Chronomodulated chemotherapy: clinical value and possibilities for dissemination in the United States

Modern medicine has been relatively slow to apply chronotherapeutic principles to standard oncologic practice. Despite the impressive body of evidence supporting the use of chronochemotherapy, with only a rare exception most oncology clinics in the United States lack the expertise and capability to implement it. At the same time, American medicine has increasingly come to recognize the importance of toxicity mitigation, cytoprotection, and quality of life for patients undergoing cancer treatment. However, toxicity mitigation strategies such as chronomodulated infusional chemotherapy and novel cytoprotective agents are not widely embraced by U.S. physicians. This article explores some reasons why this situation exists, including the influence of non-medical biases that may affect management decisions on the application of chemotherapy. The author conducted a survey of U.S. companies representing the three private insurance payers available (HMO, PPO, Indemnity) as well as representatives of Medicare and Medicaid. Responses to the survey confirmed that U.S. insurers do not at present officially reimburse for chronotherapy; however, changes will come about through educational efforts aimed at increasing awareness among insurers as to the clinical benefits and cost-effectiveness of this mode of treatment. At this juncture, the outlook for cancer chronotherapy as a first-line approach to the treatment of metastatic cancer in the United States remains uncertain. Under the current method of insurance reimbursement, the advancement of chronotherapy in the United States is threatened despite evidence that such treatment is both therapeutically sound and cost-effective.     

Branchial and renal handling of urea in the gulf toadfish,Opsanus beta: the effect of exogenous urea loading

The objective of this study was to determine whether the pulsatile facilitated diffusion transport mechanism (tUT) found in the gills of the gulf toadfish (Opsanus beta) and the active secretion transporter thought to be present in its kidney could be saturated when faced with elevated plasma urea concentrations. Toadfish were infused with four consecutive exogenous urea loads at a rate of 0, 150, 300 and 600 micromol kg(-1) h(-1). Initial plasma and urine urea concentrations were 8.1+/-0.9 and 12.4+/-1.5 mmol l(-1), respectively, and steadily increased with increasing infused loads of urea to a maximum of 36.8+/-2.8 mmol l(-1) in the plasma and 39.8+/-6.5 mmol l(-1) in the urine. There was only a very weak relationship (r=0.17) between pulse size (measured as branchial excretion during pulsatile excretion of urea) and plasma urea concentration (slope=9.79 micromol-N kg(-1) per mmol-N l(-1); P<0.05) suggesting that the branchial excretion mechanism was already saturated at normal plasma urea concentrations. Urine flow rate (0.15+/-0.03 ml kg(-1) h(-1)) and glomerular filtration rate (0.025+/-0.004 ml kg(-1) h(-1)) remained constant throughout the experiment despite the increased volume load. Renal urea secretion rate maintained a strong linear relationship (r=0.84) to plasma urea levels (slope=0.391 micromol-N kg(-1) h(-1) per mmol-N l(-1); P<0.001) with no observable transport maximum, suggesting that the renal secretory transport mechanism was not saturated even at plasma urea levels well above normal, in contrast to the branchial excretion mechanism.     

Examining costs of induced and constitutive immune investment in Tenebrio molitor

Central to the conceptual basis of ecological immunity is the notion that immune effector systems are costly to produce, run, and/or maintain. Using the mealworm beetle, Tenebrio molitor, as a model we investigated two aspects of the costs of innate immunity. We conducted an experiment designed to identify the cost of an induced immune response, and the cost of constitutive investment in immunity, as well as potential interactions. The immune traits under consideration were the encapsulation response and prophylactic cuticular melanization, which are mechanistically linked by the melanin-producing phenoloxidase cascade. If immunity is costly, we predicted reduced longevity and/or fecundity as a consequence of investment in either immune trait. We found a measurable longevity cost associated with producing an inducible immune response (encapsulation). In contrast to other studies, this cost was expressed under ad libitum feeding conditions. We found no measurable costs for constitutive investment in immunity (prophylactic investment in cuticular colour).     

Adaptive decision making in a lymphocyte infusion trial

We describe an adaptive Bayesian design for a clinical trial of an experimental treatment for patients with hematologic malignancies who initially received an allogeneic bone marrow transplant but subsequently suffered a disease recurrence. Treatment consists of up to two courses of targeted immunotherapy followed by allogeneic donor lymphocyte infusion. The immunotherapy is a necessary precursor to the lymphocyte infusion, but it may cause severe liver toxicity and is certain to cause a low white blood cell count and low platelets. The primary scientific goal is to determine the infusion time that has the highest probability of treatment success, defined as the event that the patient does not suffer severe toxicity and is alive with recovered white blood cell count 50 days from the start of therapy. The method is based on a parametric model accounting for toxicity, time to white blood cell recovery, and survival time. The design includes an algorithm for between-patient immunotherapy dose de-escalation based on the toxicity data and an adaptive randomization among five possible infusion times according to their most recent posterior success probabilities. A simulation study shows that the design reliably selects the best infusion time while randomizing greater proportions of patients to superior infusion times.     

Vanadium-contaminated perioperatively administered infusion solutions and drugs

Vanadium was determined in 51 solutions and drugs for intravenous administration and in 6 salt components of a multitrace element solution using electrothermal atomic absorption spectrometry. The highest V contaminations were found in albumin solutions showing values of more than 600 μg/L V. Two heparines contained 14.3 and 122 μg/L V, respectively. In the ultratrace element solution, 14.8 μg/L vanadium were determined. The most contaminated salt of this solution was Mn(II)-dl-aspartate (12.8 μg V/g). The concentrations of unbound V (V _f ) in the albumin solutions were between 0.31 and 299 μg/L. The manufacturing process is the reason for V contamination. The biological half-life of V administered intravenously by albumin solutions in man was about 125 h.     

Dose-finding based on feasibility and toxicity in T-cell infusion trials

A new modality for treatment of cancer involves the ex vivo growth of cancer-specific T-cells for subsequent infusion into the patient. The therapeutic aim is selective destruction of cancer cells by the activated infused cells. An important problem in the early phase of developing such a treatment is to determine a maximal tolerated dose (MTD) for use in a subsequent phase II clinical trial. Dose may be quantified by the number of cells infused per unit body weight, and determination of an MTD may be based on the probability of infusional toxicity as a function of dose. As in a phase I trial of a new chemotherapeutic agent, this may be done by treating successive cohorts of patients at different dose levels, with each new level chosen adaptively based on the toxicity data of the patients previously treated. Such a dose-finding strategy is inadequate in T-cell infusion trials because the number of cells grown ex vivo for a given patient may be insufficient for infusing the patient at the current targeted dose. To address this problem, we propose an algorithm for trial conduct that determines a feasible MTD based on the probabilities of both infusibility and toxicity as functions of dose. The method is illustrated by application to a dendritic cell activated lymphocyte infusion trial in the treatment of acute leukemia. A simulation study indicates that the proposed methodology is both safe and reliable.     

米库氯铵闭环靶控输注用于全麻老年患者的药效学研究

目的:探讨米库氯铵用于老年患者闭环输注的用量及其药效学。方法:选择择期全麻手术青年(18~30岁)和老年患者(60~75岁)各35例,经闭环肌松注射系统给予米库氯铵,采用4个成串刺激尺神经,通过拇内收肌的收缩反应以监测TOF值(T4/T1)。记录两组患者注入米库氯铵后的肌松起效时间、血流动力学变化、不良反应及停药后的神经肌肉功能的恢复情况。结果:两组患者在诱导期T1至T4各时间点HR、SBP、DBP、SpO_2的比较,差异均无统计学意义(P0.05)。与青年组相比,老年组米库氯铵闭环输注肌松起效时间和恢复时间均较长(P0.05),但拔管时间无差别(P0.05)。米库氯铵闭环输注肌松抑制THD90%的用量老年组为3.6±1.7μg·kg-1·min-1,青年组为4.3±1.5μg·kg~(-1)·min-1,差异无统计学意义(P0.05)。两组患者均未发现皮肤潮红、支气管痉挛、低血压、肌松残余等不良反应。结论:米库氯铵闭环输注应用于老年患者术毕拔管时间与青年患者相当,且不增加不良反应,是老年患者肌松诱导和维持的可选方案。     

3D Flexible Carbon Felt Host for Highly Stable Sodium Metal Anodes

Sodium (Na) metal, which possesses a high theoretical capacity and the lowest electrochemical potential, is regarded as a promising anode material for Na–metal batteries. However, both Na dendrite growth and large volume change in cycling have severely impeded its practical applications. This study demonstrates that a 3D flexible carbon (C) felt which is already commercialized in large‐scale can be employed as a host for prestoring Na via a melt infusion strategy, through which a Na/C composite anode is obtained. The resulting anode exhibits a stable voltage profile and a small hysteresis over 120 cycles in carbonate‐based electrolytes in symmetrical cells owing to the fact that the metallic Na is confined in a conductive carbon felt host, which increases the Na⁺ deposition sites to lower the effective current density and render a uniform Na nucleation, restricting the dimension change in electrochemical cycling. More importantly, effective inhibition of Na dendrite growth and large volume change is achieved. When coupled with a Na_0.67Ni_0.33Mn_0.67O₂ cathode, the Na/C composite demonstrates a good suitability in full cells. This work provides an alternative option for the fabrication of stable Na metal anodes, which is of great significance for the practical applications of Na metal anodes in high‐energy‐density batteries.     

Autologous iPSC-Based Vaccines Elicit Anti-tumor Responses In Vivo

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Endogenous Reprogramming of Alpha Cells into Beta Cells,Induced by Viral Gene Therapy,Reverses Autoimmune Diabetes

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