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Khoshbin E, Westrope C, Pooboni S, Machin D, Killer H, Peek GJ, Sosnowski AW, Firmin RK. Performance of polymethyl pentene oxygenators for neonatal extracorporeal membrane oxygenation: a comparison with silicone membrane oxygenators. Perfusion 2016; 20:129-34. [PMID: 16038383 DOI: 10.1191/0267659105pf797oa] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To review the performance of polymethyl pentene versus silicone oxygenators in terms of efficiency in priming and oxygenation, oxygenator resistance, requirements for coagulation proteins and consumption of blood products, for neonatal extracorporeal membrane oxygenation (ECMO) patients. Study design: Forty consecutive neonates were selected retrospectively pre- and post-introduction of the new polymethyl pentene (PMP) oxygenators. They formed two equal groups. After calculation of the sample size, data were collected from ELSO registry forms and patient records. Results were analysed using parametric and non-parametric tests. Results: Neonatal PMP (N-PMP) oxygenators were smaller, faster and easier to prime. They were less efficient than silicone oxygenators, especially in carbon dioxide elimination, and, therefore, required higher sweeps. The preservation of coagulation proteins was significantly better, but there was no reduction in the consumption of blood products, despite having less than half the surface area and significantly lower blood path resistance. Conclusion: Small PMP oxygenators (Medos Hilite 800 LT) provide adequate gas exchange and offer technical advantages in terms of more efficient priming, reduced haemodynamic resistance and better control and preservation of coagulation proteins than silicone oxygenators.
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Affiliation(s)
- Espeed Khoshbin
- Division of Cardiac Surgery and Heart Link ECMO Centre, Glenfield University Hospital, Leicester, UK.
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2
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Kang YF, Qiao HX, Xin LZ, Ge LP. Chain elongation analog of resveratrol as potent cancer chemoprevention agent. J Physiol Biochem 2016; 72:445-52. [PMID: 27160168 DOI: 10.1007/s13105-016-0487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/12/2016] [Indexed: 11/26/2022]
Abstract
Resveratrol is identified as a natural cancer chemoprevention agent. There has been a lot of interest in designing and developing resveratrol analogs with cancer chemoprevention activity superior to that of parent molecule and exploring their action mechanism in the past several decades. In this study, we have synthesized resveratrol analogs of compounds A-C via conjugated chain elongation based on isoprene unit retention strategy. Remarkably, cytotoxic activity analysis results indicated that compound B possesses the best proliferation inhibition activity for NCI-H460 cells in all the test compounds. Intriguingly, compound B displayed a higher cytotoxicity against human non-small cell lung cancer cells (NCI-H460) compared to normal human embryonic lung fibroblasts (MRC-5). Afterward, flow cytometry analysis showed that compound B would induce cell apoptosis. We further researched the action mechanism. When NCI-H460 cells were incubated by compound B for 6 or 9 h, respectively, the intracellular reactive oxygen species (ROS) level was enhanced obviously. With elevation of intracellular ROS level, flow cytometry measurement verified mitochondrial transmembrane potential collapse, which was accompanied by the up-regulation of Bax and down-regulation of Bcl-2. More interestingly, compound B increased the expression of caspase-9 and caspase-3, which induced cell apoptosis. Moreover, compound B arrested cell cycle in G0/G1 phase. These are all to provide useful information for designing resveratrol-based chemoprevention agent and understanding the action mechanism.
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Affiliation(s)
- Yan-Fei Kang
- College of Laboratory Medicine, Hebei North University, 11 Diamond Street South, Zhangjiakou, 075000, Hebei Province, People's Republic of China.
| | - Hai-Xia Qiao
- College of Laboratory Medicine, Hebei North University, 11 Diamond Street South, Zhangjiakou, 075000, Hebei Province, People's Republic of China
| | - Long-Zuo Xin
- College of Agriculture and Forestry Science and Technology, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Li-Ping Ge
- College of Laboratory Medicine, Hebei North University, 11 Diamond Street South, Zhangjiakou, 075000, Hebei Province, People's Republic of China
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3
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Song JC, Deresinski S. Hepatotoxicity of antifungal agents. Curr Opin Investig Drugs 2005; 6:170-7. [PMID: 15751740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Antifungal agents have been implicated in numerous cases of hepatotoxicity throughout the past few decades. Hepatotoxic reactions to antifungal agents range from slight, asymptomatic abnormalities in liver function tests to potentially fatal fulminant hepatic failure. Clinically significant hepatic injury resulting from antifungal therapy most commonly manifests as acute hepatocellular, cholestatic or mixed hepatocellular-cholestatic reactions. In general, reactions usually resolve on cessation of therapy, but some antifungal agents may induce chronic liver damage. This review will summarize the hepatotoxicity profiles of the major classes of antifungal agents and will provide recommendations for drug monitoring in order to minimize the risk of hepatotoxicity.
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Affiliation(s)
- Jessica C Song
- Department of Pharmacy Services, Santa Clara Valley Medical Center, San Jose, CA 95128, USA.
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4
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Antifungal drugs. Treat Guidel Med Lett 2005; 3:7-14. [PMID: 15671963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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5
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Abstract
Invasive fungal infections pose major management problems for clinicians caring for hematopoietic cell transplant patients. Two major fungal genera, Candida and Aspergillus, account for most fungal infections. Rates of systemic Candida infection range from 15% to 25%, mostly in the pre-engraftment period. Prophylaxis by fluconazole has dramatically reduced the frequency of early Candida infections. Caspofungin has recently been shown to offer an excellent alternative to amphotericin B (with less toxicity) or fluconazole (with a broader spectrum) for therapy of systemic Candida infections. Aspergillus infections occur in 15% to 20% of allogeneic hematopoietic cell transplant patients, most frequently in the post-engraftment period; they are associated with a severe diminution of cell-mediated immune responses by graft-versus-host disease and prolonged corticosteroid use. Voriconazole, a recently introduced broad-spectrum azole, has excellent activity against Aspergillus and is generally well tolerated. Voriconazole currently offers the best prospect for success and tolerance as a first-line treatment for aspergillosis. Second-line therapies include lipid formulations of amphotericin B, caspofungin, or intravenous itraconazole. Unfortunately, early initiation of therapy for aspergillosis is frequently not possible because of inaccurate diagnostics. One new diagnostic, the galactomannan assay, has recently been approved, and others are in development; these offer promise for earlier diagnosis without the need for invasive procedures. It is hoped that these new therapies and new diagnostics will usher in a new era of antifungal therapy.
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Affiliation(s)
- John R Wingard
- Blood and Marrow Transplant Program, Division of Hematology/Oncology, University of Florida Shands Cancer Center, Gainesville, USA.
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6
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Gallo R, Ciambellotti A, Cozzani E, Parodi A. Peristomal allergic contact dermatitis caused by Stomahesive paste: An additional case. J Am Acad Dermatol 2002; 47:633. [PMID: 12271318 DOI: 10.1067/mjd.2002.124249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Abstract
Colorectal cancer is one of the most common internal malignancies in Western society. The cause of this disease appears to be multifactorial and involves genetic as well as environmental aspects. The human colon is continuously exposed to a complex mixture of compounds, which is either of direct dietary origin or the result of digestive, microbial and excretory processes. In order to establish the mutagenic burden of the colorectal mucosa, analysis of specific compounds in feces is usually preferred. Alternatively, the mutagenic potency of fecal extracts has been determined, but the interpretation of these more integrative measurements is hampered by methodological shortcomings. In this review, we focus on exposure of the large bowel to five different classes of fecal mutagens that have previously been related to colorectal cancer risk. These include heterocyclic aromatic amines (HCA) and polycyclic aromatic hydrocarbons (PAH), two exogenous factors that are predominantly ingested as pyrolysis products present in food and (partially) excreted in the feces. Additionally, we discuss N-nitroso-compounds, fecapentaenes and bile acids, all fecal constituents (mainly) of endogenous origin. The mutagenic and carcinogenic potency of the above mentioned compounds as well as their presence in feces, proposed mode of action and potential role in the initiation and promotion of human colorectal cancer are discussed. The combined results from in vitro and in vivo research unequivocally demonstrate that these classes of compounds comprise potent mutagens that induce many different forms of genetic damage and that particularly bile acids and fecapentaenes may also affect the carcinogenic process by epigenetic mechanisms. Large inter-individual differences in levels of exposures have been reported, including those in a range where considerable genetic damage can be expected based on evidence from animal studies. Particularly, however, exposure profiles of PAH and N-nitroso compounds (NOC) have to be more accurately established to come to a risk evaluation. Moreover, lack of human studies and inconsistency between epidemiological data make it impossible to describe colorectal cancer risk as a result of specific exposures in quantitative terms, or even to indicate the relative importance of the mutagens discussed. Particularly, the polymorphisms of genes involved in the metabolism of heterocyclic amines are important determinants of carcinogenic risk. However, the present knowledge of gene-environment interactions with regard to colorectal cancer risk is rather limited. We expect that the introduction of DNA chip technology in colorectal cancer epidemiology will offer new opportunities to identify combinations of exposures and genetic polymorphisms that relate to increased cancer risk. This knowledge will enable us to improve epidemiological study design and statistical power in future research.
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Affiliation(s)
- T M de Kok
- Department of Health Risk Analysis and Toxicology, University of Maastricht, PO Box 616, 6200 MD, Maastricht, Netherlands.
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Abstract
We report a case of severe peristomal dermatitis that was refractory to conventional treatments. Patch testing revealed positive allergies to myroxylon perulase (balsam of Peru), propylene glycol, Stomahesive paste, and Gantrez. This is the second reported case of patch-test-positive peristomal allergy to Gantrez.
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Affiliation(s)
- L A Scalf
- University of Louisville, School of Medicine, Division of Dermatology, Kentucky, USA
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9
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Abstract
RAPA represents a likely candidate for addition to the maintenance immunosuppressive regimen, for it seems to potentiate markedly the efficacy fo CyA-based therapy. RAPA reduces the incidence of acute rejection episodes; indeed, it may even be useful to disrupt ongoing steroid- and antibody-resistant cellular and humoral acute rejection reactions. Some data in model systems, both in vitro and in vivo, suggest that RAPA may afford prophylaxis against chronic rejection. The enhanced immunosuppression is likely to permit reduction in CyA doses/concentration, thereby mitigating its nephrotoxic effects, and to permit withdrawal of corticosteroids, providing relief from their osteopenic, myopathic, and metabolic effects. As with other potent immunosuppressives, RAPA causes a range of adverse side effects, most importantly myelosuppression and hyperlipidemia. Hypothesis-testing investigations are already underway to elucidate the mechanisms of the adverse effects so as to design strategies to minimize their impact on posttransplant morbidity.
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Affiliation(s)
- B D Kahan
- University of Texas Medical School, Houston 77030, USA
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10
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Abstract
OBJECTIVE Sirolimus (RAPA) is a new immunosuppressive drug currently in Phase III clinical trials in combination with cyclosporine A (CsA). The toxicity profiles for CsA and RAPA are only partially overlapping, with RAPA toxicity consisting primarily of hyperlipidemia and myelodepression but without the nephrotoxicity, neurotoxicity, and hepatotoxicity, which are seen with CsA. Patients in the clinical trial are being monitored using HPLC or LC/MS/MS assays; there is no immunoassay for RAPA reported to date. We have previously reported a radioreceptor assay (RRA) for RAPA, which has an excellent correlation with the HPLC assay (r = 0.997). The RRA has several advantages including excellent precision, sensitivity, rapid turnaround time, and a one-step extraction procedure. We report the evaluation of blood samples from patients who were exhibiting RAPA toxicity and comparison of the RRA results with the HPLC results. METHODS EDTA whole blood specimens (n = 42) were obtained from six renal transplant recipients taking RAPA and CsA and exhibiting decreased platelet counts. Thirty-two samples from patients without decreased platelet counts were also received. The samples were analyzed with the RRA and the results were compared to those obtained with the HPLC assay. RESULTS By HPLC, the results ranged from 3.2-72.6 micrograms/L RAPA with 43% of the results > or = 30 micrograms/L. With the RRA, the range was 7.7-83.0 micrograms/L RAPA equivalents, with 60% of the results > or = 30 micrograms/L. The RRA results are distinctly higher than the HPLC results all along the range. The correlation between the two assays was 0.861, with a slope of 0.966 and a Y-intercept of 11.1. CONCLUSION Since the RRA is consistently higher than HPLC concentration in patients with decreased platelet counts, but correlates well in patients with no signs of toxicity, the RRA may be useful for monitoring patients for toxicity, by giving a better indication of increasing degree of immunosuppression than the HPLC assay.
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Affiliation(s)
- N Goodyear
- Department of Laboratory Medicine, Children's National Medical Center, Washington, DC 20010, USA
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11
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Brattström C, Säwe J, Tydén G, Herlenius G, Claesson K, Zimmerman J, Groth CG. Kinetics and dynamics of single oral doses of sirolimus in sixteen renal transplant recipients. Ther Drug Monit 1997; 19:397-406. [PMID: 9263380 DOI: 10.1097/00007691-199708000-00007] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sirolimus is a new immunosuppressive drug that has been evaluated in animal experiments. The current study was conducted on humans with reformulated sirolimus in doses from 3 mg/m2 to 15 mg/m2. Sixteen renal transplant recipients were included in this phase I study to determine the safety, tolerance, and preliminary pharmacokinetics of increasing single doses of orally administered sirolimus. All 16 patients had stable renal graft function after a renal transplant at least 6 months before the study. Basal immunosuppression consisted of cyclosporine and prednisolone (n = 10) or cyclosporine, azathioprine, and prednisolone (n = 6). Four groups (I, 3 mg/m2; II, 5 mg/m2; III, 10 mg/m2; IV, 15 mg/m2) of four patients were assigned randomly to receive sirolimus (n = 3) or placebo (n = 1). Among the 12 patients who received sirolimus, five had mild transient study events such as headache, nausea, mild dizziness, hypoglycemia, epistaxis, and decrease in platelets. No serious adverse events occurred and no nephrotoxic effects could be related to the single dose administration of sirolimus. The only study event that was judged as probably related to sirolimus was the single case of thrombocytopenia. The other events were evaluated as possibly related. Thrombocytopenia occurred at the highest dose level (15 mg/m2 sirolimus). In two of the patients in the placebo group, slight elevations of liver enzymes and serum amylase were seen. Blood and plasma sirolimus concentrations were analyzed by an electrospray-high performance liquid/mass spectrophotometric (ESP-HPLC/MS) method Sirolimus showed an extensive red blood cell distribution with a mean blood/ plasma ratio of 49.1. The elimination half-life ranged from 43.8 to 86.5 hours (mean 56.9 hours). The Cmax and the area under the concentration versus time curves (AUC) correlated reasonably with doses from 3 to 15 mg/m2. The oral dose clearance ranged from 42 to 339 ml/h.kg. No clinically significant differences were seen in the trough concentrations of cyclosporine or the AUCs before and after the administration of sirolimus. Administration of single oral doses of sirolimus from 3 to 15 mg/m2 was safe and well tolerated in stable renal transplant recipients. Thrombocytopenia may be the dose-limiting toxicity. Additional phase II and phase III clinical trials will define the immunosuppressive efficacy of sirolimus.
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Affiliation(s)
- C Brattström
- Department of Transplantation Surgery, Huddinge University Hospital, Sweden
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12
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Abstract
Tacrolimus (FK506), mycophenolate mofetil, sirolimus (rapamycin), gusperimus, and monoclonal antibody preparations are new immunosuppressive agents, some of which are already approved for clinical use, while others are currently undergoing clinical trials. The present article provides an overview of adverse drug interactions between these immunosuppressants and other drugs which may be used concomitantly. Preliminary data suggest that a pharmacodynamic interaction can occur between tacrolimus and nonsteroidal anti-inflammatory drugs, associated with an increased risk of nephrotoxicity. Erythromycin, clarithromycin, clotrimazole, fluconazole, ketoconazole, and danazol have been shown to increase tacrolimus blood concentrations, while rifampicin (rifampicin) was found to decrease tacrolimus blood concentrations. Evidence from experimental studies suggest that several other drugs also known to affect cytochrome P450 activity may have significant effects on the pharmacokinetics of tacrolimus. On the other hand, tacrolimus itself may inhibit the metabolism of coadministered drugs. This interaction may be attributed to the enhanced renal impairment which has been observed in patients treated with tacrolimus and cyclosporin. The bioavailability of mycophenolic acid, the active metabolite of mycophenolate mofetil, has been reported to be reduced by aluminium/magnesium hydroxide-containing antacids and cholestyramine. Mycophenolic acid, sirolimus and gusperimus may impair bone marrow function and this adverse effect may be enhanced by concomitant administration of other myelosuppressive drugs. There is some evidence that coadministered sirolimus and cyclosporin cause an increase in each other's blood concentrations. An increased risk of central nervous system adverse effects has been described following the combined use of indomethacin and the monoclonal antibody muromonab CD3 (OKT3).
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Affiliation(s)
- C Mignat
- Department of Pharmacology, Christian Albrechts University of Kiel, Germany
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13
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Affiliation(s)
- B D Kahan
- Department of Surgery, University of Texas Medical School at Houston 77030, USA
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14
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Abstract
Amphotericin B (AmB) is one of the rare drugs that affect the course of experimental prion diseases and modify the kinetics of abnormal prion protein accumulation in the central nervous system. Therefore, AmB could be used as a pharmacological tool to contribute to our understanding of the pathogenic mechanisms involved in these neurodegenerative disorders.
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Affiliation(s)
- K T Adjou
- Service de Neurovirologie, CEA/CRSSA, DSV/DRM, Fontenay aux Roses, France.
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15
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Jusko WJ, Ferron GM, Mis SM, Kahan BD, Zimmerman JJ. Pharmacokinetics of prednisolone during administration of sirolimus in patients with renal transplants. J Clin Pharmacol 1996; 36:1100-6. [PMID: 9013365 DOI: 10.1002/j.1552-4604.1996.tb04162.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The pharmacokinetic interaction of multiple oral doses of sirolimus (rapamycin) and prednisone were evaluated in 40 stable patients with renal transplants receiving concomitant multiple doses of cyclosporine. Nine sirolimus dosage levels from 1 mg/m2/day to 13 mg/m2/day were studied and compared with placebo. Plasma concentrations of prednisone, prednisolone, and cortisol were measured by high-performance liquid chromatography and analyzed by noncompartmental methods. Mean pharmacokinetic values of prednisolone found before sirolimus administration were as follows: peak plasma concentration (Cmax) was 187 ng/mL; time to peak plasma concentration (tmax) was 2.03 hours; rate of reaching peak plasma concentration (Cmax divided by the area under the concentration-time curve [AUC]) was 0.149 hour-1; terminal half-life (t1/2) was 3.60 hours; AUC was 1206 ng.hour/mL; and apparent clearance (Cl/F) was 0.094 L/hour/kg. During the 2 weeks of concomitant administration, prednisolone elimination decreased in relation to sirolimus dosages. These changes were modest, with mean increases of 18% in Cmax and 27% in t1/2 and mean decreases of 27% in Cl/F for the groups receiving 6 mg/m2/day to 13 mg/m2/day. Most patients initially had plasma cortisol concentrations indicative of adrenal suppression. With sirolimus treatment, the Cmax of cortisol did not decrease further, but the AUC (8:00 AM-8:00 PM) values were significantly lower, independent of sirolimus exposure. The AUC for cyclosporine did not correlate with sirolimus and prednisolone exposure. A 2-week course of sirolimus showed a slight pharmacokinetic interaction between sirolimus and prednisolone/prednisone/cortisol in stable patients with renal transplants.
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Affiliation(s)
- W J Jusko
- Department of Pharmaceutics, School of Pharmacy, State University of New York at Buffalo 14260, USA
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16
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Affiliation(s)
- R Parslew
- Department of Dermatology, Royal Liverpool University Hospital Trust, UK
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17
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Blazar BR, Taylor PA, Panoskaltsis-Mortari A, Sehgal S, Vallera DA. In vivo inhibition of cytokine responsiveness and graft-versus-host disease mortality by rapamycin leads to a clinical-pathological syndrome discrete from that observed with cyclosporin A. Blood 1996; 87:4001-9. [PMID: 8611733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Rapamycin (RAPA) has been shown to be a highly effective means of reducing the lethality of graft-versus-host disease (GVHD) in B10.BR recipients of allogeneic C57BL/6 donor cells. RAPA-treated mice had no clinical (e.g., weight loss, diarrhea, lethargy) or histologic evidence of classical acute or chronic GVHD but did develop a clinical-pathological syndrome consisting of ulcerative dermatitis, bile duct proliferation, and a nondestructive peribronchiolar pulmonary infiltration. Because RAPA was found to interfere with the deletion of self-reactive T cells, we wondered whether the RAPA-induced syndrome was related to failed negative selection or altered alloreactivity. We now show that the RAPA-induced syndrome is due to effects on mature, donor-derived alloreactive T cells. By titering the number of T cells infused we were able to vary the syndrome incidence. In contrast to the syndrome seen after cyclosporin A (CsA) administration, the RAPA syndrome did not require an intact thymus and the disease could not be adoptively transferred. The addition of CsA (which blocks T-cell cytokine production) to RAPA (which blocks T-cell cytokine response) prevented the generation of this syndrome, suggesting that the tissue manifestations seen in RAPA only treated recipients were caused by cytokine production and release. RAPA also caused this alloimmune syndrome in recipients of minor histocompatibility antigen disparate donor cells, showing that the RAPA effects were not restricted to a single donor-recipient strain combination or to instances in which the donor and recipient were fully major histocompatibility complex disparate. We conclude that RAPA is a highly effective means of preventing murine acute GVHD, and that when combined with CsA, warrants consideration for human investigations.
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Affiliation(s)
- B R Blazar
- Department of Pediatrics, University of Minnesota Hospital and Clinic, Minneapolis 55455, USA
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18
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Brattström C, Tydén G, Säwe J, Herlenius G, Claesson K, Groth CG. A randomized, double-blind, placebo-controlled study to determine safety, tolerance, and preliminary pharmacokinetics of ascending single doses of orally administered sirolimus (rapamycin) in stable renal transplant recipients. Transplant Proc 1996; 28:985-6. [PMID: 8623489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- C Brattström
- Department of Transplantation Surgery, Huddinge Hospital, Sweden
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19
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Johnson EM, Zimmerman J, Duderstadt K, Chambers J, Sorenson AL, Granger DK, Almond PS, Fryer JP, Leventhal JR, Scarola J, Matas AJ, Canafax DM. A randomized, double-blind, placebo-controlled study of the safety, tolerance, and preliminary pharmacokinetics of ascending single doses of orally administered sirolimus (rapamycin) in stable renal transplant recipients. Transplant Proc 1996; 28:987. [PMID: 8623490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- E M Johnson
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA
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20
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Hartner WC, Van der Werf WJ, Lodge JP, Gilchrist B, De Fazio SR, Markees TG, Yatko C, Monaco AP, Gozzo JJ. Effect of rapamycin on renal allograft survival in canine recipients treated with antilymphocyte serum, donor bone marrow, and cyclosporine. Transplantation 1995; 60:1347-50. [PMID: 8525533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Rapamycin (Rapa) monotherapy can promote renal allograft survival in dogs, but it is very toxic. To attempt to augment the effectiveness of Rapa and reduce its toxicity in a tolerance induction protocol, canine renal allograft recipients were treated briefly with antilymphocyte serum (ALS), donor bone marrow cells (BMC), and a limited course of cyclosporine (CsA). Rapa had little effect when CsA-treated recipients were given ALS on days -5 to -1 and BMC on day +1. When combined with CsA given days +13 to +42, ALS on days -5 to +7, and BMC on day +10, Rapa at 0.3 mg/kg on day +8 plus alternate days +15 to +39 significantly increased overall survival and was compatible with long-term survival after immunosuppression (6 grafts, 1 graft > 212 days, 1 graft > 470 days). Rapa appeared to prevent early rejections that can occur during treatment with these ALS/BMC/CsA protocols. Little toxicity of Rapa was observed with any treatment.
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Affiliation(s)
- W C Hartner
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA 02115, USA
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21
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Kneteman NM, Lakey JR, Wagner T, Finegood D. Beneficial metabolic impact of the novel immunosuppressant rapamycin in chronic canine islet autograft recipients. Transplant Proc 1995; 27:3213. [PMID: 8539919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- N M Kneteman
- Surgical-Medical Research Institute, University of Alberta, Edmonton, Canada
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22
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Abstract
The immunosuppressant cyclosporine A revolutionized treatment of graft rejection. Two newer agents, FK506 and rapamycin, show great clinical potential. These drugs suppress the immune system by forming protein-drug complexes that interact with and inhibit key components of the signal transduction pathways required for T-cell activation. The target of the cyclophilin A-cyclosporine A and FKBP12-FK506 complexes is calcineurin, a protein phosphatase required for signaling via the T-cell receptor. Cyclosporine A and FK506 nephrotoxicity may reflect renal-specific functions of calcineurin. The target of the FKBP12-rapamycin complex is TOR, a lipid and protein kinase homolog that is likely to be required for T-cell proliferation in response to interleukin-2. The identification of cyclosporine A, FK506, and rapamycin targets reveals much concerning T-cell signaling and provides the means to design novel immunosuppressants with reduced toxicity.
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Affiliation(s)
- M E Cardenas
- Department of Genetics, Duke University Medical Center, Durham, North Carolina, USA
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23
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Bennett WM. The nephrotoxicity of immunosuppressive drugs. Clin Nephrol 1995; 43 Suppl 1:S3-7. [PMID: 7540121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Nephrotoxicity from immunosuppressive drugs can complicate otherwise successful therapy. This paper reviews the clinical and pathophysiologic aspects of nephrotoxicity. The chronic progressive nephropathy is emphasized based on a recently developed animal model. Experimental and clinical data regarding FK506, new cyclosporine analogs, and Rapamycin are also discussed.
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Affiliation(s)
- W M Bennett
- Division of Nephrology, Hypertension and Clinical Pharmacology, Oregon Health Sciences University, Portland 97201, USA
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24
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Abstract
Several novel immunosuppressive agents have been developed in recent years. They exhibited not only remarkable immunosuppressive potency but also side effects. They are still short of the final goal in terms of immunosuppression for organ transplantation. Combination treatment is more effective and safer to use, and it will prevail in the future.
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Affiliation(s)
- T Ochiai
- Department of Surgery, School of Medicine, Chiba University, Japan
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Blazar BR, Taylor PA, Snover DC, Sehgal SN, Vallera DA. Murine recipients of fully mismatched donor marrow are protected from lethal graft-versus-host disease by the in vivo administration of rapamycin but develop an autoimmune-like syndrome. J Immunol 1993; 151:5726-41. [PMID: 8228258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We investigated the ability of the macrolide antifungal agent rapamycin (RAPA) to inhibit murine graft-vs-host disease induced across the MHC barrier. An optimum dose (1.5 mg/kg) given for 14 days beginning on the day of transplant (and then three times weekly until 1 mo) effectively and significantly (p < 0.001) protected 80% of irradiated B10.BR recipients of C57Bl/6 bone marrow/spleen grafts for over 90 days, whereas 80% of control mice died by day 37. Using a congenic model in which a mixture of Ly5.1+ bone marrow (T cell-depleted) and Ly5.2+ spleen cells allowed us to distinguish mature and immature cells, we found that RAPA inhibits the splenic expansion of mature donor-derived T cells in B10.BR recipients after bone marrow transplantation. In addition, phenotyping studies revealed that RAPA causes a massive reduction of immature CD4+CD8+ T cells in the thymus, indicating that RAPA probably interferes with maturation of immature CD3-CD4-CD8- T cells to CD4+CD8+ T cells. There was also a predilection toward development or intrathymic retention of the more mature CD3+CD4-CD8+ or CD3+CD4+CD8- cells in the thymus of long term survivors. These same observations were made in different experiments with mice given syngeneic bone marrow transplantation and RAPA. However, RAPA administration was associated with the occurrence of an autoimmune-like syndrome, consisting of ulcerative dermatitis, hepatic bile duct proliferation, and nondestructive lymphoid peribronchiolar infiltration of the lung. RAPA interfered with the deletion of potentially self-reactive T cells that occurs in thymic development. The failure of clonal deletion was observed in allogeneic and syngeneic transplants given RAPA, although only the allografted mice experienced an autoimmune-like syndrome. Some, but not all, of the nondeleted V beta populations were functionally active. These new findings bear certain dissimilarities to the syndrome and lesions observed with cyclosporin A treatment, particularly in the observation of bile duct proliferation and ulcerative skin lesions. Nonetheless, because of the potent effect of RAPA in preventing lethal graft-vs-host induced across the MHC, further investigation of the immune consequences of this highly effective compound is warranted.
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Affiliation(s)
- B R Blazar
- Department of Pediatrics, University of Minnesota Hospital and Clinic, Minneapolis 55455
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Almond PS, Moss A, Nakhleh RE, Melin M, Chen S, Salazar A, Shirabe K, Matas AJ. Rapamycin: immunosuppression, hyporesponsiveness, and side effects in a porcine renal allograft model. Transplantation 1993; 56:275-81. [PMID: 8356580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Rapamycin prolongs allograft survival and induces donor-specific tolerance in some small animal transplant models. Large animal studies, however, are limited. We studied rapamycin in a porcine renal allograft model. Donor-recipient combinations were chosen based on high response in pretransplant MLCs. Allografts were anastomosed to the aorta and vena cava and the native kidneys removed. There were 5 treatment groups: (a) no immunosuppression; (b) triple therapy (CsA, 1 mg/kg/day; AZA, 2-3 mg/kg/day; and PRED, 3-4 mg/kg/day); (c) rapamycin (0.75 mg/kg/day i.m.) in carboxymethylcellulose (CMC); (d) rapamycin (0.25 mg/kg/day i.m. in CMC); and (e) a vehicle (CMC) control. Serum creatinine levels were determined every other day. Most allografts were biopsied once a week. Immunosuppression was stopped after 30 days. Mean graft survival in nonimmunosuppressed recipients was 6.8 +/- 3.6 days. Mean graft survival in triple therapy recipients (n = 10) was 45.7 +/- 36 days vs. 59.6 +/- 11.4 days in rapamycin (0.25 mg/kg/day) recipients (n = 7) (P = 0.51). Both triple therapy and rapamycin improved renal allograft survival versus nonimmunosuppressed controls (P = 0.0025 and 0.001, respectively). Serum creatinine levels were significantly lower (P < 0.05) in rapamycin versus triple therapy recipients. We conclude that rapamycin is a potent immunosuppressant in a porcine renal allograft model and may avoid the elevated serum creatinine levels associated with CsA.
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Affiliation(s)
- P S Almond
- Department of Surgery, University of Minnesota, Minneapolis 55455
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Fryer J, Yatscoff RW, Pascoe EA, Thliveris J. The relationship of blood concentrations of rapamycin and cyclosporine to suppression of allograft rejection in a rabbit heterotopic heart transplant model. Transplantation 1993; 55:340-5. [PMID: 8434385 DOI: 10.1097/00007890-199302000-00021] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Heterotopic heart transplants were performed on 50 New Zealand white rabbits. Groups of 5 rabbits were randomly assigned to receive, through an intravenous route, rapamycin (RAPA) or cyclosporine at the following doses: RAPA (0.05, 0.1, 0.5, and 1.0 mg/kg/day); CsA (5.0, 10.0, and 15.0 mg/kg/day). Drug vehicle and saline controls were also included. Trough blood concentrations were monitored in both RAPA- and CsA-treated groups on a weekly basis throughout the study. Biochemical assessment of renal and liver function was performed at the beginning and end of the study. Animals receiving RAPA exhibited excellent allograft survival; only two animals in the lowest dosage group (0.05 mg/kg/day) rejected their grafts. In contrast, no rejection occurred in the CsA-treated groups. Animals that rejected their grafts were maintained on the drug until the endpoint of the study was reached at 60 days posttransplant to monitor drug induced side-effects. In some instances animals were sacrificed prior to this time due to infectious and other complications. No significant changes in renal or liver function were noted in the RAPA-treated group, while in the group of animals receiving the highest dose of CsA (15.0 mg/kg/day) a significant decrease in creatinine clearance was noted. A correlation was shown to exist between dose and the trough concentrations of both drugs. The whole-blood concentrations of RAPA that resulted in maximal efficacy with minimal toxicity was in the range of 10-60 micrograms/L. Rabbits having trough whole-blood concentrations of < 10 micrograms/L rejected their grafts. A much wider therapeutic range for CsA (50-300 micrograms/L) was noted. The results suggest that RAPA is as efficacious as CsA in prevention of allograft rejection in the animal model tested. The therapeutic monitoring of trough blood concentrations of RAPA, as with CsA, may be useful in guiding dosage adjustments to maximize the immunosuppressive efficacy while minimizing drug-induced side-effects.
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Affiliation(s)
- J Fryer
- Department of Surgery, University of Manitoba, Winnipeg, Canada
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Toxins derived from Fusarium moniliforme: fumonisins B1 and B2 and fusarin C. IARC Monogr Eval Carcinog Risks Hum 1993; 56. [PMID: 8411627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Walpoth B, Galdikas J, Vorburger T, Altermatt HJ, Schaffner T, Althaus U, Billingham M, Morris R. Assessment of new immunosuppressive drugs in a rat cardiac allograft heterotopic model. Eur Surg Res 1992; 24:243-8. [PMID: 1380460 DOI: 10.1159/000129212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We assessed FK506 (FK) and rapamycin (RPM) in a heterotopic abdominal rat heart transplant model using a major histocompatibility mismatch (DA to LEW). The end point of our study was histologic grading of rejection (Billingham and working formulation) at 1 week. Two doses of FK (2.0 and 8.0 mg/kg p.o., q.d.) and RPM (1.5 and 6.0 mg/kg i.p., q.d.) were compared to allografts without and with ciclosporin (12.5 mg/kg p.o., q.d.) treatment. Results show: (1) weak heartbeat and full rejection on day 5 in all untreated allografts; (2) weak heartbeat and high degree of rejection in groups receiving low doses of FK and RPM; (3) strong heartbeat and mild rejection in both high FK and RPM dose groups comparable to the results of the hearts treated with ciclosporin; (4) 1 animal in each high FK and RPM dose group showed possible signs of toxicity, and (5) the strength of the heartbeat was not a reliable indicator of the efficacy of an immunosuppressive drug. We conclude that even in a major histocompatibility mismatch model at the time of the strongest immune response (1 week), all three tested drugs can reduce the degree of rejection from severe (untreated allografts) to mild if given in an adequate dosage.
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Affiliation(s)
- B Walpoth
- Department of Thoracic and Cardiovascular Surgery, University of Berne, Switzerland
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Devor DE, Henneman JR, Keefer LK, Logsdon DL, Rice JM, Streeter AJ, Ward JM. Carcinogenicity study of fecapentaene-12 diacetate on skin painting in SENCAR mice. Cancer Lett 1991; 56:11-5. [PMID: 2004349 DOI: 10.1016/0304-3835(91)90187-m] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To investigate the effects of both diol esterification and coadministration with antioxidant on the tumorigenicity of fecapentaene-12 (FP-12) preparations, diacetylfecapentaene-12 (DAFP-12) in dimethylsulfoxide (DMSO) was applied to SENCAR mouse skin with or without the stabilizer, vitamin E, twice/week for 5 weeks, following which all animals were promoted for up to 25 weeks by weekly applications of 12-O-tetradecanoylphorbol-13-acetate (TPA). While positive controls receiving 7,12-dimethylbenz[a]anthracene (DMBA) instead of DAFP-12 in a similar protocol all developed papillomas (average of 23/animal), papilloma incidence in mice given DAFP-12 did not differ significantly from that of the vehicle control. We conclude that DAFP-12 shows little or no tumor initiating activity for mouse skin even when coadministered with vitamin E.
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Affiliation(s)
- D E Devor
- Laboratory of Comparative Carcinogenesis, National Cancer Institute, Frederick Cancer Research and Development Center, MD 21702
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Szymanski IO, Odgren PR, Teno RA, Jacobson MS, Surgenor DM. Storage of platelets in earth orbit. Effect of gravity and the formulation of plastic storage containers on platelet IgG and C3. Vox Sang 1989; 57:116-9. [PMID: 2781740 DOI: 10.1111/j.1423-0410.1989.tb01147.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We investigated the effects of gravitational force and three different plastic formulations of the storage bags on the quality of stored platelets by measuring the changes in platelet-associated immunoglobulin G (IgG) and two antigenic markers of the third component of human complement (C3), C3d and C3c. Pooled platelets were stored in parallel at microgravity (MG) and on the ground (1 g) using three different plastic polymers: (1) polyvinylchloride (PVC) plasticized with di-2-ethylhexyl phthalate (DEHP); (2) PVC plasticized with trioctyl trimellitate (TOTM), and (3) unplasticized polyolefin (PO). The IgG and C3 were quantified by an automated antiglobulin consumption test in freeze/thaw disrupted platelets (total IgG or C3). The baseline values for platelet associated IgG and C3, measured after 2.5 days of storage at 1 g just prior to the launch, fell within the normal range. Following an additional 6.5 day storage, platelets stored at MG had accumulated significantly less C3d than those stored at 1 g, suggesting that MG storage was beneficial. Specific plastic formulations also exerted a significant effect on the accumulation of these immunoproteins, the effect being particularly pronounced at MG. The smallest increases of IgG and C3 were seen in platelets stored in TOTM and the largest in those stored in DEHP. It is possible that further studies at MG would permit a clear characterization of the effects of other independent storage variables.
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Affiliation(s)
- I O Szymanski
- Blood Bank, University of Massachusetts Medical Center, Worcester
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Abstract
A woman developed dermatitis from Stomadhesive paste used to secure her colostomy appliance. Patch testing revealed that she was allergic to Gantrez (N-butylmonoester of polymethyl vinyl ether maleic acid in an ethanol solution), a water soluble copolymer with stabilizing properties used in the production of Stomadhesive.
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Pradalier A, Dry J, Artigou C, Chateau M. [Dermatopolymyositis during desensitization with candidin]. Rev Med Interne 1985; 6:253-6. [PMID: 4048686 DOI: 10.1016/s0248-8663(85)80114-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A dermatopolymyositis observation is reported. An urticaria has preceded the dermatopolymyositis and has been treated by a desensitivity procedure. The possible connection between this treatment and the dermatopolymyositis occurring is debated. This observation gives the opportunity to point out the importance of a thorough knowledge of the phenomena involved by such a treatment.
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Ruppin H. [Strategy for the prevention of fungal infections. In immuno-suppressed patients no combination of azoles and polyenes]. Fortschr Med 1984; 102:489. [PMID: 6735322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Guirguis SS, Cohen MB. Occupational chemical exposures in artificial organic fiber industries. G Ital Med Lav 1984; 6:159-66. [PMID: 6534781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This review discusses artificial organic fibers that are produced from materials of natural origin such as rayons, cellulose triacetates and proteins; or made from polymerised chemicals such as polyamides, polyesters, polyvinyls, modacrylics, carbon fibers, polyolefins, polyurethane and polytetrafluoroethylene. Chemicals involved include monomers, solvents, flame retardants, pigments and other additives. Occupational exposure to chemicals in the production stages are discussed and also the potential health hazards involved are reviewed. Current exposure levels, engineering controls and work practices for some of the chemicals used in the Ontario artificial fiber industry are discussed. Recommendations are made for areas that need further study and/or investigation.
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Abstract
Polyene antibiotics such as amphotericin and nystatin increase membrane permeability and thus increase the amount of oxygen consumed in active electrolyte transport. In isolated perfused rat kidneys, the polyenes produced extensive injury to the medullary thick ascending limb, a segment of the nephron with limited oxygen supply. This damage was prevented if reabsorptive transport was inhibited by ouabain. Cell death under these circumstances thus appears to be mediated by increased oxygen demand for transport activity.
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Abstract
A 12-year-old girl developed a periorbital leukoderma from contact with swim goggles. She had worn the same goggles the preceding year and re-used them after the leukoderma had cleared without any ill effects. The hypopigmentation was believed to be caused by the leakage of breakdown products in the neoprene rubber or glue. These breakdown products may have caused a toxic rather than an allergic reaction on skin contact, inhibiting melanin production possibly by competitive inhibition of tyrosine oxidation. These chemical compounds probably leaked from the goggles and were eventually exhausted. This possibility may explain why the leukoderma did not recur after re-use of the goggles.
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Yukun L, Yingyuan Z, Zhiling Z, Meifang Z, Ziying D, Tiancai L, Jiezhi F, Jinji H. Globoroseomycin, a new antifungal antibiotic. Chin Med J (Engl) 1979; 92:443-50. [PMID: 114368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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41
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Grigor'eva NN. [Effect of polychlorpinen on the adrenal cortex]. Vrach Delo 1977:125-7. [PMID: 919468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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42
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Calas E, Castelain PY, Lapointe HR, Ducos P, Cavelier C, Duprat P, Poitou P. Allergic contact dermatitis to a photopolymerizable resin used in printing. Contact Dermatitis 1977; 3:186-94. [PMID: 201427 DOI: 10.1111/j.1600-0536.1977.tb03644.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Organic photopolymerizable resins increasingly used in printing make it possible to produce flexible, lighter plates. A certain number of skin lesions and general symptoms appeared upon manipulation of plates made by the Letterflex process. In the workshop where this study was carried out, 12 out of 15 people suffered various degrees of skin lesions. The epicutaneous tests and biopsies performed indicate an allergic type reaction to one of the resin's constituents, polythiol. Experiments with animals confirm the strong allergenicity of this compound.
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43
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Ziegler V, Schubert H, Süss E, Standau H. [Animal experiment studies on the sensitizing potency of shoe lacquer on a polychloroprene base]. Dermatol Monatsschr 1975; 161:276-80. [PMID: 1222824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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44
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Fillastre JP. [Tubulointerstitial nephropathies due to antibiotics]. J Urol Nephrol (Paris) 1973; 79:428-39. [PMID: 4374559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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