High-Level Spinal Cord Injury and the Failure of US Acute Rehabilitation: An Analysis and Commentary

ABSTRACT

Acute and long-term morbidity and mortality rates have not changed in the United States for people with high-level spinal cord injury in 40 yrs, neither has the conventional invasive respiratory management for these patients. This is despite a 2006 challenge to institutions for a paradigm shift to avoid or decannulate patients of tracheostomy tubes. Centers in Portugal, Japan, Mexico, and South Korea decannulate high-level patients to up to continuous noninvasive ventilatory support and use mechanical insufflation exsufflation, as we have done and reported since 1990, but there has been no such paradigm shift in US rehabilitation institutions. The quality of life and financial consequences of this are discussed. An example of decannulation of a relatively easy case, after failure to do so during 3 mos of acute rehabilitation, is presented to encourage institutions to begin to learn and apply noninvasive management before decannulating more severe patients with little to no ventilator free breathing ability.

Inhibition of IRF5 hyperactivation protects from lupus onset and severity

The transcription factor IFN regulatory factor 5 (IRF5) is a central mediator of innate and adaptive immunity. Genetic variations within IRF5 are associated with a risk of systemic lupus erythematosus (SLE), and mice lacking Irf5 are protected from lupus onset and severity, but how IRF5 functions in the context of SLE disease progression remains unclear. Using the NZB/W F1 model of murine lupus, we show that murine IRF5 becomes hyperactivated before clinical onset. In patients with SLE, IRF5 hyperactivation correlated with dsDNA titers. To test whether IRF5 hyperactivation is a targetable function, we developed inhibitors that are cell permeable, nontoxic, and selectively bind to the inactive IRF5 monomer. Preclinical treatment of NZB/W F1 mice with an inhibitor attenuated lupus pathology by reducing serum antinuclear autoantibodies, dsDNA titers, and the number of circulating plasma cells, which alleviated kidney pathology and improved survival. Clinical treatment of MRL/lpr and pristane-induced lupus mice with an inhibitor led to significant reductions in dsDNA levels and improved survival. In ex vivo human studies, the inhibitor blocked SLE serum-induced IRF5 activation and reversed basal IRF5 hyperactivation in SLE immune cells. We believe this study provides the first in vivo clinical support for treating patients with SLE with an IRF5 inhibitor.

Not all Sicca is Sjögren's and not all Sjögren's is Sicca

Symptoms of dry eyes or dry mouth, otherwise known as sicca symptoms, are not always present in patients with Sjögren's syndrome (SS). Approximately 20% of patients with SS do not have sicca symptoms. An unusual case of a patient presenting with complete left-sided facial hemiparesis, a history of partial bilateral sensorineural hearing loss who was found to have elevated antinuclear antibody (ANA) with high titer positive SSA/Ro antibody, evidence of bilateral parotitis on imaging and absence of sicca symptoms, prompted us to perform a literature review. Twelve case reports relating facial nerve palsy and Sjögren's were found and only one described a similar constellation of features of unilateral facial weakness and otalgia. Management of facial nerve palsy related to Sjögren's is unclear but pharmacological agents have included corticosteroids, intravenous immune globulin (IVIG), cyclophosphamide, and plasmapheresis. This case report describes a patient whose facial nerve palsy is attributed to SS, explores peripheral and central nervous system involvement in SS, and provides some recommended treatments. 

RNAi Transfection Optimized in Primary Naïve B Cells for the Targeted Analysis of Human Plasma Cell Differentiation

Upon antigen recognition, naïve B cells undergo rapid proliferation followed by differentiation to specialized antibody secreting cells (ASCs), called plasma cells. Increased circulating plasma cells are reported in patients with B cell-associated malignancies, chronic graft-vs.-host disease, and autoimmune disorders. Our aim was to optimize an RNAi-based method that efficiently and reproducibly knocks-down genes of interest in human primary peripheral B cells for the targeted analysis of ASC differentiation. The unique contributions of transcriptional diversity in species-specific regulatory networks and the mechanisms of gene function need to be approached directly in human B cells with tools to hone our basic inferences from animal models to human biology. To date, methods for gene knockdown in human primary B cells, which tend to be more refractory to transfection than immortalized B cell lines, have been limited by losses in cell viability and ineffective penetrance. Our single-step siRNA nucleofector-based approach for human primary naïve B cells demonstrates reproducible knockdown efficiency (~40–60%). We focused on genes already known to play key roles in murine ASC differentiation, such as interferon regulatory factor 4 (IRF4) and AID. This study reports a validated non-viral method of siRNA delivery into human primary B cells that can be applied to study gene regulatory networks that control human ASC differentiation.

IRF4 and IRF5 transcription factors exhibit shared and distinct roles in regulating human B cell differentiation and function

Upon recognition of antigen, B cells undergo rapid proliferation followed by differentiation to specialized antibody secreting cells (ASCs). Increased levels of ASCs are seen in autoimmune diseases, such as systemic lupus erythematosus (SLE), and some B cell-associated malignancies. Studies suggest that altered transcription factor (TF) expression and/or activation play a role in the imbalance of B cell subsets in these diseases. Interferon regulatory factor 5 (IRF5) is one such TF, as polymorphisms in IRF5 associate with risk of numerous autoimmune diseases and correlate with elevated IRF5 expression in SLE patients. Recent findings from IRF5 knockdown (KD) in purified naïve B cells identified IRF5 as an early intrinsic regulator of B cell activation, proliferation and plasma cell differentiation in response to TLR9 activation. In this study, IRF4 was identified as a new IRF5 target gene by ChIP-Seq and RNA-Seq analysis. IRF4 expression is high in ASCs and murine studies show that it plays an essential, cell-intrinsic role in the generation of germinal center B cells. To date, little is known of IRF4 function in human ASC differentiation or whether these two factors (IRF4 and 5) cooperate. Activation of TLR9 and B cell receptor (BCR) revealed distinct kinetic changes in IRF4 and IRF5 during the early transition of naïve B cells to ASCs. Moreover, IRF4 KD of human primary naïve B cells resulted in significant IgD retention and reduced plasmablast (PB) differentiation without loss of early B cell activation (CD86) or key regulatory factors of class switch recombination in response to TLR9/BCR stimulation. Together, these results show that IRF4 and IRF5 are kinetically distinct TFs that have non-redundant roles in human ASC differentiation.

B Cell-Intrinsic Role for IRF5 in TLR9/BCR-Induced Human B Cell Activation, Proliferation, and Plasmablast Differentiation

Upon recognition of antigen, B cells undergo rapid proliferation followed by differentiation to specialized antibody secreting cells (ASCs). During this transition, B cells are reliant upon a multilayer transcription factor network to achieve a dramatic remodeling of the B cell transcriptional landscape. Increased levels of ASCs are often seen in autoimmune diseases and it is believed that altered expression of regulatory transcription factors play a role in this imbalance. The transcription factor interferon regulatory factor 5 (IRF5) is one such candidate as polymorphisms in IRF5 associate with risk of numerous autoimmune diseases and correlate with elevated IRF5 expression. IRF5 genetic risk has been widely replicated in systemic lupus erythematosus (SLE), and loss of Irf5 ameliorates disease in murine lupus models, in part, through the lack of pathogenic autoantibody secretion. It remains unclear, however, whether IRF5 is contributing to autoantibody production through a B cell-intrinsic function. To date, IRF5 function in healthy human B cells has not been characterized. Using human primary naive B cells, we define a critical intrinsic role for IRF5 in B cell activation, proliferation, and plasmablast differentiation. Targeted IRF5 knockdown resulted in significant immunoglobulin (Ig) D retention, reduced proliferation, plasmablast differentiation, and IgG secretion. The observed decreases were due to impaired B cell activation and clonal expansion. Distinct from murine studies, we identify and confirm new IRF5 target genes, IRF4, ERK1, and MYC, and pathways that mediate IRF5 B cell-intrinsic function. Together, these results identify IRF5 as an early regulator of human B cell activation and provide the first dataset in human primary B cells to map IRF5 dysfunction in SLE.

Incremental net monetary benefit of ocrelizumab relative to subcutaneous interferon β-1a

AIM

Disease-modifying therapies (DMTs) impact the natural history of relapsing forms of multiple sclerosis (RRMS) by reducing annual relapse rates and slowing disability progression. The effect of DMTs on indirect costs has not been consistently explored in cost-effectiveness studies thus far. The value to patients of an emerging DMT, ocrelizumab, was quantified in comparison to subcutaneous interferon beta-1a (IFNβSC) for the prevalent RRMS population with mild-to-moderate disability in the US, based on two Phase 3 trials, OPERA I and OPERA II, of ocrelizumab vs IFNβSC in RRMS.

MATERIALS AND METHODS

A Markov model was developed to compare disability progression as measured by Expanded Disability Status Scale (EDSS) and relapse outcomes over a 30-year horizon for ocrelizumab vs IFNβSC. Direct, indirect, and informal costs (2016 US dollars) and utilities for EDSS health states were obtained from the literature. Hazard ratios for disability progression and relapse rates were estimated from clinical trials. Value was assessed by calculating the net monetary benefit (NMB), defined as the monetary value of discounted quality-adjusted life years (QALYs) minus total costs, where the value of a QALY was $150,000. One-way sensitivity analyses were conducted.

RESULTS

Ocrelizumab was associated with an incremental gain of 0.84 QALYs and cost savings of $287,713 relative to IFNβSC, resulting in an incremental NMB (INMB) of $413,611 per person over 30 years. The INMB increased by $151,763 for those initiating ocrelizumab at EDSS level 1 vs level 4. Influential parameters were QALY value, treatment costs, and disability progression; however, all sensitivity analyses indicated that the INMB for ocrelizumab relative to IFNβSC was ≥$300,000 per person.

CONCLUSIONS

Ocrelizumab provides greater value to RRMS patients compared with IFNβSC. Initiating ocrelizumab at lower EDSS levels leads to a greater cumulative value due to slower disability progression, which extends years with higher quality-of-life.

Short-term costs of preeclampsia to the United States health care system

BACKGROUND

Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States.

OBJECTIVE

This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in 2012.

STUDY DESIGN

We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set.

RESULTS

Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age.

CONCLUSION

In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

Product safety spillovers and market viability for biologic drugs

When a pharmaceutical manufacturer experiences a safety problem, negative impacts on profitability can spread to its competitors. Reduced consumer confidence, product recalls, and litigation are limited to the responsible manufacturer only if that manufacturer can be clearly linked to the safety problem. We analyze the impact of "accountability" for safety problems on manufacturer entry decisions and investments to mitigate risk. Consistent with prior research, we find investment levels increase with accountability in a duopoly market, and that accountability can thus enhance market viability and improve consumer welfare. However, we also analyze the impact of accountability on entry of a competitor, after the originator's exclusivity has expired. Accountability promotes the development of a robust market by raising expected profits, particularly for an entrant with a relatively low likelihood of a safety problem. Yet entry need not improve consumer welfare, and may benefit the incumbent in our model. In contrast to the traditional entry deterrence mechanism, when accountability is sufficiently low, increased incumbent investment encourages entry. Our analysis has important implications for biologic drugs, insofar as pathways for entry by "biosimilars" have been established in Europe and the United States, and informs pharmacovigilance and other accountability policies for biologics.

Reconsidering the economic value of multiple sclerosis therapies

OBJECTIVES

To illustrate a more comprehensive view of value associated with medicines treating a highly severe illness and to apply these insights to estimate the costs and benefits of 3 treatments for multiple sclerosis (MS): Avonex, Tysabri, and Tecfidera.

STUDY DESIGN

Retrospective study spanning 2002 to 2013. We used economic theory to derive the value of therapy to patients with MS and to individuals who face the risk of contracting MS in the future, under the alternative assumptions that therapies were fully insured or paid for out of pocket.

METHODS

Models were parameterized through secondary data analysis and targeted literature review. Estimates of individual value were aggregated to the societal level using therapy-specific treatment prevalence rates. Aggregate consumer value was compared with manufacturer revenue.

RESULTS

In the baseline model, Avonex, Tysabri, and Tecfidera generated $46.2 billion of total value to consumers, almost one-third of which accrued to those without MS. The total value to consumers was double manufacturer revenue. Results were qualitatively robust to the use of alternate epidemiological and economic parameters. We found that value to the healthy is positively related to disease severity, and that value to both the sick and the healthy are larger when costs are shared via health insurance.

CONCLUSIONS

Theory predicts that treatments for severe disease provide "peace of mind" value to the healthy. Avonex, Tysabri, and Tecfidera have generated significant social value, a large majority of which accrues to consumers. Future economic valuations of medical technology should consider both the potential value to the healthy and the effects of insurance.

The Rising Burden of Preeclampsia in the United States Impacts Both Maternal and Child Health

OBJECTIVE

Preeclampsia is one of the top six causes of maternal mortality in the United States (US) and is associated with considerable perinatal morbidity and mortality. Evidence suggests the US incidence of preeclampsia has increased dramatically over the past two decades. This study aims to compile, summarize, and critique the literature on the health and economic burden of preeclampsia and early-onset preeclampsia.

STUDY DESIGN

We reviewed the literature for estimates of burden of preeclampsia and early-onset preeclampsia to both mother and child, summarized the evidence on economic and social burden, and highlighted current gaps in the literature.

RESULTS

No recent studies comprehensively assess the costs and health consequences of preeclampsia or early-onset preeclampsia for both mother and child. Where it exists, the literature suggests preeclampsia and early-onset preeclampsia cause numerous adverse health consequences, but these conditions currently lack effective treatment. The need for preterm delivery from early-onset preeclampsia suggests its costs are substantial: very (28-31 weeks) and extremely (<28 weeks) preterm birth cost approximately 40 and 100 times a term pregnancy, respectively.

CONCLUSION

Given the severity of outcomes from preeclampsia, further research on its health and economic consequences is essential to inform policy and resource allocation decisions in health care.

A novel CD141+ human blood plasmacytoid dendritic cell subtype produces high levels of IFN-α and acquires virus-associated cellular material from live tumor cells (VIR9P.1136)

Dendritic cells (DCs) are a heterogeneous population important in regulating both innate and adaptive immunity. Human blood DCs are broadly characterized as pDC(BDCA2+), mDC1(BDCA1+), and mDC2(BDCA3+(CD141)). While much work has focused on the functional role of CD141hi mDCs, we investigated the maturation potential and functional significance of a novel subtype of classically defined plasmacytoid DCs (BDCA2+) co-expressing intermediate levels of BDCA3. Using flow cytometry, we identified four human blood DC subsets: BDCA2+/3-, BDCA2+/3int, BDCA2-/3int, and BDCA2-/3hi. Upon stimulation with TLR9 agonists CpG-A or HSV-1, the BDCA2+/3int DCs had the highest frequency of IFN-α+ and TNF-α+ cells among these DC subtypes. The BDCA2+/3int compared to BDCA2+/3- DCs also become more activated and mature with relatively higher expression of co-stimulatory and migratory surface receptors in response to HSV-1. IRF7, the master regulator of IFN production in pDCs, was constitutively expressed by BDCA2+/3- and BDCA2+/3int ­DCs but not by BDCA2- DCs. Both BDCA2+/3int and to a lesser extent, BDCA2+/3- DC preferentially acquired cellular material from HSV-infected Raji cells. These data indicate that BDCA2+/3int DCs exhibit major functions associated with classical pDCs and are phenotypically and functionally distinct from BDCA2-/3int and BDCA2-/3hi DCs. Together these results describe a novel CD141+ pDC subset that is very potent and virus responsive as compared to the CD141hi mDCs.

Transcellular degradation of axonal mitochondria

It is generally accepted that healthy cells degrade their own mitochondria. Here, we report that retinal ganglion cell axons of WT mice shed mitochondria at the optic nerve head (ONH), and that these mitochondria are internalized and degraded by adjacent astrocytes. EM demonstrates that mitochondria are shed through formation of large protrusions that originate from otherwise healthy axons. A virally introduced tandem fluorophore protein reporter of acidified mitochondria reveals that acidified axonal mitochondria originating from the retinal ganglion cell are associated with lysosomes within columns of astrocytes in the ONH. According to this reporter, a greater proportion of retinal ganglion cell mitochondria are degraded at the ONH than in the ganglion cell soma. Consistently, analyses of degrading DNA reveal extensive mtDNA degradation within the optic nerve astrocytes, some of which comes from retinal ganglion cell axons. Together, these results demonstrate that surprisingly large proportions of retinal ganglion cell axonal mitochondria are normally degraded by the astrocytes of the ONH. This transcellular degradation of mitochondria, or transmitophagy, likely occurs elsewhere in the CNS, because structurally similar accumulations of degrading mitochondria are also found along neurites in superficial layers of the cerebral cortex. Thus, the general assumption that neurons or other cells necessarily degrade their own mitochondria should be reconsidered.

Conditions and constraints for astrocyte calcium signaling in the hippocampal mossy fiber pathway

The spatiotemporal activities of astrocyte Ca²⁺ signaling in mature neuronal circuits remain unclear. We used genetically encoded Ca²⁺ and glutamate indicators as well as pharmacogenetic and electrical control of neurotransmitter release to explore astrocyte activity in the hippocampal mossy fiber pathway. Our data revealed numerous localized, spontaneous Ca²⁺ signals in astrocyte branches and territories, but these were not driven by neuronal activity or glutamate. Moreover, evoked astrocyte Ca²⁺ signaling changed linearly with the number of mossy fiber action potentials. Under these settings, astrocyte responses were global, suppressed by neurotransmitter clearance, and mediated by glutamate and GABA. Thus, astrocyte engagement in the fully developed mossy fiber pathway was slow and territorial, contrary to that frequently proposed for astrocytes within microcircuits. We show that astrocyte Ca²⁺ signaling functionally segregates large volumes of neuropil and that these transients are not suited for responding to, or regulating, single synapses in the mossy fiber pathway.

Type III IFNs are produced by and stimulate human plasmacytoid dendritic cells

Plasmacytoid dendritic cells (pDC) are rare cells found in peripheral blood and lymphoid tissues. pDC are considered to be "professional" type I IFN-producing cells and produce 10- to 100-fold more IFN-α than other cell types in response to enveloped viruses or synthetic TLR7 and TLR9 agonists. In this study, purified pDC were found to express high levels of IFN-λ receptor mRNA, as well as cell-surface IFN-λ receptor. We have developed intracellular flow cytometry assays using Abs to IFN-λ1/3 or -λ2 to assess the expression of IFN-λ proteins by pDC. We observed that a subset of human pDC expresses only intracellular IFN-α, whereas another subset produces both IFN-α and IFN-λ after stimulation with virus or the TLR9 agonist, CpG A; the cells that coexpressed IFN-α and IFN-λ were the cells with the highest levels of IFN-α expression. Ab cross-linking of CD4 or CD303 molecules on pDC inhibited both HSV-induced IFN-λ and IFN-α production. Like the production of IFN-α, the HSV-induced IFN-λ production in pDC was mediated through TLR9 and independent of virus replication. Exogenous IFN-λ treatment of pDC resulted in increased virus-induced expression of both IFN-α and IFN-λ. In addition, both exogenous IFN-λ and -α inhibited dexamethasone-induced apoptosis of pDC. We conclude that pDC are major producers of IFN-λ1 and -λ2 in response to viral stimulation and also express functional receptors for this cytokine. Thus, IFN-λ can serve as an autocrine signal to strengthen the antiviral response of pDC by increasing IFN-α and IFN-λ production, resulting in prolonged pDC survival.

Phenotypic and functional characterization of human blood BDCA3+ subsets (106.4)

There has been a recent focus on human blood DCs expressing BDCA3 (CD141). However, these cells are not fully characterized. Our study aimed to understand whether they constitute a homogeneous population or if they are related to two other DC subsets: plasmacytoid DCs (BDCA2+) and myeloid DCs (BDCA1+). We constructed multi-color panels for surface phenotyping of blood BDCA3+ DCs by flow cytometric analysis. We observed that lineage- PBMC heterogeneously distribute into BDCA3hi and BDCA3int subsets, with the latter subset expressing higher levels of CCR5 and CXCR4. Surface phenotyping of lineage- PBMC for the BDCA2 (found on pDC) and BDCA3 surface antigens yielded a subset of BDCA2+/BDCA3int cells, representing 15-30% of BDCA2+/lin- pDC. To assess functional significance of this population, we stimulated PBMC with TLR9 agonists CpGA or HSV-1 and stained for intracellular IFN-α and TNF-α in cells expressing BDCA2 and/or BDCA3. The BDCA2+/BDCA3int subpopulation produced IFN-α and TNF-α and upregulated the transcription factor IRF-7 more strongly than the BDCA2+/BDCA3- subpopulation, while the BDCA2-/BDCA3+ subpopulation constitutively expressed the lowest level of IRF-7 and barely produced IFN-α. However, similarly lower levels of TNF-α were found in the BDCA2-/BDCA3+ and BDCA2+/BDCA3- subpopulations when compared to the BDCA2+/BDCA3int subpopulation. These results suggest that the BDCA2+/BDCA3int subset has major functions associated with classical pDCs.

MicroRNA-9 is an activation-induced regulator of PDGFR-beta expression in cardiomyocytes

The platelet derived growth factor receptor (PDGFR) is an important target for novel anti-cancer therapeutics, but agents targeting PDGFR have been associated with cardiotoxicity. Cardiomyocyte PDGFR-β signaling in pressure-overloaded hearts induces compensatory angiogenesis via a paracrine-signaling cascade. Tight regulation of receptor tyrosine kinases in response to ligand stimulation is a critical part of any such cascade. The objective of the present study was to characterize the early and late regulation of PDGFR-β following ligand stimulation and define a potential role for microRNAs (miRNAs) predicted to interact with the 3'UTR of PDGFR-β in feedback regulation. Using two in-vitro model systems (U87 glioblastoma cells and neonatal cardiomyocytes), we observed that in response to stimulation with PDGF-BB, levels of PDGFR-β declined beginning at one hour, persisting for 48 h. PDGFR-β mRNA levels declined beginning at 6h after receptor activation. Early, but not late activation-induced receptor downregulation was proteasome dependent. Levels of miRNA-9 (miR-9) were significantly increased in U87 cells and cardiomyocytes beginning 6h after addition of ligand. In response to pressure overload, miR-9 levels were significantly reduced in the hearts of cardiac-specific PDGFR-β knockout mice. Luciferase reporter assays demonstrate that miR-9 directly interacts with its predicted seed in the 3'UTR of PDGFR-β. Increasing miR-9 levels reduces levels of PDGFR-β, resulting in a reduction in the paracrine angiogenic capacity of cardiomyocytes, consistent with the established function of cardiomyocyte PDGFR-β. Importantly, increase of anti-miR-9 in cardiomyocytes attenuates ligand-induced PDGFR-β downregulation. In conclusion, we have identified miR-9 as an activation-induced regulator of PDGFR-β expression in cardiomyocytes that is part of a negative feedback loop which serves to modulate PDGFR-β expression upon ligand-stimulation through direct interaction with the 3'UTR of PDFGR-β. This article is part of a Special Issue entitled 'Possible Editorial'.

Abstract P3-14-06: Pharmacokinetic (PK) Interaction Potential of Trastuzumab-DM1 (T-DM1) and Pertuzumab (P) in Pts with HER2-Positive, Locally Advanced or MBC: Results from a Phase 1b/2 Study

Introduction

T-DM1 is an antibody-drug conjugate (ADC) composed of the cytotoxic DM1 conjugated to trastuzumab and retaining its antitumor properties. P is a HER2-directed monoclonal antibody that inhibits HER2 dimerization and subsequent signaling. The combination of T-DM1 and P has demonstrated synergistic antitumor activity in HER2-positive xenograft models. T-DM1 and P are expected to undergo proteolytic degradation with no significant involvement of cytochrome P450 isoenzymes. In contrast, DM1 is metabolized mainly by CYP3A4 and to a limited extent by CYP3A5. Therefore, a key component in evaluating this combination clinically is determining whether a PK-based drug interaction potential exists when these drugs are administered together. Assessment of PK-based therapeutic protein-ADC interaction potential is novel, as antibodies have typically been combined with chemotherapy in clinical studies. Methods

This 3+3 dose escalation, open-label, phase 1b/2 study evaluated the safety, tolerability, PK, and efficacy of T-DM1 (3.0 mg/kg q3w or 3.6 mg/kg q3w [established phase 2 dose]) in combination with P (840 mg loading dose; 420 mg q3w thereafter) in pts with HER2-positive locally advanced or MBC. Because of the half-life of both agents, staggered dosing was not a practical approach to assess the PK interaction. Thus, both drugs were administered sequentially on Day 1 of each cycle. All pts receiving study treatment were evaluated for serum concentrations of T-DM1, total trastuzumab (conjugated and unconjugated to DM1), and plasma concentrations of DM1, at pre-specified time points. To avoid the interference of P with the quantification of total trastuzumab, a new assay that allows capturing trastuzumab in the presence of P was developed and validated. PK of T-DM1 and related analytes were compared with historical single agent data by population and/or noncompartmental analyses. Whether combination with P was a significant covariate of T-DM1 clearance and central volume of distribution (V1) was tested. The confidence intervals (CIs) of the ratios of clearance and V1 of combination to monotherapy were estimated. A CI containing 1 is indicative of comparable parameters. Results

PK data were available for 63 pts. Combination with P was not a significant covariate of T-DM1 clearance and V1 (P&gt;0.05 by the log likelihood ratio test). The combination to monotherapy ratios for clearance and V1 had a 95% CI of [0.90-1.04] and [0.95-1.06], respectively, indicating comparable clearance and V1 of combination and monotherapy. The average post-hoc Bayesian estimates of T-DM1 clearance and V1 in the presence of P were 0.69±0.14 L/day and 3.3±0.41 L, which were comparable with historical measures of 0.73±0.19 L/day and 3.4±0.57 L with monotherapy. The average maximal concentration of total trastuzumab in cycle 1 was 101±29 μg/ml in the 3.0 mg/kg TDM1 dose (n=3) and 98±32 μg/ml for the 3.6 mg/kg dose (n=60). The maximum DM1 level was &lt;17 ng/mL at both T-DM1 doses. The PK of total trastuzumab and DM1 were also comparable with monotherapy (data not shown).

Conclusions

This assessment suggests that P does not alter the PK of T-DM1 when these drugs are administered together.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-14-06.

Nonlinear spectra of ZnO: reverse saturable, two- and three-photon absorption

We present a broadband (460 - 980 nm) analysis of the nonlinear absorption processes in bulk ZnO, a large-bandgap material with potential blue-to-UV photonic device applications. Using an optical parametric amplifier we generated tunable 1-kHz repetition rate laser pulses and employed the Z-scan technique to investigate the nonlinear absorption spectrum of ZnO. For excitation wavelengths below 500 nm, we observed reverse saturable absorption due to one-photon excitation of the sample, agreeing with rate-equation modeling. Two- and three-photon absorption were observed from 540 to 980 nm. We also determined the spectral regions exhibiting mixture of nonlinear absorption mechanisms, which were confirmed by photoluminescence measurements.

Femtosecond laser waveguide micromachining of PMMA films with azoaromatic chromophores

We report on the femtosecond-laser micromachining of poly(methyl methacrylate) (PMMA) films doped with nonlinear azoaromatic chromophores: Disperse Red 1, Disperse Red 13 and Disperse Orange 3. We study the conditions for controlling chromophore degradation during the micromachining of PMMA doped with each chromophore. Furthermore, we successfully used fs-micromachining to fabricate optical waveguides within a bulk sample of PMMA doped with these azochromophores.

Plasma pharmacokinetics and cerebrospinal fluid concentrations of erlotinib in high-grade gliomas: A novel, phase I, dose escalation study

2054

Background: Erlotinib (ERL) is an inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase. EGFR is overexpressed in glioblastoma multiforme (GBM). The primary objectives of this study were to determine the maximum tolerated dose (MTD), dose limiting toxicity (DLT) and to evaluate plasma and cerebrospinal fluid (CSF) ERL concentrations using a novel every 72 hour ERL dosing schedule. Methods: Patients = 18 years of age with GBM or high grade glioma with evidence of disease progression following first line therapy (surgery/XRT/chemotherapy) and Karnofsky performance status = 60 % were included. Patients were stratified based on use of enzyme-inducing antiepileptic drugs (EIAED). Patients not on EIAED were initiated on ERL 450 mg PO every 72h, while those on EIAED were initiated on 900 mg PO every 72 h. Results: Six patients have been enrolled and assessed for safety, 5 for plasma PK and 3 for CSF concentrations. For ERL, the area under the plasma concentration versus time curve (AUC) was greater and the half-life longer in patients not receiving EIAED. However, the AUC of OSI-420, the major metabolite of ERL, was lower in patients not receiving EIAED. The OSI-420 AUC: ERL AUC ratio was increased 3 fold among patients receiving EIAED, indicative of increased hepatic metabolism and increased clearance. CSF concentrations were detectable and ranged from 1 to 3% of peak plasma concentrations. Neither group has experienced a DLT or reached the MTD. The most common side effects (grade 1/2) have been diarrhea (83%), rash (100%) and fatigue (33%). To date, there has been 1 partial response, 1 patient with stable disease and 4 patients with disease progression. The partial response and stable disease have occurred in patients with GBM. Conclusions: ERL is a well tolerated therapy. Patient enrollment and subsequent dose escalation is ongoing and updated results will be presented at the ASCO 2007 meeting.

[Table: see text]

No significant financial relationships to disclose.

Premorbid weight, body mass, and varsity athletics in ALS

Several famous athletes have been affected by ALS, and some epidemiologic studies have indicated that vigorous physical activity (heavy labor or athletics) is a risk factor for the disease. In a case-control study of 279 patients with motor neuron diseases and 152 with other neurologic diseases, the authors found that subjects with motor neuron diseases were more likely than controls to report they had always been slim or they had been varsity athletes. For slimness, the odds ratio (OR) was 2.21; 95% CI, 1.40 to 3.47. For varsity athletics, the OR was 1.70; CI, 1.04 to 2.76.

Liquid chromatographic-tandem mass spectrometric urine assay for a highly metabolized cyclic ureidobenzenesulfonamide: issues concerning assay specificity and quality control preparation

An LC-MS-MS method was validated for the quantitation of a beta(3) agonist (A) in human urine to support Phase I studies. A was designed to accelerate metabolism for weight reduction. During assay development a significant loss of A was apparent from frozen urine quality control samples. The addition of 0.75% bovine serum albumin (BSA) in urine (v/v) was required to maximize the recovery of A from urine. Urine samples were basified and extracted into methyl t-butyl ether-isopropyl alcohol (90:10, v/v). The organic layer was washed, evaporated, reconstituted, and injected onto a 5 cm, C8 HPLC column prior to MS-MS analysis. The standard curve was linear from 5 to 500 ng/ml. Intraday precision for peak area ratios from BSA urine samples at seven separate concentrations over a range of 5-500 ng/ml (n=5) was <4.0% and calculated concentrations were within 91-115% of nominal concentrations. Interday precision for BSA urine quality control (QC) samples at four separate concentrations (n=10 of each) was <5.0% and individual calculated concentrations were within 90-111% of nominal concentrations. This work emphasizes that potential metabolites and quality control standards should be prepared and assayed as early as possible in method development, especially before the sample collection section of the clinical protocol is prepared. The methods described here have wide utility to other compounds containing basic benzene sulfonamides and to beta3 agonist candidates.

Beta(3)-adrenoceptor agonist-induced increases in lipolysis, metabolic rate, facial flushing, and reflex tachycardia in anesthetized rhesus monkeys

The effects of two beta(3)-adrenergic receptor agonists, (R)-4-[4-(3-cyclopentylpropyl)-4,5-dihydro-5-oxo-1H-tetrazol-1-yl]-N-[4-[2-[[2-hydroxy-2-(3-pyridinyl)ethyl]amino]ethyl]phenyl]benzenesulfonamide and (R)-N-[4-[2-[[2-hydroxy-2-(3-pyridinyl)- ethyl]amino]ethyl]phenyl]-1-(4-octylthiazol-2-yl)-5-indolinesulfonamide, on indices of metabolic and cardiovascular function were studied in anesthetized rhesus monkeys. Both compounds are potent and specific agonists at human and rhesus beta(3)-adrenergic receptors. Intravenous administration of either compound produced dose-dependent lipolysis, increase in metabolic rate, peripheral vasodilatation, and tachycardia with no effects on mean arterial pressure. The increase in heart rate in response to either compound was biphasic with an initial rapid component coincident with the evoked peripheral vasodilatation and a second more slowly developing phase contemporaneous with the evoked increase in metabolic rate. Because both compounds exhibited weak binding to and activation of rhesus beta(1)-adrenergic receptors in vitro, it was hypothesized that the increase in heart rate may be reflexogenic in origin and proximally mediated via release of endogenous norepinephrine acting at cardiac beta(1)-adrenergic receptors. This hypothesis was confirmed by determining that beta(3)-adrenergic receptor agonist-evoked tachycardia was attenuated in the presence of propranolol and in ganglion-blocked animals, under which conditions there was no reduction in the evoked vasodilatation, lipolysis, or increase in metabolic rate. It is not certain whether the beta(3)-adrenergic receptor-evoked vasodilatation is a direct effect of compounds at beta(3)-adrenergic receptors in the peripheral vasculature or is secondary to the release or generation of an endogenous vasodilator. Peripheral vasodilatation in response to beta(3)-adrenergic receptor agonist administration was not attenuated in animals administered mepyramine, indomethacin, or calcitonin gene-related peptide(8-37). These findings are consistent with a direct vasodilator effect of beta(3)-adrenergic receptor agonists.

ATP depletion increases tyrosine phosphorylation of beta-catenin and plakoglobin in renal tubular cells

This study examines the hypothesis that the loss of integrity of the junctional complex induced by ATP depletion is related to alterations in tyrosine phosphorylation of the adherens junction proteins beta-catenin and plakoglobin. ATP depletion of cultured mouse proximal tubular (MPT) cells induces a marked increase in tyrosine phosphorylation of both beta-catenin and plakoglobin. The tyrosine phosphatase inhibitor vanadate has the same effect in ATP-replete (control) monolayers, whereas genistein, a tyrosine kinase inhibitor, reduces phosphorylation of both proteins in ATP-replete monolayers and prevents the hyperphosphorylation of these proteins with ATP depletion. This study also demonstrates that the fall in the transepithelial resistance of MPT monolayers induced by ATP depletion can be reproduced by treatment of ATP-replete monolayers with vanadate, whereas genistein substantially ameliorates the fall in transepithelial resistance induced by ATP depletion. Also, using immunofluorescence microscopy it was demonstrated that ATP depletion results in a marked diminution of E-cadherin staining in the basolateral membrane of MPT cells. Vanadate mimics this effect of ATP depletion, whereas genistein ameliorates the reduction in the intensity of E-cadherin staining induced by ATP depletion. Because it is has been well established that hyperphosphorylation of the catenins leads to dissociation of the adherens junction and to dysfunction of the junctional complex, it is proposed that the increase in tyrosine phosphorylation of catenins observed in MPT cells during ATP depletion contributes to the loss of function of the junctional complex associated with sublethal injury.

SNARE proteins regulate H(+)-ATPase redistribution to the apical membrane in rat renal inner medullary collecting duct cells

The interaction of soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins provides the necessary steps for vesicle docking fusion. In inner medullary collecting duct (IMCD) cells, acid secretion is regulated in part by exocytotic insertion and endocytotic retrieval of an H(+)-ATPase to and from the apical membrane. We previously suggested a role for SNARE proteins in exocytotic insertion of proton pumps in IMCD cells. The purpose of the present study was to determine whether SNARE proteins are associated with the 31-kDa subunit of H(+)-ATPase in IMCD cells during exocytosis and to determine the effects of clostridial toxins on SNARE-mediated trafficking of H(+)-ATPase. Cell acidification induced a marked increment of H(+)-ATPase in the apical membrane. However, pretreating cells with clostridial toxins blocked the cellular translocation of the 31-kDa subunit. Immunoprecipitation of IMCD cell homogenate, using antibodies against either the 31-kDa subunit of H(+)-ATPase or vesicle-associated membrane protein-2, co-immunoprecipitated N-ethylmaleimide-sensitive factor, alpha-soluble NSF attachment protein (alpha-SNAP), synaptosome-associated protein-23, syntaxin, and vesicle-associated membrane protein-2. Pretreatment with clostridial toxin resulted in reduced co-immunoprecipitation of H(+)-ATPase and syntaxin. These experiments document, for the first time, a putative docking fusion complex in IMCD cells and a physical association of the H(+)-ATPase with the complex. The sensitivity to the action of clostridial toxin indicates the docking-fusion complex is a part of the exocytotic mechanism of the proton pump.

Prior heat stress inhibits apoptosis in adenosine triphosphate-depleted renal tubular cells

BACKGROUND

This study tested the following hypotheses: (a) renal tubular epithelial cells subjected to transient adenosine triphosphate (ATP) depletion undergo apoptosis, and (b) induction of heat stress proteins (HSPs) inhibits cell death following ATP depletion, possibly by interacting with anti-apoptotic signal proteins.

METHODS

To simulate ischemia in vivo, cells derived from opossum kidney proximal tubule (OK) were subjected to ATP depletion (5 mM cyanide, 5 mM 2-deoxy-D-glucose, and 0 mM glucose) for 1 to 1. 5 hours, followed by recovery (10 mM glucose without cyanide). The presence of apoptosis was assessed by morphological and biochemical criteria. The effect of prior heat stress or caspase inhibition on apoptosis and cell survival were assessed.

RESULTS

In the ATP-depleted cell, both Hoechst dye and electron microscopy revealed morphological features that are typical of apoptosis. On an agarose gel, a "ladder pattern" typical of endonucleosomal DNA degradation was observed. Prior heat stress reduced the number of apoptotic-appearing cells, significantly decreased DNA fragmentation, and improved cell survival compared with controls (73.0 +/- 1% vs. 53.0 +/- 1.5%; P < 0.05). Two different caspase inhibitors also improved survival, suggesting that apoptosis is a cause of cell death in this model. Compared with ATP-depleted controls, prior heat stress inhibited the pro-apoptotic changes in the ratio of Bcl2 to BAX, proteins known to regulate the apoptotic set point in renal cells. HSP 72, a known cytoprotectant, co-immunoprecipitated with Bcl2, an anti-apoptotic protein. Prior heat stress markedly increased the interaction between HSP 72 and Bcl2.

CONCLUSIONS

Transient ATP depletion causes apoptosis in tubular epithelial cells. Prior HS inhibits apoptosis and improves survival in these cells. Novel interactions between HSP 72 and Bcl2 may be responsible, at least in part, for the protection afforded by prior heat stress against ATP depletion injury.

Effect of acidification on the location of H+-ATPase in cultured inner medullary collecting duct cells

In previous studies, our laboratory has utilized a cell line derived from the rat inner medullary collecting duct (IMCD) as a model system for mammalian renal epithelial cell acid secretion. We have provided evidence, from a physiological perspective, that acute cellular acidification stimulates apical exocytosis and elicits a rapid increase in proton secretion that is mediated by an H+-ATPase. The purpose of these experiments was to examine the effect of acute cellular acidification on the distribution of the vacuolar H+-ATPase in IMCD cells in vitro. We utilized the 31-kDa subunit of the H+-ATPase as a marker of the complete enzyme. The distribution of this subunit of the H+-ATPase was evaluated by immunohistochemical techniques (confocal and electron microscopy), and we found that there is a redistribution of these pumps from vesicles to the apical membrane. Immunoblot evaluation of isolated apical membrane revealed a 237 +/- 34% (P < 0.05, n = 9) increase in the 31-kDa subunit present in the membrane fraction 20 min after the induction of cellular acidification. Thus our results demonstrate the presence of this pump subunit in the IMCD cell line in vitro and that cell acidification regulates the shuttling of cytosolic vesicles containing the 31-kDa subunit into the apical membrane.

Anticonvulsants for soman-induced seizure activity

This report describes studies of anticonvulsants for the organophosphorus (OP) nerve agent soman: a basic research effort to understand how different pharmacological classes of compounds influence the expression of seizure produced by soman in rats, and a drug screening effort to determine whether clinically useful antiepileptics can modulate soman-induced seizures in rats. Electroencephalographic (EEG) recordings were used in these studies. Basic studies were conducted in rats pretreated with HI-6 and challenged with 1.6 x LD50 soman. Antimuscarinic compounds were extremely effective in blocking (pretreatment) or terminating soman seizures when given 5 min after seizure onset. However, significantly higher doses were required when treatment was delayed for more than 10 min, and some antimuscarinic compounds lost anticonvulsant efficacy when treatment was delayed for more than 40 min. Diazepam blocked seizure onset, yet seizures could recur after an initial period of anticonvulsant effect at doses </=2.5 mg/kg. Diazepam could terminate ongoing seizures when given 5 min after seizure onset, but doses up to 20 mg/kg were ineffective when treatment was delayed for 40 min. The GABA uptake inhibitor, tiagabine, was ineffective in blocking or terminating soman motor convulsions or seizures. The glutamate receptor antagonists, NBQX, GYKI 52466, and memantine, had weak or minimal antiseizure activity, even at doses that virtually eliminated signs of motor convulsions. The antinicotinic, mecamylamine, was ineffective in blocking or stopping seizure activity. Pretreatment with a narrow range of doses of alpha2-adrenergic agonist, clonidine, produced variable protection (40-60%) against seizure onset; treatment after seizure onset with clonidine was not effective. Screening studies in rats, using HI-6 pretreatment, showed that benzodiazepines (diazepam, midazolam and lorazepam) were quite effective when given 5 min after seizure onset, but lost their efficacy when given 40 min after onset. The barbiturate, pentobarbital, was modestly effective in terminating seizures when given 5 or 40 min after seizure onset, while other clinically effective antiepileptic drugs, trimethadione and valproic acid, were only slightly effective when given 5 min after onset. In contrast, phenytoin, carbamazepine, ethosuximide, magnesium sulfate, lamotrigine, primidone, felbamate, acetazolamide, and ketamine were ineffective.

H+ secretion is inhibited by clostridial toxins in an inner medullary collecting duct cell line

Renal epithelial cell H+ secretion is an exocytic-endocytic phenomenon. In the inner medullary collecting duct (IMCD) cell line, which we have utilized as a model of renal epithelial cell acid secretion, we found previously that acidification increased exocytosis and alkalinization increased endocytosis. It is likely, therefore, that the rate of proton secretion is regulated by the membrane insertion and retrieval of proton pumps. There is abundant evidence from studies in the nerve terminal and the chromaffin cell that vesicle docking, membrane fusion, and discharge of vesicular contents (exocytosis) involve a series of interactions among so-called trafficking proteins. The clostridial toxins, botulinum and tetanus are proteases that specifically inactivate some of these proteins. In these experiments we demonstrated, by immunoblot and immunoprecipitation, the presence in this IMCD cell line of the specific protein targets of these toxins, synaptobrevin/vesicle-associated membrane proteins (VAMP), syntaxin, and synaptosomal-associated protein-25 (SNAP-25). Furthermore, we showed that these toxins markedly inhibit the capacity of these cells to realkalinize after an acid load. Thus these data provide new insight into the mechanism for H+ secretion in the IMCD.

Effect of neuromuscular blockade on facial nerve monitoring

Direct facial nerve stimulation and monitoring during cerebellopontine angle (CPA) tumor surgery are critical for identification and preservation of function. Electrically evoked facial nerve monitoring was compared with ulnar train-of-four monitoring under progressive neuromuscular blockade. Using a rabbit model, the facial nerve function of six controls was compared to that of six specimens with acute or chronic injuries. Eight of 18 patients who had undergone CPA tumor resection during one year were also studied. Regression analysis correlated between ulnar nerve monitoring and facial electromyographic (EMG) peak voltage in all groups. Facial EMG was measurable, even with 75 percent receptor blockade. The results of this study support the hypothesis that high degrees of neuromuscular blockade do not preclude satisfactory EMG monitoring of the facial nerve during CPA tumor surgery. This study did demonstrate that chronically injured facial nerves may show greater sensitivity to the effects of neuromuscular blockade. Lower levels or avoidance of neuromuscular blockade should be employed under these circumstances.

Laser discectomy. Comparison of systems

Percutaneous methods of lumbar disc removal have gained wide popularity since the introduction of the automated suction device. Newer methods to enter this field include the Nd:YAG and Ho:YAG lasers. To date, no experimental model exists to compare the efficacy of disc removal of these devices. An in vitro disc elastance (pressure/volume) model was designed that accurately reflects the mass of dry disc removed after any type of discectomy procedure. The experimental design consists of an infusion pump compressing a static column of air in line with the disc through a 12-gauge needle. Both mechanical and laser devices exhibited a reproducible treatment plateau, beyond which no disc removal was effected. Total energy, as opposed to power, was found to be the main determinant of the extent of disc removal during laser discectomy. Finally, in the experimental model of juvenile swine the automated suction device exhibited superior disc removal compared to the two lasers, but the clinical applicability of this is debatable. Disc space elastance offers a rapid and reproducible method to quantitate the extent of disc removal after intradiscal treatment methods and if employed in human cadaver spines may minimize the need for clinical trials to compare different devices and techniques.

Intracranial cryosurgery in a canine model: a pilot study

Although virtually abandoned decades ago following the introduction of levodopa for the treatment of movement disorders, intracranial cryosurgery potentially offers a simple and accurate means of destroying deep-seated lesions when coupled with computed tomographic-stereotaxic placement techniques. We performed a pilot investigation of the size and histology of brain cryolesions in six dogs, using a 3-mm probe maintained at -160 degrees C for 6 minutes while simiultaneously monitoring the process by real-time ultrasound. Lesion diameter was 1.4 +/- 0.1 cm at less than or equal to 2 days but enlarged to 2.25 +/- 0.21 cm at 1 week, primarily at the expense of white matter. Ultrasound appearance of the lesion was characterized by a hyperechoic ice ball, the size of which consistently underestimated true size (determined by histology). By microscopy, the lesion was a hemorrhagic infarction that incited little surrounding edema and exhibited a sharp transitional zone. These data indicate that the cryosurgical probe can lesion significant volumes of brain in a reproducible and discrete fashion with minimal reaction to the surrounding tissue. Further work is required to clarify the observed "growth" of lesion size between days 2 and 7.

Percutaneous laser discectomy with the Ho:YAG laser

A prototype Ho:YAG (2.15 microns) laser operating at 2-J/pulse, 3 Hz through a 600-microns fiber was employed to perform laser discectomies at the L3-4 disc through an 18G needle in five juvenile pigs. No temperature elevations were recorded in the posterior longitudinal ligament at the disc level and all animals recovered fully with no adverse sequelae, even immediately upon awakening from anesthesia. Pathologic examination demonstrated a wide swath of coagulation necrosis confined to the disc space. The Ho:YAG laser, owing to its close approximation to the intense 2.0 microns absorption band of water, appears to be a viable candidate for clinical trials of laser discectomy.

A comparison of cholinergic effects of HI-6 and pralidoxime-2-chloride (2-PAM) in soman poisoning

The effects of HI-6 and pralidoxime chloride (2-PAM) on soman-induced lethality, time to death and several cholinergic parameters in rats were compared to understand the beneficial action of HI-6. Treatment with atropine sulfate (ATS) or HI-6 alone protected against 1.2 and 2.5 LD50s of soman respectively, whereas 2-PAM or methylated atropine (AMN) alone afforded no protection. Addition of ATS, but not AMN, to HI-6-treated rats enhanced the protection from 2.5 to 5.5 LD50s. HI-6 increased the time-to-death, while 2-PAM had no effect; a combination of HI-6 and ATS provided the most significant increase in time-to-death. Cholinesterase (ChE) activity was not altered in any tissue by ATS, HI-6 or 2-PAM treatment individually, but was markedly inhibited in all tissues by 100 micrograms/kg of soman. In soman-poisoned rats, the HI-6, but not the 2-PAM, group had significantly higher levels of ChE in blood and other peripheral tissues than did the group given soman alone. Neither HI-6 nor 2-PAM affected soman-inhibited ChE in the brain. Additional ATS treatment had no effect on ChE activity. HI-6 and 2-PAM neither modified baseline brain acetylcholine (ACh) or choline (Ch) levels nor protected against soman-induced ACh or Ch elevation. 2-PAM exhibited a 4-fold more potent in vitro inhibition of 3H-quinuclidinyl benzilate (3H-QNB) binding and sodium-dependent high-affinity Ch uptake (HACU) than did HI-6 in brain tissues. The findings that 2-PAM is a more potent in vitro inhibitor of muscarinic receptor binding and HACU than HI-6, and yet neither elevates ChE activity in the periphery nor protects rats against soman poisoning, indicate the importance of higher ChE activity in the periphery of HI-6-treated rats. Maintenance by HI-6 of a certain amount of active ChE in the periphery appears to be important for survival after soman exposure.

Effects of hematocrit on thixotropic properties of human blood

The rheological properties of whole human blood exhibit thixotropic behavior at low shear rates up to about ten reciprocal seconds (1). The accepted cause of this shear rate-dependent and time-dependent behavior is the progressive breakdown of rouleaux into individual red cells. Huang developed a rheological equation which incorporates the kinetics of rouleau breakdown in his models (2). This five-parameter equation was used successfully to represent the hysteresis loop and the torque-decay curve of whole human blood. Numerical values of these five thixotropic parameters, which characterize the rheological behavior of the blood from apparently healthy human subjects, were established (3). In this communication, we examined the effect of hematocrit on each of the above mentioned parameters. The results show that the following parameters will increase their values with an increase in hematocrit: the yield stress, Newtonian contribution of viscosity, non-Newtonian contribution of viscosity, apparent viscosity and the equilibrium value of the structural parameter which indicates the relative amount of rouleaux in blood. Mathematical equations were developed to give the relationship between parameters and hematocrit. Two other thixotropic parameters, viz. the kinetic rate constant of rouleaux breakdown into individual red cells and the order of the breakdown reaction, were found to be independent of the hematocrit. It is consistent with reaction kinetic theory that the rate constant and the order of reaction are independent of the concentration of reactants.

Reconstruction of large fronto-orbital defects with Dacron polyurethane custom prosthesis and autogenous bone

Reconstruction of large defects of the frontal bone and bony orbit may be required following trauma or ablative tumor surgery. Autogenous bone or alloplastic implants used alone may prove inadequate due to difficulties obtaining symmetric contours with bone and lack of strength and resistance to infection with alloplastic materials. These problems can be overcome with the combined use of a prefabricated Dacron polyurethane mesh prosthesis (Osteo-Mesh, Xomed, Inc.) to establish contour of the forehead and superciliary ridges, and underlying split-rib grafts to protect the brain and isolate the paranasal sinuses. This technique is not indicated for small frontal defects, but it should be considered for use by the head and neck surgeon who is faced with the challenge of reconstructing a major fronto-orbital defect.

Involvement of His HC3 (146) beta in the Bohr effect of human hemoglobin. Studies of native and N-ethylmaleimide-treated hemoglobin A and hemoglobin Cowtown (beta 146 His replaced by Leu)

The involvement of the COOH-terminal histidines of the beta chains of human hemoglobin in the allosteric mechanism of oxygen binding has been the topic of intensive discussion. Data presented here on the functional properties of native and chemically modified forms of Hb Cowtown (beta 146 His replaced by Leu) suggest that approximately half of the alkaline Bohr effect is attributable to the imidazole of His HC3(146) beta. The contribution of this residue to the alkaline Bohr effect has been estimated variably as 40-60% and 15% or less. Equilibrium and kinetic studies show that the amino acid substitution in Hb Cowtown decreases the stability of the low affinity conformation, resulting in an increased oxygen affinity and altered sensitivity to anionic effectors. Detailed analysis of Hill plots of oxygen binding according to the Adair scheme reveals that, under conditions of moderate ionic strength (chloride = 0.1 M), the K2 and K3 values for Hb A and Hb Cowtown differ, whereas the K1 and K4 values are closely similar over the physiological pH range. The decreased pH sensitivity of Hb Cowtown is associated with a decreased pH sensitivity of K1, the first Adair constant. In contrast to des-His(146 beta) hemoglobin, the cooperative interactions shown by Hb Cowtown under conditions of moderate ionic strength are not reduced in comparison to those of Hb A. This and the similarity of K1 and K4 values for Hb A and Hb Cowtown indicate that under these conditions the salt bridge formed by the COOH-terminal imidazole group does not significantly contribute to the free energy difference between "T-state" and "R-state" hemoglobin. It appears that the salt bridge formed by the COOH-terminal carboxyl group stabilizes the deoxy, T-state, conformation to a greater degree than previously appreciated. Chemical modification of the Cys(93 beta) residue of Hb Cowtown with N-ethylmaleimide causes a decrease in its oxygen affinity, in contrast to the increase in affinity exhibited by N-ethylmaleimide-modified Hb A. Hemoglobins A and Cowtown have remarkably similar oxygen binding properties after this modification and are shown to have K1 and K4 values distinctly different from those of unmodified Hb A. The properties of native and chemically modified forms of Hb Cowtown are indicative of a large contribution of the His HC3 (146) beta residue to the alkaline Bohr effect and also illustrate how chemical modifications or changes of strategic amino acid residues can result in pronounced differences in the conformational equilibrium of an allosteric protein.