Bone Marrow Quality Index: A Predictor of Acute Graft-versus-Host Disease in Hematopoietic Stem Cell Transplantation for Thalassemia

Bone marrow (BM) continues to be the preferred source of stem cells in allogenic transplantation for nonmalignant disorders. Granulocyte colony-stimulating factor (G-CSF)-primed BM is associated with low rates of acute graft-versus-host disease (aGVHD) and allows reduced collection volumes while ensuring speedy engraftment. However, variability in BM harvest quality is a concern. This study evaluated the utility of a novel indicator, the Bone Marrow Quality Index (BMQI), to predict aGVHD. We analyzed 184 consecutive first matched related donor bone marrow transplants for thalassemia using G-CSF-primed bone marrow over 6 years from March 2017 to April 2023 across 2 centers in India. BMQI was defined as the ratio of the G-CSF-primed BM WBC count to the peripheral blood WBC count within 24 hours of harvest. European Society for Blood and Marrow Transplantation criteria were used to grade aGVHD. The log-rank test was used to assess the impact of BMQI on aGVHD. The chi-square test was used to compare categorical data, and the Wilcoxon rank-sum test was used to compare the numerical data. A Cox proportional hazards model was used to investigate the association of BMQI vis-à-vis other factors on aGVHD. Of the 184 patients studied, 19 had a BMQI <.9, 18 had a BMQI between .9 and 1, and the remaining 147 had a BMQI >1. The rate of aGVHD grade II-IV was 37% in patients with a BMQI <.9 , 22% in those with BMQI .9 to 1, and 12% in those with BMQI >1 (P = .018). Patients with BMQI <.9 had a 3.1-fold greater chance (95% confidence interval [CI], .9 to 10.6) and those with BMQI .9 to 1 had a 2-fold greater chance (95% CI, .5 to 6.6) of developing aGVHD grade II-IV. BMQI was the significant predictor associated with aGVHD hazard (P = .014). BMQI appears to be the most relevant and controllable predictor of aGVHD. It is a novel, informative, and very simple indicator that could influence aGVHD prophylaxis decision making. Our indicator is accurately measurable, inexpensive, precise, and timely; furthermore, it does not involve any sophisticated equipment and thus may be widely applicable. Prior knowledge of poor BM quality may help intensify prophylaxis and monitoring for aGVHD, as well as trigger a review of collection procedures.

Safety and Efficacy of Thalidomide and Hydroxyurea Combination in Beta Thalassemia Patients

Beta thalassemia results from imbalance in alpha and beta globin chains causing severe anemia, transfusion dependency, and iron overload. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment. Patients without the option of HSCT may benefit from Hemoglobin F (HbF) inducing agents like thalidomide and hydroxyurea (HU). We conducted a retrospective analysis on 87 beta thalassemia patients who received a combination of low dose thalidomide and HU from January 2017 to December 2020. Patients received combination of HU 500 mg everyday (> 30 kg) or every alternate day (< 30 kg) and thalidomide 100 mg (> 30 kg) or 50 mg (< 30 kg) once daily. Parameters such as transfusion requirement, anthropometry, Hb levels, ferritin, drug side effects etc. were monitored and evaluated at the end of one year of therapy. Sixty-three patients (72%) achieved transfusion independence and were eligible for the study. Median time to transfusion independence was 6 months (range 3-11 months). At the end of 1 year, overall response rate was 72%. There was significant improvement in the Hb levels, ferritin values and height at the end of 1 year of follow up. No grade 3 or 4 toxicities were noted. We document improvement of Hb levels, transfusion independence, reduction in iron overload, and improvement in growth parameters with minimal side effects at the end of 1 year of follow up.

Is it safe and efficacious to remove central lines in pediatric bone marrow transplant patients with platelets less than 20,000/μl?

Background

Patients with tunneled central venous lines (CVL) may develop bloodstream infections which at times are difficult to control without line removal. Concomitant severe thrombocytopenia with platelet transfusion refractoriness is often considered a major contraindication to any procedure involving a major blood vessel. There is very little literature on the clinical risks of tunneled central line removal in febrile pancytopenia patients.

Procedure

We analyzed complications and outcomes in all our patients, a total of 52, who underwent CVL removal with platelets <20,000/μl.

Results

CVL removal was done on a median day of 17.5 with 47 of the 52 patients never having achieved platelets engraftment prior to line removal. No bleeding episodes or unplanned transfusions could be associated with CVL removal. No other complications were also reported. All patients had time to hemostasis within 5 min of catheter removal. Removal of CVL under local anesthesia remained complication‐free even at platelet counts less than 20,000/ul. A total of 31 patients were febrile at the time of CVL removal, of which 17 became afebrile within 2 days. We found no difference in defervescence when comparing those whose antibiotic therapy was changed/escalated versus those in whom it was not.

Conclusion

Our findings suggest that central lines can be safely removed with platelet counts less than 20,000/ul and that this may result in enhanced bloodstream infection control. This might be particularly relevant to neutropenic patients in this day and age of multidrug‐resistant organism emergence and paucity of new effective antibiotics.

Do weekly surveillance cultures contribute to antibiotic stewardship and correlate with outcome of HSCT in children - a multicentre real-world experience of 5 years from Indian subcontinent?

BACKGROUND

The utility of weekly rectal swab surveillance cultures (RSSC) as a resource to identify gut colonisation with Extended Spectrum Beta-Lactamase (ESBL)-producing E Coli or Klebsiella pneumoniae carbapenemase (KPC) producing organisms, to guide empirical antibiotic therapy in HSCT patients continues to be a subject of interest. There is urgency to assess and justify modifications to empirical antibiotics based upon regional epidemiology and patient groups.

OBJECTIVE

To study the utility of weekly rectal swab surveillance cultures (RSSC) to guide empirical antibiotics therapy and the impact of gut colonisation on transplant outcomes.

STUDY DESIGN

This is a retrospective analysis of 317 successive first transplants done in three pediatric bone marrow transplant centres in Indian sub-continent, mainly for hemoglobinopathies, between April 2016 and April 2021. Transplantation, infection control and febrile neutropenia management protocols are identical among the three centres. First line antibiotics were chosen based on RCCS reports i.e. meropenem and high dose meropenem with colistin for ESBL and carbapenemase resistant colonisation respectively for first half of the study and no adjustment was made in the second half. Clinical response to antibiotics, long term outcomes, antibiotic-resistant bacteraemia and acute GVHD were analysed. Log-rank test, Chi-squared test and Wilcoxon test were used to compare data using R Statistical software.

RESULTS

Of all 871 weekly RSSC done, 162 were positive for ESBL- or KPC-resistant organism. RCCS were ESBL-positive in 106 patients (33%) and KPC-positive in 10 patients (3%). Within 97 ESBL-positive patients for whom antimicrobial susceptibility testing (AST) report was available, only 22 (25%) demonstrated clinical resistance of Pip-Taz. Within the 10 KPC-positive patients' clinical resistance was observed only in 4 (40%) to Pip-Taz and 3 (30%) to meropenem. For ESBL-positive RSSC where 1st line empirical antibiotics were used, 66% of the patients responded clinically. Even within the 15 who were resistant to 1st line empirical antibiotics (Pip-Taz) on RSSC reports, 67% responded to Pip-Taz clinically. Within these patients 27 (56%) never needed any carbapenems. Using Pip-Taz empirically in ESBL-positive patients did not prolong meropenem use within 100 days of transplantation (p=0.18). For KPC-positive RSSC where 1st line empirical antibiotics were used, all patients clinically responded, including 4 who were resistant to Pip-Taz and 3 patients who were meropenem resistant on RCCS. Comparing patients who were ESBL-positive, KPC-positive and neither, no statistically significant difference was seen in overall survival (p=0.95), disease free survival (p=0.45), transplant related mortality (p=0.97), rejection (p=0.68) and rate of acute GVHD grade II-IV (p=0.78). Comparing the ESBL-positive patients who did and did not get higher-level empirical antibiotics, no statistical difference was seen in overall survival (p=0.32), disease free survival (p=0.64), transplant related mortality (p=0.65), rejection (p=0.46), acute GVHD grade II-IV (p=0.26) or antibiotic resistant bacteraemia (p=0.3).

CONCLUSIONS

In context of transplantation for non-malignant HSCTs, empiric antibiotic choice based on rectal swab surveillance cultures is not justified, even in regions with a high prevalence of antimicrobial resistance. Antimicrobial susceptibility testing (AST) reports in surveillance cultures did not correlate with in-vivo clinical response. Colonisation reported on weekly surveillance rectal swab cultures showed no correlation with clinical outcomes.

Pre-transplant donor-type red cell transfusion is a safe and effective strategy to reduce isohemagglutinin titers and prevent donor marrow infusion reactions in major ABO-mismatched transplants

ABO incompatibility is not a barrier to allogeneic stem cell transplant but may result in acute hemolytic reactions. As stem cell product manipulation is cumbersome, we are reporting the effectiveness and safety of donor-type red cell infusion as a method of reducing acute hemolytic reaction while using marrow as stem cell source. In major ABO-mismatched bone marrow transplants, manipulation of marrow product requires expertise and expensive equipment, which may not be readily available to transplant centers in low- and middle-income regions. The aim behind our study is to report a safe and effective strategy to reduce isohemagglutinin titers and prevent donor marrow infusion reactions in major ABO-mismatched transplants. We retrospectively analyzed 303 consecutive allogeneic bone marrow transplants (BMTs) for beta thalassemia major, between August 2015 and March 2020, with either major (n = 41) or bidirectional (n = 14) mismatches. When isohemagglutinin titers were 1:32 or higher, donor-type packed red blood cell was divided into 4 aliquots, irradiated and administered over 4 days at incremental volumes. Patients were observed for hemolytic reaction, and if no reaction, bone marrow was infused without manipulation. Out of 55 patients, 20 received donor-type blood infusion. Twelve patients showed evidence of mild hemolysis. None developed severe hemolytic or anaphylactic reaction. Titers were rechecked in 14 patients and all had reduction in titers, except for one. Our experience demonstrated that donor-type PRBC infusion is safe and effective in preventing acute hemolysis in major ABO-mismatched stem cell transplants even with bone marrow as graft source.

Comparison of Adverse Outcomes Following Placement of Superion Interspinous Spacer Device Versus Laminectomy and Laminotomy

BACKGROUND

Current evidence suggests placement of the Superion interspinous spacer (SISS) device compared with laminectomy or laminotomy surgery offers an effective, less invasive treatment option for patients with symptomatic lumbar spinal stenosis. Both SISS placement and laminectomy or laminotomy have risks of complications and a direct comparison of complications between the 2 procedures has not been previously studied. The purpose of this study is to compare the short-term complications of the SISS with laminectomy or laminotomy and highlight device-specific long-term outcomes with SISS.

METHODS

Via retrospective review, 189 patients who received lumbar level SISSs were compared with 378 matched controls who underwent primary lumbar spine laminectomy or laminotomy; data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. Complications analyzed included rates of wound infection, pulmonary embolism, deep venous thrombosis, urinary tract infection, sepsis, septic shock, cardiac arrest, death, and reoperation within 30 days of index surgery. Differences between groups were analyzed using the χ²test. Device-specific complication (DSC) rates included device malfunction or misplacement (DM), device explantation (DE), spinous process fracture (SPF), and subsequent spinal surgery (SSS).

RESULTS

No differences in demographics or comorbidities existed between groups. There was no significant difference in rates of complications between groups. A total of 44.4% of patients in the SISS group experienced DSCs with 11.1% of patients experiencing DM, 21.1% experiencing an SPF, 20.1% requiring DE, and 24.3% requiring SSS. Having at least 1 DSC significantly increased odds of SSS, odds ratio >120, P < .0001.

CONCLUSION

Rates of 30-day complications in the SISS group were not significantly different from patients undergoing laminectomy or laminotomy. Rates of 2-year DSC within SISS and cumulative risk associated with these complications should be considered further as they likely represent need for additional procedures for patients and substantial cost to the healthcare system.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Having no differences in adverse events between laminectomies or laminotomies and SISS plus evidence of substantial device-specific long-term adverse outcomes and reoperation should be given consideration when deciding on surgical intervention of 1-2 level lumbar spinal stenosis.

A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocol

BACKGROUND

Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery.

METHODS

The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13-17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a 'healthy living' behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness.

DISCUSSION

UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression.

TRIAL REGISTRATION

ISRCTN, ISRCTN66452702 . Registered 9 April 2020.

Optical spin injection and spin lifetime in Ge heterostructures

We demonstrate optical orientation in Ge/SiGe quantum wells and study their spin properties. The ultrafast electron transfer from the center of the Brillouin zone to its edge allows us to achieve high spin polarizations and to resolve the spin dynamics of holes and electrons. The circular polarization degree of the direct gap photoluminescence exceeds the theoretical bulk limit, yielding ∼37% and ∼85% for transitions with heavy and light holes states, respectively. The spin lifetime of holes at the top of the valence band is estimated to be ∼0.5  ps and it is governed by transitions between light and heavy hole states. Electrons at the bottom of the conduction band, on the other hand, have a spin lifetime that exceeds 5 ns below 150 K. Theoretical analysis of the spin relaxation indicates that phonon-induced intervalley scattering dictates the spin lifetime of electrons.

Parental perceptions regarding healthy behaviours for preventing overweight and obesity in young children: a systematic review of qualitative studies

Evidence is increasingly pointing towards the importance of early life strategies to prevent childhood overweight and obesity. This systematic review synthesizes qualitative research concerning parental perceptions regarding behaviours for preventing overweight and obesity in young children. During May and June 2008, a range of electronic databases were searched and together with lateral searching techniques 21 studies were identified for review. Data extraction and synthesis using thematic content analysis revealed six organizing and 32 finer level themes. These related to child factors, family dynamics, parenting, knowledge and beliefs, extra-familial influences and resources and environment. Themes were mapped to a socioecological model which illustrated how factors at individual, interpersonal, community, organizational and societal levels interact in complex ways to impact on parental perceptions about healthy behaviours for preventing child overweight. Although parents suggested several ideas to promote healthy child weight-related behaviours, many of their views concerned perceived barriers, some of which may be amenable to practical intervention. Furthermore, intergenerational influences on parental health beliefs and knowledge suggest that health promotion strategies may be more effective if directed at the wider family, rather than parents alone. Significantly, many parents believed strategies to promote healthy weight should start early in a child's life.

A serious drug interaction leading to spontaneous total hyphema

A 70 year-old diabetic man receiving anti-coagulant therapy (Warfarin) for pulmonary embolism secondary to factor V Leiden deficiency, presented to the hospital for chest pain. After initial evaluation, he was started on aspirin (300 mg) and clopidogrel (300 mg). Three days after he was discharged, he presented with preseptal cellulitis complicating left upper eyelid chalazion. Initially, he was treated with several anti-microbial agents used sequentially. Although, the cellulitis resolved, he developed total hyphema of the left eye. The complication seems to have resulted from a complex interaction amongst anti-microbial agents, Warfarin and anti-platelet agents.

Early fatherhood: a mapping of the evidence base relating to pregnancy prevention and parenting support

Teenage pregnancy prevention programmes targeted at young women have received considerable attention from researchers and programme developers. However, to date, relatively limited information is available on preventing teenage fatherhood or improving outcomes for young fathers. A notable gap is concerned with understanding the forms of sexual health programmes that are most effective from the perspective of young men. We conducted a systematic mapping to identify studies involving young men aimed at preventing teenage pregnancy, improving outcomes for teenage fathers or exploring the perspectives of young men around pregnancy and fatherhood. We searched a wide range of electronic databases from January 1996 to August 2008. Three quantitative and 15 qualitative studies were identified, of which nine were UK based. Key themes related to the inappropriateness of current sexual health promotion to respond to the needs of young men. While young men often possessed very similar ideals to young women, existing programmes were problematic when they negatively stereotyped young men and ineffectively addressed models of masculinity or the difficulties young men may have forming meaningful relationships. Further investigations are required on programme development for young men, particularly on sexual health promotion interventions for 'looked-after' young men and those from unstable childhoods.

A panel of artificial APCs expressing prevalent HLA alleles permits generation of cytotoxic T cells specific for both dominant and subdominant viral epitopes for adoptive therapy

Adoptive transfer of virus-specific T cells can treat infections complicating allogeneic hematopoietic cell transplants. However, autologous APCs are often limited in supply. In this study, we describe a panel of artificial APCs (AAPCs) consisting of murine 3T3 cells transduced to express human B7.1, ICAM-1, and LFA-3 that each stably express one of a series of six common HLA class I alleles. In comparative analyses, T cells sensitized with AAPCs expressing a shared HLA allele or autologous APCs loaded with a pool of 15-mer spanning the sequence of CMVpp65 produced similar yields of HLA-restricted CMVpp65-specific T cells; significantly higher yields could be achieved by sensitization with AAPCs transduced to express the CMVpp65 protein. T cells generated were CD8(+), IFN-gamma(+), and exhibited HLA-restricted CMVpp65-specific cytotoxicity. T cells sensitized with either peptide-loaded or transduced AAPCs recognized epitopes presented by each HLA allele known to be immunogenic in humans. Sensitization with AAPCs also permitted expansion of IFN-gamma(+) cytotoxic effector cells against subdominant epitopes that were either absent or in low frequencies in T cells sensitized with autologous APCs. This replenishable panel of AAPCs can be used for immediate sensitization and expansion of virus-specific T cells of desired HLA restriction for adoptive immunotherapy. It may be of particular value for recipients of transplants from HLA-disparate donors.

Ocimum sanctumModulates Selenite-Induced Cataractogenic Changes and Prevents Rat Lens Opacification

PURPOSE

To study the effect of Ocimum sanctum (OS) on selenite-induced morphological and biochemical changes in isolated rat lenses as well as on cataract incidence in rat pups.

METHODS

Transparent rat lenses were divided into normal, selenite-only, and four treated groups. Selenite-only and treated group lenses were subjected to oxidative stress in vitro by incorporating sodium selenite (100 microM) in the culture medium. The effect of OS (70, 140, 280, and 560 microg/ml) was studied on the levels of reduced glutathione (GSH) and thiobarbituric acid reacting substances (TBARS) in selenite-challenged lenses. The lowest concentration of OS offering significant modulation on these two parameters was determined. Subsequently, the effect of prior and cotreatment with the lowest effective concentration of OS was studied on TBARS, GSH, and on lens antioxidant enzymes such as superoxide dismutase (SOD), glutathione peroxidase (GSHPx), catalase (CAT), and glutathione-S-transferase (GST). Changes in lens protein profiles under different incubation conditions were analyzed by SDS gel-electrophoresis. In vivo, cataract was induced by a single subcutaneous injection of sodium selenite (25 micromole/kg b.w.) to 9-day-old rat pups. The anticataract effect of OS (5 and 10 mg/kg b.w.) injected intraperitoneally 4 hr prior to selenite challenge was evaluated by the presence of lens nuclear opacity in rat pups on the 16th postnatal day. Insolubilization of lens proteins post-selenite injection was monitored for 4 days.

RESULTS

The lenses in the selenite-only group developed cortical opacities in 24 hr. OS showed different degrees of positive modulation in selenite-induced morphological as well as biochemical changes. The lowest effective dose of OS that significantly modulated glutathione and thiobarbituric acid reacting substances was found to be 140 microg/ml. At this dose, a significant increase in antioxidant enzyme levels and preservation of normal lens protein profile was observed. OS at the dose of 70 microg/ml did not show any significant protection with respect to either morphology or biochemistry of lenses. In vivo, 5 and 10 mg/kg of OS reduced the incidence of selenite cataract by 20% and 60%, respectively, and prevented protein insolubilization as well.

CONCLUSIONS

Aqueous extract of OS possesses potential anticataract activity against selenite-induced experimental cataractogenesis. The protective effect was supported by restoration of the antioxidant defense system and inhibition of protein insolubilization of rat lenses as well.

Management of cancer-related vertebral compression fracture: Comparison of treatment options: A literature meta-analysis

e20529

Objective: The objective of this review was to compare the efficacy and safety of treatment options for management of vertebral compression fractures (VCF) secondary to multiple myeloma and/or metastatic tumors based on a meta-analysis of the literature. Methods: A search was performed of published literature through November 2008. All articles reporting at least one clinical outcome were included. VAS pain scores and cement extravasation were the most common efficacy and safety outcomes reported in the included studies and were considered for analysis. The mean weighted difference in VAS scores or the effect size was calculated using the number of patients in each study as the weights. The paired t-test was used to assess significance of these differences. A 95% confidence interval (CI) was computed around these differences. The significance of difference (VAS and % cement extravasations) between different modes of treatment was assessed using a two sample t-test. Results: A total of 59 studies met the inclusion criteria and were included in the meta-analysis. The majority of the included studies (56 studies) were case series. No randomized controlled study was identified. The total sample size from the included study was 4,460 patients - 73% of patients had a diagnosis of tumor metastasis to the vertebral column; 18% had a diagnosis of multiple myeloma. Percutaneous vertebroplasty (VP) was described in 57.6% studies; balloon kyphoplasty (BKP) in 20.3%; conservative/combined (CC) therapy in 22%. Results are shown in the Table . Conclusions: This meta-analysis indicates that BKP is more effective than either VP or conservative therapy in relieving pain secondary to cancer-related VCF and that BKP is a safer intervention than VP based on the analysis of the rates of cement extravasation.

[Table: see text]

No significant financial relationships to disclose.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH STRATEGY

We searched the Cochrane Injuries Group specialised register, CENTRAL (2007, Issue 1), MEDLINE (1994 to March 2007), EMBASE (1974 to March 2007), and the National Research Register (2007, issue 1). Bibliographies of trials retrieved were searched, and drug companies manufacturing colloids were contacted for information. The search was last updated in March 2007.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The outcomes measured were death, amount of whole blood transfused, and incidence of adverse reactions.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the quality of the trials.

MAIN RESULTS

Seventy trials, with a total of 4375 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 24 trials and poor or uncertain in the rest. Deaths were obtained in 46 trials. For albumin or PPF versus hydroxyethyl starch (HES) 25 trials (n = 1234) reported mortality. The pooled relative risk (RR) was 1.14 (95% CI 0.91 to 1.43). For albumin or PPF versus gelatin, seven trials (n = 636) reported mortality. The RR was 0.97 (95% CI 0.68 to 1.39). For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 18 trials (n = 1337) reported mortality and RR was 1.00 (95% CI 0.80 to 1.25). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Thirty-seven trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Nineteen trials recorded adverse reactions, but none occurred.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Adoptive transfer of antigen-specific T-cells of donor type for immunotherapy of viral infections following allogeneic hematopoietic cell transplants

Allogeneic marrow and cytokine-mobilized peripheral blood stem cells adequately depleted of T cells prevent acute and chronic forms of graft versus host disease in HLA-matched and non-identical hosts without any posttransplant immunosuppressive prophylaxis. Current cytoreductive regimens secure consistent durable engraftment, and full donor chimerism. The risk of relapse following such transplants in patients with AML and ALL has been low, and not different from that recorded following unmodified transplants. However, in HLA-disparate hosts the risk of infections caused by EBV, CMV, and certain fungi are increased. To address this limitation, others and we are exploring adoptive immunotherapies with in vitro generated, pathogen-specific T cells. Early clinical trials already indicate the potential of such T cells to treat and prevent life threatening diseases caused by these pathogens, particularly in recipients of T cell depleted grafts who do not require ongoing treatment with immunosuppressive agents, and therefore provide a permissive environment for the expansion and persistence of the T cells following adoptive transfer. New more predictable strategies are under development, which should allow such therapies to be broadly applicable.

Generation of CMV-specific T lymphocytes using protein-spanning pools of pp65-derived overlapping pentadecapeptides for adoptive immunotherapy

Cell-mediated immunity is essential for control of human cytomegalovirus (HCMV) infection. We used a pool of 138 synthetic overlapping pentadecapeptides overspanning the entire pp65 protein to generate polyclonal CMV-specific T-cell lines from 12 CMV-seropositive donors inheriting different HLA genotypes. Autologous monocyte-derived dendritic cells (DCs) pulsed with this complete pool consistently induced highly specific T cells that selectively recognized 1-3 pentadecapeptides identified by secondary responses to a mapping grid of pentadecapeptide subpools with single overlaps. Responses against peptide-loaded targets sharing single HLA class I or II alleles identified the restricting HLA alleles. HLA-A*0201+ donors consistently responded to pentadecapeptides containing HLA-A*0201-binding epitope(aa495-503)NLVPMVATV. T-cell lines from other donors contained high frequencies of CD4 and/or CD8 T cells selectively reactive against peptides presented by other HLA alleles, including both known epitopes such as (aa341-350)QYDPVAALF (HLA-A*2402) as well as unreported epitopes such as (aa267-275)HERNGFTVL (HLA-B*4001 and B*4002) and (aa513-523)FFWDANDIYRI (HLA-DRB1*1301). These T cells consistently lysed CMV-infected target cells. Thus, this approach fosters expansion and selection of HLA-restricted CMV-pp65-reactive T-cell lines of high specificity that also lyse CMV-infected targets, and from a functional and regulatory perspective, may have advantages for generating virus-specific T cells for adoptive immunotherapy.

Biological and conformational study of beta-substituted prolines in MT-II template: steric effects leading to human MC5 receptor selectivity

To investigate the molecular basis for the interaction of the chi-constrained conformation of melanotropin peptide with the human melanocortin receptors, a series of beta-substituted proline analogs were synthesized and incorporated into the Ac-Nle-C[Asp-His-D-Phe-Arg-Trp-Lys]-NH2 (MT-II) template at the His6 and D-Phe7 positions. It was found that the binding affinities generally diminished as the steric bulk of the p-substituents of the 3-phenylproline residues increased. From (2S, 3R)-3-phenyl-Pro6 to (2S, 3R)-3-(p-methoxyphenyl)-Pro6 analogs the binding affinity decreased 23-fold at the human melanocortin-3 receptor (hMC3R), 17-fold at the hMC4R, and eight-fold at the hMC5R, but selectivity for the hMC5R increased. In addition, the substitution of the D-Phe7 residue with a (2R, 3S)-3-phenyl-Pro resulted in greatly reduced binding affinity (10(3)-10(5)) at these melanocortin receptors. Macromodel's Large Scale Low Mode (LLMOD) with OPLS-AA force field simulations revealed that both MT-II and SHU-9119 share a similar backbone conformation and topography with the exception of the orientation of the side chains of D-Phe7/D-Nal (2')7 in chi space. Introduction of the dihedrally constrained phenylproline analogs into the His6 position (analogs 2-6) caused topographical changes that might be responsible for the lower binding affinities. Our findings indicate that hMC3 and hMC4 receptors are more sensitive to steric effects and conformational constraints than the hMC5 receptor. This is the first example for melanocortin receptor selectivity where the propensity of steric interactions in chi space of beta-modified Pro6 analogs of MT-II has been shown to play a critical role for binding as well as bioefficacy of melanotropins at hMC3 and hMC4 receptors, but not at the hMC5 receptor.

Impact of environmental pollution on the eye

PURPOSE

To study the effect of environmental toxins on the ocular surface in persons travelling through highly polluted areas of the metropolis of Delhi.

METHODS

A total of 500 apparently healthy volunteers recruited from the metropolis of Delhi were examined to establish the frequency of ocular surface disorders. All subjects underwent a slit-lamp examination, tear break-up time (BUT) test, Rose Bengal test, Schirmer's test and tear lysozyme level test.

RESULTS

Subjects in the study group had significantly higher levels of ophthalmic symptoms compared to the control group. In all, 105 (42%) and 125 (50%) subjects in the study group compared to 50 (20%) and 65 (26%) in the control group complained of redness and irritation (p < 0.05). There was no significant difference in visual acuity (VA) between the two groups, with best corrected VA being 6/9 or better in 92% of the study group and 96% of the control group. The average (+/-standard deviation) Schirmer's test result was 13.42+/-6.67 mm in the study group compared to 15.95+/-6.14 mm in the control group. This difference was statistically significant. The BUT was also significantly lower in the study group (12.97+/-6.12 seconds) compared to the control group (19.23+/-5.70 seconds) (p < 0.001). The Rose Bengal test and tear lysozyme activity did not show any significant difference between the two groups.

CONCLUSION

According to our study, environmental conditions appear to have a very significant effect on the ocular surface. There were very high levels of subclinical ocular surface changes among persons travelling in highly polluted areas.

Lycopene attenuates oxidative stress induced experimental cataract development: an in vitro and in vivo study

OBJECTIVES

Lycopene, a nutritional antioxidant, was evaluated for its anticataract potential to further establish its role in cataract prevention.

METHODS

The ability of lycopene to modulate the biochemical parameters was investigated by in vitro studies. Enucleated rat lenses were maintained in organ culture containing Dulbecco's Modified Eagles Medium alone or in addition with 100 microM selenite and served as the normal and control groups, respectively. For the test group, the control medium was supplemented with 10 microM lycopene. The lenses were incubated for 24 h at 37 degrees C. At the end of the incubation period, the lenses were examined for morphologic variation, and biochemical parameters such as reduced glutathione, the lipid peroxidation product malondialdehyde, and the antioxidant enzymes glutathione peroxidase, glutathione S-transferase, superoxide dismutase, and catalase were estimated. In vivo selenite cataract was induced in 9-d-old rats by subcutaneous injection of sodium selenite (25 micromoles/kg of body weight). The rats in the test group were injected with lycopene (200 microg/kg body weight, intraperitoneally) 4 h before the selenite challenge. The incidence of cataract was observed when the rats first opened their eyes. Galactose cataract was induced in rats by feeding 30% galactose in the diet. Rats in the test group were fed orally with 200 microg/kg of lycopene daily, and rats in the control group received only vehicle. Cataract stages were graded at regular intervals.

RESULTS

A fall (25%) in the glutathione level and a rise (32%) in the malondialdehyde content were observed in control as opposed to normal lenses. Lycopene supplementation in the medium significantly (P < 0.001) restored glutathione and malondialdehyde levels. A significant decrease in the activity of antioxidant enzymes also was observed in the control lenses. A significant restoration in the activities of superoxide dismutase (P < 0.05) and catalase and glutathione S-transferase (P < 0.01), with no effect on glutathione peroxidase, was observed in the lycopene-supplemented group. Lycopene also reduced the incidence of selenite cataract. Only 9% of the eyes in the test group developed dense nuclear opacity as opposed to 83% in the control group. A significant delay in the onset and progression of galactose cataract was observed with oral feeding of lycopene. Only 35% of the eyes developed mature cataract as opposed to 100% in the control group.

CONCLUSIONS

Lycopene protects against experimental cataract development by virtue of its antioxidant properties, and it may be useful for prophylaxis or therapy against cataracts.

Green tea (Camellia sinensis) protects against selenite-induced oxidative stress in experimental cataractogenesis

Cataract is the leading cause of blindness worldwide. It is a multifactorial disease primarily associated with oxidative stress produced by free radicals. The protection offered by various antioxidants in cataract development is well established. Polyphenolic compounds present in green tea (Camellia sinensis) are reported to possess antioxidant property in various pathological conditions. The present study was undertaken to evaluate the anticataract potential of green tea leaf (GTL) extract in the development of lens opacification. Enucleated rat lenses were randomly divided into normal, control and treated groups and incubated for 24 h at 37 degrees C. Oxidative stress was induced by sodium selenite in the culture medium of the two groups (except the normal group). The medium of the treated group was additionally supplemented with GTL extract. After incubation, lenses were subjected to glutathione and malondialdehyde estimation. Enzyme activity of superoxide dismutase, catalase and glutathione peroxidase was also measured in different sets of the experiment. In vivo cataract was induced in 9-day-old rat pups of both control and treated groups by a single subcutaneous injection of sodium selenite. The treated pups were injected GTL extract intraperitoneally prior to selenite challenge and continued for 2 consecutive days thereafter. Cataract incidence was evaluated on 16th postnatal day by slit lamp examination. There was positive modulation of biochemical parameters in the organ culture study. Green tea was also found to reduce the incidence of selenite cataract in vivo. The results suggest that green tea possesses significant anticataract potential and acts primarily by preserving the antioxidant defense system.

Lycopene prevents sugar-induced morphological changes and modulates antioxidant status of human lens epithelial cells

Cataract is a multifactorial disease. Osmotic stress, together with weakened antioxidant defence mechanisms, is attributed to the changes observed in human diabetic cataract. Epidemiological studies provide evidence that nutritional antioxidants slow down the progression of cataract. The usefulness of lycopene, a dietary carotenoid, in the pathogenesis of human cataracts has not been studied so far. Since the epithelium is the metabolic unit of the lens, the effect of lycopene on galactose-induced morphological changes and antioxidant status of human lens epithelial cells (HLEC) in culture was evaluated in the present study. HLEC of fresh cadaver eyes obtained from an eye bank were cultured in medium supplemented with fetal calf serum (200 ml/l). On confluency, the cells were subcultured in medium containing either 30 mm-d-galactose or 30 mm-d-galactose+lycopene (5, 10 or 20 microm) for 72 h. The cells were observed under the phase-contrast microscope and transmssion electron microscope for any morphological changes and then harvested for the estimation of various biochemical variables. Malondialdeyde, glutathione and antioxidant enzymes were significantly altered in the control as compared with the normal cultures. Vacuolization was also observed in the presence of galactose. Addition of lycopene confers significant protection against these changes in HLEC.

Pyruvate modulates antioxidant status of cultured human lens epithelial cells under hypergalactosemic conditions

Lens epithelial cells are the metabolic unit of the lens and antioxidant enzymes are mainly concentrated here. The purpose of this study was to maintain human lens epithelial cells (HLEC) in culture and examine the status of antioxidant enzymes (glutathione peroxidase (GSHPx), catalase (CAT), glutathione-S-transferase (GST)), lipid peroxidation product malondialdehyde (MDA) and glutathione (GSH) levels in these cells under normal as well as hypergalactosemic (30 mM galactose) conditions. Further, effect of pyruvate, a physiological antioxidant has also been evaluated on these parameters. For conducting experiments, anterior capsule specimens obtained from fresh cadaver eyes from eye bank were cultured in Dulbecco's Modified Eagle's Medium (DMEM) supplemented with 20% fetal calf serum. Upon confluency, the cells were subcultured in three separate flasks containing DMEM alone (normal group), DMEM + 30 mM D-galactose (control group), DMEM + 30 mM D-galactose + 5 mM pyruvate (test group) and incubated for 24 or 72 h. These cells were observed under the phase contrast microscope for any morphological changes and harvested for the estimation of various antioxidant parameters. Our results show significant weakened antioxidant defense in HLEC when incubated in the presence of galactose as compared to normal. Addition of pyruvate significantly modulated levels of GSH, MDA, GSHPx, CAT and GST.

Pyruvate inhibits galactosemic changes in cultured cat lens epithelial cells

An attempt was made to maintain cat lens epithelial cells (CLEC) in culture and study the morphology, growth and survival of these cells in vitro. The influence of incorporation of galactose (30 mM) into the culture medium on the morphology and biochemistry of CLEC in the primary culture was then investigated. To establish the effect of galactose on CLEC, various biochemical parameters associated with galactosemic cataract such as aldose reductase (AR), Na+K+ATPase, glutathione, polyol and soluble/insoluble proteins were estimated after 24 h of incubation. The effect of pyruvate (5 mM), a 'physiological antioxidant', on the changes induced by galactose in CLEC was studied. CLEC in culture showed regular hexagonal cells with prominent nuclei. The CLEC culture attained confluency in 11 days during primary culture and semiconfluency in 14 days in two subsequent passages. Vacuolization and significantly raised AR activity, polyol levels and insoluble protein contents were observed; they had no effect on Na+K+ATPase and soluble protein after 24 h of incubation in the culture medium with galactose. Supplementation of pyruvate (5 mM) resulted in a lesser number of vacuoles together with a positive modulation of these parameters.

A new approach to search for the bioactive conformation of glucagon: positional cyclization scanning

In search for the bioactive conformation of glucagon, "positional cyclization scanning" was used to determine secondary structures of glucagon required for maximal interaction with the glucagon receptor. Because glucagon is flexible in nature, its bioactive conformation is not known except for an amphiphilic helical conformation at the C-terminal region. To understand the conformational requirement for the N-terminal region that appears to be essential for signal transduction, a series of glucagon analogues conformationally constrained by disulfide or lactam bridges have been designed and synthesized. The conformational restrictions via disulfide bridges between cysteine i and cysteine i + 5, or lactam bridges between lysine i and glutamic acid i + 4, were applied to induce and stabilize certain corresponding secondary structures. The results from the binding assays showed that all the cyclic analogues with disulfide bridges bound to the receptor with significantly reduced binding affinities compared to their linear counterparts. On the contrary, glucagon analogues containing lactam bridges, in particular, c[Lys(5), Glu(9)]glucagon amide (10) and c[Lys(17), Glu(21)]glucagon amide (14), demonstrated more than 7-fold increased receptor binding affinities than native glucagon. These results suggest that the bioactive conformation of glucagon may adopt a helical conformation at the N-terminal region as well as the C-terminal region, which was not evident from earlier biophysical studies of glucagon.

Development of potent glucagon antagonists: structure-activity relationship study of glycine at position 4

We examined the functional role of glycine at position 4 in the potent glucagon antagonist [desHis(1), Glu(9)]glucagon amide, by substituting the L- and D-enantiomers of alanine and leucine for Gly(4) in this antagonist. The methyl and isobutyl side-chain substituents were introduced to evaluate the preference shown by the glucagon receptor, if any, for the orientation of the N-terminal residues. The L-amino acids demonstrated only slightly better receptor recognition than the D-enantiomers. These results suggest that the Gly(4) residue in glucagon antagonists may be exposed to the outside of the receptor. The enhanced binding affinities of analogs 1 and 3 compared with the parent antagonist, [desHis(1), Glu(9)]glucagon amide, may have resulted from the strengthened hydrophobic patch in the N-terminal region and/or the increased propensity for a helical conformation due to the replacement of alanine and leucine for glycine. Thus, as a result of the increased receptor binding affinities, antagonist activities of analogs 1-4 were increased 10-fold compared with the parent antagonist, [desHis(1), Glu(9)]glucagon amide. These potent glucagon antagonists have among the highest pA(2) values of any glucagon analogs reported to date.

Development of potent truncated glucagon antagonists

In pursuit of truncated glucagon analogues that can interact with the glucagon receptor with substantial binding affinity, 23 truncated glucagon analogues have been designed and synthesized. These truncated analogues consist of several fragments of glucagon with 11 or 12 amino acid residues (1-4), conformationally constrained analogues containing the sequence of the middle region of glucagon (5-15), and truncated analogues containing the sequence of the C-terminal region (16-23). Biological assays of these analogues showed that the truncated glucagon analogues with the sequence of the C-terminal region possess significantly better binding affinity compared to the truncated analogues with the sequence of the middle region, and these analogues (17-23) demonstrated potent antagonistic activity (pA(2) values between 6.5 and 7.5). On the basis of these results, it can be suggested that glucagon interacts with its receptor with two hydrophobic patches located in the middle and the C-terminal regions of glucagon, and both hydrophobic patches are necessary for significant receptor recognition. These two hydrophobic binding motifs, located in two different regions of glucagon, appear to be the reason why the earlier attempts to obtain truncated analogues with good binding affinity did not result in any success. Long peptide hormones such as glucagon seem to require more than one binding pocket on the receptors for maximal interaction.

Design and synthesis of conformationally constrained glucagon analogues

Glucagon was systematically modified by forming lactam bridges within the central region of the molecule to give conformationally constrained cyclic analogues. Six cyclic glucagon analogues have been designed and synthesized. They are c[Asp(9),Lys(12)][Lys(17,18), Glu(21)]glucagon-NH(2) (1), c[Asp(9),Lys(12)]glucagon-NH(2) (2), c[Lys(12),Asp(15)]glucagon-NH(2) (3), c[Asp(15), Lys(18)]glucagon-NH(2) (4), [Lys(17)-c[Lys(18), Glu(21)]glucagon-NH(2) (5), and c[Lys(12),Asp(21)]glucagon-NH(2) (6). The receptor binding potencies and receptor second messenger activities were determined by radio-receptor binding assays and adenylate cyclase assays, respectively, using rat liver plasma membranes. Most interestingly, analogues 1, 2, 3, and 4 were antagonists of glucagon stimulated adenylate cyclase activity, whereas analogues 5 and 6 were partial agonists in the functional assay. All of the cyclic analogues were found to have reduced binding potencies relative to glucagon. The structural features that might be responsible for these effects were studied using circular dichroism spectroscopy and molecular modeling. These results demonstrated the significant modulations of both receptor binding affinity and transduction (adenylate cyclase activity) that can accompany regional conformational constraints even in larger polypeptide ligands. These studies suggest that the entire molecular conformation, including the flexible middle portion, is important for molecular recognition and transduction at the hepatic glucagon receptor.

Acquired internal mammary artery to pulmonary artery fistula following bypass surgery

We report two patients with acquired fistulas between the internal mammary and pulmonary arteries after coronary bypass surgery. This is a rare complication of bypass surgery and may be a cause of recurrent angina postoperatively due to coronary artery steal. A table of all the cases reported in the literature is compiled.

Structure-function studies on positions 17, 18, and 21 replacement analogues of glucagon: the importance of charged residues and salt bridges in glucagon biological activity

We have designed and synthesized eight compounds 2-9 which incorporate various amino acid residues in positions 17, 18, and 21 of the glucagon molecule: 2, [Lys17]glucagon amide; 3, [Lys18]glucagon amide; 4, [Nle17,Lys18,Glu21]glucagon amide; 5, [Orn17,18, Glu21]glucagon amide; 6, [d-Arg17]glucagon; 7, [d-Arg18]glucagon; 8, [d-Phe17]glucagon; and 9, [d-Phe18]glucagon. Compared to glucagon (IC50 = 1.5 nM), analogues 2-9 were found to have binding affinity IC50 values (in nM) of 0.7, 4.1, 1.0, 2.0, 5.0, 25.0, 43.0, and 32.0, respectively. When these compounds were tested for their ability to stimulate adenylate cyclase (AC) activity, they were found to be full or partial agonists having maximum stimulation values of 100, 100, 100, 100, 87, 78, 94, and 100%, respectively. On the basis of the X-ray crystal structure of [Lys17,18,Glu21]glucagon amide reported here, the ability to form a salt bridge between Lys18 and Glu21 is probably key to their increased binding and second messenger activities. Among the eight analogues synthesized here, only analogue 4 preserves the ability to form a salt bridge between Lys18 and Glu21. However, since these modifications are minor they do not seem to change the amphiphilic character of the C-terminus, allowing these analogues to reach 78-100% stimulation in the adenylate cyclase assay. Biological data from analogues 6-9 supports the idea that position 18 of glucagon may influence binding only, while position 17 may influence both receptor recognition and transduction.

The role of phenylalanine at position 6 in glucagon's mechanism of biological action: multiple replacement analogues of glucagon

Extensive evidence gathered from structure-activity relationship analysis has identified and confirmed specific positions in the glucagon sequence that are important either for binding to its receptor or for signal transduction. Fifteen glucagon analogues have been designed and synthesized by incorporating structural changes in the N-terminal region of glucagon, in particular histidine-1, phenylalanine-6, and aspartic acid-9. This investigation was conducted to study the role of phenylalanine at position 6 on the glucagon mechanism of action. These glucagon analogues have been made by either deleting or substituting hydrophobic groups, hydrophilic groups, aromatic amino acids, or a D-phenylalanine residue at this position. The structures of the new analogues are as follows: [des-His1, des-Phe6, Glu9]glucagon-NH2 (1); [des-His1,Ala6,Glu9]glucagon-NH2 (2); [des-His1,Tyr6,Glu9]glucagon-NH2 (3); [des-His1,Trp6,Glu9]-glucagon-NH2 (4); [des-His1,D-Phe6,Glu9]glucagon-NH2 (5); [des-His1,Nle6,Glu9]glucagon-NH2 (6); [des-His1,Asp6,Glu9]glucagon-NH2 (7); [des-His1,des-Gly4,Glu9]glucagon-NH2 (8); [desPhe6,-Glu9]glucagon-NH2 (9); [des-Phe6]glucagon-NH2 (10); [des-His1, des-Phe6]glucagon-NH2 (11); [des-His1, des-Phe6,Glu9]glucagon (12); [des-Phe6,Glu9]glucagon (13); [des-Phe6]glucagon (14); and [des-His1, des-Phe6]glucagon (15). The receptor binding potencies IC50 values are 48 (1), 126 (2), 40 (3), 19 (4), 100 (5), 48 (6), 2000 (7), 52 (8), 113 (9), 512 (10), 128 (11), 1000 (12), 2000 (13), 500 (14), and 200 nM (15). All analogues were found to be antagonists unable to activate the adenylate cyclase system even at concentrations as high as 10(-5) M except for analogues 6 and 8, which were found to be weak partial agonists/partial antagonists with maximum stimulation between 6-12%. In competitive inhibition experiments, all the analogues caused a right shift of the glucagon-stimulated adenylate cyclase dose-response curve. The pA2 values were 8.20 (1), 6.40 (2), 6.20 (3), 6.25 (4), 6.30 (5), 6.30 (7), 6.05 (8), 6.20 (9), 6.30 (10), 6.25 (11), 6.10 (12), 6.20 (13), 6.20 (14), and 6.35 (15).

Structure-activity studies of hydrophobic amino acid replacements at positions 9, 11 and 16 of glucagon

We have designed and synthesized eight compounds 2-9 which incorporate neutral, hydrophobic amino acid residues in positions 9, 11 and 16 of the glucagon molecule: (2) [desHis1, Val9. Ile11,16] glucagon amide, (3) [desHis1, Val9,11,16] glucagon amide, (4) [desHis1, Val9, Leu11,16]glucagon amide, (5) [desHis1, Nle9, Ile11,16]glucagon amide, (6) [desHis1, Nle9, Val11,16] glucagon amide, (7) [desHis1,-Nle9, Leu11,16] glucagon amide, (8) [desHis1, Val9, Leu11,16, Lys17,18, Glu21] glucagon amide and (9) [desHis1, Nle9, Leu11,16, Lys17,18, Glu21] glucagon amide. The effect of neutral, hydrophobic residues at positions 9, 11 and 16 led to good binding to the glucagon receptor. Compared to glucagon (IC50 = 1.5 nM), analogues 2-9 were found to have IC50 values of 6.0, 6.0, 11.0, 9.0, 2.5, 2.8, 6.5 and 7.0 nM, respectively. When these compounds were tested for their ability to block adenylate cyclase (AC) activity, they were found to be antagonists having no stimulation of adenyl cyclase, with pA2 values of 6.15, 6.20, 6.30, 7.25, 6.10, 7.30, 6.25 and 7.25, respectively.

Pure glucagon antagonists: biological activities and cAMP accumulation using phosphodiesterase inhibitors

Five new glucagon analogues have been designed, synthesized, characterized and their biological activities tested. The investigation was centered on modifications in the N-terminal region in particular, residues at Thr5, Phe6 and Tyr10 positions, with the goal of obtaining pure glucagon antagonists in our newly developed high sensitivity cAMP accumulation assay. The structures of the designed compounds are: [des-His1, des-Phe6, Glu9] glucagon-NH2 (1); [des-His1, des-Phe6, Glu9, Phe10]glucagon-NH2 (2); [des-His1, Tyr5, des-Phe6, Glu9]glucagon-NH2 (3); [des-His1, Phe5, des-Phe6, Glu9]glucagon-NH2 (4) and [des-His1, des-Phe6, Glu9, D-Arg18]glucagon-NH2 (5). The binding potencies IC50 values in (nM) were 48.0, 27.4, 26.0, 20.0 and 416.0, respectively. All of these analogues when tested in the classical adenylate cyclase assay demonstrate antagonist properties, and in competition experiments, all caused a rightward-shift of the glucagon stimulated adenylate cyclase dose-response curve. The pA2 values for these analogues were 8.20 (1); 6.25 (2); 6.10 (3); 6.25 (4); and 6.08 (5), respectively. A newly revised assay has been developed to determine the intracellular cAMP accumulation levels in hepatocytes at the highest possible sensitivity. Four of the five glucagon analogues in this report (analogues 1, 2, 4 and 5), did not activate the adenylate cyclase in the presence of Rolipram up to a maximal physiological concentration of 1 microM, and thus are pure antagonists.

Low level cyclic adenosine 3',5'-monophosphate accumulation analysis of [des-His1, des- Phe6, Glu9] glucagon-NH2 identifies glucagon antagonists from weak partial agonists/antagonists

[des-His1, des-Phe6,Glu9]Glucagon-NH2 is a newly designed glucagon antagonist. This analog has a binding IC50 of 48 nM (compared to glucagon IC50 of 1.5 nM) and demonstrates pure antagonism in an adenylate cyclase assay. Although the number of glucagon antagonists has grown rapidly recently, closer examination suggested that many of these antagonists retained very low, almost imperceptible levels of cAMP accumulation that were sufficient to elicit an in vivo biological response. To investigate more carefully this secondary biological signal, we measured cAMP accumulation in a revised assay using isolated hepatocytes in the presence of the phosphodiesterase (PDE) inhibitor Rolipram. The PDE inhibitors Rolipram and isobutyl-1-methylxanthine (IBMX) increased the sensitivity of the cAMP accumulation assay from approximately 10-fold for the native hormone to 35-fold above basal levels. On the other hand, amrinone, another PDE inhibitor, did not affect the cAMP accumulation caused by glucagon. The use of PDE inhibitors indicated that three glucagon analogs that had previously been reported to have strong antagonist properties in classical adenylate cyclase assays were actually weak partial agonists in this new assay system. [N alpha-Trinitrophenyl-His1, homo-Arg12]glucagon, [des-amino-His1,D-Phe4,Tyr5, Arg12, Lys17,18,Glu21]glucagon, and [des-His1,Glu9]glucagon-NH2 demonstrated 233%, 21%, and 5.5% cAMP accumulation relative to the native hormone in the presence of 25 microM Rolipram. On the other hand, [des-His1,des-Phe6,Glu9]glucagon-NH2, a newly designed glucagon antagonist, did not activate adenylate cyclase in the presence of Rolipram up to a maximal physiological concentration of 1 microM, indicating that it was a pure antagonist of glucagon-induced adenylate cyclase activity and also the first one in this class. This compound and others were tested in a glycogen phosphorylase assay. As [des-His1,des- Phe6,Glu9]glucagon-NH2 did not activate phosphorylase activity, it was chosen as our candidate for in vivo testing in streptozotocin-induced diabetic rats. An initial dose of 0.75 mg/kg was found to cause the greatest lowering of blood glucose levels (to 63% of the initial levels in 15 min) when the bolus was followed by continuous infusion of 25 micrograms/kgxmin for 1 h.

Topographical amino acid substitution in position 10 of glucagon leads to antagonists/partial agonists with greater binding differences

The role of position 10 in the beta-turn region of glucagon was investigated by substituting chiral constrained amino acids and other modifications in the N-terminal region. A series of glucagon analogues have been designed and synthesized by incorporating beta-methylphenylalanine isomers (2S,3S, 2S,3R, 2R,3R, and 2R,3S) at position 10 in order to explore the structural and topographical requirements of the glucagon receptor, and, in addition, utilizing previous studies which indicated that antagonism could be enhanced by modifications (des-His1, Glu9) and a bulky group at position 5. The structures of the new analogues are as follows: [des-His1,-Tyr5,Glu9]glucagon-NH2 (II), [des-His1,Tyr5,Glu9,Phe10]glucagon-NH2 (III), [des-His1,Tyr5,Glu9,-Ala10]glucagon-NH2 (IV), [des-His1,Tyr5,Glu9,(2S,3R)-beta-MePhe10]glucagon-NH2 (V), [des-His1,-Tyr5,Glu9,(2S,3S)-beta-MePhe10]glucagon-NH2 (VI), [des-His1,Tyr5,Glu9,D-Tyr10]glucagon-NH2 (VII), [des-His1,Tyr5,Glu9,D-Phe10]glucagon-NH2 (VIII), [des-His1,Tyr5,Glu9,D-Ala10]glucagon-NH2 (IX), [des-His1,Tyr5,Glu9,(2R,3R)-beta-MePhe10]glucagon-NH2 (X), and [des-His1,Tyr5,Glu9,(2R,3S)-beta-MePhe10]glucagon-NH2 (XI). These analogues led to dramatically different changes in in vitro binding affinities for glucagon receptors. Their receptor binding potencies IC50 values (nM) are 2.3 (II), 4.1 (III), 395.0 (IV), 10.0 (V), 170.0 (VI), 74.0 (VII), 34.5 (VIII), 510.0 (IX), 120.0 (X), and 180.0 (XI). Analogues II, III, V, VI, and XI were found to be weak partial agonists/partial antagonists with maximum stimulation between 5%-9%, while the other compounds (IV and VII-X) were antagonists unable to activate the adenylate cyclase system even at concentrations as high as 10(-5) M. In competition experiments, all of the analogues caused a right shift of the glucagon-stimulated adenylate cyclase dose-response curve. The pA2 values were 6.60 (II), 6.85 (III), 6.20 (IV), 6.20 (V), 6.10 (VI), 6.50 (VII), 6.20 (VIII), 5.85 (IX), 6.20 (X), and 6.00 (XI). Putative topographical requirements of the glucagon receptor for the aromatic side chain conformation in position 10 of glucagon antagonists are discussed.