use Questionnaire.

Results: Potentially substantive reductions in stress scores were associated with polyunsaturated fatty acid supplementation: α-linolenic acid (mean difference [MD] = −3.34, 95% confidence interval [CI] = −7.97 to 1.29), linoleic acid (MD = −4.08, 95% CI = −8.97 to 0.82), γ-linolenic acid (MD = −2.23, 95% CI = −7.20 to 2.74), and eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) (MD = −4.05, 95% CI = −8.07 to −0.03). There were negative correlations between intake of vitamin B6 and vitamin C and stress (ρ = −0.50 and −0.35, respectively). Compared with nonsupplementers, stress scores were on average 0.92 units lower among those supplementing with magnesium and vitamin B6 concurrently (95% CI = −3.88 to 2.03). An increase in vitamin B6 through food was related to lower stress scores. For most nutrients, intake from food was positively associated with supplementation status.

Conclusion: There is some evidence to suggest potentially meaningful associations between intake of particular nutrients and stress, although CIs were wide and there were no statistically significant relationships observed. Further research is warranted to investigate any potential benefits more precisely using randomized controlled trials or large-scale observational studies.

The effect of evidence-based, treatment-oriented, clinical practice guidelines on improving patient care outcomes: a systematic review protocol

REVIEW QUESTION

The question that this systematic review aims to address is: does the use of evidence-based, treatment-oriented, clinical practice guidelines by healthcare professionals result in improvements in patient outcomes?

Dissociated Agonist of Glucocorticoid Receptor or Prednisone for Active Rheumatoid Arthritis: Effects on P1NP and Osteocalcin Pharmacodynamics

Fosdagrocorat (PF‐04171327), a dissociated agonist of the glucocorticoid receptor, has potent anti‐inflammatory activity in patients with rheumatoid arthritis with reduced adverse effects on bone health. To identify fosdagrocorat doses with bone formation marker changes similar to prednisone 5 mg, we characterized treatment‐related changes in amino‐terminal propeptide of type I collagen (P1NP) and osteocalcin (OC) with fosdagrocorat (1, 5, 10, or 15 mg) and prednisone (5 or 10 mg) in a phase II randomized trial (N = 323). The time course of markers utilized a mixed‐effects longitudinal kinetic‐pharmacodynamic model. Median predicted changes from baseline at week 8 with fosdagrocorat 5, 10, and 15 mg were −18, −22, and −22% (P1NP), and −7, −13, and −17% (OC), respectively. Changes with prednisone 5 and 10 mg were −15% and −18% (P1NP) and −10% and −17% (OC). The probability of fosdagrocorat doses up to 15 mg being noninferior to prednisone 5 mg for P1NP and OC changes was >90%.

The impact of essential fatty acid, B vitamins, vitamin C, magnesium and zinc supplementation on stress levels in women: a systematic review

BACKGROUND

Women juggling multiple roles in our complex society are increasingly experiencing psychological stress. Dietary supplementation to manage stress is widespread despite limited supporting evidence. A systematic review of the available literature was undertaken to investigate the efficacy of specific dietary supplements in managing female stress and anxiety.

OBJECTIVES

To identify the impact of essential fatty acids (EFAs), B vitamins, vitamin C, magnesium and/or zinc, consumed as dietary supplements to the daily diet, on female stress and anxiety levels.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Women aged 18 years and over, who had participated in a study where stress and/or anxiety were assessed.

TYPES OF INTERVENTION(S)

Dietary supplementation with EFAs, B vitamins, vitamin C, magnesium and/or zinc.

TYPES OF COMPARATORS

Supplements, either alone or combined, were compared with either no intervention or placebo.

TYPES OF STUDIES

Randomized controlled and pseudo-randomized trials were included.

OUTCOMES

Stress and anxiety were assessed using self-report or physiological outcome measures.

SEARCH STRATEGY

Published and unpublished studies were sought via MEDLINE (via PubMed), Embase, Scopus, CINAHL, PsycINFO, PsycARTICLES, MedNar, National Institute of Mental Health and the International Association for Women's Mental Health.

METHODOLOGICAL QUALITY

Methodological quality was evaluated using standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Data were extracted using the standardized data extraction instruments from the Joanna Briggs Institute.

DATA SYNTHESIS

Due to heterogeneity of the included studies, narrative synthesis was performed.

RESULTS

Fourteen studies were included in this review. Essential fatty acids were effective in reducing perceived stress and salivary cortisol levels during pregnancy and anxiety in premenstrual women, and anxiety during menopause in the absence of depression, but were ineffective when depression was disregarded. Disregarding the hormonal phase, EFAs were ineffective in reducing stress or anxiety in four groups of women. Combined magnesium and vitamin B6 supplementation reduced premenstrual anxiety but had no effect when used in isolation and did not affect stress in women suffering from dysmenorrhea when combined or used in isolation. Older women experienced anxiety reduction using vitamin B6, but not folate or vitamin B12. High-dose sustained-release vitamin C was effective in reducing anxiety and blood pressure in response to stress.

CONCLUSION

The current review suggests that EFAs may be effective in reducing prenatal stress and salivary cortisol and may reduce anxiety during premenstrual syndrome and during menopause in the absence of depression. Magnesium and vitamin B6 may be effective in combination in reducing premenstrual stress, and vitamin B6 alone may reduce anxiety effectively in older women. High-dose sustained-release vitamin C may reduce anxiety and mitigate increased blood pressure in response to stress.

IMPLICATIONS FOR PRACTICE

Essential fatty acids may be effective in reducing prenatal stress and salivary cortisol levels, and premenstrual or menopausal anxiety in the absence of depression. Combining magnesium and vitamin B6 may reduce premenstrual anxiety and vitamin B6 may reduce anxiety in older women. High-dose sustained-release vitamin C may reduce anxiety and mitigate increased blood pressure in response to stress.

IMPLICATIONS FOR RESEARCH

Investigating supplementation in longer term studies is warranted and should include compliance testing, the use of inert substances as controls and reliable outcome measures.

Rotenone prevents impact-induced chondrocyte death

Mechanical insult to articular cartilage kills chondrocytes, an event that may increase the risk of posttraumatic osteoarthritis. Recent reports indicate that antioxidants decrease impact-induced chondrocyte death, but the source(s) of oxidants, the time course of oxidant release, and the identity of the oxidative species generated in response to injury are unknown. A better understanding of these processes could lead to new treatments of acute joint injuries. To that end, we studied the kinetics and distribution of oxidant production in osteochondral explants subjected to a single, blunt-impact injury. We followed superoxide production by measuring the time-dependent accumulation of chondrocyte nuclei stained with the superoxide-sensitive probe dihydroethidium. The percentage of chondrocytes that were dihydroethidium-positive was 35% above baseline 10 min after impact, and 65% above baseline 60 min after impact. Most positive cells were found within and near areas contacted directly by the impact platen. Rotenone, an electron transport chain inhibitor, was used to test the hypothesis that mitochondria contribute to superoxide release. Rotenone treatment significantly reduced dihydroethidium staining, which remained steady at 15% above baseline for up to 60 min postimpact. Moreover, rotenone reduced chondrocyte death in impact sites by more than 40%, even when administered 2 h after injury (p < 0.001). These data show that much of the acute chondrocyte mortality caused by in vitro impact injuries results from superoxide release from mitochondria, and suggest that brief exposure to free radical scavengers could significantly improve chondrocyte viability following joint injury.

The effectiveness of a weak opioid medication versus a cyclo-oxygenase-2 (COX-2) selective non-steroidal anti-inflammatory drug in treating flare-up of chronic low-back pain: results from two randomized, double-blind, 6-week studies

Two 6-week studies compared the analgesic efficacy, tolerability and safety of a non-steroidal anti-inflammatory drug (celecoxib 200 mg twice a day [bid]) and an opioid (tramadol HCl 50 mg four times a day [qid]) in subjects with chronic low-back pain (CLBP). Successful responders (primary endpoint) were defined as subjects completing 6 weeks of treatment and having > or = 30% improvement on the Numerical Rating Scale for pain. A total of 796 and 802 subjects were randomized to treatment in study 1 and study 2, respectively. A significantly greater percentage of celecoxib-treated subjects were successful responders compared with tramadol HCl-treated subjects (study 1: 63.2% versus 49.9%, respectively; study 2: 64.1% versus 55.1%, respectively). Fewer adverse events (AEs) and serious AEs were reported in the celecoxib-treated group. Overall, celecoxib 200 mg bid was more effective than tramadol HCl 50 mg qid in the treatment of CLBP, with fewer AEs reported.

Particle-mediated gene delivery in vivo and in vitro

Particle-mediated or "gene gun" technology has been developed as a nonviral method for gene transfer into various mammalian tissues. Gene delivery is achieved by physical force: a strong shock wave is generated that accelerates DNA-coated gold particles to high speeds, providing them with the momentum needed to penetrate the targeted cells. This unit describes general procedures for in vivo and in vitro DNA and RNA transfections by particle-mediated delivery. The Basic Protocol and an alternate protocol address in vivo delivery to mouse skin. In vitro delivery to cryopreserved and adherent cells is also described.

The use of antibiotic-containing agars for the isolation of extended-spectrum β-lactamase-producing organisms in intensive care units

MacConkey agar containing either cefotaxime 1.0 mg/L or ceftazidime 1.0 mg/L was evaluated for use in screening for extended-spectrum beta-lactamase (ESBL)-producing organisms. The media were evaluated using known ESBL-positive and -negative strains and 630 clinical specimens over a 6-month period. All Enterobacteriaceae isolated were identified and screened for ESBL production by phenotypic methods. In total, 14 ESBL-producing organisms were detected in the clinical samples. All known ESBL-positive strains were also detected. The use of both screening plates was required to detect all ESBLs.

Validation of a monoclonal antibody-based capture enzyme-linked immunosorbent assay for detection of Campylobacter fetus

A monoclonal antibody (MAb)-based antigen capture enzyme-linked immunosorbent assay (ELISA) was compared with the routine culture methodology for the detection of Campylobacter fetus subspecies from bovine and ovine field samples inoculated into Clark's transport enrichment medium (TEM). The work was a collaboration between two different diagnostic laboratories, one in Canada and the other in England. In both labs, TEM samples were incubated for 4 days at 35 degrees C and then tested by culture and ELISA. The ELISA consisted of initial screening with MAb M1825 against C. fetus subspecies core lipopolysaccharide (LPS). All samples positive on ELISA screening were then retested by ELISA with MAb M1825 and MAbs M1177, M1183, and M1194, which recognize serotype A- and/or serotype B-specific C. fetus subspecies LPS epitopes. The Canadian samples consisted of 1,060 preputial washings from 529 bulls, of which 18 were positive by both culture and ELISA and 1,042 were negative by both methods. The English samples consisted of 321 tissue specimens, mostly stomach contents and placentas, from 190 aborted ovine and bovine fetuses. A total of 262 samples were negative by culture and ELISA, 52 samples were positive by culture and ELISA, and 7 samples were culture negative but ELISA positive. The results for all 70 culture-positive isolates were confirmed by conventional biochemical methods as C. fetus subsp. fetus, with 39 presumptively identified by the ELISA as serotype A and 30 presumptively identified as serotype B and with one sample containing isolates presumptively identified as serotype A and serotype B. A receiver operating characteristic analysis of the combined ELISA data from both countries resulted in an area under the curve of 0.997, with a sensitivity of 100% and a specificity of 99.5% relative to the results of culture. The data confirm that this ELISA method can be used as an excellent test for the screening of field samples in TEM for the presence of C. fetus subspecies.

Evidence of a pharmacogenomic response to interleukin-l receptor antagonist in rheumatoid arthritis

Biological activity of the IL-1 system depends on the balance between two proinflammatory proteins (IL-1alpha and IL-1beta) and the related anti-inflammatory protein, the IL-1 receptor antagonist (IL-1Ra). The genes for these proteins lie within 430 kb on human chromosome 2. Based on a clinical trial of human recombinant IL-1ra in rheumatoid arthritis, we tested whether IL-1 genotype might be related to the likelihood of response to anti-IL-1 therapy. A positive response was defined as a reduction of at least 50% in the number of swollen joints by week 24, following treatment with either 150 mg/day IL-1ra or placebo. The response rate to treatment, independent of genotype, was 48% (44/91). A highly significant association was found between carriage of the rarer allele at IL1A(+4845) and response to treatment (P=0.0009; OR=4.85 (1.85,12.70)). The response rate in patients carrying this allele was 63.4% compared with 26.3% in noncarriers. A weaker association was found for IL1B(+3954) (P=0.02). There was a highly significant interaction between treatment (150 mg/day or placebo) and the composite genotype across IL1A(+4845) and IL1B(+3954) (P=7.6 x 10(-5)). No associations with IL-1 genotypes were found in patients receiving placebo. Thus, a significant pharmacogenomic effect was found in the treatment of RA patients with recombinant IL-1ra.

Broad-spectrum antimicrobial activity of hemoglobin

While hemoglobin is one of the most well characterized proteins due to its function in oxygen transport, few additional properties of hemoglobin have been described. While screening serum samples for novel antimicrobial factors, it was found that intact hemoglobin tetramers, including that from human, exhibited considerable activity against gram-positive and gram-negative bacteria, and fungi. To further characterize this surprising activity, the antimicrobial potency of sections of human hemoglobin was tested against a panel of microorganisms. In all cases separate testing of the alpha and beta subunits provided activity at least as potent as the intact tetramer. This activity is derived from the protein portion of hemoglobin since removal of the heme prosthetic group did not lead to decreases in potency. In addition, cyanogen bromide cleavage of both subunits provided fragments that still contained substantial antimicrobial activity. It has been possible to map specific regions of the human hemoglobin molecule that are responsible for significant antimicrobial activity. The carboxyl terminal thirty amino acids of the beta subunit, which form a cationic alpha-helix based on the crystal structure of the intact tetramer, were active against Escherichia coli, Staphylococcus aureus and Candida albicans. In view of the fact that different hemoglobin-derived peptide fragments exhibit diverse antibiotic activities, it is conceivable that, in addition to its role in oxygen transport. hemoglobin functions as an important multi-defense agent against a wide range of microorganisms.

Recruitment of components of Polycomb Group chromatin complexes in Drosophila

Polycomb Group complexes assemble at polycomb response elements (PREs) in vivo and silence genes in the surrounding chromatin. To study the recruitment of silencing complexes, we have targeted various Polycomb Group (PcG) proteins by fusing them to the LexA DNA binding domain. When LexA-PC, -PSC, -PH or -SU(Z)2 are targeted to a reporter gene, they recruit functional PcG-silencing complexes that recapitulate the silencing behavior of a PRE: silencing is sensitive to the state of activity of the target chromatin. When the target is transcriptionally active, silencing is not established but when the target is not active at syncytial blastoderm, it becomes silenced. The repressed state persists through embryonic development but cannot be maintained in larval imaginal discs even when the LexA-PcG fusion is constitutively expressed, suggesting a discontinuity in the mechanism of repression. These proteins also interact with other PC-containing complexes in embryonic nuclear extracts. In contrast LexA-PHO is neither able to silence nor to interact with PC-containing complexes. Analysis of pho mutant embryos and of PRE constructs whose PHO-binding sites are mutated suggests that, while PHO is important for silencing in imaginal discs, it is not necessary for embryonic PcG silencing.

A multicenter, double-blind, dose-ranging, randomized, placebo-controlled study of recombinant human interleukin-1 receptor antagonist in patients with rheumatoid arthritis: radiologic progression and correlation of Genant and Larsen scores

OBJECTIVE

To evaluate radiographic progression and the relationship of radiologic scores obtained by the Genant and Larsen methods in a clinical trial of recombinant human interleukin-1 receptor antagonist (IL-1Ra).

METHODS

Patients with rheumatoid arthritis (RA) were randomized into 4 groups: placebo (n = 121) or IL-1Ra at a daily dosage of 30 mg (n = 119), 75 mg (n = 116), or 150 mg (n = 116). Hand radiographs obtained at baseline, 24 weeks, and 48 weeks were scored using both methods.

RESULTS

At 24 weeks, by the Genant method, there was significant reduction in the score for progression of joint space narrowing (JSN) and the total score (a combination of erosion and JSN) in all treatment groups. Least-squares mean changes in the Genant erosion score from baseline to 24 weeks were significantly reduced after treatment with IL-1Ra at 30 mg/day and for all IL-1Ra treatment groups combined. The changes corresponded to a reduction of 38% in erosion, 58% in JSN, and 47% in total score. Patients treated with IL-1Ra at 75 mg/day had a significant reduction in the Larsen erosive joint count (LEJC), and all IL-1RA-treated groups combined showed a 45% reduction. Correlations (r) between the Genant total and Larsen scores were 0.84 at baseline, 0.83 at week 24, and 0.83 at week 48 (P < 0.0001); correlations between the Genant erosion score and the LEJC were 0.83 (P < 0.0001) at all visits; correlations between the Genant total and the Larsen scores were 0.32 and 0.49 (P < 0.0001) for progression from baseline to week 24 and from baseline to week 48, respectively; correlations between the Genant erosion score and the LEJC were 0.36 and 0.41 (P < 0.0001) for progression to weeks 24 and 48, respectively.

CONCLUSION

IL-1Ra reduced radiologic progression of RA. Scores by the 2 methods correlated strongly for each individual time point, but much less strongly for assessments of disease progression.

Efficacy of sustained blood levels of interleukin-1 receptor antagonist in animal models of arthritis: comparison of efficacy in animal models with human clinical data

OBJECTIVE

To determine the role of interleukin-1 receptor antagonist (IL-1Ra) in rat adjuvant arthritis and rat type II collagen-induced arthritis, and to compare the efficacy in rat models with that seen in human clinical trials of IL-1Ra.

METHODS

Rats with developing adjuvant arthritis or established collagen-induced arthritis were treated with IL-1Ra by continuous infusion in order to determine and maintain efficacious blood levels of this IL-1 inhibitory protein in the rats for comparison with human clinical data. The effects of treatment in the rats were monitored by sequential caliper measurement of the ankle joints, determination of final paw weights, and histologic evaluation with particular emphasis on bone and cartilage lesions. The effects of IL-1Ra on joint swelling and radiographic bone damage in patients with rheumatoid arthritis (RA) in a 6-month trial were compared with the findings in rats.

RESULTS

Dramatic differences in the profile of IL-1Ra activity were seen between the 2 groups of rats. Modest antiinflammatory effects were observed in the adjuvant arthritis rats treated with IL-1Ra. However, marked inhibition of bone resorption occurred, even at doses with which antiinflammatory activity was not seen. In contrast, IL-1Ra treatment of rats with established collagen-induced arthritis resulted in nearly complete suppression of all aspects of the disease when adequate blood levels of IL-1Ra were maintained. Treatment of RA patients with IL-1Ra (150 mg daily) resulted in modest inhibition of joint swelling and inhibition of radiographic progression of bone lesions.

CONCLUSION

IL-1 appears to be of major importance in mediating the bone resorption that occurs in rat adjuvant arthritis, but is less important in the pathogenesis of periarticular inflammation in this disease. In contrast, IL-1 is of major importance in mediating all aspects of disease progression in rat collagen-induced arthritis. Similar to the response in adjuvant arthritic rats, RA patients treated with IL-1Ra showed only modest antiinflammatory activity, but had evidence of inhibition of progression of bone resorption. However, a comparison of the plasma levels of IL-1Ra in humans and rats suggests that the optimal level of dosing for continuous saturation of IL-1 receptors may not have been achieved in humans, although this was achieved in the rat studies.

Treatment of rheumatoid arthritis with recombinant human interleukin-1 receptor antagonist

OBJECTIVE

To evaluate the efficacy and safety of interleukin-1 receptor antagonist (IL-1Ra) in patients with rheumatoid arthritis (RA).

METHODS

Patients with active and severe RA (disease duration <8 years) were recruited into a 24-week, double-blind, randomized, placebo-controlled, multicenter study. Doses of nonsteroidal antiinflammatory drugs and/or oral corticosteroids (< or =10 mg prednisolone daily) remained constant throughout the study. Any disease-modifying antirheumatic drugs that were being administered were discontinued at least 6 weeks prior to enrollment. Patients were randomized to 1 of 4 treatment groups: placebo or a single, self-administered subcutaneous injection of IL-1Ra at a daily dose of 30 mg, 75 mg, or 150 mg.

RESULTS

A total of 472 patients were recruited. At enrollment, the mean age, sex ratio, disease duration, and percentage of patients with rheumatoid factor and erosions were similar in the 4 treatment groups. The clinical parameters of disease activity were similar in each treatment group and were consistent with active and severe RA. At 24 weeks, of the patients who received 150 mg/day IL-1Ra, 43% met the American College of Rheumatology criteria for response (the primary efficacy measure), 44% met the Paulus criteria, and statistically significant improvements were seen in the number of swollen joints, number of tender joints, investigator's assessment of disease activity, patient's assessment of disease activity, pain score on a visual analog scale, duration of morning stiffness, Health Assessment Questionnaire score, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the rate of radiologic progression in the patients receiving IL-1Ra was significantly less than in the placebo group at 24 weeks, as evidenced by the Larsen score and the erosive joint count. IL-1Ra was well tolerated and no serious adverse events were observed. An injection-site reaction was the most frequently observed adverse event, and this resulted in a 5% rate of withdrawal from the study among those receiving IL-1Ra at 150 mg/day.

CONCLUSION

This study confirmed both the efficacy and the safety of IL-1Ra in a large cohort of patients with active and severe RA. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion.

Treatment of rheumatoid arthritis with recombinant human interleukin-1 receptor antagonist

OBJECTIVE

To evaluate the efficacy and safety of interleukin-1 receptor antagonist (IL-1Ra) in patients with rheumatoid arthritis (RA).

METHODS

Patients with active and severe RA (disease duration <8 years) were recruited into a 24-week, double-blind, randomized, placebo-controlled, multicenter study. Doses of nonsteroidal antiinflammatory drugs and/or oral corticosteroids (< or =10 mg prednisolone daily) remained constant throughout the study. Any disease-modifying antirheumatic drugs that were being administered were discontinued at least 6 weeks prior to enrollment. Patients were randomized to 1 of 4 treatment groups: placebo or a single, self-administered subcutaneous injection of IL-1Ra at a daily dose of 30 mg, 75 mg, or 150 mg.

RESULTS

A total of 472 patients were recruited. At enrollment, the mean age, sex ratio, disease duration, and percentage of patients with rheumatoid factor and erosions were similar in the 4 treatment groups. The clinical parameters of disease activity were similar in each treatment group and were consistent with active and severe RA. At 24 weeks, of the patients who received 150 mg/day IL-1Ra, 43% met the American College of Rheumatology criteria for response (the primary efficacy measure), 44% met the Paulus criteria, and statistically significant improvements were seen in the number of swollen joints, number of tender joints, investigator's assessment of disease activity, patient's assessment of disease activity, pain score on a visual analog scale, duration of morning stiffness, Health Assessment Questionnaire score, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the rate of radiologic progression in the patients receiving IL-1Ra was significantly less than in the placebo group at 24 weeks, as evidenced by the Larsen score and the erosive joint count. IL-1Ra was well tolerated and no serious adverse events were observed. An injection-site reaction was the most frequently observed adverse event, and this resulted in a 5% rate of withdrawal from the study among those receiving IL-1Ra at 150 mg/day.

CONCLUSION

This study confirmed both the efficacy and the safety of IL-1Ra in a large cohort of patients with active and severe RA. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion.

Effects of interleukin-1 receptor antagonist in a slow-release hylan vehicle on rat type II collagen arthritis

PURPOSE

To determine the effect of hylan fluid (HA), a model slow release vehicle on the pharmacokinetic profile and efficacy of interleukin-1 receptor antagonist (IL-1ra) in rats with established type II collagen arthritis.

METHODS

Female Lewis rats with type II collagen arthritis were treated daily, every other day or every third day with single subcutaneous (sc) injections of IL-1ra formulated in HA and the effects on arthritis determined. Results were compared to those obtained with IL-1ra in citrate buffered saline with EDTA and polysorbate (CSEP). Sequential blood levels were determined in rats injected sc with IL-1ra in CSEP or HA.

RESULTS

Incorporation into HA led to slower release of IL-1ra into the bloodstream and maintained therapeutic blood levels of IL-1ra for a longer time compared to the IL-1ra/CSEP formulation. Single daily sc doses of 100 mg/kg IL-1ra in CSEP were ineffective in type II collagen arthritis. By contrast, once per day dosing of 100 mg/kg IL-1ra in HA provided 78% inhibition of paw swelling. Every other day dosing with 100 mg/kg IL-1ra in HA resulted in 62% inhibition. IL-1ra (100 mg/ kg in HA) given every third day provided 19% inhibition of arthritis. Improved efficacy correlated with improved pharmacokinetics.

CONCLUSIONS

Administration of IL-1ra in the slow release vehicle HA improves pharmacokinetics and efficacy in rat type II collagen arthritis.

Immunization of pigs with a particle-mediated DNA vaccine to influenza A virus protects against challenge with homologous virus

Particle-mediated delivery of a DNA expression vector encoding the hemagglutinin (HA) of an H1N1 influenza virus (A/Swine/Indiana/1726/88) to porcine epidermis elicits a humoral immune response and accelerates the clearance of virus in pigs following a homotypic challenge. Mucosal administration of the HA expression plasmid elicits an immune response that is qualitatively different than that elicited by the epidermal vaccination in terms of inhibition of the initial virus infection. In contrast, delivery of a plasmid encoding an influenza virus nucleoprotein from A/PR/8/34 (H1N1) to the epidermis elicits a strong humoral response but no detectable protection in terms of nasal virus shed. The efficacy of the HA DNA vaccine was compared with that of a commercially available inactivated whole-virus vaccine as well as with the level of immunity afforded by previous infection. The HA DNA and inactivated viral vaccines elicited similar protection in that initial infection was not prevented, but subsequent amplification of the infection is limited, resulting in early clearance of the virus. Convalescent animals which recovered from exposure to virulent swine influenza virus were completely resistant to infection when challenged. The porcine influenza A virus system is a relevant preclinical model for humans in terms of both disease and gene transfer to the epidermis and thus provides a basis for advancing the development of DNA-based vaccines.

Developing particle-mediated gene-transfer technology for research into gene therapy of cancer

Gene therapy aims to (1) introduce specific genes into a host to replace defective ones (replacement therapy); (2) suppress expression of certain undesirable genes (antisense therapy); or (3) provide additional biological activities (supplement therapy). Naked DNA and viral or non-viral vectors containing candidate genes for human gene therapy are being actively pursued by researchers in molecular medicine. New gene transfer technologies are rapidly developing and some have proved to be powerful tools for medical research. This review discusses the development and application of particle-mediated gene transfer technology in experimental systems and its potential clinical utilities.

Gene gun-mediated skin transfection with interleukin 12 gene results in regression of established primary and metastatic murine tumors

Particle-mediated (gene gun) in vivo delivery of the murine interleukin 12 (IL-12) gene in an expression plasmid was evaluated for antitumor activity. Transfer of IL-12 cDNA into epidermal cells overlying an implanted intradermal tumor resulted in detectable levels (266.0 +/- 27.8 pg) of the transgenic protein at the skin tissue treatment site. Despite these low levels of transgenic IL-12, complete regression of established tumors (0.4-0.8 cm in diameter) was achieved in mice bearing Renca, MethA, SA-1, or L5178Y syngeneic tumors. Only one to four treatments with IL-12 cDNA-coated particles, starting on day 7 after tumor cell implantation, were required to achieve complete tumor regression. This antitumor effect was CD8+ T cell-dependent and led to the generation of tumor-specific immunological memory. By using a metastatic P815 tumor model, we further showed that a delivery of IL-12 cDNA into the skin overlying an advanced intradermal tumor, followed by tumor excision and three additional IL-12 gene transfections, could significantly inhibit systemic metastases, resulting in extended survival of test mice. These results suggest that gene gun-mediated in vivo delivery of IL-12 cDNA should be further developed for potential clinical testing as an approach for human cancer gene therapy.

Azurocidin, a natural antibiotic from human neutrophils: expression, antimicrobial activity, and secretion

The azurophil granules of human PMN contain four antibiotic proteins, the serprocidins, which have extensive homology to one another and to serine proteases. Azurocidin, a member of this family, is a 29-kDa glycoprotein with broad spectrum antimicrobial activity and chemotactic activity toward monocytes. Insect cells transfected with a baculovirus vector carrying azurocidin cDNA produced a recombinant azurocidin protein. We purified the recombinant azurocidin protein from the culture medium of the infected cells and showed that it retained the antimicrobial activity of the native neutrophil-derived molecule. In addition, we present evidence that a 49-amino-acid region of the recombinant azurocidin protein is required for its secretion from insect cells.

In vivo particle-mediated cytokine gene transfer into canine oral mucosa and epidermis

Cytokines can stimulate immune effector cells present within the oral mucosa and epidermis to respond to vaccination or to combat cancer. However, intravenous cytokine delivery is often inefficient and frequently accompanied by systemic toxicity. The goal of this study was to evaluate dogs as a large animal model for gene therapy of cancer because they develop spontaneous oral and epidermal tumors. In this report, we demonstrate that particle-mediated gene transfer of beta-galactosidase, luciferase, interleukin-2, interleukin-6, and granulocyte-macrophage colony stimulating factor (GM-CSF) complementary DNA (cDNA) into the oral mucosa and epidermis of healthy dogs resulted in effective, localized, transgenic protein expression. Additionally, the epidermal sites transfected with GM-CSF developed a profound inflammatory reaction characterized by neutrophilic infiltration. Clinical pathology analyses were unremarkable. These results demonstrate that in vivo particle-mediated gene transfer of canine oral mucosa and epidermis with cytokine cDNA can result in production of biologically active transgenic cytokines with minimal toxicity. These findings have applications to cancer immunotherapy using a gene gun approach.

Distinct parasegmental and imaginal enhancers and the establishment of the expression pattern of the Ubx gene

The expression domain of the Ubx gene in Drosophila embryos is bounded by the product of the hb gene, acting as a repressor. We show that all Ubx fragments that bind Hb protein in vitro contain parasegmental enhancers active in the embryo in specific parasegmental patterns. We have found three new embryonic enhancer elements in the upstream region, in addition to the two previously identified. Each produces a pattern initially bounded at PS6 by Hb but sooner or later breaks down this boundary and begins to express in the anterior region. These enhancers do not respond to the long-term maintenance mediated by the Polycomb group of genes. They also cease functioning after germ band extension. Expression in imaginal tissues is due to a set of entirely separate and independent imaginal disc enhancers. These do not contain Hb binding sites and by themselves have no anterior/posterior positional information, although some distinguish between ventral and dorsal discs. A third kind of element, the Polycomb Response Element (PRE), has no enhancer activity but causes long-term maintenance of the expression domain of other enhancers present in the vicinity. The interaction of these elements results in the correct expression of Ubx in imaginal tissues.

Gene gun-based nucleic acid immunization: elicitation of humoral and cytotoxic T lymphocyte responses following epidermal delivery of nanogram quantities of DNA

Particle-mediated (gene gun) DNA transfer to the epidermis was evaluated for its ability to elicit humoral and cytotoxic T lymphocyte responses using decreasing quantities of plasmid DNA-based antigen expression vectors. Using plasmids encoding human growth hormone, human alpha-1-antitrypsin, and influenza virus nucleoprotein, strong immune responses were observed in mice following immunization with as little as 16 ng of DNA using an electric discharge gene delivery system. Significant antibody titers were observed against these antigens following a primary immunization, with responses rising dramatically following a boost. Increasing the DNA dose above 16 ng per immunization had little beneficial effect. In contrast to particle-mediated DNA delivery, intramuscular or intradermal inoculation required greater than 5000-fold more DNA to achieve comparable results. Data are also presented demonstrating that a simple, hand-held version of the Accell DNA delivery system, employing compressed helium as the particle motive force, achieves immune responses comparable to the traditional electric discharge device.

In vivo and in vitro gene transfer to mammalian somatic cells by particle bombardment

Chimeric chloramphenicol acetyltransferase and beta-galactosidase marker genes were coated onto fine gold particles and used to bombard a variety of mammalian tissues and cells. Transient expression of the genes was obtained in liver, skin, and muscle tissues of rat and mouse bombarded in vivo. Similar results were obtained with freshly isolated ductal segments of rat and human mammary glands and primary cultures derived from these explants. Gene transfer and transient expression were also observed in eight human cell culture lines, including cells of epithelial, endothelial, fibroblast, and lymphocyte origin. Using CHO and MCF-7 cell cultures as models, we obtained stable gene transfer at frequencies of 1.7 x 10(-3) and 6 x 10(-4), respectively. The particle bombardment technology thus provides a useful means to transfer foreign genes into a variety of mammalian somatic cell systems. The method is applicable to tissues in vivo as well as to isolated cells in culture and has proven effective with all cell or tissue types tested thus far. This technology may therefore prove to be applicable in various aspects of gene therapy.

Modulation of levels of messenger RNA for tissue-type plasminogen activator in rat Sertoli cells, and levels of messenger RNA for plasminogen activator inhibitor in testis peritubular cells

Messenger RNA for tissue-type plasminogen activator has been detected in RNA extracts from rat Sertoli cells in culture. Relative levels are increased in Sertoli cells stimulated by follicle-stimulating hormone or by dibutyryl cyclic AMP (dbcAMP) and decreased in cells maintained in the presence of transforming growth factor beta, type 1 (TGF-beta 1). Messenger RNA for plasminogen activator inhibitor, type 1 (PAI-1) has been detected in RNA extracts from rat peritubular myoid cells. Relative levels are increased in peritubular cells stimulated by TGF-beta 1, and decreased by the presence of dbcAMP in the medium. Data are interpreted to indicate that net protease activities in the seminiferous tubule are regulated at transcriptional levels by endocrine and paracrine agents.

Androgens inhibit plasminogen activator activity secreted by Sertoli cells in culture in a two-chambered assembly

The addition of androgens (testosterone or dihydrotestosterone) resulted in decreased levels of detectable plasminogen activator activity in the medium when Sertoli cells were maintained in culture in a serum-free chemically defined medium in a two-chambered assembly. This occurred in the presence or absence of extracellular matrix or peritubular cells in the system. In the complete two-chambered assembly, addition of androgens simultaneously resulted in a small but significant increase in the integrity of the Sertoli cell barrier separating the two chambers, as indicated by slower rates of equilibration of [3H]methoxyinulin between inner and outer chambers. These responses to steroids appeared to be androgen specific, since other steroids examined (17 beta-estradiol, progesterone, and dexamethasone) had no detectable effects on levels of plasminogen activator activities or on barrier function. We confirmed that when FSH or (Bu)2cAMP is added to stimulate plasminogen activator secretion by Sertoli cells, the integrity of the barrier is decreased, provided no antiproteases are present in the serum-free medium. Simultaneous addition of androgens inhibited these effects of (Bu)2cAMP on Sertoli cells, but did not influence the responses of Sertoli cells to FSH. We compare actions of androgens on Sertoli cells in culture under various conditions and discuss the possible physiological significance of the inhibition of plasminogen activator activity.

Polar solvents in the chemoprevention of dimethylbenzanthracene-induced rat mammary cancer

Differentiating agents have been used experimentally and clinically as an adjuvant in the treatment of cancer, but their role in chemoprevention is limited. We used 5% dimethylsulfoxide (DMSO), 1% and 4% methylsulfonylmethane (MSM), 0.3% N-methylformamide (NMF), and retinol acetate (RA) in the chemoprevention of rat mammary breast cancer. One hundred fifty 42-day-old Sprague-Dawley rats were randomized into six groups (control, RA, DMSO, 1% MSM, NMF, and 4% MSM) and received chemopreventive agents along with standard rat chow ad libitum. Eight days later, 15 mg of 7,12-dimethylbenzanthracene was given by oral gastric intubation. The animals were examined weekly for tumor incidence and size (biplanar analysis). Animals were followed up for 240 to 300 days. Tumor incidence was not statistically affected. Time to appearance (latency period) of both tumors and cancers were prolonged by NMF, DMSO, and 4% MSM. Doubling times of all cancers produced were prolonged by DMSO and RA. No group exhibited toxic reactions or significant weight loss. Polar solvents and differentiating agents, specifically NMF, DMSO, and 4% MSM, were effective in the chemoprevention of dimethylbenzanthracene-induced mammary cancers.