Phase I/IIa Trial in Advanced Pancreatic Ductal Adenocarcinoma Treated with Cytotoxic Drug-Packaged, EGFR-Targeted Nanocells and Glycolipid-Packaged Nanocells

PURPOSE

We assessed the safety and efficacy of an EGFR-targeted, super-cytotoxic drug, PNU-159682-packaged nanocells with α-galactosyl ceramide-packaged nanocells (E-EDV-D682/GC) in patients with advanced pancreatic ductal adenocarcinoma (PDAC) who had exhausted all treatment options.

PATIENTS AND METHODS

ENG9 was a first-in-man, single-arm, open-label, phase I/IIa, dose-escalation clinical trial. Eligible patients had advanced PDAC, Eastern Cooperative Oncology Group status 0 to 1, and failed all treatments. Primary endpoints were safety and overall survival (OS).

RESULTS

Of 25 enrolled patients, seven were withdrawn due to rapidly progressive disease and one patient withdrew consent. All 25 patients were assessed for toxicity, 24 patients were assessed for OS, which was also assessed for 17 patients completing one treatment cycle [evaluable subset (ES)]. Nineteen patients (76.0%) experienced at least one treatment-related adverse event (graded 1 to 2) resolving within hours. There were no safety concerns, dose reductions, patient withdrawal, or treatment-related deaths.

Median OS (mOS) was 4.4 months; however, mOS of the 17 ES patients was 6.9 months [208 days; range, 83-591 days; 95.0% confidence interval (CI), 5.6-10.3 months] and mOS of seven patients who did not complete one cycle was 1.8 months (54 days; range, 21-72; 95.0% CI, 1.2-2.2 months). Of the ES, 47.1% achieved stable disease and one partial response. Ten subjects in the ES survived over 6 months, the longest 19.7 months. During treatments, 82.0% of the ES maintained stable weight.

CONCLUSIONS

E-EDV-D682/GC provided significant OS, minimal side effects, and weight stabilization in patients with advanced PDAC. Advanced PDAC can be safely treated with super-cytotoxic drugs via EnGeneIC Dream Vectors to overcome multidrug resistance.

Promoting evaluation capacity building in a complex adaptive system

This study provides results from an NSF funded, four year, case study about evaluation capacity building in a complex adaptive system, the Nanoscale Informal Science Education Network (NISE Net). The results of the Complex Adaptive Systems as a Model for Network Evaluations (CASNET) project indicate that complex adaptive system concepts help to explain evaluation capacity building in a network. The NISE Network was found to be a complex learning system that was supportive of evaluation capacity building through feedback loops that provided for information sharing and interaction. Participants in the system had different levels of and sources of evaluation knowledge. To be successful at building capacity, the system needed to have a balance between both centralized and decentralized control, coherence, redundancy, and diversity. Embeddedness of individuals within the system also provided support and moved the capacity of the system forward. Finally, success depended on attention being paid to the control of resources. Implications of these findings are discussed.

Are Nursing Codes of Practice Ethical?

This article provides a theoretical critique from a particular ‘ideal type’ ethical perspective of professional codes in general and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Code of professional conduct (reprinted on pp. 77-78) in particular.

Having outlined a specific ‘ideal type’ of what ethically informed and aware practice may be, the article examines the extent to which professional codes may be likely to elicit and engender such practice. Because of their terminological inexactitudes and confusions, their arbitrary values and principles, their lack of helpful ethical guidance, and their exclusion of ordinary moral experience, a number of contemporary professional codes in health and social care can be arraigned as ethically inadequate. The UKCC Code of professional conduct embodies many of these flaws, and others besides. Some of its weaknesses in this respect are anatomized before some tentative suggestions are offered for the reform of codes and the engendering of greater ethical awareness among professionals in the light of greater public ethical concerns and values.

Abstract 260: Systemic Loss of p62 Reduces Pressure Overload Induced Cardiac Hypertrophy, Dysfunction and Apoptosis

Introduction: p62 is a pleiotropic protein with defined roles in TNFα signaling, protein aggregate formation, and protein degradation processes. Current data suggest that p62 is a stress-response protein, with increased protein levels reported in TAC, MI, I/R, and protein aggregation models of cardiac disease. To date, there has been little study on the gain- or loss- of p62 function in cardiomyocyte/cardiac pathology. Our preliminary data found that adenoviral overexpression of p62 caused cardiomyocyte hypertrophy and cytotoxicity and that p62 was upregulated by pressure-overload stress.

Hypothesis: Loss of p62 will be cardioprotective against pressure-overload pathology.

Methods: Systemic p62 knockout mice underwent sham or transverse-aortic constriction surgery and were studied longitudinally to 8 weeks post-surgery by echocardiography.

Results: Hearts from p62-null mice had significantly preserved cardiac function (%Fractional Shortening) over wild-type controls. p62-deficient mice had significantly less cardiac hypertrophy (heart weight/body weight ratios and myofiber cross-sectional areas) and showed no chamber dilation (LVED) in response to pressure-overload stress, unlike wild-types. Hearts from wild-type mice showed pronounced fibrotic remodeling and induction of apoptosis (TUNEL), while p62 knockouts had significantly less collagen staining and no evidence of apoptotic stimulation. Overexpression of p62 in rat neonatal cardiomyocytes significantly inhibited proteasomal catalytic activities (>50%) and showed increased indices of cardiomyocyte cell death.

Conclusion: Our data show that induction of p62 is deleterious in vitro and that loss of p62 imparts cardioprotection against hemodynamic stress in vivo . The beneficial phenotype observed in hearts from p62-deficient mice may be due to p62-dependent mechanisms responsible for proteasomal dysfunction and apoptosis activation.

Targeted nanoparticle delivery of doxorubicin into placental tissues to treat ectopic pregnancies

Abnormal trophoblast growth can cause life-threatening disorders such as ectopic pregnancy, choriocarcinoma, and placenta accreta. EnGeneIC Delivery Vehicles (EDVs) are nanocells that can promote tissue-specific delivery of drugs and may be useful to medically treat such disorders. The objective of this study was to determine whether EDVs loaded with the chemotherapeutic doxorubicin and targeting the epidermal growth factor receptor (EGFR, very highly expressed on the placental surface) can regress placental cells in vitro, ex vivo, and in vivo. In female SCID mice, EGFR-targeted EDVs induced greater inhibition of JEG-3 (choriocarcinoma cells) tumor xenografts, compared with EDVs targeting an irrelevant antigen (nontargeted EDVs) or naked doxorubicin. EGFR-targeted EDVs were more readily taken up by human placental explants ex vivo and induced increased apoptosis (M30 antibody) compared with nontargeted EDVs. In vitro, EGFR-targeted EDVs administered to JEG-3 cells resulted in a dose-dependent inhibition of cell viability, proliferation, and increased apoptosis, a finding confirmed by continuous monitoring by xCELLigence. In conclusion, EGFR-targeted EDVs loaded with doxorubicin significantly inhibited trophoblastic tumor cell growth in vivo and in vitro and induced significant cell death ex vivo, potentially mediated by increasing apoptosis and decreasing proliferation. EDVs may be a novel nanoparticle treatment for ectopic pregnancy and other disorders of trophoblast growth.

Crime and health: a preliminary study into the effects of crime on the mental health of UK university students

In this paper we report on the findings from a preliminary study in the UK into the effects of crime on health. The aim of the study was to investigate what victims of crime report to be the effects of both actual crime and the fear of crime on their physical and psychological health (as well as social well-being) and what actions they take (if any) to deal with these effects. A survey method was adopted using a modified version of the 'Health, Quality of Life and Crime Questionnaire' with 866 undergraduate student respondents from three UK universities. University students were selected as the sample population because, as a group, they form a specific 'victim community'. Conclusions extrapolated from the respondents' replies were first, there are serious negative health effects (particularly on psychological health) of a considerable minority of those students who are victims of crime. Second, the vast majority of the victims did not initiate any health intervention. Third, a large minority of the victims did not report the crime to the police. Fourth, a majority of both victims and non-victims suffered psychological negative effects from the fear of crime. Fifth, there is a huge gender imbalance among those affected by crime with female students much more fearful of crime than men. Moreover, female students were much more likely to use specific strategies to lower the risk of crime. These conclusions suggest that there may be important policy implications for universities, the police, victim support organizations and mental health services, regarding the effects of crime on students. This study is intended as a preliminary stage for subsequent in-depth and larger projects.

Cause for concern: the absence of consideration of public and ethical interest in British public policy

In the UK, many fundamentally important policy decisions that are likely to affect the relationship between citizens and care services are now made at the sublegislative level and without adequate ethical consideration and scrutiny. This is well exemplified in the proposed guidance on the disclosure of information on children. A recent consultation paper by the UK government on the subject proposes an approach that seeks a simple technical solution to a complex problem, emphasising control and surveillance. This reflects pressure to be seen to act. The document fails with regard to ethical reflection appropriate to the complexity of the issue, an appreciation of complex relationships of trust, and a proper sense of the richness and complexity of the public interest. Such policies would, if implemented, fundamentally change the relationships between citizens and their carers, and among carers and the law and the state. This and similar proposals require far more ethical scrutiny and consideration of the public interest in the widest sense.

Need humanities be so useless? Justifying the place and role of humanities as a critical resource for performance and practice

Justifying the existence, position, and relevance of academic humanities scholarship may be difficult in the face of chronic practical needs in health care. Such scholarship may seem parasitic on human activity and performance that directly contributes to human wellbeing and health care. Here, a possible and partial justification for the importance of scholarship in the humanities as a critical resource for practice and performance is undertaken by two humanities scholars. Human identity and emotion are reflected and defined by performances, both in the traditional disciplines of the humanities, such as art and literature, and in the sciences and medicine. The critical attitude that such performances might inadvertently undermine is sustained by the humanities. The humanities disciplines ask the question: "What is it to be human?" Uncritical emotion and expression, arising, for example, from understanding developments in medicine and science, which might exclude or corrupt much that is of value in the healthcare sector and other areas of practical performance, can be constrained by this.

Medical Humanities: a vision and some cautionary notes

This article aims to engender discussion about the nature and future of medical humanities. First, a normative personal vision of medical humanities as an inclusive movement is outlined. Some of the problems that may emerge if medical humanities conceives itself too narrowly are then discussed. The case of the rise of the medical ethics movement is used to show what can happen to a movement that restricts itself too quickly and then the stages of the "death course of a discipline" are described and assayed. The article concludes with a plea for medical humanities to remain a "broad church", exploratory, pluralistic movement rather than aiming to become a paramedical academic discipline.

In vivo ligand-inducible regulation of gene expression in a gutless adenoviral vector system

Transcriptional regulation that is rapid, reversible, and repeatedly inducible would greatly enhance the safety and efficacy of many gene therapy strategies. We developed a chimeric ligand-inducible regulation system based on the human estrogen receptor. This system has two components, the responsive promoter driving expression of the transgene of interest, and the ligand-inducible chimeric transcription factor. The transcription factor is composed of a novel DNA binding domain and a modified estrogen receptor ligand-binding domain. A point mutation in the ligand-binding domain significantly reduces estrogen binding while allowing binding of the estrogen antagonist, tamoxifen. We used a gutless adenoviral vector system and incorporated both components into two separate vectors. A single gutless vector encoding both system components was also generated. The tamoxifen-mediated induciblity of transgene expression of the gutless vector system was compared in vitro and in vivo with the analogous components incorporated into early generation, E1/E2a/E3-deficient adenoviral vectors. In normal mice, both the gutless vector and early generation systems displayed inducibility in the presence of tamoxifen. Importantly, the gutless vector system was inducible to extremely high levels, at least four times over a 2-month period. In contrast, the early generation vector system was inducible only once. Furthermore, the early generation system displayed significant toxicity, as evidenced by extremely high liver enzyme levels, abnormal liver pathology, and rapid loss of vector DNA from the liver, while the gutless vector system displayed minimal toxicity. These data directly demonstrate the improved in vivo function of the tamoxifen-inducible transcriptional regulation system in the context of the gutless adenoviral vectors.

Optimization of the generation and propagation of gutless adenoviral vectors

Adenoviral vectors devoid of all viral coding regions are referred to by many names, including gutless vectors. Gutless vectors display reduced toxicity and immunogenicity, increased duration of transgene expression, and increased coding capacity compared to early generation vectors, which contain the majority of the viral backbone genes. However, the production of gutless vectors at a scale and purity suitable for clinical use has limited the utility of this technology. In this work we describe the optimization of the production of gutless vectors. We constructed an improved helper virus and generated an alternative gutless vector producer cell line, PERC6-Cre. We demonstrated increased gutless vector yields, minimal helper virus contamination, and no replication-competent adenovirus contamination using the optimized system. Furthermore, the PERC6-Cre cells were adapted to serum-free suspension culture and high-titer gutless vector preparations were produced using bioreactor technology, suggesting the feasibility of gutless vector scale-up for clinical use. Finally, we observed that helper virus lacking a packaging signal could be packaged at a low frequency, revealing an inherent limitation to the differential packaging strategy for gutless vector propagation.

Putting the public back into public health. Part II. How can public health be accountable to the public?

The practice of public health involves the application of evidence to improving population health, and should be accountable to the public. Accountability to the public can be considered either at the individual doctor-patient interface or through population-level policy making. The public, at both patient and population levels, should join the professionals at each stage of the 'population health evidence cycle'-in asking for, collecting, understanding and using evidence. A greater appreciation of the non-professional, public perspective would represent a substantial commitment to transforming our understanding and needs for different kinds of evidence required to improve the health of the population.

Putting the public back into public health. Part I. A re-definition of public health

The practice of public health has been criticized as being too involved with a narrow, managerial agenda focused on health care rather than the wider horizons of public good. Public accountability is central to the practice of public health, but is not mentioned in current definitions. We offer a new definition that recognizes the centrality of the public, and which should help public health professionals interpret their own role: 'Use of theory, experience and evidence derived through the population sciences to improve the health of the population, in a way that best meets the implicit and explicit needs of the community (the public)'.

Sustained human factor VIII expression in hemophilia A mice following systemic delivery of a gutless adenoviral vector

Gutless adenoviral vectors are devoid of all viral coding regions and display reduced cytotoxicity, diminished immunogenicity, and an increased coding capacity compared with early generation vectors. Using hemophilia A, a deficiency in clotting factor VIII (FVIII), as a model disease, we generated and evaluated a gutless vector encoding human FVIII. The FVIII gutless vector grew to high titer and was reproducibly scaled-up from vector seed lots. Extensive viral DNA analyses revealed no rearrangements of the vector genome. A quantitative PCR assay demonstrated helper virus contamination levels of <2%, with the best preparation containing 0.3% helper virus. We compared the gutless vector with an E1/E2a/E3-deficient (Av3) early generation vector encoding an identical FVIII expression cassette following intravenous administration to hemophilia A mice. Gutless vector-treated mice displayed 10-fold higher FVIII expression levels that were sustained for at least 9 months. In contrast, mice treated with the Av3 vector displayed FVIII levels below the limit of sensitivity of the assay at 3 months. Assessment of hepatotoxicity by measuring the serum levels of liver enzymes demonstrated that the gutless vector was significantly less toxic than the Av3 vector at time points later than 7 days. At the highest dose used, both vectors caused a transient 10-fold increase in liver enzymes 1 day after vector administration, suggesting that this increase was caused by direct toxicity of the input capsid proteins. These data demonstrate that the gutless vector displayed increased duration and levels of FVIII expression, and was significantly less toxic than an analogous early generation vector.

Distinct domains of erythroid Krüppel-like factor modulate chromatin remodeling and transactivation at the endogenous beta-globin gene promoter

Characterization of the mechanism(s) of action of trans-acting factors in higher eukaryotes requires the establishment of cellular models that test their function at endogenous target gene regulatory elements. Erythroid Krüppel-like factor (EKLF) is essential for beta-globin gene transcription. To elucidate the in vivo determinants leading to transcription of the adult beta-globin gene, functional domains of EKLF were examined in the context of chromatin remodeling and transcriptional activation at the endogenous locus. Human EKLF (hEKLF) sequences, linked to an estrogen-responsive domain, were studied with an erythroblast cell line lacking endogenous EKLF expression (J2eDeltaeklf). J2eDeltaeklf cells transduced with hEKLF demonstrated a dose-dependent rescue of beta-globin transcription in the presence of inducing ligand. Further analysis using a series of amino-terminal truncation mutants of hEKLF identified a distinct internal domain, which is sufficient for transactivation. Interestingly, studies of the chromatin structure of the beta-promoter revealed that a smaller carboxy-terminal domain generated an open promoter configuration. In vitro and in vivo binding studies demonstrated that this region interacted with BRG1, a component of the SWI/SNF chromatin remodeling complex. However, further study revealed that BRG1 interacted with an even smaller domain of EKLF, suggesting that additional protein interactions are required for chromatin remodeling at the endogenous beta-promoter. Taken together, our findings support a stepwise process of chromatin remodeling and coactivator recruitment to the beta-globin promoter in vivo. The J2eDeltaeklf inducible hEKLF system will be a valuable tool for further characterizing the temporal series of events required for endogenous beta-globin gene transcription.

Spirituality. Come all ye faithful

A growing body of research suggests that religion and spirituality can have a positive effect on mental and physical health. Like any other powerful belief system, they also have potential for harm. Further research is needed if they are to be understood and therapeutically incorporated into healthcare.

NHS values. I want to tell you a story

Many NHS staff feel that they are unable to put their values into action because of the constraints on the service. They want a working environment where trust is possible and mistakes can be made without retribution. The reality is often bullying and attempts at innovation being met with reproach.

Do case studies mislead about the nature of reality?

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis.

NHS values. What are we here for?

Following more than a decade of change, the NHS is keen to explore the values driving its daily life. Consistency between values and behaviour are an important part of building an organisation's identity and confidence. It is likely that pluralistic values inform the NHS more now than was the case in the early years of the welfare state.

CCAAT displacement protein, a regulator of differentiation-specific gene expression, binds a negative regulatory element within the 5' end of the human papillomavirus type 6 long control region

We have reported previously that a 636-bp fragment spanning the 5' two-thirds of the human papillomavirus type 6 (HPV6)-W50 long control region (LCR) functions as a transcriptional silencer (A. Farr, S. Pattison, B.-S. Youn, and A. Roman, J. Gen. Virol. 76:827-835, 1995). We have utilized nested deletion analyses to implicate a 66-bp sequence which appears to be critical for this activity. A comparison of the transcriptional regulatory activities of the LCRs of HPV6-W50 and HPV6b (which has a 94-bp deletion, resulting in the elimination of the 66-bp sequence) indicates that sequences within the 94-bp region negatively regulate the activity of the intact HPV6 LCR. Two sequence-specific DNA-protein interactions were visualized via electrophoretic mobility shift assays. One of the binding events is mediated by the transcriptional repressor CCAAT displacement protein (CDP), a factor which is active in undifferentiated cells but inactive in terminally differentiated cells. This conclusion is based on the following three lines of evidence: (i) a consensus CDP binding site oligonucleotide serves as a competitor in band shift assays, (ii) the band shift complex is not seen when a CDP-negative nuclear extract is used, and (iii) anti-CDP antiserum specifically inhibits the binding. These studies identify a DNA-protein interaction occurring within the 5' end of the LCR which may be important in maintaining the tight link between keratinocyte differentiation and HPV gene expression.

Detection of silencer activity in the long control regions of human papillomavirus type 6 isolated from both benign and malignant lesions

Human papillomavirus type 6 (HPV-6) DNA is the predominant HPV type found in condyloma acuminata: it is rarely found in carcinomas. We have previously reported cloning and characterizing an HPV-6 from a vulvar condyloma (HPV6-W50) and an HPV-6 from a vulvar carcinoma (HPV6-T70). The E5, E6 and E7 proteins encoded by the two genomes were identical, however, the two genomes differed in the long control region (LCR). Cloning of the entire LCR into the enhancerless plasmid pSVEcat showed that the two LCRs had comparable enhancer activity. Since the major differences between the two LCRs resided in the 5' end of the LCR, upstream of the L1 polyadenylation signal, we subcloned the two LCRs to analyse more closely their effect on cat gene expression. The data indicated that LCR subclones of the two genomes had comparable chloramphenicol acetyltransferase (CAT) activity. A negative regulatory region was detectable when the test plasmids were transfected into HeLa and C33A cells and in primary keratinocytes. A decrease in CAT activity was also detected when the SV40 early promoter was replaced with the putative HPV-6 E6 promoter. The negative regulatory region functioned in a position- and orientation-independent manner, thus fulfilling the definition of a silencer.

Reducing the risk of cancers. A distance learning resource for cancer prevention throughout the EC

This paper describes an initiative in distance learning for cancer prevention for health care professionals throughout the EC. 'Reducing the Risk of Cancers' is a multi-media integrated study pack of learning materials prepared by the Open University (U.K.) with funding from the Europe Against Cancer programme of the European Commission. The teaching materials aim to enhance cancer prevention and health promotion skills and competencies amongst health care professionals at local level. In the paper the background to the pack is considered, the production process is described and the aims and philosophy of the teaching materials are outlined. The content of the pack is described and usage, dissemination and evaluation for health professionals throughout Europe are discussed.

Functional consequences of ligand-dependent conformational changes in trypsin-solubilized and in membrane particle constrained-acetylcholinesterase

The effect of a class of ligands on the catalytic activity of acetylcholinesterase (acetylcholine hydrolase, EC 3.1.1.7) from Torpedo californica electroplax tissue has been studied via the transient reaction of a fluorophoric acetylcholine analog, 7-(N,N-dimethyl)carbamoxy-N-methylquinolinium iodide (M7C). These "peripheral" ligands inhibit the formation of a metastable carbamyl-enzyme intermediate from M7C. They induce slow isomerization to a new conformational state that shows little or no reaction with M7C. At saturating ligand concentration, the unimolecular isomerization rate constant is 0.03 +/- 0.01 sec-1, a slow rate compared to the rate of carbamylation of the active conformation. Peripheral ligands alter the distribution between reactive and unreactive conformations, thus inducing biphasic rates and amplitudes of carbamylation. The amplitudes, but not the two specific rates, are affected by the concentration of ligand. Zn2+ and d-tubocurarine are two ligands that induce the same slow isomerization rate. On the basis of this identity of function by ligands of disparate structure, we postulate the existence of only a single active conformation and a single inactive conformation (stabilized by interaction with both ligands). In the absence of ligands, the active conformation predominates. Peripheral ligands bind specifically to the inactive conformation. Alkaline earth cations such as Ca2+ and Mg2+ interact strongly and preferentially with the active conformation and drive the conformational equilibrium toward the active state. Ligand-induced inactivation is observed both with highly purified trypsin-solubilized enzyme and with enzyme bound to unfractionated membrane fragments.