Introducing a new proforma for the safe use of intraoperative tourniquets in orthopaedic surgery

INTRODUCTION

The routine use of pneumatic tourniquets in orthopaedic surgery is widely adopted in current practice; however, practice varies considerably based mainly on anecdotal and cultural traditions. This Quality Improvement Project evaluated current service as per the newly published British Orthopaedic Association Standards for Trauma & Orthopaedics guideline on 'The Safe Use of Intraoperative Tourniquets'.

METHODS

Patient records were reviewed retrospectively for all patients who underwent orthopaedic surgery in September 2021 at one NHS hospital trust. Simultaneously, a nine-question survey was distributed to the orthopaedic teams allowing assessment of non-quantifiable aspects of the guidelines. The results were delivered as a local presentation, and trust-wide dissemination of posters using the mnemonic 'PRESSURE' was used to educate staff. The quantitative audit was repeated twice, after this intervention (March 2022) and after the advent of a new electronic patient record system with an online proforma (January 2023).

RESULTS

There was significant improvement (p<0.05) in all aspects of tourniquet documentation between the audit cycles. Maximum advised tourniquet duration was exceeded in <2% of cases regardless of guideline publication. Recommended pressures were used in less than one-third of cases in all audit cycles, with no significant change throughout. More than 50% of respondents sized their tourniquet on 'whatever looked best fit'.

CONCLUSIONS

Despite tourniquet usage being part of the UK Trauma & Orthopaedic Surgery curriculum, this study is the first to highlight a lack of compliance with 'gold standard' guidelines and the need for increased training for staff to ensure patients are exposed to the safest possible environment. Although electronic proformas can aid recording of information, the limitation to change is cultural tradition and anecdotal experience.

660 Trapeziectomy Versus Joint Replacement for First Carpometacarpal (CMC-1) Joint Osteoarthritis: A Systematic Review and Meta-Analysis

Aim

The challenge of managing first carpometacarpal (CMC-1) joint osteoarthritis is the lack of guidance on which surgical intervention is superior. This systematic review and meta-analysis compares joint replacement (JR) and trapeziectomy techniques to provide an update.

Method

In August 2020, MEDLINE, Embase and Web of Science were searched for eligible studies that compared these two techniques for the treatment of CMC-1 joint osteoarthritis (PROSPERO registration ID: CRD42020189728). Primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH and pain visual analogue scale (VAS) scores. Secondary outcomes, such as total complication, dislocation, and revision surgery rates, were also measured.

Results

From 1909 studies identified, 14 studies (1005 patients) were eligible. Our meta-analysis found that post-operative QuickDASH score was lower for patients in the JR group, indicating decreased disability following this technique (5 studies, p = 0.0002). However, pain VAS scores were similar between the two groups (5 studies, p = 0.22). Interestingly, JR techniques had significantly greater odds of overall complications (12 studies; OR 2.27; 95% CI 1.17-4.40, p = 0.02) and significantly greater odds of revision surgery (9 studies; OR 5.14; 95% CI 2.06-12.81, p = 0.0004).

Conclusions

Overall, based on low to moderate quality evidence, we found that JR treatments may result in better function with less disability with comparable pain (VAS) scores; however, JR has greater odds of complications and greater odds of requiring revision surgery. More robust RCTs that compare JR and TRAP with standardised outcome measures and long-term follow-up would add to the overall quality of evidence.

Calcineurin Orchestrates Lateral Transfer of Aspergillus fumigatus during Macrophage Cell Death

RATIONALE

Pulmonary aspergillosis is a lethal mold infection in the immunocompromised host. Understanding initial control of infection and how this is altered in the immunocompromised host are key goals for comprehension of the pathogenesis of pulmonary aspergillosis.

OBJECTIVES

To characterize the outcome of human macrophage infection with Aspergillus fumigatus and how this is altered in transplant recipients on calcineurin inhibitor immunosuppressants.

METHODS

We defined the outcome of human macrophage infection with A. fumigatus, as well as the impact of calcineurin inhibitors, through a combination of single-cell fluorescence imaging, transcriptomics, proteomics, and in vivo studies.

MEASUREMENTS AND MAIN RESULTS

Macrophage phagocytosis of A. fumigatus enabled control of 90% of fungal germination. However, fungal germination in the late phagosome led to macrophage necrosis. During programmed necroptosis, we observed frequent cell-cell transfer of A. fumigatus between macrophages, which assists subsequent control of germination in recipient macrophages. Lateral transfer occurred through actin-dependent exocytosis of the late endosome in a vasodilator-stimulated phosphoprotein envelope. Its relevance to the control of fungal germination was also shown by direct visualization in our zebrafish aspergillosis model in vivo. The calcineurin inhibitor FK506 (tacrolimus) reduced cell death and lateral transfer in vitro by 50%. This resulted in uncontrolled fungal germination in macrophages and also resulted in hyphal escape.

CONCLUSIONS

These observations identify programmed, necrosis-dependent lateral transfer of A. fumigatus between macrophages as an important host strategy for controlling fungal germination. This process is critically dependent on calcineurin. Our studies provide fundamental insights into the pathogenesis of pulmonary aspergillosis in the immunocompromised host.

Cytotoxicity of polycations: Relationship of molecular weight and the hydrolytic theory of the mechanism of toxicity

The mechanism of polycation cytotoxicity and the relationship to polymer molecular weight is poorly understood. To gain an insight into this important phenomenon a range of newly synthesised uniform (near monodisperse) linear polyethylenimines, commercially available poly(l-lysine)s and two commonly used PEI-based transfectants (broad 22kDa linear and 25kDa branched) were tested for their cytotoxicity against the A549 human lung carcinoma cell line. Cell membrane damage assays (LDH release) and cell viability assays (MTT) showed a strong relationship to dose and polymer molecular weight, and increasing incubation times revealed that even supposedly "non-toxic" low molecular weight polymers still damage cell membranes. The newly proposed mechanism of cell membrane damage is acid catalysed hydrolysis of lipidic phosphoester bonds, which was supported by observations of the hydrolysis of DOPC liposomes.

HIV Replication in CD4-Negative Cell Lines: Effect of Cloning, CD4 Expression and Inhibition by Dextrin Sulphate

HIV-1 infects CD4 negative (CD4) cell lines with low efficiency. Infected CD4 cells have a low copy number of HIV proviruses per cell and require a high multiplicity of infection. Following CD4 transfection, most human cell lines permit high efficiency HIV entry and replication. We have compared entry and inhibition of HIV-1 into CD4 cells and their equivalent CD4 positive (CD4+) transfectants. Entry of HIV-1 into both CD4+ and CD4− was completely inhibited by a novel sulphated polysaccharide, dextrin sulphate (DS) at 100 μg ml−1, whereas anti-CD4 antibodies only inhibited HIV infection of CD4+ cells. One glial cell line, U251SP-CD4, expressed surface CD4, but this did not increase HIV-1 susceptibility compared to the CD4− U251SP cell line. Subclones of the CD4− cell lines TE671 and U251SP were no more permissive for infection than their corresponding parental line. HIV-1 infected CD4− cells have a significantly lower provirus copy number than CD4+ cells, confirming that the block to HIV-1 replication is predominantly at entry. The action of DS was examined in conjunction with soluble recombinant CD4 (srCD4); DS was found to potentiate the inhibiting effect of srCD4.

Alternatives to antibiotics-a pipeline portfolio review

Antibiotics have saved countless lives and enabled the development of modern medicine over the past 70 years. However, it is clear that the success of antibiotics might only have been temporary and we now expect a long-term and perhaps never-ending challenge to find new therapies to combat antibiotic-resistant bacteria. A broader approach to address bacterial infection is needed. In this Review, we discuss alternatives to antibiotics, which we defined as non-compound approaches (products other than classic antibacterial agents) that target bacteria or any approaches that target the host. The most advanced approaches are antibodies, probiotics, and vaccines in phase 2 and phase 3 trials. This first wave of alternatives to antibiotics will probably best serve as adjunctive or preventive therapies, which suggests that conventional antibiotics are still needed. Funding of more than £1·5 billion is needed over 10 years to test and develop these alternatives to antibiotics. Investment needs to be partnered with translational expertise and targeted to support the validation of these approaches in phase 2 trials, which would be a catalyst for active engagement and investment by the pharmaceutical and biotechnology industry. Only a sustained, concerted, and coordinated international effort will provide the solutions needed for the future.

Controlling the cytokine storm in severe bacterial diarrhoea with an oral Toll-like receptor 4 antagonist

Shigella dysenteriae causes the most severe of all infectious diarrhoeas and colitis. We infected rhesus macaques orally and also treated them orally with a small and non-absorbable polypropyletherimine dendrimer glucosamine that is a Toll-like receptor-4 (TLR4) antagonist. Antibiotics were not given for this life-threatening infection. Six days later, the clinical score for diarrhoea, mucus and blood was 54% lower, colon interleukin-8 and interleukin-6 were both 77% lower, and colon neutrophil infiltration was 75% less. Strikingly, vasculitis did not occur and tissue fibrin thrombi were reduced by 67%. There was no clinical toxicity or adverse effect of dendrimer glucosamine on systemic immunity. This is the first report in non-human primates of the therapeutic efficacy of a small and orally bioavailable TLR antagonist in severe infection. Our results show that an oral TLR4 antagonist can enable controlled resolution of the infection-related-inflammatory response and can also prevent neutrophil-mediated gut wall necrosis in severe infectious diarrhoeas.

Phagocytosis-dependent activation of a TLR9-BTK-calcineurin-NFAT pathway co-ordinates innate immunity to Aspergillus fumigatus

Transplant recipients on calcineurin inhibitors are at high risk of invasive fungal infection. Understanding how calcineurin inhibitors impair fungal immunity is a key priority for defining risk of infection. Here, we show that the calcineurin inhibitor tacrolimus impairs clearance of the major mould pathogen Aspergillus fumigatus from the airway, by inhibiting macrophage inflammatory responses. This leads to defective early neutrophil recruitment and fungal clearance. We confirm these findings in zebrafish, showing an evolutionarily conserved role for calcineurin signalling in neutrophil recruitment during inflammation. We find that calcineurin–NFAT activation is phagocytosis dependent and collaborates with NF-κB for TNF-α production. For yeast zymosan particles, activation of macrophage calcineurin–NFAT occurs via the phagocytic Dectin-1–spleen tyrosine kinase pathway, but for A. fumigatus, activation occurs via a phagosomal TLR9-dependent and Bruton's tyrosine kinase-dependent signalling pathway that is independent of MyD88. We confirm the collaboration between NFAT and NF-κB for TNF-α production in primary alveolar macrophages. These observations identify inhibition of a newly discovered macrophage TLR9–BTK–calcineurin–NFAT signalling pathway as a key immune defect that leads to organ transplant-related invasive aspergillosis.

Nebulised amphotericin B-polymethacrylic acid nanoparticle prophylaxis prevents invasive aspergillosis

Aspergillus species are the major life threatening fungal pathogens in transplant patients. Germination of inhaled fungal spores initiates infection, causes severe pneumonia, and has a mortality of > 50%. This is leading to the consideration of pre-exposure prophylaxis to prevent infection. We made a very low MWt amphotericin B-polymethacrylic acid nanoparticle. It was not toxic to lung epithelial cells or monocyte-derived-macrophages in-vitro, or in an in-vivo transplant immuno-suppression mouse model of life threatening invasive aspergillosis. Three days of nebuliser based prophylaxis delivered the nanoparticle effectively to lung and prevented both fungal growth and lung inflammation. Protection from disease was associated with > 99% killing of the Aspergillus and a 90% reduction in lung TNF-α; the primary driver of tissue destructive immuno-pathology. This study provides in-vivo proof-of-principle that very small and cost-effective nanoparticles can be made simply, and delivered safely and effectively to lung by the aerosol route to prevent fungal infections.

From the Clinical Editor

Aspergillus is an opportunistic pathogen, which affects immunocompromised patients. One novel way to help fight against this infection is pre-exposure prophylaxis. The authors here made PMA based anionic hydrogels carrying amphotericin B, with mucoadhesive behavior. They showed that aerosol route of the drug was very effective in protecting against the disease in an in-vivo model and should provide a stepping-stone towards clinical trials in the future.

Clinical assessment of the sensory ataxias; diagnostic algorithm with illustrative cases

Ataxia is a common neurological syndrome resulting from cerebellar, vestibular or sensory disorders. The recognition and characterisation of sensory ataxia remains a challenge. Cerebellar ataxia is the more common and easier to identify; sensory ataxia is often mistaken for cerebellar ataxia, leading to diagnostic errors and delays. A coherent aetiological work-up is only possible if clinicians initially recognise sensory ataxia. We discuss ways to separate sensory from cerebellar ataxia, the causes of sensory ataxia and the clinico-neurophysiological syndromes causing the sensory ataxia syndromes. We summarise a logical tiered approach as a diagnostic algorithm.

A new and clinically relevant murine model of solid-organ transplant aspergillosis

Invasive fungal infections (IFIs) are a major cause of death in organ transplant patients. The murine hydrocortisone-mediated immunosuppression model of pulmonary aspergillosis is commonly used to characterise IFIs in these patients. However, this model does not take into account the effects of calcineurin inhibitors on transplant immunity to IFIs or the fungal calcineurin pathway, which is required for both virulence and antifungal drug resistance. To address these two issues, a new and clinically relevant transplant immunosuppression model of tacrolimus (FK506) and hydrocortisone-associated pulmonary aspergillosis was developed. We first characterised IFIs in 406 patients with a lung transplant. This showed that all of the patients with pulmonary aspergillosis were immunosuppressed with calcineurin inhibitors and steroids. Murine pharmacokinetic studies demonstrated that an ideal dose of 1 mg/kg/day of FK506 intraperitoneally produced blood trough levels in the human therapeutic range (5-12 ng/ml). There was increased mortality from pulmonary aspergillosis in a transplant-relevant immunosuppression model using both FK506 and hydrocortisone as compared with immunosuppression using hydrocortisone only. Lung histopathology showed neutrophil invasion and tracheobronchitis that was associated with reduced lung tumour necrosis factor-α (TNFα), JE (homologue of human MCP-1) and KC (homologue of human IL-8) at 24 hours, but increased lung TNFα, JE and KC at 48 hours when fungal burden was high. Furthermore, FK506 directly impaired fungal killing in alveolar macrophages in vitro, with FK506-mediated inhibition of the radial growth of Aspergillus fumigatus in vitro occurring at the low concentration of 5 ng/ml. Taken together, these findings show that the immunosuppressive activity of FK506 outweighs its antifungal activity in vivo. These observations demonstrate that FK506 impairs innate immune responses and leads to an incremental increase in susceptibility to IFIs when it is combined with steroids. This new and clinically relevant mouse model of invasive aspergillosis is a valuable addition to the further study of both fungal immunity and antifungal therapy in organ transplantation.

Secondary aorto-enteric fistula presenting over a 2-month period with recurrent gastrointestinal bleeding

A female in her sixties presented with recurrent gastrointestinal bleeding over a two-month period requiring multiple hospital admissions. Inconclusive upper and lower gastrointestinal endoscopies in addition to an initial negative CT angiogram initially left the diagnosis uncertain. A subsequent catastrophic bleed prompted a further CT angiogram that demonstrated a fistula between the aorta and third part of the duodenum with active contrast extravasation. Emergency surgery was carried out but ultimately the patient did not survive.

Renal allograft recipients fail to increase interferon-γ during invasive fungal diseases

Invasive fungal diseases are a major cause of death in renal allograft recipients. We previously reported that adjunctive recombinant human interferon-γ therapy has clinical utility for invasive fungal diseases after renal transplantation. We have now developed a rapid peripheral blood-based quantitative real-time PCR assay that enables accurate profiling of cytokine imbalances. Our preliminary studies in renal transplant patients with invasive fungal diseases suggest that they fail to mount an adequate interferon-γ response to the fungal infection. In addition, they have reduced IL-10 and increased TNF-α when compared to stable renal transplant patients. These preliminary cytokine profiling-based observations provide a possible explanation for the therapeutic benefit of adjunctive human interferon-γ therapy in renal allograft recipients with invasive fungal diseases.

Preventing acute gut wall damage in infectious diarrhoeas with glycosylated dendrimers

Intestinal pathogens use the host's excessive inflammatory cytokine response, designed to eliminate dangerous bacteria, to disrupt epithelial gut wall integrity and promote their tissue invasion. We sought to develop a non-antibiotic-based approach to prevent this injury. Molecular docking studies suggested that glycosylated dendrimers block the TLR4-MD-2-LPS complex, and a 13.6 kDa polyamidoamine (PAMAM) dendrimer glucosamine (DG) reduced the induction of human monocyte interleukin (IL)-6 by Gram-negative bacteria. In a rabbit model of shigellosis, PAMAM-DG prevented epithelial gut wall damage and intestinal villous destruction, reduced local IL-6 and IL-8 expression, and minimized bacterial invasion. Computational modelling studies identified a 3.3 kDa polypropyletherimine (PETIM)-DG as the smallest likely bioactive molecule. In human monocytes, high purity PETIM-DG potently inhibited Shigella Lipid A-induced IL-6 expression. In rabbits, PETIM-DG prevented Shigella-induced epithelial gut wall damage, reduced local IL-6 and IL-8 expression, and minimized bacterial invasion. There was no change in β-defensin, IL-10, interferon-β, transforming growth factor-β, CD3 or FoxP3 expression. Small and orally delivered DG could be useful for preventing gut wall tissue damage in a wide spectrum of infectious diarrhoeal diseases.

–>See accompanying article http://dx.doi.org/10.1002/emmm.201201668

Computational design principles for bioactive dendrimer based constructs as antagonists of the TLR4-MD-2-LPS complex

The cell surface interaction between bacterial lipopolysaccharide (LPS), Toll-like receptor 4 (TLR4) and MD-2 is central to bacterial sepsis syndromes and wound healing. We have shown that a generation (G) 3.5 polyamidoamine (PAMAM) dendrimer that was partially glycosylated with glucosamine inhibits TLR4-MD-2-LPS induced inflammation in a rabbit model of tissue scaring. However, it was a mixture of closely related chemical species because of the polydispersity of the starting PAMAM dendrimer. Generation 2 triazine dendrimers with single chemical entity material status are available at low cost and at the kilogram scale. PAMAM dendrimer can be synthetically grafted onto this triazine core dendrimer to make new triazine-PAMAM hybrid dendrimers. This led us to examine whether molecular modelling methods could be used to identify the key structural design principles for a bioactive lead molecule that could be synthesized and biologically evaluated. We describe our computer aided molecular studies of several dendrimer based constructs and the key design principles identified. Our approach should be more broadly applicable to the biologically focused, rational and accelerated design of molecules for other TLR receptors. They could be useful for treating infectious, inflammatory and malignant diseases.

Partially glycosylated dendrimers block MD-2 and prevent TLR4-MD-2-LPS complex mediated cytokine responses

The crystal structure of the TLR4-MD-2-LPS complex responsible for triggering powerful pro-inflammatory cytokine responses has recently become available. Central to cell surface complex formation is binding of lipopolysaccharide (LPS) to soluble MD-2. We have previously shown, in biologically based experiments, that a generation 3.5 PAMAM dendrimer with 64 peripheral carboxylic acid groups acts as an antagonist of pro-inflammatory cytokine production after surface modification with 8 glucosamine molecules. We have also shown using molecular modelling approaches that this partially glycosylated dendrimer has the flexibility, cluster density, surface electrostatic charge, and hydrophilicity to make it a therapeutically useful antagonist of complex formation. These studies enabled the computational study of the interactions of the unmodified dendrimer, glucosamine, and of the partially glycosylated dendrimer with TLR4 and MD-2 using molecular docking and molecular dynamics techniques. They demonstrate that dendrimer glucosamine forms co-operative electrostatic interactions with residues lining the entrance to MD-2's hydrophobic pocket. Crucially, dendrimer glucosamine interferes with the electrostatic binding of: (i) the 4'phosphate on the di-glucosamine of LPS to Ser118 on MD-2; (ii) LPS to Lys91 on MD-2; (iii) the subsequent binding of TLR4 to Tyr102 on MD-2. This is followed by additional co-operative interactions between several of the dendrimer glucosamine's carboxylic acid branches and MD-2. Collectively, these interactions block the entry of the lipid chains of LPS into MD-2's hydrophobic pocket, and also prevent TLR4-MD-2-LPS complex formation. Our studies have therefore defined the first nonlipid-based synthetic MD-2 antagonist using both animal model-based studies of pro-inflammatory cytokine responses and molecular modelling studies of a whole dendrimer with its target protein. Using this approach, it should now be possible to computationally design additional macromolecular dendrimer based antagonists for other Toll Like Receptors. They could be useful for treating a spectrum of infectious, inflammatory and malignant diseases.

From sequence to 3D structure of hyperbranched molecules: application to surface modified PAMAM dendrimers

The molecular modeling of hyperbranched molecules is currently constrained by difficulties in model building, due partly to lack of parameterization of their building blocks. We have addressed this problem with specific relevance to a class of hyperbranched macromolecules known as dendrimers by describing a new concept and developing a method that translates monomeric linear sequences into a full atomistic model of a hyperbranched molecule. Such molecular-modeling-based advances will enable modeling studies of important biological interactions between naturally occurring macromolecules and synthetic macromolecules. Our results also suggest that it should be possible to apply this sequence-based methodology to generate hyperbranched structures of other dendrimeric structures and of linear polymers.

Wound Healing Versus Regeneration: Role of the Tissue Environment in Regenerative Medicine

One of the major challenges in the field of regenerative medicine is how to optimize tissue regeneration in the body by therapeutically manipulating its natural ability to form scar at the time of injury or disease. It is often the balance between tissue regeneration, a process that is activated at the onset of disease, and scar formation, which develops as a result of the disease process that determines the ability of the tissue or organ to be functional. Using biomaterials as scaffolds often can provide a "bridge" for normal tissue edges to regenerate over small distances, usually up to 1 cm. Larger tissue defect gaps typically require both scaffolds and cells for normal tissue regeneration to occur without scar formation. Various strategies can help to modulate the scar response and can potentially enhance tissue regeneration. Understanding the mechanistic basis of such multivariate interactions as the scar microenvironment, the immune system, extracellular matrix, and inflammatory cytokines may enable the design of tissue engineering and wound healing strategies that directly modulate the healing response in a manner favorable to regeneration.

Exogenous interferon-gamma immunotherapy for invasive fungal infections in kidney transplant patients

The incidence of invasive fungal infections (IFIs) in nonneutropenic solid organ transplant patients is increasing. We report our clinical experience with the use of interferon-gamma (IFN-gamma) immunotherapy in seven renal transplant patients who developed life threatening, disseminated IFIs refractory to conventional antifungal drug therapy. The infections were all microbiologically and histologically proven. The rapid cure of these disseminated infections with exogenous IFN-gamma injections was not associated with impaired kidney allograft function despite the use of liposomal amphotericin B in all cases. No clinical toxicity from the IFN-gamma immunotherapy was seen and no IFI relapsed during long-term follow-up. Our experience is both uncontrolled and in patients with unpredictable fungal infection-related outcomes. However, compared to standard approaches, the accelerated cure of life threatening, disseminated IFIs with 6 weeks of combination antifungal drug therapy and IFN-gamma immunotherapy saved lives, retained allograft function and led to substantial cost savings in this small patient group.

Mimicking PAMAM Dendrimers with Ampholytic, Hybrid Triazine Dendrimers: A Comparison of Dispersity and Stability

Two strategies are applied to mimic the ampholytic nature of the surfaces of half-generation PAMAM dendrimers and yet retain the very narrow dispersity inherent of triazine dendrimers. Both strategies start with a monodisperse, single-chemical entity, generation two triazine dendrimer presenting twelve surface amines that is available at the kilogram scale. The first method relies on reaction with methyl bromoacetate. Complete conversion of the surface primary amines to tertiary amines occurs to provide 24 surface esters. Extended reaction times lead to quarternization of the amines while other unidentified species are also present. The resulting polyester can be quantitatively hydrolyzed using 4M aqueous HCl to yield a dendrimer with 12 tertiary amines and 24 carboxylic acids about a hydrophobic triazine core. The second method utilizes Michael additions of methyl acrylate to yield 24 surface esters. This reaction proceeds more rapidly and more cleanly than the former strategy. Hydrolysis of this material proceeds quantitatively using 4M aqueous HCl to yield desired dendrimer. In both cases, MALDI-TOF mass spectrometry provides compelling evidence of reaction progress. Electrophoretic analysis confirms the ampholytic nature of these materials with the former targets having a pI value in the 1.8 < pI < 3.4 range, and the latter having a pI value in the 4.7 < pI < 5.9. These ranges bookend the pH range within which PAMAM dendrimers become zwitterionic, 3.4 < pI < 4.7. The strategy of using monodisperse amine-terminated dendrimer constructs as core offers significant advantage over PAMAM homopolymers including dispersity, ease of characterization and batch-to-batch reproducibility. These triazine dendrimers could ultimately be adopted into materials with applications wherein the demands of purity have hitherto remained unsatisfied.

Electrophoretic Behavior of Anionic Triazine and PAMAM Dendrimers: Methods for Improving Resolution and Assessing Purity Using Capillary Electrophoresis

The synthesis and characterization of second- and third-generation triazine dendrimers bearing carboxylic acid groups on the periphery are reported. These materials were synthesized by exhaustive succinylation of amine-terminated dendrimers. (1)H and (13)C NMR spectra are consistent with the desired products, but these techniques are limited by degeneracy in signals. MALDI-TOF mass spectrometry confirms the presence of the desired material. These materials display pH-dependent solubility in water. Capillary electrophoresis proves to be valuable in multiple elements of this work, and general protocols emerge that appear to be useful for the characterization of lower-generation anionic dendrimers. Specifically, capillary electrophoresis provides a convenient method for monitoring the removal of excess succinic anhydride/succinic acid and offers additional clues to the chemical nature of the impurities in these samples. Optimization of the background electrolyte and instrumental parameters allows for the assessment of the purity of these triazine targets as well as comparison with two sets of commercially available anionic poly(amidoamine) (PAMAM) dendrimers. Corroborative information from the different orthogonal analytical techniques employed supports the hypothesis that triazine dendrimers exist as very narrowly disperse mixtures of macromolecules approaching, in some cases, single chemical entities.

Optimisation of the Degree of Sulfation of a Polymer Based Construct to Block the Entry of HIV-1 into Cells

Blocking the entry of HIV-1 into CD4+ cells is an important new therapeutic target for the development of novel vaginal microbicides. In this study, sulfated derivatives of the linear polysaccharide dextrin were synthesised whose percentage sulphation increased incrementally from 7.4 to 48.3%. Their anti-HIV-1 activity in C8166 cells was first seen when percentage sulfation reached 33.2%, but it was only seen in peripheral blood mononuclear cells when it reached 36.3%. It did not increase further when sulfation reached 40.2%. Primary viruses with a V3 loop charge of greater than +5 were blocked by 80 microg/ml of dextrin 2 sulfate but primary viruses with a V3 loop charge of less than +3 required 1,600 microg/ml to block viral entry effectively. Our results identify the relative contribution of the percentage sulfation of a polymer based construct for optimising its anti-HIV-1 activity whilst minimising its toxicity. A better understanding of these structure-function relationships will inform the design and development of novel vaginal microbicides to effectively block the sexual transmission of all primary viral isolates of HIV-1.

Leber's hereditary optic neuropathy associated with multiple sclerosis: Harding's syndrome

We describe a 32-year-old woman with sequential, severe, painless visual loss in one eye and then the other, and three temporally distinct episodes of neurological disturbance suggestive of demyelination in the spinal cord. She was positive for the T14484C mutation in the mitochondrial genome, one of three common mutations causing Leber's hereditary optic neuropathy. In addition, MRI identified areas of demyelination within the periventricular white matter of the brain and within the spinal cord. The coexistence of multiple sclerosis and Leber's hereditary optic neuropathy (Harding's syndrome) is known to occur more often than would be expected by chance; therefore, screening for the Leber's mutations in multiple sclerosis patients with severe visual loss should be considered because this has important prognostic and genetic implications.

Disulfide bridge based PEGylation of proteins

PEGylation is a clinically proven strategy for increasing the therapeutic efficacy of protein-based medicines. Our approach to site-specific PEGylation exploits the thiol selective chemistry of the two cysteine sulfur atoms from an accessible disulfide. It involves two key steps: (1) disulfide reduction to release the two cystine thiols, and (2) bis-alkylation to give a three-carbon bridge to which PEG is covalently attached. During this process, irreversible denaturation of the protein does not occur. Mechanistically, the conjugation is conducted by a sequential, interactive bis-alkylation using alpha,beta-unsaturated-beta'-mono-sulfone functionalized PEG reagents. The combination of: - (a) maintaining the protein's tertiary structure after reduction of a disulfide, (b) bis-thiol selectivity of the PEG reagent, and (c) PEG associated steric shielding ensure that only one PEG molecule is conjugated at each disulfide. Our studies have shown that peptides, proteins, enzymes and antibody fragments can be site-specifically PEGylated using a native and accessible disulfide without destroying the molecules' tertiary structure or abolishing its biological activity. As the stoichiometric efficiency of our approach also enables recycling of any unreacted protein, it offers the potential to make PEGylated biopharmaceuticals as cost-effective medicines.

Identification and insertion of 3-carbon bridges in protein disulfide bonds: a computational approach

More than 42,000 3D structures of proteins are available on the Internet. We have shown that the chemical insertion of a 3-carbon bridge across the native disulfide bond of a protein or peptide can enable the site-specific conjugation of PEG to the protein without a loss of its structure or function. For success, it is necessary to select an appropriate and accessible disulfide bond in the protein for this chemical modification. We describe how to use public protein databases and molecular modeling programs to select a protein rationally and to identify the optimum disulfide bond for experimental studies. Our computational approach can substantially reduce the time required for the laboratory-based chemical modification. Identification of solvent-accessible disulfides using published structural information takes approximately 2 h. Predicting the structural effects of the disulfide-based modification can take 3 weeks.

PEGylation of native disulfide bonds in proteins

PEGylation has turned proteins into important new biopharmaceuticals. The fundamental problems with the existing approaches to PEGylation are inefficient conjugation and the formation of heterogeneous mixtures. This is because poly(ethylene glycol) (PEG) is usually conjugated to nucleophilic amine residues. Our PEGylation protocol solves these problems by exploiting the chemical reactivity of both of the sulfur atoms in the disulfide bond of many biologically relevant proteins. An accessible disulfide bond is mildly reduced to liberate the two cysteine sulfur atoms without disturbing the protein's tertiary structure. Site-specific PEGylation is achieved with a bis-thiol alkylating PEG reagent that sequentially undergoes conjugation to form a three-carbon bridge. The two sulfur atoms are re-linked with PEG selectively conjugated to the bridge. PEGylation of a protein can be completed in 24 h and purification of the PEG-protein conjugate in another 3 h. We have successfully applied this approach to PEGylation of cytokines, enzymes, antibody fragments and peptides, without destroying their tertiary structure or abolishing their biological activity.

Site-Specific PEGylation of Protein Disulfide Bonds Using a Three-Carbon Bridge

The covalent conjugation of a functionalized poly(ethylene glycol) (PEG) to multiple nucleophilic amine residues results in a heterogeneous mixture of PEG positional isomers. Their physicochemical, biological, and pharmaceutical properties vary with the site of conjugation of PEG. Yields are low because of inefficient conjugation chemistry and production costs high because of complex purification procedures. Our solution to these fundamental problems in PEGylating proteins has been to exploit the latent conjugation selectivity of the two sulfur atoms that are derived from the ubiquitous disulfide bonds of proteins. This approach to PEGylation involves two steps: (1) disulfide reduction to release the two cysteine thiols and (2) re-forming the disulfide by bis-alkylation via a three-carbon bridge to which PEG was covalently attached. During this process, irreversible denaturation of the protein did not occur. Mechanistically, the conjugation is conducted by a sequential, interactive bis-alkylation using alpha,beta-unsaturated beta'-monosulfone functionalized PEG reagents. The combination of (a) maintaining the protein's tertiary structure after disulfide reduction, (b) the mechanism for bis-thiol selectivity of the PEG reagent, and (c) the steric shielding of PEG ensure that only one PEG molecule is conjugated at each disulfide bond. PEG was site-specifically conjugated via a three-carbon bridge to 2 equiv of the tripeptide glutathione, the cyclic peptide hormone somatostatin, the tetrameric protein l-asparaginase, and to the disulfides in interferon alpha-2b (IFN). SDS-PAGE, mass spectral, and NMR analyses were used to confirm conjugation, thiol selectivity, and connectivity. The biological activity of the l-asparaginase did not change after the attachment of four PEG molecules. In the case of IFN, a small reduction in biological activity was seen with the single-bridged IFN (without PEG attached). A significantly larger reduction in biological activity was seen with the three-carbon disulfide single-bridged PEG-IFNs and with the double-bridged IFN (without PEG attached). The reduction of the PEG-IFN's in vitro biological activity was a consequence of the steric shielding caused by PEG, and it was comparable to that seen with all other forms of PEG-IFNs reported. However, when a three-carbon bridge was used to attach PEG, our PEG-IFN's biological activity was found to be independent of the length of the PEG. This property has not previously been described for PEG-IFNs. Our studies therefore suggest that peptides, proteins, enzymes, and antibody fragments can be site-specifically PEGylated across a native disulfide bond using three-carbon bridges without destroying their tertiary structure or abolishing their biological activity. The stoichiometric efficiency of this approach also enables recycling of any unreacted protein. It therefore offers the potential to make PEGylated biopharmaceuticals as cost-effective medicines for global use.

Site-specific PEGylation of native disulfide bonds in therapeutic proteins

Native disulfide bonds in therapeutic proteins are crucial for tertiary structure and biological activity and are therefore considered unsuitable for chemical modification. We show that native disulfides in human interferon alpha-2b and in a fragment of an antibody to CD4(+) can be modified by site-specific bisalkylation of the two cysteine sulfur atoms to form a three-carbon PEGylated bridge. The yield of PEGylated protein is high, and tertiary structure and biological activity are retained.

Cure of disseminated cryptococcal infection in a renal allograft recipient after addition of gamma-interferon to anti-fungal therapy

The immunosuppressive regimens that are used in solid organ transplantation are potent inhibitors of Th0 as well as Th1 and Th2 cell-mediated immune responses. This predisposes patients to disseminated cryptococcal infections. Mortality in such patients remains very high despite advances in anti-fungal chemotherapy. We describe a case of disseminated cryptococcal disease in a renal allograft recipient that failed to respond to prolonged treatment with several anti-fungal drugs. However, addition of the immuno-modulator, interferon-gamma, resulted in the formation of granulomas and the resolution of his disease within 4-6 weeks. As we cannot find a similar example of combination therapy for disseminated cryptococcal disease in the solid organ transplant literature, we propose that interferon-gamma could be used in synergy with anti-fungal drugs to cure disseminated cryptococcal infections in solid organ transplant patients.

Short communication: pitfalls of culturing C8166 cells in serum-free media

Long-term culture of C8166 cells in serum-free media can result in changes in their level of expression of immunologically important cell surface makers and a loss of infectivity by HIV-1. We have now demonstrated that these phenotypic changes are due to an outgrowth of a very small number of contaminating cells of mouse origin. Our observations emphasize the importance of carefully recharacterizing any cells that have been adapted to grow in a serum-free culture media.

Dendrimer drugs prevent scar tissue formation

Extract: Dendrimers are hyperbranched synthetic macromolecules that can be made with structural precision. So far, their biomedical applications have been limited to drug delivery. Dendrimers with cationic (i.e., amine or NH3+) end groups are toxic after repeated intravenous use or topical ocular application. In contrast, anionic (i.e., carboxy or COO-) dendrimers are not toxic. For example, cationic dendrimers cause substantial changes to red blood cell morphology at 10 mug/ml whilst anionic dendrimers have no such effect at 2,000 mug/ml. We set out to determine whether the receptor-ligand interactions between carbohydrates and proteins, which mediate many important aspects of cell surface-mediated immuno-regulation could be pharmacologically manipulated using new anionic dendrimer-based drugs. Any such medicine would have to possess multiple and cooperative receptor binding properties. Previous attempts to pharmacologically manipulate such interactions with synthetic linear polymers have failed because of the structural diversity of the polymers used, and because they activated immunological cell death pathways and blood clotting pathways.

Polyvalent dendrimer glucosamine conjugates prevent scar tissue formation

Dendrimers are hyperbranched macromolecules that can be chemically synthesized to have precise structural characteristics. We used anionic, polyamidoamine, generation 3.5 dendrimers to make novel water-soluble conjugates of D(+)-glucosamine and D(+)-glucosamine 6-sulfate with immuno-modulatory and antiangiogenic properties respectively. Dendrimer glucosamine inhibited Toll-like receptor 4-mediated lipopolysaccharide induced synthesis of pro-inflammatory chemokines (MIP-1 alpha, MIP-1 beta, IL-8) and cytokines (TNF-alpha, IL-1 beta, IL-6) from human dendritic cells and macrophages but allowed upregulation of the costimulatory molecules CD25, CD80, CD83 and CD86. Dendrimer glucosamine 6-sulfate blocked fibroblast growth factor-2 mediated endothelial cell proliferation and neoangiogenesis in human Matrigel and placental angiogenesis assays. When dendrimer glucosamine and dendrimer glucosamine 6-sulfate were used together in a validated and clinically relevant rabbit model of scar tissue formation after glaucoma filtration surgery, they increased the long-term success of the surgery from 30% to 80% (P = 0.029). We conclude that synthetically engineered macromolecules such as the dendrimers described here can be tailored to have defined immuno-modulatory and antiangiogenic properties, and they can be used synergistically to prevent scar tissue formation.

Monitoring HIV disease with new and clinically useful surrogate markers

PURPOSE OF REVIEW

This review aims to identify which patient based observations could enable the development of new surrogate markers for widespread clinical use.

RECENT FINDINGS

Anti-retroviral drug therapy reduces but does not abolish HIV transmission and replication in all body compartments. It is now clear that monitoring plasma HIV RNA does not help to predict drug failure or to define the existence of persistent viral reservoirs.

SUMMARY

New surrogate markers are required for long-term patient monitoring and to enable the evaluation of additional therapeutic strategies.

The heat-shock protein receptor CD91 is up-regulated in monocytes of HIV-1-infected "true" long-term nonprogressors

A small proportion of patients with human immunodeficiency virus type 1 (HIV-1) remains asymptomatic for a long period after infection. It is thought that a vigorous immune response may contribute to long-term nonprogression, though studies are confounded by heterogeneity among patients. We studied the levels of HIV-1 receptors, costimulatory T-cell molecules, and dendritic cell (DC) numbers in 18 patients with long-term infection, CD4 counts greater than 400 cells/mm(3), and HIV-1 viral loads lower than 50 copies/mL. These patients were further differentiated through the presence or absence of 2-LTR DNA circles, a possible marker for residual ongoing HIV-1 replication. A statistically significant increase in levels of CD91, the heat-shock protein (HSP) receptor, was observed in therapy-naive patients who had no evidence of ongoing viral replication (P =.01). This difference was most notable on their monocytes. High levels of CD91 may be a host factor that contributes to the maintenance of long-term nonprogression. The ability of CD91 to internalize alpha-defensins and to cross-present exogenous antigen to cytotoxic T lymphocytes through major histocompatibility complex (MHC) class 1 may maintain CD8(+) responses in these patients.

Identification of two mutually exclusive groups after long-term monitoring of HIV DNA 2-LTR circle copy number in patients on HAART

BACKGROUND

Anti-retroviral drug therapy reduces but does not abolish HIV transmission and replication throughout the body. HIV DNA 2-long terminal repeat (2-LTR) circles have been shown in point-based studies to persist in some patients whose plasma HIV RNA was undetectable. However, the degree of fluctuation of circle copy number over time has not been determined.

METHODS

A reliable, reproducible and robust quantitative LightCycler (LC qPCR)-based assay for HIV DNA 2-LTR circles in peripheral blood mononuclear (PBMN) cells was established. A prospective, longitudinal study of these circles was undertaken in HIV-1-positive patients on anti-retroviral therapy whose plasma HIV RNA was undetectable at < 50 copies/ml. Patients starting therapy for the first time were also monitored.

RESULTS

A cohort of 60 patients whose plasma HIV RNA was undetectable for 32 +/- 2 months were monitored for circles for 15 +/- 2 months. The circle copy number ranged from < 10 to 620 copies/106 PBMN cells. The circle-negative (< 10 copies/1 x 106 PBMN) cells group of 36 patients and the circle-positive (> 10 copies/106 PBMN cells) group of 24 patients were mutually exclusive (P < 0.0001). The mean circle half-life in seven of the 10 patients starting anti-retroviral therapy for the first time was 5.7 days.

CONCLUSION

The circle assay is useful for identifying those patients in whom transmission of infectious virus continues despite prolonged periods of time during which plasma HIV RNA is undetectable. New drug combinations and new therapeutic approaches should be aimed at those patients whose plasma HIV RNA is undetectable but who remain positive for 2-LTR circles.

Cognition and the inhibitory control of saccades in schizophrenia and Parkinson's disease

Historically, various lines of evidence have converged on the view that the brain expends much of its neural resources on inhibiting its own activity in a critical step towards the cognitive control of behaviour. The loss of inhibitory control is widely reported in neurological and psychiatric disorders; however, the consequences of reduced inhibition in terms of wider cognitive effects on cognitive control operations such as planning, abstract thought, working memory and the ability to appreciate the perspective of others ('theory of mind') has been widely overlooked. The antisaccade paradigm examines the conflict between a prepotent stimulus that produces a powerful urge to fixate the target, and the overriding goal to 'look' in the opposite direction. In this chapter we illustrate how this paradigm is increasingly used to explore the relationship of inhibitory control and cognition in Parkinson's disease, schizophrenia and healthy participants. Evidence is presented that is consistent with the theory of cognitive inhibition as a distinct process that can be dissociated from working memory. We conclude that the inhibitory control of saccadic eye movement should be studied in the wider context of cognitive operations.