Rare lysosomal disease registries: lessons learned over three decades of real-world evidence

Lysosomal storage disorders (LSD) are rare diseases, caused by inherited deficiencies of lysosomal enzymes/transporters, that affect 1 in 7000 to 1 in 8000 newborns. Individuals with LSDs face long diagnostic journeys during which debilitating and life-threatening events can occur. Clinical trials and classical descriptions of LSDs typically focus on common manifestations, which are not representative of the vast phenotypic heterogeneity encountered in real-world experience. Additionally, recognizing that there was a limited understanding of the natural history, disease progression, and real-world clinical outcomes of rare LSDs, a collaborative partnership was pioneered 30 years ago to address these gaps. The Rare Disease Registries (RDR) (for Gaucher, Fabry, Mucopolysaccharidosis type I, and Pompe), represent the largest observational database for these LSDs. Over the past thirty years, data from the RDRs have helped to inform scientific understanding and the development of comprehensive monitoring and treatment guidelines by creating a framework for data collection and establishing a standard of care, with an overarching goal to improve the quality of life of affected patients. Here, we highlight the history, process, and impact of the RDRs, and discuss the lessons learned and future directions.

An online Sexual Health and Rehabilitation eClinic (TrueNTH SHAReClinic) for prostate cancer patients: a feasibility study

Purpose

The primary objective was to determine the feasibility of implementing the TrueNTH SHAReClinic as a pan-Canadian sexual health and rehabilitation intervention for patients treated for localized prostate cancer.

Methods

The feasibility study was designed to evaluate the accessibility and acceptability of the intervention. Participants from five institutions across Canada were enrolled to attend one pre-treatment and five follow-up online clinic visits over 1 year following their prostate cancer (PC) treatment.

Results

Sixty-five patients were enrolled in the intervention. Website analytics revealed that 71% completed the intervention in its entirety, including the educational modules, with an additional 10% completing more than half of the intervention. Five thousand eighty-three views of the educational modules were made along with 654 views of the health library items. Over 1500 messages were exchanged between participants and their sexual health coaches. At 12 months, the intervention received an overall average participant rating of 4.1 out of 5 on a single item satisfaction measure.

Conclusion

Results support the TrueNTH SHAReClinic as highly acceptable to participants as defined by intervention adherence and engagement. The TrueNTH SHAReClinic demonstrated promise for being a feasible and potentially resource-efficient approach to effectively improving the sexual well-being of patients after PC treatment.

Effects of the macroalga Asparagopsis taxiformis and oregano leaves on methane emission, rumen fermentation, and lactational performance of dairy cows

Asparagopsis taxiformis (AT) is a source of multiple halogenated compounds and, in a limited number of studies, has been shown to decrease enteric CH₄ emission in vitro and in vivo. Similarly, oregano has been suggested as a potential CH₄ mitigating agent. This study consisted of 2 in vitro and 2 in vivo experiments. Experiment (Exp.) 1 was aimed at establishing the effect of AT on CH₄ emission in vitro. Two experiments (Exp. 2 and 3) with lactating dairy cows were conducted to determine the antimethanogenic effect of AT and oregano (Exp. 3) in vivo. Another experiment (Exp. 4) was designed to investigate stability of bromoform (CHBr₃) in AT over time. In Exp. 3, 20 Holstein cows were used in a replicated 4 × 4 Latin square design with four 28-d periods. Treatments were basal diet (control) or basal diet supplemented with (dry matter basis) 0.25% AT (LowAT), 0.50% AT (HighAT), or 1.77% oregano (Origanum vulgare L.) leaves. Enteric gas emissions were measured using the GreenFeed system (C-Lock Inc., Rapid City, SD), and rumen samples were collected for fermentation analysis using the ororuminal technique. In Exp.1 (in vitro), relative to the control, AT (at 1% dry matter basis, inclusion rate) decreased CH₄ yield by 98%. In Exp. 3, HighAT decreased average daily CH₄ emission and CH₄ yield by 65% and 55%, respectively, in experimental periods 1 and 2, but had no effect in periods 3 and 4. The differential response to AT among experimental periods was likely a result of a decrease in CHBr₃ concentration in AT over time, as observed in Exp. 4 (up to 84% decrease in 4 mo of storage). In Exp. 3, H₂ emission was increased by AT and, as expected, the proportion of acetate in the total volatile fatty acids in the rumen was decreased and those of propionate and butyrate were increased by HighAT compared with the control. Compared with the control, HighAT decreased dry matter intake, milk yield, and energy-corrected milk yield in Exp. 3. Milk composition was not affected by treatment, except lactose percentage and yield were decreased by HighAT. Concentrations of iodine and bromide in milk were increased by HighAT compared with the control. Milk CHBr₃ concentration and its organoleptic characteristics were not different between control and HighAT. Oregano had no effect on CH₄ emission or lactational performance of the cows in Exp. 3. Overall, AT included at 0.50% in the ration of dairy cows can have a large mitigation effect on enteric CH₄ emission, but dry matter intake and milk production may also decrease. There was a marked decrease in the CH₄ mitigation potential of AT in the second half of Exp. 3, likely resulting from CHBr₃ decay over time.

Counselled Patients with Stroke Still Experience Sexual and Relational Problems 1–5 Years After Stroke Rehabilitation

To describe sexual functioning/satisfaction and relational satisfaction of patients with stroke who received sexual counselling during their rehabilitation 1–5 years thereafter. All adult patients with stroke admitted to one Dutch Rehabilitation Centre between January 2010 and January 2014 with at least two consultations with a sexologist were invited to participate in this cross-sectional survey study. Patients were asked to complete a questionnaire on sexual functioning, relational satisfaction (Maudsley Marital Questionnaire, 0–80; low–high dissatisfaction), health-related quality of life (HRQoL) short-form12 (SF-12) mental and physical component scale (MCS and PCS; 0–100, low–high HRQoL) and mood Hospital Anxiety Depression Scale (HADS, 0–21 low–high depression/anxiety). Descriptive statistics were used for sexual functioning/satisfaction and relational satisfaction. Spearmans’s correlation analysis (rs) analyzed the relationships between sexual satisfaction, relational satisfaction, PCS, MCS, depression and anxiety. Of 296 eligible patients, 62 (21%) completed the questionnaires. Mean age 55.4 (SD11.0) years, time-since-stroke 3.5 (SD3.6) years, 33 (53%) were male and 18 (29%) were single. Being sexually (very) unsatisfied was reported by 31 (54%) responders, with 63% being male and 44% female. Median MMQ-score relational satisfaction was 12.0 (IQR 4.25–23.25). A moderate correlation was present between sexual and relational satisfaction (rs = 0.35, p = 0.02). In male respondents relational satisfaction was highly correlated with lower levels of anxiety (rs = 0.54, p = 0.01) and depressive symptoms (rs = 0.71, p = 0.00). Patients with stroke who received sexual counselling during their rehabilitation treatment experience high relational satisfaction in the long term after stroke, despite their problems in sexual functioning.

Animal movement drives variation in seed dispersal distance in a plant-animal network

Frugivores play differing roles in shaping dispersal patterns yet seed dispersal distance is rarely quantified across entire communities. We model seed dispersal distance using gut passage times and bird movement for the majority (39 interactions) of known bird-tree interactions on the island of Saipan to highlight differences in seed dispersal distances provided by the five avian frugivores. One bird species was found to be a seed predator rather than a disperser. The remaining four avian species dispersed seeds but differences in seed dispersal distance were largely driven by interspecific variation in bird movement rather than intraspecific variation in gut passage times. The median dispersal distance was at least 56 m for all species-specific combinations, indicating all species play a role in reducing high seed mortality under the parent tree. However, one species-the Micronesian Starling-performed 94% of dispersal events greater than 500 m, suggesting this species could be a key driver of long-distance dispersal services (e.g. linking populations, colonizing new areas). Assessing variation in dispersal patterns across this network highlights key sources of variation in seed dispersal distances and suggests which empirical approaches are sufficient for modelling how seed dispersal mutualisms affect populations and communities.

Identifying Determinants of Intervention Sustainability in Cancer Survivorship Care

Background: Substantial gains could be made in reducing the cancer burden if current scientific evidence was applied in practice. The World Health Organization estimates that, worldwide, one-third of cancer cases could be prevented and another one-third cured if evidence was consistently implemented and sustained in cancer care. However, moving evidence-based interventions into care has proven a significant challenge. Even when interventions are put into practice, they often fail to become integrated into the long-term routines of organizations. This poor sustainability means many patients do not benefit from the best care possible. There is little empirical data on the factors that influence the sustainability of interventions in clinical settings. Aim: To identify the determinants of, and explore the processes that facilitate, sustainability of interventions in cancer care survivorship. Sustainability was defined as the continued use of an intervention and its associated components and/or the continued achievement of the intended benefits after the initial funding or support period. Methods: We first conducted an environmental scan to identify interventions in cancer survivorship care implemented in Canada. This was followed by a literature review to ascertain the evidence base for each intervention and identify those meeting the US National Cancer Institute's criteria for evidence-based interventions. We then recruited key individuals relevant to the evidence-based interventions for semistructured in-depth interviews to explore issues related to their sustainability. Interview data are being analyzed through an inductive grounded theory approach using constant comparative analysis. Results: Twenty-seven individuals participated in the interviews. Preliminary findings reveal five factors that influenced whether, and the extent to which, interventions were sustained in cancer survivorship care. Participants emphasized (1) access to sufficient resources and funding is critical to sustaining interventions after the initial funding period. The ability of a team or organization to (2) evaluate a new intervention and demonstrate its quality and usefulness was often perceived as necessary to obtain continued funding as well as ongoing buy in and support from key stakeholders. In addition, the (3) extent to which the intervention can be adapted, (4) support of senior management, and (5) existence of an on-the-ground champion to continuously promote, adapt, lead, and spread the intervention were perceived as important factors that contribute to an intervention's sustained use. Conclusion: Research into determinants and processes of sustainability is critical to ensure we plan and act in ways that maximize the sustained use of interventions shown to benefit patients and our cancer systems. Issues related to evaluation, adaptability, and ongoing moral and material supports should be considered before, during, and after implementation efforts.

When Environmental Forces Collide

Multiple factors often interact to amplify the effects of severe storms, droughts, and other extreme water-related events.

Epidemiologic Investigation of Highly Pathogenic H5N2 Avian Influenza Among Upper Midwest U.S. Turkey Farms, 2015

In 2015, an outbreak of H5N2 highly pathogenic avian influenza (HPAI) occurred in the United States, severely impacting the turkey industry in the upper midwestern United States. Industry, government, and academic partners worked together to conduct a case-control investigation of the outbreak on turkey farms in the Upper Midwest. Case farms were confirmed to have HPAI-infected flocks, and control farms were farms with noninfected turkey flocks at a similar stage of production. Both case and control farms were affiliated with a large integrated turkey company. A questionnaire administered to farm managers and supervisors assessed farm biosecurity, litter handling, dead bird disposal, farm visitor and worker practices, and presence of wild birds on operations during the 2 wk prior to HPAI confirmation on case premises and the corresponding time frame for control premises. Sixty-three farms, including 37 case farms and 26 control farms were included in the analysis. We identified several factors significantly associated with the odds of H5N2 case farm status and that may have contributed to H5N2 transmission to and from operations. Factors associated with increased risk included close proximity to other turkey operations, soil disruption (e.g., tilling) in a nearby field within 14 days prior to the outbreak, and rendering of dead birds. Observation of wild mammals near turkey barns was associated with reduced risk. When analyses focused on farms identified with H5N2 infection before April 22 (Period 1), associations with H5N2-positive farm status included soil disruption in a nearby field within 14 days prior to the outbreak and a high level of visitor biosecurity. High level of worker biosecurity had a protective effect. During the study period after April 22 (Period 2), factors associated with HPAI-positive farm status included nonasphalt roads leading to the farm and use of a vehicle wash station or spray area. Presence of wild birds near dead bird disposal areas was associated with reduced risk. Study results indicated that the initial introduction and spread of H5N2 virus likely occurred by both environmental and between-farm pathways. Transmission dynamics appeared to change with progression of the outbreak. Despite enhanced biosecurity protocols, H5N2 transmission continued, highlighting the need to review geographic/topologic factors such as farm proximity and potential dust or air transmission associated with soil disruption. It is likely that biosecurity improvements will reduce the extent and speed of spread of future outbreaks, but our results suggest that environmental factors may also play a significant role in farms becoming infected with HPAI.

On the energetics of P–P bond dissociation of sterically strained tetraamino-diphosphanes

Thermochemical data for the homolytic P–P bond fission in tetraaminodiphosphanes (R₂N)₂P–P(NR₂)₂ were determined experimentally and computationally. The results confirm that radical formation is favoured by entropic and structural relaxation effects, and disfavoured by dispersion forces. Unlike aminophosphenium cations, the radicals display no strong preference for a planar (R₂N)₂P unit.

An anionic phosphenium complex as an ambident nucleophile

Treatment of an N-heterocyclic chlorophosphine with Collman's reagent or K[HFe(CO)₄]/NaH gave a unique anionic phosphenium complex which behaves as an ambident nucleophile.

Does simulation booster impact retention of resuscitation procedural skills and teamwork?

OBJECTIVE

The Neonatal Resuscitation Program (NRP) has transitioned to a simulation-based format. We hypothesized that immersive simulation differentially impacts similar trainee populations' resuscitation knowledge, procedural skill and teamwork behavior.

STUDY DESIGN

Residents from NICU and non-NICU programs were randomized to either control or a booster simulation 7 to 10 months after NRP. Procedural skill and teamwork behavior instruments were validated. Individual resident's resuscitation performance was assessed at 15 to 18 months. Three reviewers rated videos.

RESULT

Fifty residents were assessed. Inter-rater reliability was good for procedural skills (0.78) and team behavior (0.74) instruments. The intervention group demonstrated better procedural skills (71.6 versus 64.4) and teamwork behaviors (18.8 versus 16.2). The NICU program demonstrated better teamwork behaviors (18.6 versus 15.5) compared with non-NICU program.

CONCLUSION

A simulation-enhanced booster session 9 months after NRP differentiates procedural skill and teamwork behavior at 15 months. Deliberate practice with simulation enhances teamwork behaviors additively with residents' clinical resuscitation exposure.

Use of personal protective measures by Thai households in areas with avian influenza outbreaks

Thailand has had multiple poultry outbreaks of highly pathogenic avian influenza (HPAI) H5N1 since its first emergence in 2004. Twenty-five human cases of HPAI H5N1 avian influenza have been reported in the country, including 17 fatalities, and contact with infected dead or dying poultry has been identified as a risk factor for human infection. This study assessed the use of protective equipment and hand hygiene measures by Thai poultry-owning households during activities involving poultry contact. Surveys conducted in 2008 included questions regarding poultry-related activities and protective measures used during an HPAI outbreak (2005) and 3 years after the study location's last reported outbreak (2008). For both time periods, poultry owners reported limited use of personal protective equipment (PPE) during all activities and inconsistent hand washing practices after carrying poultry and gathering eggs. This is the first time that PPE use in Thailand has been quantified for a large study group. These data are important for ongoing characterization of HPAI risk and for the crafting of educational messages.

Characterization of influenza a outbreaks in Minnesota swine herds and measures taken to reduce the risk of zoonotic transmission

Influenza A virus infections commonly cause respiratory disease in swine and can be transmitted between people and pigs, with potentially novel strains introduced into herds and spilling back into the human population. The goals of this study were to characterize influenza infections in Minnesota pigs and assess biosecurity measures used by swine workers. Veterinarians submitting influenza-positive swine samples to the University of Minnesota Veterinary Diagnostic Laboratory between October 2007 and April 2009 were surveyed regarding disease-related information and biosecurity procedures at each farm. Influenza-positive samples were submitted year-round, peaking in spring and fall. H1N1 was the most commonly detected subtype (56%), followed by H3N2 (14%) and H1N2 (12%). Most positive submissions were associated with illness in growing pigs (median age 8.8 weeks, IQR 5-15). Median morbidity and mortality were 25% (IQR 10-48) and 2% (IQR 0.5-3.5), respectively. Vaccination of sows and growing pigs was conducted at 71% and 7.9% of the swine farms, respectively. Specialized footwear was reported as the most common form of protective equipment used by workers. Employee vaccination for seasonal influenza was 19%. The sow vaccination rate in this study is consistent with national data, although growing pig vaccination is lower than the national average. Seasonal and age trends identified here may provide diagnostic guidance when growing pigs experience respiratory disease. Inconsistent use of protective equipment and employee vaccination at swine farms indicates the need for further discussion and research of approaches to minimize interspecies influenza transmission on swine farms.

Use of low-dose pregabalin in patients undergoing laparoscopic cholecystectomy

BACKGROUND

The objective of this study was to examine the effects of low-dose pregabalin on the analgesic efficacy, side-effects, and recovery profile in patients undergoing laparoscopic cholecystectomy.

METHODS

One hundred and sixty-two patients aged 18-65 yr, of ASA physical status I-III, undergoing elective outpatient laparoscopic cholecystectomy were recruited and randomized in this prospective, placebo-controlled, double-blind study to receive one of the following study medications orally: pregabalin 50 mg, pregabalin 75 mg, or placebo, 1 h before surgery and then every 12 h after operation for a total of three doses. Postoperative numeric pain scores, analgesic consumption, recovery score (QoR-40), and side-effects (opioid-related symptom distress scale) were assessed in the early postoperative period (every 15 min during the first hour, at 90, 120 min, 6, and 12 h) and at days 1, 2, and 7. Data were analysed using an intention-to-treat method.

RESULTS

Compared with the placebo group, the pain scores were lower in the pregabalin 75 mg group in the first 90 min after surgery (P<0.05). Pregabalin 50 mg resulted in pain reduction at 30 and 45 min (P<0.05) relative to placebo. The analgesic consumption, side-effects, and recovery scores were similar among the three groups.

CONCLUSIONS

Perioperative administration of pregabalin 75 mg provided limited analgesic benefit in the postoperative period. An updated meta-analysis confirms this finding (see Supplementary material).

Characteristics and Adaptability of Some New Isolates of Clostridium thermocellum

Six strains of Clostridium thermocellum isolated from various environments were characterized as to growth rate, production of reducing sugars, ethanol, and acetic acid from cellulose, base composition of DNA, and the abilities to adapt to ethanol and to grow at 45 degrees C. Five of the six new isolates produced 7 to 15% more ethanol and two produced about 45% more reducing sugars than a standard reference strain. One strain (MC-6) adapted more readily to growth in 2% ethanol than the others.

First-line treatment with single agent rituximab, followed by maintenance rituximab plus anti-idiotype Id-KLH active immunotherapy vaccine (FavId) in patients (pts) with low-grade non-Hodgkin lymphoma (NHL): Preliminary results of a phase II trial

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Background: Single agent rituximab produces a high response rate when used as first-line treatment, and maintenance rituximab prolongs remission duration. Active immunotherapy is a promising treatment approach, when administered following remission induction by initial therapy. In this phase II trial, we evaluate the feasibility, toxicity, and efficacy of administering concurrent maintenance rituximab plus Id-KLH vaccine in pts with low-grade NHL. Methods: Pts with previously untreated low-grade NHL (grade 1/2 follicular or SLL) who were judged to be candidates for single agent rituximab therapy were eligible. All pts had initial biopsy for production of the Id-KLH vaccine. All pts received rituximab 375mg/m2 IV, weekly × 4. Pts with CR/CRu, PR, or stable disease at 8 weeks proceeded with maintenance rituximab (standard 4 week courses at 6 month intervals for 3 courses) and Id-KLH vaccination (Id-KLH 1cc day 1; GMCSF 250μg SQ days 1–4) monthly × 8, beginning month 3, then every 2 months during the second year. Pts were monitored for response rate, progression- free survival, and toxicity. Results: To date, 36 of a planned 56 pts have been enrolled. Idiotype vaccine was successfully manufactured in 27 of 32 pts (84%), with 4 in production. Of the 27 pts for whom Id-KLH was successfully manufactured, 2 progressed during rituximab. 19 of 25 pts (14FL;5SLL) have had response determined after rituximab: 8 PR (42%), 11 stable (58%; 4 of 5 SLL). Pts have now received rituximab maintenance therapy plus Id-KLH for durations of 6 - 34 months. 6 of 19 pts (3 SLL) progressed at months 5, 6, 9, 9, 10, and 12, respectively. Treatment has been well tolerated, with no unusual toxicities observed. Rituximab-related hypotension and atrial fibrillation occurred in 1 pt. The most common Id-KLH related adverse event has been injection site reaction. Conclusions: Concurrent maintenance therapy with rituximab plus Id-KLH is safe and well tolerated. At present, 6 of 25 pts (24%) have progressed (including 3 of the 5 SLL pts) with a median followup of 19 months. This trial is continuing.

No significant financial relationships to disclose.

Phase II trial of a 10-epitope CTL vaccine, EP-2101, in metastatic NSCLC patients

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Background: The 10-peptide EP-2101 vaccine is designed to induce multi-specific CTL responses against epitopes in CEA, p53, HER-2/neu and MAGE 2/3. Seven epitopes are modified for enhanced MHC binding or heteroclitic T-cell activation including the previously described CAP1–6D heteroclitic analog and 2 epitopes are native wild-type (WT) sequences. Also included is the helper epitope PADRE. We report here immunogenicity results from a Phase II trial of the EP-2101 vaccine. Methods: 66 HLA-A2+ good performance patients with Stage IIIB/IV NSCLC were enrolled. Patients received 6 induction doses (0.5 mg/epitope) q3 wks followed by maintenance treatments at 2–3 month intervals. Endpoints included survival and induction of immune responses. CTL responses in peripheral blood MNC were measured after a 10 day in vitro stimulation with peptide followed by an IFNγ ELISPOT assay. Results: 33 patients completed induction and the first 11 patients were monitored for CTL against all vaccine epitopes. Seven of 11 patients generated responses against ≥ 4 epitopes after 3 and 6 vaccine doses and 8 patients generated CTL against ≥ 3 WT vaccine epitopes and WT sequences of vaccine analogs. Responses ranged between 10–50 spots/5x10e4 cells with stronger responses of >100 spots observed. All 9 vaccine epitopes were immunogenic in at least 1 patient. CTL responses against epitopes were maintained at Wk 30 and/or Month 9 in 7 of 8 patients. At Month 12, 2 of 4 patients also had detectable CTL against the vaccine. The 22 remaining patients were monitored against 5 representative vaccine epitopes. 13 of these patients generated CTL responses to ≥ 2 epitopes and 7 patients generated responses to ≥ 3 epitopes. Th-cell responses against PADRE measured with a direct IFNγ ELISPOT assay were observed in 18 of the 33 patients tested. Toxicities attributable to vaccine were mild and consisted mostly of injection site reactions. Follow-up for survival is ongoing. Conclusions: The peptide vaccine EP-2101 is well-tolerated and induces broadly-specific CTL responses in metastatic NSCLC patients.

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Creatine supplementation in Parkinson disease: a placebo-controlled randomized pilot trial

Mitochondrial dysfunction plays a major role in the pathogenesis of Parkinson disease (PD). Creatine (Cr) is an ergogenic compound that exerts neuroprotective effects in animal models of PD. We conducted a 2-year placebo-controlled randomized clinical trial on the effect of Cr in 60 patients with PD. Cr improved patient mood and led to a smaller dose increase of dopaminergic therapy but had no effect on overall Unified Parkinson's Disease Rating Scale scores or dopamine transporter SPECT.

Growth and nutritive quality of Poa pratensis as influenced by ozone and competition

Interspecific plant competition has been hypothesized to alter effects of early-season ozone (O3) stress. A phytometer-based approach was utilized to investigate O3 effects on growth and nutritive quality of Poa pratensis grown in monoculture and in mixed cultures with four competitor-plant species (Anthoxanthum odoratum, Achillea millefolium, Rumex acetosa and Veronica chamaedrys). Mesocosms were exposed during April/May 2000-2002 to charcoal-filtered air+25 ppb O3 (control) or non-filtered air+50 ppb O3 (elevated O3). Biomass production was not affected by O3, but foliar injury symptoms were observed in May 2002. Early-season O3 exposure decreased relative food value of P. pratensis by an average of 8%, which is sufficient to have nutritional implications for its utilization by herbivores. However, forage quality response to O3 was not changed by interspecific competition. Lack of injury and nutritive quality response in P. pratensis harvested in September may reflect recovery from early-season O3 exposure.

Transdermal delivery from a lipid sponge phase--iontophoretic and passive transport in vitro of 5-aminolevulinic acid and its methyl ester

The hydrochloride salts of 5-aminolevulinic acid (ALA) and its methyl ester (m-ALA), respectively, were dissolved in a lipid sponge phase comprising monoolein, propylene glycol and aqueous buffer at concentrations of approximately 0.25% and 16% w/w m-ALA. The iontophoretic and passive delivery of ALA and m-ALA from this formulation through porcine skin in vitro were measured and compared to formulations used in clinical practice, 20% w/w ALA in Unguentum M and Metvix (a cream containing 16% w/w m-ALA). A sponge phase with 16% w/w m-ALA showed a higher passive flux (approximately 140 nmol cm(-2) h(-1) at 5 h) but a lower iontophoretic flux (approximately 800 nmol cm(-2) h(-1) at 5 h) compared to the clinically used products but the differences are hardly significant due to large standard deviations. ALA and m-ALA in sponge phase formulation showed iontophoretic fluxes in the range 80-100 nmol cm(-2) h(-1) at 3 h, i.e. values comparable to the passive fluxes from the more concentrated vehicles. The results demonstrate that the lipid sponge phase, a thermodynamically stable liquid with amphiphilic character, may have potential as a transdermal drug delivery vehicle.

Development of a closed-system process for clinical-scale generation of DCs: evaluation of two monocyte-enrichment methods and two culture containers

BACKGROUND

Clinical immunotherapy trials using DCs depend on large-scale methods for DC generation that fulfil current good manufacturing practice requirements. Our goal was to develop data on two variables, monocyte-enrichment method and culture container, which could be used to design a closed-system process for ex vivo generation of immature DCs.

METHODS

Mononuclear cells were collected by leukapheresis and enriched for monocytes by either counterflow centrifugal elutriation, or immunomagnetic selection using Isolex, an automated closed-system device. Monocytes were cultured for 7 days in serum-free medium with GM-CSF and IL-4, using either plastic flasks or gas-permeable Stericell bags. Monocytes and cultured DCs were evaluated for yield, flow cytometric phenotype, and in vitro function in MLR, and autologous recall responses to tetanus toxoid and influenza virus.

RESULTS

Enriched monocyte products from elutriation and immunomagnetic selection were equivalent in yield and purity, and were capable of generating immature DCs in either flasks or bags. DCs from all four culture conditions were equivalent in yield, phenotype, and in vitro function. Mean DC yield was 67-80% per seeding monocyte, and 11-13% per starting mononuclear cell (MNC). A leukapheresis product containing 5 x 10(9) MNCs processed by this method could therefore yield approximately 5 x 10(8) immature DCs.

DISCUSSION

In this manufacturing process, the Isolex system was equivalent to elutriation, and Stericell bags were equivalent to flasks. Together, the Isolex system and Stericell bags can be incorporated into a closed-system process to generate immature DCs.

CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke

BACKGROUND AND PURPOSE

Diffusion-weighted MRI (DWI) has become a commonly used imaging modality in stroke centers. The value of this method as a routine procedure is still being discussed. In previous studies, CT was always performed before DWI. Therefore, infarct progression could be a reason for the better result in DWI.

METHODS

All hyperacute (<6 hours) stroke patients admitted to our emergency department with a National Institutes of Health Stroke Scale (NIHSS) score >3 were prospectively randomized for the order in which CT and MRI were performed. Five stroke experts and 4 residents blinded to clinical data judged stroke signs and lesion size on the images. To determine the interrater variability, we calculated kappa values for both rating groups.

RESULTS

A total of 50 patients with ischemic stroke and 4 patients with transient symptoms of acute stroke (median NIHSS score, 11; range, 3 to 27) were analyzed. Of the 50 patients, 55% were examined with DWI first. The mean delay from symptom onset until CT was 180 minutes; that from symptom onset until DWI was 189 minutes. The mean delay between DWI and CT was 30 minutes. The sensitivity of infarct detection by the experts was significantly better when based on DWI (CT/DWI, 61/91%). Accuracy was 91% when based on DWI (CT, 61%). Interrater variability of lesion detection was also significantly better for DWI (CT/DWI, kappa=0.51/0.84). The assessment of lesion extent was less homogeneous on CT (CT/DWI, kappa=0.38/0.62). The differences between the 2 modalities were stronger in the residents' ratings (CT/DWI: sensitivity, 46/81%; kappa=0.38/0.76).

CONCLUSIONS

CT and DWI performed with the same delay after onset of ischemic stroke resulted in significant differences in diagnostic accuracy. DWI gives good interrater homogeneity and has a substantially better sensitivity and accuracy than CT even if the raters have limited experience.