Operative tactics in floor of mouth and tongue cancer resection - the importance of imaging and planning

Complete tumour resection (R0 margin) is an axiom of surgical oncology. Oral cancer ablation is challenging, due to anatomical, functional, and aesthetic considerations. R0 margin is strongly linked to better survival outcomes with great variation in the R0 % across units. This is commonly attributed to disease biology. Without disputing the importance of biological characteristics, we contend that image-based anatomical surgical planning has an important role to play in achieving complete resection. Here, we present our approach utilising cross-sectional imaging, anatomical characteristics and spatial awareness in planning resections for floor of mouth (FOM) and oral tongue cancers. We highlight the challenge of controlling the deep tumour margin lingual to mandible due to anterior vector constraints and emphasise the importance of resecting the genial muscles in a planned fashion and that any rim resection should be obliquely sagittal. In resecting lateral FOM tumours, assessing extension to the parapharyngeal fat is crucial; and mandibular rim resection at a sagittal plane below the mylohyoid line is often required. Assessing the proximity of the contralateral neurovascular pedicle, pre-epiglottic space and hyoid bone are crucial parameters to determine the extent of tongue tumour resection. Our cohort included 173 patients with FOM SCC and 299 patients with tongue SCC. Six patients (3.5%) from the FOM group and eight patients (3%) from the tongue group had involved (R1) margins following surgery. This was associated with local relapse (p<0.05). In conclusion, we demonstrate that image-based planning can aid achieving R0 resections and reduce disease relapse.

A case of recurrent hepatic haemangioendothelioma

Hepatic haemangioendothelioma is a rare (1:1,000,000) mesenchymal tumour of the liver of vascular origin. Metastatic malignancies, other primary liver tumours and cholangiocarcinomas all have significantly worse prognoses and may mimic hepatic haemangioendothelioma. Hence, careful pathological assessment with appropriate tumour markers and immunohistochemistry are essential. We present a rare case of recurrence of hepatic haemangioendothelioma after 10 years post-hemihepatectomy. Surgical approaches include liver resection, liver transplantation and ablative techniques with chemotherapy and radiotherapy reserved for patients where a surgical approach is not possible. Hepatic haemangioendothelioma has an unpredictable course that is generally indolent and it is associated with a significantly better long-term survival. Consequently, it is important that these tumours are recognised and the approach to the diagnosis should be methodical. Owing to the protracted course of the disease, a prolonged duration of surveillance and an aggressive approach towards disease recurrence are essential for long-term survival.

Intravenous omega-3 fatty acids are associated with better clinical outcome and less inflammation in patients with predicted severe acute pancreatitis: A randomised double blind controlled trial

BACKGROUND AND AIMS

Omega-3 fatty acids (FA) can ameliorate the hyper-inflammatory response that occurs in conditions such as severe acute pancreatitis (SAP) and this may improve clinical outcome. We tested the hypothesis that parenteral omega-3 FA from a lipid emulsion that includes fish oil could be beneficial in patients with predicted SAP by reducing C-reactive protein (CRP) concentration (primary outcome), and modulating the inflammatory response and improving clinical outcome (secondary outcomes).

METHODS

In a phase II randomized double-blind single-centre controlled trial, patients with predicted SAP were randomised to receive a daily infusion of fish oil containing lipid emulsion (Lipidem® 20%, BBraun) for 7 days (n = 23) or a daily infusion of a lipid emulsion without fish oil (Lipofundin® MCT 20%, BBraun) (n = 22).

RESULTS

On admission, both groups had comparable pancreatitis predicted severity and APACHE II scores. Administration of fish oil resulted in lower total blood leukocyte number (P = 0.04), CRP (P = 0.013), interleukin-8 (P = 0.05) and intercellular adhesion molecule 1 (P = 0.01) concentrations, multiple organ dysfunction score, sequential organ failure assessment score (P = 0.004), early warning score (P = 0.01), and systemic inflammatory response syndrome (P = 0.03) compared to the control group. The fish oil group had fewer new organ failures (P = 0.07), lower critical care admission rate (P = 0.06), shorter critical care stay (P = 0.03) and shorter total hospital stay (P = 0.04).

CONCLUSIONS

It is concluded that intravenous administration of a fish oil containing lipid emulsion, a source of omega-3 FA, improves clinical outcomes in patients with predicted SAP, benefits that may be linked to reduced inflammation. CLINICALTRIALS.

GOV NUMBER

NCT01745861.

EU CLINICAL TRIALS REGISTER

EudraCT (2010-018660-16).

Patient-reported outcome measure for neuromyelitis optica: pretesting of preliminary instrument and protocol for further development in accordance with international guidelines

OBJECTIVE

This study outlines the development of a patient-reported outcome measure (PROM), an instrument to obtain self-reported health status for neuromyeltis optica (NMO), a disabling neurological condition.

DESIGN

Development was conducted in accordance with international guidance for PROMs including systematic review of existing literature, item generation guided by qualitative interviews, health-related quality of life conceptual framework and clinical expert panel and cognitive interviews with NMO patients.

SETTING

Participants were identified through a national NMO clinic in a tertiary NHS neurosciences service.

PARTICIPANTS

15 individuals with NMO participated in cognitive interviews requiring review and ranking of proposed PROM items and qualitative feedback on content, layout and response options.

RESULTS

Participants endorsed the draft instrument as reflecting their experience of the condition and as being easy to understand. Rating and ranking of item relevance and importance reduced the draft instrument from 106 to 48 items. Participant feedback on overlapping items eliminated a further 2 items and resulted in a preliminary instrument of 46 items. As a direct result of participant feedback ordering of the 10 domains was revised, a 4 option Likert scale was employed and a 4-week recall period for impact of symptoms was selected.

CONCLUSIONS

A 46-item instrument developed in accordance with international PROM development guidelines through literature review, developed by subject matter experts and refined through pretesting examining content validity provides a preliminary measure for assessing patient-report of health status in NMO. Further evaluation is proposed including sensitivity to clinical change, and international contributions to evaluating the measure are encouraged.

Mycobacterium tuberculosis-associated synthetic mycolates differentially exert immune stimulatory adjuvant activity

Mycolic acids (MAs) are highly hydrophobic long-chain α-alkyl β-hydroxy fatty acids present in the cell wall of Mycobacterium tuberculosis (Mtb) as a complex mixture of molecules with a common general structure but with variable functional groups in the meromycolate chain. In this study, we addressed the relationship between the MA molecular structure and their contribution to the development of T-cell immune responses. Hereto, we used the model antigen ovalbumin and single synthetic MAs, differing in oxygenation class and cis versus trans proximal cyclopropane configuration, as immune stimulatory agents. Subcutaneous delivery of liposome-formulated MAs with a proximal cis cyclopropane elicited antigen-specific Th1 and cytotoxic T-cell immune responses, whereas intratracheal immunization elicited pulmonary Th17 responses. These immune stimulatory activities depended not only on the cis versus trans proximal cyclopropane configuration but also on the MA oxygenation class. Our study thus shows that both the presence and nature of the functional groups in the meromycolate chain affect the immune stimulatory adjuvant activity of Mtb mycolates and suggests that Mtb bacilli may impact on the host protective immune response by modulating the cis versus trans stereochemistry of its mycolates as well as by altering the oxygenation class of the meromycolate functional group.

GM-CSF treatment prevents respiratory syncytial virus-induced pulmonary exacerbation responses in postallergic mice by stimulating alveolar macrophage maturation

BACKGROUND

Human respiratory syncytial virus (RSV) is a frequent cause of asthma exacerbations, yet the susceptibility of asthmatic patients to RSV is poorly understood.

OBJECTIVE

We sought to address the contribution of resident alveolar macrophages (rAMs) to susceptibility to RSV infection in mice that recovered from allergic airway eosinophilia.

METHODS

Mice were infected with RSV virus after clearance of allergic airway inflammation (AAI). The contribution of post-AAI rAMs was studied in vivo by means of clodronate liposome-mediated depletion, adoptive transfer, and treatment with recombinant cytokines before RSV infection.

RESULTS

After clearing the allergic bronchial inflammation, post-AAI mice had bronchial hyperreactivity and increased inflammatory cell influx when infected with RSV compared with nonallergic mice, whereas viral clearance was comparable in both mouse groups. Post-AAI rAMs were necessary and sufficient for mediating these proinflammatory effects. In post-AAI mice the residing CD11c(hi) autofluorescent rAM population did not upregulate the terminal differentiation marker sialic acid-binding immunoglobulin-like lectin F and overproduced TNF and IL-6 through increased nuclear factor κB nuclear translocation. In line with these results, post-AAI lungs had reduced levels of the rAM maturation cytokine GM-CSF. Intratracheal administration of GM-CSF induced final rAM maturation in post-AAI mice and prevented the increased susceptibility to RSV-induced hyperreactivity and inflammation.

CONCLUSION

Defective production of GM-CSF leads to insufficient post-AAI rAM maturation in mice that recovered from an AAI, causing increased susceptibility to RSV-induced immunopathology. Promoting the differentiation of post-AAI rAMs might be a therapeutic option for preventing RSV-induced exacerbations in human asthmatic patients.

Elicitation of health state utilities associated with varying severities of flares in Systemic Lupus Erythematosus

Background

Systemic Lupus Erythematosus (SLE) is characterised by fluctuating periods of minimal disease activity and ‘flare’. Flare is an important outcome variable impacting the disease burden associated with SLE. The objective of this study was to obtain population-based utility values for varying severities of flare to measure the impact on health-related quality of life (HRQoL) in Australia, Canada, France, Japan, Spain and the UK.

Methods

Six health states (HS) for varying severities of flare were developed based on literature, patient blogs, and interviews with patients (n = 12), rheumatologists (n = 7) and nurses (n = 2). HS were validated by independent clinical experts (n = 6) and pilot interviews (n = 10, UK). HS were evaluated using the time-trade-off (TTO) method during face-to-face interviews with a minimum representative sample (n = 100) of the general population, per-country. Visual Analog Scale (VAS) scores were obtained to validate TTO scores. TTO scores were converted into utility values.

Results

The highest mean TTO utility scores were observed for the anchor HS (minimal disease activity) across all countries; means ranged from 0.66 in Japan to 0.82 in UK. All flare HS were associated with a disutility compared with the anchor HS (p < 0.001), means ranged across countries: mild flare HS: 0.55–0.71, moderate flare HS: 0.38–0.53, severe renal flare HS: 0.33–0.45, severe central nervous system (CNS) flare HS: 0.30–0.45 and severe generalised flare HS: 0.19–0.33. Mean VAS scores followed the same trend.

Conclusions

These results show increasing severity of flare has a detrimental impact on HRQoL. The severe generalised flare HS received the lowest mean utility score suggesting that the perceived day-to-day impact of a severe generalised flare was greater than a severe CNS or severe renal flare. This is, to the best of our knowledge, the first utility study to assess varying severities of flare in SLE across six different countries.

A novel systemically administered Toll-like receptor 7 agonist potentiates the effect of ionizing radiation in murine solid tumor models

Although topical TLR7 therapies such as imiquimod have proved successful in the treatment of dermatological malignancy, systemic delivery may be required for optimal immunotherapy of nondermatological tumors. We report that intravenous delivery of the novel small molecule TLR7 agonist, DSR-6434, leads to the induction of type 1 interferon and activation of T and B lymphocytes, NK and NKT cells. Our data demonstrate that systemic administration of DSR-6434 enhances the efficacy of ionizing radiation (IR) and leads to improved survival in mice bearing either CT26 or KHT tumors. Of the CT26 tumor-bearing mice that received combined therapy, 55% experienced complete tumor resolution. Our data reveal that these long-term surviving mice have a significantly greater frequency of tumor antigen specific CD8(+) T cells when compared to age-matched tumor-naïve cells. To evaluate therapeutic effects on spontaneous metastases, we showed that combination of DSR-6434 with local IR of the primary tumor significantly reduced metastatic burden in the lung, when compared to time-matched cohorts treated with IR alone. The data demonstrate that systemic administration of the novel TLR7 agonist DSR-6434 in combination with IR primes an antitumor CD8(+) T-cell response leading to improved survival in syngeneic models of colorectal carcinoma and fibrosarcoma. Importantly, efficacy extends to sites outside of the field of irradiation, reducing metastatic load. Clinical evaluation of systemic TLR7 therapy in combination with IR for the treatment of solid malignancy is warranted.

Challenges and advances towards the rational design of mRNA vaccines

In recent years, mRNA vaccines have emerged as a safe and potent approach for the induction of cellular immune responses. Whereas initial studies were limited to the ex vivo loading of dendritic cells (DCs) with antigen-encoding mRNA, recent progress has led to the development of improved mRNA vaccines that enable direct in vivo targeting of DCs. Although preclinical studies demonstrated their potency in inducing antitumor immunity, several bottlenecks hinder the broader application of mRNA vaccines. In this review, we discuss the challenges associated with mRNA-based vaccination strategies, the technological advances that have been made to overcome these limitations, and the hurdles that remain to be tackled for the development of an optimal mRNA vaccine.

Use of mRNA for vaccination or gene therapy: delivery route determines the verdict (P4316)

The use of DNA and viral vector vaccines for the induction of cellular immune responses is increasingly gaining interest. However, concerns have been raised regarding the safety of these immunization strategies. Due to their lack of genome integration, mRNA-based vaccines have emerged as a promising alternative. In this study we evaluated the potency of antigen-encoding mRNA either delivered via complexation with the cationic lipid DOTAP/DOPE, or delivered via in vivo electroporation as a novel vaccination approach. By using luciferase-encoding mRNA we showed that in vivo electroporation of mRNA induces high levels of luciferase at the injection site, while protein expression in mice injected with DOTAP/DOPE complexed mRNA was barely above background levels. Despite the high levels of protein expression, in vivo electroporation of mRNA failed to elicit immune responses against the encoded antigen. In contrast, lipid-based delivery of mRNA induced antigen-specific, functional T cell responses resulting in specific killing of peptide-pulsed cells and the induction of humoral responses. In summary, in vivo electroporation of antigen-encoding mRNA induces high levels of protein expression but no immune responses, thus presenting an ideal tool for mRNA-based gene therapy, while lipid-based delivery offers advantages for vaccination purposes due to the induction of low protein levels but strong antigen-specific cellular immunity.

Inflammatory DCs fail to present antigen but provide a crucial source of IL-12 in priming Th1 responses to CpG based vaccines. (P4514)

DCs govern the induction of antigen specific adaptive immunity and thus constitute the main targets of novel vaccine approaches. Classical steady state DCs consist of multiple subsets, differing in their capacity to respond to TLR stimulation and to present antigen to CD4 and CD8 T cells. Under inflammatory conditions, an additional subset of monocyte derived inflammatory DCs (iDCs) arises. Although the innate role of iDCs in antimicrobial immunity is now clearly established, their role in directing the adaptive response is less evident. Immunization with OVA combined with the TLR9 agonist CpG resulted in the fast recruitment of CCR2 CD64 Ly6Chi CD11bhi monocytes to the draining lymph nodes, where they gradually adopt a CD11cint MHCIIint phenotype. Although a large fraction of these iDCs were OVA+, sorted iDCs failed to present the antigen to OT-I and OT-II T cells. Instead, antigen presentation was limited to migratory DCs. iDCs however proved to be the major source the Th1 polarising cytokine IL12. To investigate the role of iDC-derived IL12 in priming Th1 responses, mixed CCR2-/- /IL12-/- bone marrow chimaeras were immunized with OVA/CpG. In these chimaeras, solely IL12-/- iDCs can reach the lymph node, while classical lymph node DCs are fully competent of producing IL12. When compared to control WT/IL12-/- chimaeras, CCR2 -/-/IL12-/- mice displayed dramatically reduced Th1 responses, establishing the crucial role of iDCs in priming Th1 responses.

Innate imprinting of resident alveolar macrophages in RSV-induced allergic asthma exacerbations (P6003)

Acute RSV-infections are seen as instigators of exacerbations in allergic asthma patients. The question which cells and/or molecules that orchestrate viral-induced asthma exacerbations remains unanswered. We now show that the innate (antiviral) functionality of post-asthma resident alveolar macrophages (rAM), present after the clearance of the allergic bronchial inflammation, is imprinted by this preceding allergic inflammation. In contrast to naïve rAM, post-asthma rAM exhibited strong proinflammatory reactivity during RSV-infection which significantly contributed to the increased global pulmonary inflammation observed in RSV-infected post-asthma mice. The strong proinflammatory reactivity of post-asthma rAM was mainly due to increased NF-κB p65 activation in these cells upon RSV-infection. Furthermore, compared to naïve rAM, post-asthma rAM displayed no direct contribution to virus clearance. In fact, post-asthma rAM did not show efficient uptake of the virus. Finally, compared to naïve rAM, the basal activation state of post-asthma rAM was found to be strongly skewed towards an M2-phenotype. Consequently, the polarized M2-activation status of post-asthma rAM can serve as a possible explanation for the aberrant antiviral innate responses of these cells. Together, innate imprinting of rAM by a preceding allergic inflammation strongly impairs RSV-antiviral responses of the post-asthma lungs and can therefore contribute to the onset of asthma exacerbations.

M2e-displaying virus-like particles with associated RNA promote T helper 1 type adaptive immunity against influenza A

The ectodomain of influenza A matrix protein 2 (M2e) is a candidate for a universal influenza A vaccine. We used recombinant Hepatitis B core antigen to produce virus-like particles presenting M2e (M2e-VLPs). We produced the VLPs with and without entrapped nucleic acids and compared their immunogenicity and protective efficacy. Immunization of BALB/c mice with M2e-VLPs containing nucleic acids induced a stronger, Th1-biased antibody response compared to particles lacking nucleic acids. The former also induced a stronger M2e-specific CD4(+) T cell response, as determined by ELISPOT. Mice vaccinated with alum-adjuvanted M2e-VLPs containing the nucleic acid-binding domain were better protected against influenza A virus challenge than mice vaccinated with similar particles lacking this domain, as deduced from the loss in body weight following challenge with X47 (H3N2) or PR/8 virus. Challenge of mice that had been immunized with M2e-VLPs with or without nucleic acids displayed significantly lower mortality, morbidity and lung virus titers than control-immunized groups. We conclude that nucleic acids present in M2e-VLPs correlate with improved immune protection.

Type I IFN counteracts the induction of antigen-specific immune responses by lipid-based delivery of mRNA vaccines

The use of DNA and viral vector-based vaccines for the induction of cellular immune responses is increasingly gaining interest. However, concerns have been raised regarding the safety of these immunization strategies. Due to the lack of their genome integration, mRNA-based vaccines have emerged as a promising alternative. In this study, we evaluated the potency of antigen-encoding mRNA complexed with the cationic lipid 1,2-dioleoyl-3trimethylammonium-propane/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOTAP/DOPE ) as a novel vaccination approach. We demonstrate that subcutaneous immunization of mice with mRNA encoding the HIV-1 antigen Gag complexed with DOTAP/DOPE elicits antigen-specific, functional T cell responses resulting in specific killing of Gag peptide-pulsed cells and the induction of humoral responses. In addition, we show that DOTAP/DOPE complexed antigen-encoding mRNA displays immune-activating properties characterized by secretion of type I interferon (IFN) and the recruitment of proinflammatory monocytes to the draining lymph nodes. Finally, we demonstrate that type I IFN inhibit the expression of DOTAP/DOPE complexed antigen-encoding mRNA and the subsequent induction of antigen-specific immune responses. These results are of high relevance as they will stimulate the design and development of improved mRNA-based vaccination approaches.

Lipoplexes carrying mRNA encoding Gag protein modulate dendritic cells to stimulate HIV-specific immune responses

AIM

Cationic lipids (Lipofectamine™ [Invitrogen, Merelbeke, Belgium] and 1,2-dioleoyl-3-trimethylammonium-propane/1,2-dioleoyl-sn-glycero-3-phosphoethanolamine) and polymers (jetPEI™ and in vivo-jetPEI™ [Polyplus-transfection, Illkirch, France]) were evaluated for their potential to deliver mRNA to monocyte-derived dendritic cells.

MATERIALS & METHODS

Lipoplexes and polyplexes, containing mRNA encoding GFP or Gag protein, were incubated with human monocyte-derived dendritic cells and transfection efficiencies were assessed by flow cytometry.

RESULTS

Lipofectamine was by far the most efficient in mRNA delivery, therefore it was used in further experiments. Incubation of monocyte-derived dendritic cells isolated from HIV-1-positive donors with mRNA encoding Gag protein complexed to Lipofectamine resulted in 50% transfection. Importantly, coculture of these Gag-transfected dendritic cells with autologous T cells induced an over tenfold expansion of IFN-γ- and IL-2-secreting CD4(+) and CD8(+) T cells.

CONCLUSION

Cationic lipid-mediated mRNA delivery may be a useful tool for therapeutic vaccination against HIV-1. This approach can be applied to develop vaccination strategies for other infectious diseases and cancer.

Rational design of HIV vaccines and microbicides: report of the EUROPRISE annual conference 2011

Europrise is a Network of Excellence supported by the European Commission within the 6th Framework programme from 2007 to 2012. The Network has involved over 50 institutions from 13 European countries together with 3 industrial partners and 6 African countries. The Network encompasses an integrated program of research, training, dissemination and advocacy within the field of HIV vaccines and microbicides. A central and timely theme of the Network is the development of the unique concept of co-usage of vaccines and microbicides. Training of PhD students has been a major task, and some of these post-graduate students have here summarized novel ideas emanating from presentations at the last annual Europrise meeting in Prague. The latest data and ideas concerning HIV vaccine and microbicide studies are included in this review; these studies are so recent that the majority have yet to be published. Data were presented and discussed concerning novel immunisation strategies; microbicides and PrEP (alone and in combination with vaccines); mucosal transmission of HIV/SIV; mucosal vaccination; novel adjuvants; neutralizing antibodies; innate immune responses; HIV/SIV pathogenesis and disease progression; new methods and reagents. These – necessarily overlapping topics - are comprehensively summarised by the Europrise students in the context of other recent exciting data.

Polymeric multilayer capsule-mediated vaccination induces protective immunity against cancer and viral infection

Recombinant antigens hold high potential to develop vaccines against lethal intracellular pathogens and cancer. However, they are poorly immunogenic and fail to induce potent cellular immunity. In this paper, we demonstrate that polymeric multilayer capsules (PMLC) strongly increase antigen delivery toward professional antigen-presenting cells in vivo, including dendritic cells (DCs), macrophages, and B cells, thereby enforcing antigen presentation and stimulating T cell proliferation. A thorough analysis of the T cell response demonstrated their capacity to induce IFN-γ secreting CD4 and CD8 T cells, in addition to follicular T-helper cells, a recently identified CD4 T cell subset supporting antibody responses. On the B cell level, PMLC-mediated antigen delivery promoted the formation of germinal centers, resulting in increased numbers of antibody-secreting plasma cells and elevated antibody titers. The functional relevance of the induced immune responses was validated in murine models of influenza and melanoma. On a mechanistic level, we have demonstrated the capacity of PMLC to activate the NALP3 inflammasome and trigger the release of the potent pro-inflammatory cytokine IL-1β. Finally, using DC-depleted mice, we have identified DCs as the key mediators of the immunogenic properties of PMLC.

Surface-engineered polyelectrolyte multilayer capsules: synthetic vaccines mimicking microbial structure and function

Immunizing: to evoke highly potent immune responses against recombinant antigens, hollow capsules consisting of layers of dextran sulphate and poly-L-arginine that encapsulate the antigen ovalbumin (orange circles) were coated with immune-activating CpG-containing oligonucleotides (green). These capsules were readily internalized by dendritic cells and showed activity in further immunization experiments.

How can we improve our understanding of cardiovascular safety liabilities to develop safer medicines?

Given that cardiovascular safety liabilities remain a major cause of drug attrition during preclinical and clinical development, adverse drug reactions, and post-approval withdrawal of medicines, the Medical Research Council Centre for Drug Safety Science hosted a workshop to discuss current challenges in determining, understanding and addressing 'Cardiovascular Toxicity of Medicines'. This article summarizes the key discussions from the workshop that aimed to address three major questions: (i) what are the key cardiovascular safety liabilities in drug discovery, drug development and clinical practice? (ii) how good are preclinical and clinical strategies for detecting cardiovascular liabilities? and (iii) do we have a mechanistic understanding of these liabilities? It was concluded that in order to understand, address and ultimately reduce cardiovascular safety liabilities of new therapeutic agents there is an urgent need to: • Fully characterize the incidence, prevalence and impact of drug-induced cardiovascular issues at all stages of the drug development process. • Ascertain the predictive value of existing non-clinical models and assays towards the clinical outcome. • Understand the mechanistic basis of cardiovascular liabilities; by addressing areas where it is currently not possible to predict clinical outcome based on preclinical safety data. • Provide scientists in all disciplines with additional skills to enable them to better integrate preclinical and clinical data and to better understand the biological and clinical significance of observed changes. • Develop more appropriate, highly relevant and predictive tools and assays to identify and wherever feasible to eliminate cardiovascular safety liabilities from molecules and wherever appropriate to develop clinically relevant and reliable safety biomarkers.

Polyelectrolyte capsules-containing HIV-1 p24 and poly I:C modulate dendritic cells to stimulate HIV-1-specific immune responses

Polyelectrolyte microcapsules (MCs) are potent protein delivery vehicles which can be tailored with ligands to stimulate maturation of dendritic cells (DCs). We investigated the immune stimulatory capacity of monocyte-derived DC (Mo-DC) loaded with these MCs, containing p24 antigen from human immunodeficiency virus type 1 (HIV-1) alone [p24-containing MC (MCp24)] or with the Toll-like receptor ligand 3 (TLR3) ligand poly I:C (MCp24pIC) as a maturation factor. MO-DC, loaded with MCp24pIC, upregulated CCR7, CD80, CD83, and CD86 and produced high amounts of interleukin-12 (IL-12) cytokine, to a similar extent as MCp24 in the presence of an optimized cytokine cocktail. MO-DC from HIV-infected patients under highly active antiretroviral therapy (HAART) exposed to MCp24 together with cytokine cocktail or to MCp24pIC expanded autologous p24-specific CD4(+) and CD8(+) T-cell responses as measured by interferon-gamma (IFN-gamma) and IL-2 cytokine production and secretion. In vivo relevance was shown by immunizing C57BL/6 mice with MCp24pIC, which induced both humoral and cellular p24-specific immune responses. Together these data provide a proof of principle that both antigen and DC maturation signal can be delivered as a complex with polyelectrolyte capsules to stimulate virus-specific T cells both in vitro and in vivo. Polyelectrolyte MCs could be useful for in vivo immunization in HIV-1 and other infections.

Severe gestational (incidental) thrombocytopenia: to treat or not to treat

Thrombocytopenia is common in pregnancy and is diverse in etiology. Immune thrombocytopenic purpura (ITP) may affect both mother and the newborn. Gestational (incidental) thrombocytopenia in an otherwise fit woman, at term is the most frequent type of thrombocytopenia and poses no clinical consequences for mother or infant. We report six women who presented with severe thrombocytopenia during pregnancy. Five were treated in late pregnancy, either with intravenous immunoglobulin (IVIg), or IVIg followed by steroids. There was no response, and four received a platelet transfusion during delivery. The platelet counts in all the infants were normal and the maternal thrombocytopenia resolved spontaneously after delivery in all cases. Our observations suggest that this is a group of patients with a severe form of gestational thrombocytopenia. The severe form of gestational thrombocytopenia appears to be rare, and recognition is important, as it may recur in subsequent pregnancies and does not require any therapeutic intervention.

The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis

BACKGROUND

Catheter-related sepsis remains the major confounding factor in the long-term delivery of TPN. Previous studies have shown that the introduction of clinical nurse specialists (CNS) can lead to a reduction in sepsis from TPN catheters. This retrospective study aimed to determine the impact of a nutrition CNS on the rate of catheter-related sepsis. Furthermore, the cost of providing such a service was examined to see if it was offset from the savings obtained from reducing venous access infection.

METHODS

Prior to the employment of a nutrition CNS, the total number of septic catheter complications were retrospectively collected over a 12-month period. Following appointment of the CNS, all patients requiring TPN were prospectively studied for signs of catheter-related sepsis and the data collected over a 4-year period.

RESULTS

The overall sepsis rate (cumulative percentage) fell significantly in the 4-year period after the nutrition CNS was appointed, from 52% to 2.3%. The reduction in venous catheter access was accompanied by a decrease in cost related to wastage of TPN and insertion of new Hickman lines.

CONCLUSION

The role of the CNS is primarily to improve the quality of care provided, but also to provide cost effectiveness. We have demonstrated that in addition to reducing infection rate of central venous catheters; the cost of employing a nutrition CNS is almost completely covered by the savings resulting from the reduction in wasted central venous catheters, TPN and operating time.