A randomized double-blind feasibility study comparing cetirizine and diphenhydramine in the prevention of paclitaxel-associated infusion-related reactions: the PREMED-F1 study

Purpose

Cetirizine is a less sedative alternative to diphenhydramine for the prevention of infusion-related reactions (IRR) to paclitaxel. However, its use remains controversial. In this study, we assessed feasibility for a future definitive non-inferiority trial comparing cetirizine to diphenhydramine as premedication to prevent paclitaxel-related IRR.

Methods

This was a single-center randomized prospective feasibility study. Participants were paclitaxel-naive cancer patients scheduled to start paclitaxel chemotherapy. They were randomly assigned to receive either intravenous diphenhydramine 50 mg + oral placebo (control) or intravenous placebo + oral cetirizine 10 mg (intervention) for their first two paclitaxel treatments. The percentage of eligible patients completing a first paclitaxel treatment and the recruitment rate were assessed (feasibility outcomes). Drowsiness was measured at baseline and at selected time points using the Stanford Sleepiness Scale (SSS) (safety outcome). IRR events were also documented (efficacy outcome).

Results

Among 37 eligible patients, 27 were recruited and randomized (control 13; intervention 14) and 25 completed the study. The recruitment rate was 4.8 participants/month, meeting the primary feasibility target. Drowsiness was the main adverse effect associated with the premedication. The increase in drowsiness compared to baseline (ΔSSS) was greater in the diphenhydramine group compared to the cetirizine group (median ΔSSS 2 (IQR 3.25) vs median ΔSSS 0 (IQR 1), p < 0.01) when measured one hour after the premedication administration. One participant had an IRR and no unexpected serious adverse event occurred.

Conclusion

The trial methods were feasible in terms of recruitment, retention, and safety. Cetirizine was significantly less sedating than diphenhydramine. IRR were infrequent and a larger trial is warranted to confirm non-inferiority for IRR prevention.

Trial registration

ClinicalTrials.gov, NCT04237090 (22.01.2020).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06734-4.

A randomized double-blind pilot study comparing cetirizine with diphenhydramine in the prevention of paclitaxel-associated infusion-related reactions

e24080

Background: Cetirizine is a less sedative alternative to diphenhydramine for the prevention of infusion-related reactions (IRR) to paclitaxel. However, there is no prospective data to support its use in this context. In this study, we conducted a feasibility study for a future definitive non-inferiority trial comparing cetirizine with diphenhydramine as premedication to prevent paclitaxel-related IRR. Methods: This was a single center randomized double-blind parallel-group prospective pilot study. Participants were paclitaxel-naive cancer patients scheduled to start paclitaxel chemotherapy, alone or in combination. They were assigned to receive either intravenous diphenhydramine 50 mg + oral placebo (diphenhydramine group) or intravenous placebo + oral cetirizine 10 mg (cetirizine group) for their first two paclitaxel treatments. To assess the feasibility of a larger study, the percentage of eligible patients completing a first paclitaxel treatment and the recruitment rate were calculated. IRR events were documented. Change in drowsiness compared with baseline was assessed using the Stanford Sleepiness Scale (SSS). Results: Among 37 eligible patients, 27 were recruited and randomized (control 13; intervention 14) and 25 completed the study. The recruitment rate was 4.8 participants/month, meeting the primary feasibility target of 4 participants per month. One participant had an IRR (cetirizine group, CTCAE grade 2) and no unexpected serious adverse events occurred. Drowsiness was the main adverse effect associated with the premedication. The increase in drowsiness compared to baseline (ΔSSS) was greater in the diphenhydramine group compared to the cetirizine group (median ΔSSS 2 (IQR 3.25) vs median ΔSSS 0 (IQR 1), p < 0.01) when measured one hour after the administration of the premedication. Patient self-assessed moderate or intense discomfort caused by drowsiness was exclusively reported in the diphenhydramine group, by 4 out of 13 participants. Conclusions: The trial methods were feasible in terms of recruitment rate, retention and patient safety. IRR were infrequent and a larger trial is warranted to confirm non-inferiority for IRR prevention. Cetirizine was significantly less sedating than diphenhydramine when administered as premedication to prevent paclitaxel-associated IRR. Clinical trial information: NCT04237090. [Table: see text]

Mid-infrared spectroscopy of serum, a promising non-invasive method to assess prognosis in patients with ascites and cirrhosis

Background & aims

Prognostic tests are critical in the management of patients with cirrhosis and ascites. Biological tests or scores perform poorly in that situation. Mid-infrared fibre evanescent wave spectroscopy (MIR-FEWS) which allows for global serum metabolic profiling may provide more relevant information by measuring a wider range of metabolic parameters in serum. Here we present the accuracy of a MIR-FEWS based predictive model for the prognosis of 6 months survival in patients with ascites and cirrhosis.

Methods

Patients with ascites were prospectively included and followed up for 6 months. MIR-FEWS spectra were measured in serum samples. The most informative spectral variables obtained by MIR-FEWS were selected by FADA algorithm and then used to build the MIR model. Accuracy of this model was assessed by ROC curves and 90%/10% Monte Carlo cross-validation. MIR model accuracy for 6 months survival was compared to that of the Child-Pugh and MELD scores.

Results

119 patients were included. The mean age was 57.36±13.70, the MELD score was 16.32±6.26, and the Child-Pugh score was 9.5±1.83. During follow-up, 23 patients died (20%). The MIR model had an AUROC for 6 months mortality of 0.90 (CI95: 0.88–0.91), the MELD 0.77 (CI95: 0.66–0.89) and Child-Pugh 0.76 (CI95: 0.66–0.88). MELD and Child-Pugh AUROCs were significantly lower than that of the MIR model (p = 0.02 and p = 0.02 respectively). Multivariate logistic regression analysis showed that MELD (p<0.05, OR:0.86;CI95:0.76–0.97), Beta blockers (p = 0.036;OR:0.20;CI95:0.04–0.90), and the MIR model (p<0.001; OR:0.50; CI95:0.37–0.66), were significantly associated with 6 months mortality.

Conclusions

In this pilot study MIR-FEWS more accurately assess the 6-month prognosis of patients with ascites and cirrhosis than the MELD or Child-Pugh scores. These promising results, if confirmed by a larger study, suggest that mid infrared spectroscopy could be helpful in the management of these patients.

Chemotaxonomic discrimination of lichen species using an infrared chalcogenide fibre optic sensor: a useful tool for on-field biosourcing

Spectral analysis of lichen extracts obtained by MIR-FEWS permits to discriminate species and the identification of their major compounds. MIR-FEWS is a rapid, efficient and convenient tool for metabolic profiling.

A novel method for a fast diagnosis of septic arthritis using mid infrared and deported spectroscopy

OBJECTIVE

To assess the ability of mid infrared deported spectroscopy to discriminate synovial fluids samples of septic arthritis patients from other causes of joint effusion.

METHODS

Synovial fluids obtained from patients with clinically suspected arthritis were collected, analysed and classified according to standard diagnostic procedures as septic or non-septic. A spectroscopic analysis on synovial fluid samples was then performed using a coiled optical fiber made with chalcogenide glass. After a factorial analysis of the normalized spectra and the computation of a Fisher test used to select the most relevant components, a logistic regression model was fitted, allowing to attribute a score between 0 - non-septic -, and 1 - septic.

RESULTS

In a first phase, we analysed the synovial fluids from 122 different synovial fluids including 6 septic arthritis among arthritis of various origins. Septic synovial fluids were identified with a sensitivity of 95.8% and a specificity of 93.9% and an AUROC of 0.977. The analysis of an independent set of samples (n=42, including two septic arthritis) gave similar values.

CONCLUSIONS

Our data strongly supports the interest of mid infrared deported spectroscopy, which could be used potentially at point of care, for a rapid and easy diagnosis of septic arthritis. Now, the precision of the diagnosis must be evaluated through a multicentric study on a larger panel of patients.

Detection of the amoeba Entamoeba gingivalis in periodontal pockets

Periodontitis is a public health issue, being one of the most prevalent diseases worldwide. However, the aetiology of the disease is still unclear: genetics of patients cannot explain the dispersed or isolated localisation of gingival pockets, while bacteria-based models are insufficient to distinguish gingivitis and periodontitis. The possible role of parasites in the establishment of periodontitis has been poorly studied until now. The aim of this project was to study a potential link between colonisation of gingival crevices by the amoeba Entamoeba gingivalis and periodontitis. In eight different dental clinics in France, samples were taken in periodontal pockets (72) or healthy sites (33), and submitted to microscopic observation and molecular identification by PCR with a new set of primers designed to specifically detect E. gingivalis. This blind sample analysis showed the strong sensitivity of PCR compared with clinical diagnosis (58/72 = 81%), and microscopy (51/65 = 78%). The results of this work show that the parasites detected by microscopy mainly – if not exclusively – belong to the species E. gingivalis and that the presence of the parasite is correlated with periodontitis.

[Blood donation in urban areas]

Medical and technical developments increase the difficulty to provide sufficient safe blood for all patients in developed countries and their sociodemographic and societal changes. Sufficient national blood supply remains a reached, however still actual, challenge. Tomorrow is prepared today: the management of blood donation programs both in line with these developments and with social marketing strategies is one of the keys to success. If the main components of this organization are well known (mobile blood drives in various appropriate environments, and permanent blood donation centers) their proportions in the whole process must evolve and their contents require adaptations, especially for whole blood donation in urban areas. We have to focus on the people's way of life changes related to increasing urbanization of the society and prominent position taken by very large cities. This requires targeting several goals: to draw the attention of the potential blood-giving candidate, to get into position to collect him when he will decide it, to give meaning and recognition to his "sacrifice" (give time rather than donate blood) and to give him desire and opportunity to come back and donate one more time. In this strategy, permanent blood centers in urban areas have significant potential for whole blood collection, highlighted by the decrease of apheresis technology requirements. This potential requires profound changes in their location, conception and organization. The concept of Maison Du Don (MDD) reflects these changes.

Kerr spatial solitons in chalcogenide waveguides

Kerr spatial solitons are observed in slab chalcogenide waveguides at near-IR wavelengths. Waveguides are realized either by electron-beam evaporation or rf sputtering of a Ge-Sb-S compound deposited on oxidized silicon wafer. The Kerr coefficient of the thin film is evaluated to be 5 x 10(-18) m(2)/W from the experimentally required soliton power at 1.5 mum. Limitations due to material photosensitivity are revealed.

Chalcogenide coatings of Ge15Sb20S65 and Te20As30Se50

Chalcogenide coatings are investigated to obtain either optical components for spectral applications or optochemical sensors in the mid-infrared. The deposition of Ge(15)Sb(20)S(65) and Te(20)As(30)Se(50) chalcogenide glasses is performed by two physical techniques: electron-beam and pulsed-laser deposition. The quality of the film is analyzed by scanning electron microscopy, atomic force microscopy, and energy dispersive spectroscopy to characterize the morphology, topography, and chemical composition. The optical properties and optical constants are also determined. A CF(4) dry etching is performed on these films to obtain a channeled optical waveguide. For a passband filter made by electron-beam deposition, cryolite as a low-refractive-index material and chalcogenide glasses as high-refractive-index materials are used to favor a large refractive-index contrast. A shift of a centered wavelength of a photosensitive passband filter is controlled by illumination time.

Light trimming of a narrow bandpass filter based on a photosensitive chalcogenide spacer

We present an experimental study of the photosensitive properties of a narrow bandpass filter based on a Ge(15)Sb(20)S(65) spacer fabricated by electron beam deposition. For a single layer, near the optical bandgap of this chalcogenide material, the efficiency of the photo-bleaching increases as the central wavelength of the light source for exposure decreases. The maximum relative photo-induced change of the optical thickness reaches about 1%. By using controlled light exposure around 480 nm of a photosensitive narrow bandpass filter centered at 1550 nm, we obtained a spatially localized shift of its peak wavelength up to 5.4 nm. This property is used to perform, for the first time at our knowledge, the post trimming of a narrow bandpass filter with a light beam. A 5 x 5 mm(2) ultra uniform area in which the relative spatial variation of its peak wavelength remains below 0.004% is demonstrated.

Phosphatidylinositol-4,5-bisphosphate, PIP2, controls KCNQ1/KCNE1 voltage-gated potassium channels: a functional homology between voltage-gated and inward rectifier K+ channels

Phosphatidylinositol-4,5-bisphosphate (PIP(2)) is a major signaling molecule implicated in the regulation of various ion transporters and channels. Here we show that PIP(2) and intracellular MgATP control the activity of the KCNQ1/KCNE1 potassium channel complex. In excised patch-clamp recordings, the KCNQ1/KCNE1 current decreased spontaneously with time. This rundown was markedly slowed by cytosolic application of PIP(2) and fully prevented by application of PIP(2) plus MgATP. PIP(2)-dependent rundown was accompanied by acceleration in the current deactivation kinetics, whereas the MgATP-dependent rundown was not. Cytosolic application of PIP(2) slowed deactivation kinetics and also shifted the voltage dependency of the channel activation toward negative potentials. Complex changes in the current characteristics induced by membrane PIP(2) was fully restituted by a model originally elaborated for ATP-regulated two transmembrane-domain potassium channels. The model is consistent with stabilization by PIP(2) of KCNQ1/KCNE1 channels in the open state. Our data suggest a striking functional homology between a six transmembrane-domain voltage-gated channel and a two transmembrane-domain ATP-gated channel.

Transgenic mice overexpressing human KvLQT1 dominant-negative isoform. Part II: Pharmacological profile

OBJECTIVE

The acquired long QT syndrome results most often from the action of I(Kr) blocking-drugs on cardiac repolarization. We have evaluated a transgenic (TG) mouse (FVB) overexpressing a dominant-negative KvLQT1 isoform, as an in vivo screening model for I(Kr) blocking drugs.

RESULTS

In TG mice, six-lead ECGs demonstrated sinus bradycardia, atrioventricular block, and QTc prolongation. Various drugs were injected intraperitoneally after blockade of the autonomic nervous system and serial ECGs were recorded. The end of the initial rapid phase of the T wave corrected for heart rate using a formula for mouse heart (QTrc), was used as a surrogate for the QT interval. Dofetilide, a specific I(Kr) blocker, did not prolong the QTrc interval either in TG or in wild-type (WT) mice but dose-dependently lengthened the sinus period in TG mice but not in WT mice. Other I(Kr) blockers including E 4031, haloperidol, sultopride, astemizole, cisapride and terikalant behaved similarly to dofetilide. Tedisamil, a blocker of the transient outward current, dose-dependently prolonged the QTrc in WT mice but not in TG mice and also reduced the sinus rhythm in both WT and TG mice. Lidocaine dose-dependently shortened the QTrc interval in TG mice and also lengthened the P wave duration. Nicardipine dose-dependently shortened QTrc and also produced sinus arrest in both WT and TG mice.

CONCLUSIONS

We conclude that KvLQT1-invalidated TG mice discriminates in vivo drugs that blocks I(Kr) from drugs that block the transient outward current, the sodium current or the calcium current.

Transgenic mice overexpressing human KvLQT1 dominant-negative isoform. Part I: Phenotypic characterisation

OBJECTIVES

The KCNQ1 gene encodes the KvLQT1 potassium channel, which generates in the human heart the slow component of the cardiac delayed rectifier current, I(Ks). Mutations in KCNQ1 are the most frequent cause of the congenital long QT syndrome. We have previously cloned a cardiac KCNQ1 human isoform, which exerts a strong dominant-negative effect on KvLQT1 channels. We took advantage of this dominant-negative isoform to engineer an in vivo model of KvLQT1 disruption, obtained by overexpressing the dominant-negative subunit under the control of the alpha-myosin heavy chain promoter.

RESULTS

Three different transgenic lines demonstrated a phenotype with increasing severity. Functional suppression of KvLQT1 in transgenic mice led to a markedly prolonged QT interval associated with sinus node dysfunction. Transgenic mice also demonstrated atrio-ventricular block leading to occasional Wenckebach phenomenon. The atrio-ventricular block was associated with prolonged AH but normal HV interval in His recordings. Prolonged QT interval correlated with prolonged action potential duration and with reduced K(+) current density in patch-clamp experiments. RNase protection assay revealed remodeling of K(+) channel expression in transgenic mice.

CONCLUSIONS

Our transgenic mouse model suggests a role for KvLQT1 channels not only in the mouse cardiac repolarisation but also in the sinus node automaticity and in the propagation of the impulse through the AV node.

Electropharmacological characterization of cardiac repolarization in German shepherd dogs with an inherited syndrome of sudden death: abnormal response to potassium channel blockers

OBJECTIVES

This study sought to determine whether abnormal ventricular repolarization is implicated in cardiac arrhythmias of German shepherd dogs with inherited sudden death.

BACKGROUND

Moïse et al. (9) have identified German shepherd dogs that display pause-dependent lethal ventricular arrhythmias.

METHODS

Ventricular repolarization was studied both in vivo using electrocardiogram recordings on conscious dogs and in vitro with a standard microelectrode technique performed on endomyocardial biopsies and Purkinje fibers. Pharmacological manipulation was used to evaluate the role of potassium channels.

RESULTS

In control conditions, electrocardiogram parameters were similar in both groups of dogs, except for the PR interval (18% longer in affected dogs, p < 0.05). Injection of d,l-sotalol (2 mg/kg) prolonged QT interval more in affected dogs (+14%, n = 9) than it did in unaffected dogs (+6%, n = 6, p < 0.05) and increased the severity of arrhythmias in affected dogs. In vitro, in control conditions, action potential duration (APD90) of endomyocardial biopsies and Purkinje fibers were significantly longer in affected dogs (respectively 209 +/- 3 ms, n = 30 and 352 +/- 15 ms, n = 17) than they were in unaffected dogs (197 +/- 4 ms, n = 25 and 300 +/- 9 ms, n = 30) at a pacing cycle length (PCL) of 1,000 ms. This difference increased with PCL. The kinetics of adaptation of APD90 to a change in PCL was faster in affected dogs. D,l-sotalol (10(-5) and 10(-4)M) increased APD90 in both groups of dogs, but this increase was greater in affected dogs, with the occurrence of triggered activity on Purkinje fibers. E-4031 (10(-7) and 10(-6) M), an I(Kr)-blocker, increased APD90 similarly in both groups of dogs. Chromanol 293B (10(-6) and 10(-5)M), an I(Ks)-blocker, increased significantly APD90 in unaffected dogs but had no effect in affected dogs.

CONCLUSIONS

These results support the hypothesis of an abnormal cardiac repolarization in affected dogs. The effects of 293B suggest that I(Ks) may be involved in this anomaly.

Differential expression of KvLQT1 isoforms across the human ventricular wall

Long Q-T mutant (KvLQT1) K(+) channels associate with their regulatory subunit IsK to produce the slow component of the delayed rectifier potassium (I(Ks)) cardiac current. The amplitude of KvLQT1 current depends on the expression of a KvLQT1 splice variant (isoform 2) that exerts strong dominant negative effects on the full-length KvLQT1 protein (isoform 1). We used RNase protection assays to determine the relative expression of KvLQT1 isoforms 1 and 2 and IsK mRNAs in human ventricular layers. Overall expression of KvLQT1 and IsK genes was similar in the three layers. However, there was a significant difference in the ratio between KvLQT1 isoforms 1 and 2. Isoform 2 represented 25.2 +/- 2.3%, 31.7 +/- 1.2%, and 24.9 +/- 1.7% of total KvLQT1 expression in left ventricular endocardial, midmyocardial, and epicardial tissues, respectively. Similar data were obtained from right ventricular samples. COS-7 cells were intranuclearly injected with KvLQT1 isoforms 1 or 2 plus IsK cDNAs, using two different isoform 2-to-isoform 1 ratios. Cells injected with an isoform 2-to-isoform 1 ratio mimicking that in the midmyocardium showed a K(+) current with approximately 75% reduced amplitude compared with those injected with a ratio mimicking that in the epicardium. Our results suggest that differential expression of KvLQT1 isoform 2 in endocardial, midmyocardial, and epicardial tissues is responsible for differential I(Ks) amplitude and contributes to the regional action potential heterogeneity observed across the ventricular wall.

Effects of chronic treatment by amiodarone on transmural heterogeneity of canine ventricular repolarization in vivo: interactions with acute sotalol

OBJECTIVE

The present study was designed to examine the effects of chronic amiodarone on the different ventricular cell subtypes in situ and to evaluate its interactions with sotalol.

METHODS

Three groups of dogs were studied. Group I (n = 8) received no treatment. Group II (n = 7) and group III (n = 8) received, respectively, 100 and 200 mg amiodarone orally twice a day for 6 weeks to 8 months. In vivo studies were performed under halothane anesthesia 14 h after the last administration of amiodarone. Three leads ECG, femoral blood pressure and left ventricular intramural monophasic action potentials (MAP) were continuously recorded. Bradycardia was obtained by clamping the sinus node and beta-blockade and the heart was driven by atrial pacing. Three weeks before the in vivo experiments, the cellular electrophysiologic properties of right ventricular tissues obtained by cardiac biopsy in six treated and six control dogs were studied with standard microelectrodes.

RESULTS

Amiodarone produced a dose-dependent decrease in plasma levels of triiodothyronine (T3; 5.9 +/- 0.4 pM in control dogs, 3.1 +/- 0.2 pM in group III, P < 0.001) without affecting thyroxine (T4). Under anesthesia, the QT interval was 14% larger in group III compared to group I at a paced cycle length (PCL) of 1500 ms (P < 0.05). This is consistent with the 10% increase in endocardial MAP duration in group III at the same PCL (P < 0.05). There was no significant increase in transmural dispersion of MAP duration. In group I, sotalol induced a significant reverse use-dependent increase in MAP duration. This effect was reduced in group II and completely suppressed in group III. Amiodarone prevented the sotalol-induced increase in transmural dispersion of ventricular repolarization which was 69 +/- 12 ms in untreated dogs, 41 +/- 8 ms in group II (P < 0.05) and 34 +/- 8 ms (P < 0.05) in group III at PCL = 1500 ms. Amiodarone also prevented the sotalol-induced ventricular tachyarrhythmias. In vitro, the action potential duration was longer in amiodarone-treated dogs that in control ones (208 +/- 5 ms versus 188 +/- 9 ms at PCL = 1000 ms, P < 0.05). The sotalol-induced prolongation of repolarization was reduced in amiodarone-treated dogs.

CONCLUSION

Chronic treatment of dogs with amiodarone induced a moderate prolongation of the QT interval and MAP duration without affecting transmural dispersion of repolarization and inhibited the effects of acute sotalol, including the prolongation of repolarization, the increase in transmural dispersion of repolarization and the induction of arrhythmias.

Abnormal cardiac repolarization and impulse initiation in German shepherd dogs with inherited ventricular arrhythmias and sudden death

OBJECTIVE

We tested the hypothesis that delayed afterdepolarization (DAD)-associated rhythms in German shepherd dogs with reduced anteroseptal left ventricular (LV) sympathetic innervation derive from abnormal beta-adrenergic receptor effector coupling.

METHODS AND RESULTS

In anteroseptal LV midmyocardium of afflicted dogs, beta-receptor density was greater than that in normal dogs (P < .05), with affinity being equal in both groups. Basal and maximum isoproterenol (ISO) stimulated adenylyl cyclase activity of anteroseptal LV of afflicted dogs was greater than that in normal dogs (P < .05). Isolated anteroseptal M cell preparations of afflicted dogs studied with microelectrodes showed abnormal lengthening, rather than shortening of action potential duration in response to ISO, as well as a 61% incidence of 10(-7) mol/l ISO-induced triggered activity as compared to 12% in normals (P < .05). In contrast, there was no difference between afflicted and control dogs in triggered activity, beta-receptors or adenylyl cyclase activity in a normally innervated region of the ventricles.

CONCLUSION

In this model there is an increase in beta-receptor density and beta-adrenergic stimulation of adenylyl cyclase and of triggered activity in anteroseptal myocardium but not in a normally innervated region of the heart. Hence, abnormal beta-adrenergic signal transduction appears associated with the neural abnormality identified in dogs with inherited VT.

Adult KCNE1-knockout mice exhibit a mild cardiac cellular phenotype

The KCNE1 gene encodes a channel regulator IsK which in association with the KvLQT1 K+ channel protein determines the slow component of the cardiac delayed rectifier current. We have investigated the cellular electrophysiological characteristics of adult KCNE1-knockout mouse hearts by means of the standard microelectrode technique. Action potential parameters from the ventricular endocardium of KCNE1 -/- mice were indistinguishable from those of KCNE1 +/+ animals. In particular, KCNE1 -/- hearts did not exhibit prolonged repolarization. E-4031, a specific blocker of erg K+ channels consistently prolonged repolarization in KCNE1 +/+ but not in KCNE1 -/- hearts. By contrast, the chromanol compound 293B, a specific blocker of KvLQT1 K+ channel produced comparable effects on repolarization in KCNE1 -/- and KCNE1 +/+ mice. We conclude that invalidation of the mouse KCNE1 gene by homologous recombination leads to a mild cardiac phenotype at the cellular level.

Apparent reactivation of a red cell alloantibody in a healthy individual after G-CSF administration

Granulocyte-colony stimulating factor (G-CSF) has been successfully administered to healthy subjects to mobilize peripheral blood stem cells (PBSC) for allogeneic transplantation. Adverse events are moderate. We report the first case of apparent reactivation of an alloantibody to a blood cell antigen (Jk(a)) after G-CSF administration to a healthy subject and its transmission to the PBSC transplant recipient; no concomitant reactivation of other alloantibodies was detected. This case raises questions on the effect of G-CSF on the immune system and its safety in healthy individuals.

Amiodarone reduces transmural heterogeneity of repolarization in the human heart

OBJECTIVES

The present work was designed to test the effects of amiodarone therapy on action potential characteristics of the three cell types observed in human left ventricular preparations.

BACKGROUND

The electrophysiologic basis for amiodarone's exceptional antiarrhythmic efficacy and low proarrhythmic profile remains unclear.

METHODS

We used standard microelectrode techniques to investigate the effects of chronic amiodarone therapy on transmembrane activity of the three predominant cellular subtypes (epicardial, midmyocardial [M] and endocardial cells) spanning the human left ventricle in hearts explanted from normal, heart failure and amiodarone-treated heart failure patients.

RESULTS

Tissues isolated from the ventricles of heart failure patients receiving chronic amiodarone therapy displayed M cell action potential duration (404+/-12 ms) significantly briefer (p < 0.05) than that recorded in tissues isolated from normal hearts (439+/-22 ms) or from heart failure patients not treated with amiodarone (449+/-18 ms). Endocardial cells from amiodarone-treated heart failure patients displayed longer (p < 0.05) action potential duration (363+/-10 ms) than endocardial cells isolated from normal hearts (330+/-6 ms). As a consequence, the heterogeneity of ventricular repolarization in tissues from patients treated with amiodarone was considerably smaller than in the two other groups, especially at long pacing cycle lengths.

CONCLUSIONS

These findings may explain, at least in part, the reduction of ventricular repolarization dispersion and the lower incidence of torsade de pointes observed with chronic amiodarone therapy as compared with other class III agents.

A dominant negative isoform of the long QT syndrome 1 gene product

Mutations in the KvLQT1 gene are the cause of the long QT syndrome 1. KvLQT1 gene product is associated with the regulator protein IsK to produce a component of the delayed rectifier K+ current in cardiac myocytes. We identified an N-terminal truncated isoform of the KvLQT1 gene product, referred to as isoform 2. In RNase protection assays, isoform 2 represented 28.1 +/- 0.6% of the total KvLQT1 expression in the human adult ventricle. COS-7 cells injected intranuclearly with KvLQT1 isoform 1 cDNA exhibited a fast-activating K+ current, whereas those injected with a KvLQT1 isoform 1 plus IsK cDNA showed a slow-activating K+ current. Cells injected with KvLQT1 isoform 2 plasmid showed no detectable K+ current. Those injected with a 1/1 isoform 2/isoform 1 ratio showed no detectable K+ current. Those injected with 1/5 and 2/5 ratios showed a K+ current with markedly reduced amplitude. Coexpression of the IsK regulator consistently reduced the dominant negative effects of isoform 2. Our results indicate that KvLQT1 isoform 2 exerts a pronounced negative dominance on isoform 1 channels and that the cardiac KvLQT1 K+ channel complex is composed of at least three different proteins as follows: isoform 1, isoform 2, and IsK.

[QT interval and drugs. Recommendation for drug prescription for patients with long QT syndrome. Clinical Research Group of INSERM 4940 12: Diagnostic Clinic of Congenital Long QT Syndrome]

The genetics of the long QT syndrome are now better understood. However, there is much heterogeneity as three different genes have already been identified affecting the function of sodium and potassium channels. The aim of these recommendations is to draw up a list of drugs which are contraindicated or not recommended in patients with congenital long QT syndromes. The conraindicated drugs are those with which torsades de pointe have already been described. Drugs not recommended are substances which are not electrohysiologically neutral and for which, in view of their modes of action, their metabolism or belonging to a particular therapeutic class, make them very difficult to use in those patients. It is therefore better not to prescribe them whenever possible in this condition. These substances belong mainly to cardiovascular (especially antiarrhythmic), psychotropic, anti-infectious and antiallergic groups of drugs.

KvLQT1 potassium channel but not IsK is the molecular target for trans-6-cyano-4-(N-ethylsulfonyl-N-methylamino)-3-hydroxy-2,2-dimethyl- chromane

Mutations in the KvLQT1 gene are the cause for the long QT syndrome [Circulation 94:1996-2012 (1996)]. Coexpression of KvLQT1 in association with the channel regulator protein IsK produces a K+ current with characteristics reminiscent of the slow component of the delayed rectifier in cardiac myocytes. We explored the pharmacological properties of trans-6-cyano-4-(N-ethylsulfonyl-N-methylamino)-3-hydroxy-2,2-dime thyl- chromane (293B), a chromanol compound, on the K+ current produced by direct intranuclear injection of KvLQT1 and IsK cDNA plasmids in COS-7 cells. Injected cells were recorded by means of the whole-cell and cell-attached patch-clamp configurations under chloride-free conditions. Cells injected with KvLQT1 cDNA alone exhibited a fast-activating outward K+ current, whereas cells coinjected with KvLQT1 plus IsK cDNAs exhibited a time-dependent outward current with slower activation kinetics. The chromanol 293B blocked the K+ current related to KvLQT1 expression in both the absence or presence of IsK. The IC50 value for 293B to block KvLQT1-related current was not significantly modified by the presence of IsK (9.9 microM in the absence of IsK versus 9.8 microM in its presence). The block produced by 293B was strongly voltage-dependent inasmuch as it was close to 0 at -80 mV and occurred during a depolarizing voltage step. The time constants for the drug to block the current were in the same order of magnitude as activation kinetics of the current. Kinetics for drug unblock at the holding potential were much faster, in the order of a few tenths of a msec. KvLQT1 currents recorded in the cell-attached configuration were also blocked by externally applied 293B, suggesting that the compound penetrated the cell to block the channel. Cromakalim, another chromanol compound, also blocked KvLQT1 currents. Our results show that the chromanol compound 293B is targeted to KvLQT1 channels but not to the IsK regulator.

Age-related differences in beta-adrenergic regulation of repolarization in canine epicardial myocytes

Developmental changes occur in beta-adrenergic modulation of repolarization in canine. Purkinje fibers that may have important implications for rhythm and arrhythmias. No comparable data exist for ventricular myocardium. Therefore, we studied developmental changes in beta-adrenergic regulation of repolarization and delayed rectifier potassium current (IK) in canine ventricular epicardium. We first investigated the effects of isoproterenol (Iso) on action potentials (AP) recorded from epicardial slices with standard microelectrodes, and then we further determined the mechanisms of Iso action using the nystatin-perforated patch technique on isolated epicardial myocytes. In microelectrode studies Iso (10(-7) M) induced a shortening of the AP in preparations from adult dogs but not in those from dogs < 30 days old. These results were confirmed on AP recorded from single myocytes. Although the plateau was increased by Iso at all ages, the AP at 90% of repolarization was shortened (P < 0.05, n = 6) in adult but unchanged in < 30-day-old myocytes (NS, n = 6). Voltage-clamp studies showed that IK of adult cells was increased from a control value of 10.23 +/- 1.87 to 13.43 +/- 1.92 pA/pF with Iso (step to +50 mV, P < 0.05, n = 6), but IK was not modified in cells from young animals (6.49 +/- 2.72 pA/pF in control and 6.56 +/- 2.62 pA/pF with Iso, n = 4). Increasing the Iso concentration to 10(-5) M failed to increase IK significantly (n = 4). However, 10(-7) M Iso did increase L-type Ca2+ current from 172 +/- 31 to 262 +/- 42 pA (P < 0.05, n = 4), consistent with the effect to increase the AP plateau. These results show that there are developmental changes in beta-adrenergic regulation of repolarization in canine epicardium and that the control site of developmental changes is in the IK channel rather than the beta-adrenergic receptor cascade.

Beta-adrenergic modulation of Na-K pump activity in young and adult canine cardiac Purkinje fibers

We used standard microelectrode techniques to study the developmental changes and beta-adrenergic modulation of membrane potential and of Na-K pump activity in adult (> 1 yr of age) and neonatal (2-10 days) canine Purkinje fibers. Isoproterenol (10(-7) M) increased the rate of development and magnitude of pacing-induced hyperpolarization of adult fibers driven at a 1-s cycle length. This effect of isoproterenol was attenuated by treating dogs with pertussis toxin (PTX), (30 micrograms/kg). Other adult and neonatal fibers were superfused with a Tyrode solution containing Ba2+ 0.2 mM, Cs+ 2 mM, and 10(-6) M verapamil, thus leading to depolarization and cessation of spontaneous activity. The Na-K pump was studied by alternating solutions containing [K] at 0 mM (inhibiting the pump) and 4 mM (reactivating the pump). Although the kinetics of the Na-K pump appeared faster in neonatal fibers than in adult fibers, measurement of cell surface-to-volume ratio compensated for the difference. We therefore conclude that 1) the apparent age-related changes in Na-K pump activity in canine Purkinje fibers in fact reflect cell surface-to-volume ratio and, 2) the beta-adrenergic agonist-induced hyperpolarization in adults requires the presence of a PTX-sensitive G protein for its occurrence.

Functional beta3-adrenoceptor in the human heart

Beta3-adrenoceptors are involved in metabolism, gut relaxation, and vascular vasodilation. However, their existence and role in the human heart have not been documented. We investigated the effects of several beta-adrenoceptor agonists and antagonists on the mechanical properties of ventricular endomyocardial biopsies. In the presence of nadolol, a beta1- and beta2-adrenoceptor antagonist, isoprenaline produced consistent negative inotropic effects. Similar negative inotropic effects also resulted from the action of beta3-adrenoceptor agonists with an order of potency: BRL 37344 > SR 58611 approximately CL 316243 > CGP 12177. The dose-response curve to BRL 37344-decreasing myocardial contractility was not modified by pretreatment with nadolol, but was shifted to the right by bupranolol, a nonselective beta-adrenoceptor antagonist. Beta3-adrenoceptor agonists also induced a reduction in the amplitude and an acceleration in the repolarization phase of the human action potential. Beta3-adrenoceptor transcripts were detected in human ventricle by a polymerase chain reaction assay. These results indicate that: (a) beta3-adrenoceptors are present and functional in the human heart; and (b) these receptors are responsible for the unexpected negative inotropic effects of catecholamines and may be involved in pathophysiological mechanisms leading to heart failure.

alpha1-adrenergic stimulation induces early afterdepolarizations in ferret Purkinje fibers

The aim of this study was to evaluate whether alpha1-adrenergic stimulation, which prolongs repolarization, could induce early afterdepolarizations (EADs) in ferret Purkinje fibers. We used standard microelectrodes to study the effects of phenylephrine 10(-6)M in the presence of metoprolol 1.5 x 10(-6)M, on action potentials (AP) recorded from isolated ferret Purkinje fibers superfused with normal Tyrode's solution. Phenylephrine induced a time-dependent prolongation of the AP duration at 60 and 90% of full repolarization (APD60, APD90) from 223 +/- 8 and 269 +/- 9 ms, respectively, during control to 279 +/- 11 and 329 +/- 12 ms after 1-h superfusion (n = 29; p < 0.05 vs. control for both parameters) and 334 +/- 13 and 385 +/- 15 ms after 4 h (n = 29, p < 0.05 vs. control and 1-h superfusion for both parameters) without changing the other parameters. About one third of the fibers studied developed EADs that could be either phase 2 or phase 3 EADs. The alpha1-adrenoceptor antagonist WB 4101 (10(-7)M) limited the AP prolongation and prevented the occurrence of EADs. On the other hand, the alpha1-adrenoceptor alkylating agent chloroethylclonidine (10(-7)M) had no effect. The calcium chelator BAPTA [1,2-bis(2-aminophenoxy) ethane-N,N,N',N'-tetra-acetic acid] (2 x 10(-3)M) did not prevent the induction of EADs by phenylephrine, although it suppressed the twitch tension, showing that it did chelate the intracellular calcium. Our results show that alpha1-adrenergic stimulation prolongs repolarization in ferret Purkinje fibers and can induce EADs. This effect is mainly mediated by the WB 4101-sensitive alpha1-adrenoceptors (alpha1A- and/or alpha1C-adrenoceptors) and does not depend on intracellular calcium. alpha1-Adrenergic stimulation may have arrhythmogenic effects in patients with long QT syndrome (LQTS).

Mapping of a gene for long QT syndrome to chromosome 4q25-27

Long QT syndrome (LQTS) is a heterogeneous inherited disorder causing syncope and sudden death from ventricular arrhythmias. A first locus for this disorder was mapped to chromosome 11p15.5. However, locus heterogeneity has been demonstrated in several families, and two other loci have recently been located on chromosomes 7q35-36 and 3p21-24. We used linkage analysis to map the locus in a 65-member family in which LQTS was associated with more marked sinus bradycardia than usual, leading to sinus node dysfunction. Linkage to chromosome 11p15.5, 7q35-36, or 3p21-24 was excluded. Positive linkage was obtained for markers located on chromosome 4q25-27. A maximal LOD score of 7.05 was found for marker D4S402. The identification of a fourth locus for LQTS confirms its genetic heterogeneity. Locus 4q25-27 is associated with a peculiar phenotype within the LQTS entity.

Electrophysiologic characteristics of cells spanning the left ventricular wall of human heart: evidence for presence of M cells

OBJECTIVES

The present work was designed to provide an initial characterization of M cells in the normal human heart.

BACKGROUND

Recent studies have uncovered a unique population of cells in the midmyocardial region of the canine ventricle. These cells, named M cells, were found to possess electrophysiologic features and a pharmacologic responsiveness different from those of other myocardial cells. Although well characterized in the dog, their presence or absence in the human heart is unknown.

METHODS

Standard microelectrode techniques were used to map slices of ventricular free wall obtained from normal human hearts (n = 4). Preparations were paced at cycle lengths ranging from 1 to 10 s.

RESULTS

We identified three cell subtypes: endocardial, subepicardial (M cells) and epicardial cells. The principal features differentiating M cells from the other cell subtypes were their longer action potential duration, more accentuated action potential duration rate relations and greater maximal rate of increase in action potential upstroke (Vmax). Our findings suggest that M cells represent approximately 30% of the cellular mass of the left ventricular wall. Concordance between changes in their repolarization and changes in QTU interval provide support for the role of M cells in the generation of the electrocardiographic (ECG) U wave.

CONCLUSIONS

This study provides evidence for the existence of M cells in the human heart that contribute to heterogeneity of repolarization within the ventricular wall. Our findings provide strong support for the hypothesis that M cells contribute importantly to the manifestation of the U wave on the ECG.

Endomyocardial biopsies: a new approach for studying the electrical and mechanical properties of human ventricular myocardium

The novel endomyocardial biopsy approach described here could facilitate the study of some human pathologies for which tissue specimens are currently unavailable. Electrical and mechanical characteristics such as rat responses, effect of extracellular calcium concentration changes and beta-adrenergic tone were similar to those determined for other human ventricular tissues, indicating that endomyocardial biopsies are suitable for physiological studies. This new source of cardiac tissues should facilitate the investigation of cellular mechanisms involved in the development of previously inaccessible human diseases.

Beta-adrenergic regulation of action potentials and automaticity in young and adult canine purkinje fibers

To investigate developmental changes in the cellular electrophysiological effects of beta 1- and beta 2-adrenoceptor stimulation on canine Purkinje fibers (PF), we studied the effects of isoproterenol, a nonselective beta-agonist, and salbutamol, a preponderantly beta 2-agonist, alone or in presence of the selective beta 1-antagonist CGP-20712A or the beta 2-antagonist ICI-118551. Standard microelectrode techniques were used to study adult and neonatal (< 11 days) PF paced at a cycle length of 1 s or allowed to beat spontaneously. In paced adult PF, isoproterenol significantly increased the maximum diastolic potential and significantly decreased action potential duration at 60 and 90% of full repolarization (APD60 and APD90) in a concentration-dependent fashion. These effects were not observed in neonatal PF, which instead manifested a significant increase in phase 2 amplitude and APD30 that was not observed in adult PF. All these effects occurred as well with salbutamol but were less pronounced and required higher agonist concentrations. Isoproterenol decreased the automatic cycle length of adult fibers from 4,079 +/- 796 ms during control to 2,190 +/- 229 ms at 10(-5) M (P < 0.05) and from 1,535 +/- 105 to 1,249 +/- 90 ms in neonatal PF (P < 0.05). In both adults and neonates, > 90% of this effect was reached at a concentration of 10(-8) M. Salbutamol had the same effect but required higher concentrations. In both adults and neonates, the beta 2-antagonist ICI-118551 did not modify any of the effects of isoproterenol and salbutamol, whereas the beta 1-antagonist CGP-20712A significantly antagonized them. In conclusion, 1) the effects of beta-adrenergic stimulation on transmembrane potentials of canine PF change during development, both qualitatively (in paced PF) and quantitatively (in automatic PF) and 2) the responses seen are attributable to the activation of beta 1- and not beta 2-adrenoceptors.

Immunotherapy with interleukin-2 (IL2) and lymphokine-activated natural killer cells: improvement of clinical responses in metastatic renal cell carcinoma patients previously treated with IL2

Treatment with interleukin-2 (IL2) induces clinical responses in 15-30% of metastatic renal cell carcinoma (MRCC) patients, with mainly partial responses. In order to improve clinical response, we decided to treat partial response patients from a previous IL2 treatment with a second course of IL2 associated with lymphokine-activated natural killer (LANAK) cells. 10 patients who underwent PR after an IL2 protocol (24 x 10(6) U/m2/day, 2 days a week for 5 weeks, either alone or with interferon-gamma) subsequently received a combination of high-dose IL2 (16-20 x 10(6) U/m2/day, 2 days a week) and LANAK cell infusions. Four complete responses were obtained, and 2 additional patients whose tumour mass was further reduced achieved complete response following surgery. These results support the view that initial responses obtained with primary IL2 courses can be improved by complementary treatments. The potential role of cellular immunotherapy and, more particularly, of LANAK cells as an effective procedure to further reduce tumour burden in patients responsive to IL2 will have to be assessed in randomised studies.

Early after/depolarizations and triggered activity: mechanisms and autonomic regulation

An early after/depolarization (EAD) is an abnormality of the repolarization process of an action potential which causes an interruption or a retardation of normal repolarization. Two types were described: phase 3 EADs occur at a takeoff potential of approximately-60 mV and phase 2 EADs occur at the end of a prolonged plateau at a takeoff potential of between-10 and-30 mV. EADs can result from an increase in inward current, a reduction of outward current or both. EADs show cycle-length dependence: as cycle length increases and repolarization lengthens, EADs occur, and their magnitude increases, at a critical cycle length, can trigger the action potential of these EADs. The autonomic nervous system can also modulate EADs and trigger activity. In cesium-intoxicated Purkinje fibers, beta-adrenergic stimulation increases EAD magnitude and the occurrence of triggered activity. Cholinergic stimulation decreases EAD magnitude and suppresses triggered activity occurring after beta-adrenergic stimulation. Alpha 1-adrenergic stimulation has no effect on phase 3 EADs but induces phase 2 EADs. In normal Tyrode's solution (0 cesium), phenylephrine prolongs action potential and induces EADs. This effect seems to depend on alpha 1 A stimulation. These electrogenic abnormalities are supposed to be responsible for long QT and torsades de pointes. As our experimental data have shown that both the rate of stimulation and the autonomic nervous system could modulate EADs and trigger activity, we can speculate on the therapeutic implications of such modulations and the role of pacing as well as alpha- and beta-adrenergic antagonists.