Perioperative anemia management in colorectal cancer patients: A pragmatic approach.

Anemia, usually due to iron deficiency, is highly prevalent among patients with colorectal cancer. Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization. Preoperative anemia predicts for decreased survival. Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes, increased post-operative nosocomial infections, longer hospital stays, increased rates of cancer recurrence and perioperative venous thromboembolism. Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management, minimizes or eliminates allogeneic blood transfusion. This includes restrictive transfusion policy, thromboprophylaxis and anemia management to improve outcomes. Normalization of preoperative hemoglobin levels is a World Health Organization recommendation. Iron repletion should be routinely ordered when indicated. Oral iron is poorly tolerated with low adherence based on published evidence. Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions. Serious adverse events with intravenous iron are extremely rare. Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care. Erythropoiesis stimulating agents may improve response rates. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.

Novel micelle carriers for cyclosporin A topical ocular delivery: in vivo cornea penetration, ocular distribution and efficacy studies.

Cornea transplantation is one of the most performed graft procedures worldwide with an impressive success rate of 90%. However, for "high-risk" patients with particular ocular diseases in addition to the required surgery, the success rate is drastically reduced to 50%. In these cases, cyclosporin A (CsA) is frequently used to prevent the cornea rejection by a systemic treatment with possible systemic side effects for the patients. To overcome these problems, it is a challenge to prepare well-tolerated topical CsA formulations. Normally high amounts of oils or surfactants are needed for the solubilization of the very hydrophobic CsA. Furthermore, it is in general difficult to obtain ocular therapeutic drug levels with topical instillations due to the corneal barriers that efficiently protect the intraocular structures from foreign substances thus also from drugs. The aim of this study was to investigate in vivo the effects of a novel CsA topical aqueous formulation. This formulation was based on nanosized polymeric micelles as drug carriers. An established rat model for the prevention of cornea graft rejection after a keratoplasty procedure was used. After instillation of the novel formulation with fluorescent labeled micelles, confocal analysis of flat-mounted corneas clearly showed that the nanosized carriers were able to penetrate into all corneal layers. The efficacy of a 0.5% CsA micelle formulation was tested and compared to a physiological saline solution and to a systemic administration of CsA. In our studies, the topical CsA treatment was carried out for 14 days, and the three parameters (a) cornea transparency, (b) edema, and (c) neovascularization were evaluated by clinical observation and scoring. Compared to the control group, the treated group showed a significant higher cornea transparency and significant lower edema after 7 and 13 days of the surgery. At the end point of the study, the neovascularization was reduced by 50% in the CsA-micelle treated animals. The success rate of cornea graft transplantation was 73% in treated animals against 25% for the control group. This result was as good as observed for a systemic CsA treatment in the same animal model. This new formulation has the same efficacy like a systemic treatment but without the serious CsA systemic side effects. Ocular drug levels of transplanted and healthy rat eyes were dosed by UPLC/MS and showed a high CsA value in the cornea (11710 ± 7530 ng(CsA)/g(tissue) and 6470 ± 1730 ng(CsA)/g(tissue), respectively). In conclusion, the applied formulation has the capacity to overcome the ocular surface barriers, the micelles formed a drug reservoir in the cornea from, where a sustained release of CsA can take place. This novel formulation for topical application of CsA is clearly an effective and well-tolerated alternative to the systemic treatment for the prevention of corneal graft rejection.

Is imidacloprid an effective alternative for controlling pyrethroid-resistant populations of Triatoma infestans (Hemiptera: Reduviidae) in the Gran Chaco ecoregion?

The prevention of Chagas disease is based primarily on the chemical control of Triatoma infestans (Klug) using pyrethroid insecticides. However, high resistance levels, correlated with control failures, have been detected in Argentina and Bolivia. A previous study at our laboratory found that imidacloprid could serve as an alternative to pyrethroid insecticides. We studied the delayed toxicity of imidacloprid and the influence of the blood feeding condition of the insect on the toxicity of this insecticide; we also studied the effectiveness of various commercial imidacloprid formulations against a pyrethroid-resistant T. infestans population from the Gran Chaco ecoregion. Variations in the toxic effects of imidacloprid were not observed up to 72 h after exposure and were not found to depend on the blood feeding condition of susceptible and resistant individuals. Of the three different studied formulations of imidacloprid on glass and filter paper, only the spot-on formulation was effective. This formulation was applied to pigeons at doses of 1, 5, 20 and 40 mg/bird. The nymphs that fed on pigeons treated with 20 mg or 40 mg of the formulation showed a higher mortality rate than the control group one day and seven days post-treatment (p < 0.01). A spot-on formulation of imidacloprid was effective against pyrethroid-resistant T. infestans populations at the laboratory level.

Co-administration of plasmid-encoded granulocyte-macrophage colony-stimulating factor increases human immunodeficiency virus-1 DNA vaccine-induced polyfunctional CD4+ T-cell responses

T-cell based vaccines against human immunodeficiency virus (HIV) generate specific responses that may limit both transmission and disease progression by controlling viral load. Broad, polyfunctional, and cytotoxic CD4+T-cell responses have been associated with control of simian immunodeficiency virus/HIV-1 replication, supporting the inclusion of CD4+ T-cell epitopes in vaccine formulations. Plasmid-encoded granulocyte-macrophage colony-stimulating factor (pGM-CSF) co-administration has been shown to induce potent CD4+ T-cell responses and to promote accelerated priming and increased migration of antigen-specific CD4+ T-cells. However, no study has shown whether co-immunisation with pGM-CSF enhances the number of vaccine-induced polyfunctional CD4+ T-cells. Our group has previously developed a DNA vaccine encoding conserved, multiple human leukocyte antigen (HLA)-DR binding HIV-1 subtype B peptides, which elicited broad, polyfunctional and long-lived CD4+ T-cell responses. Here, we show that pGM-CSF co-immunisation improved both magnitude and quality of vaccine-induced T-cell responses, particularly by increasing proliferating CD4+ T-cells that produce simultaneously interferon-γ, tumour necrosis factor-α and interleukin-2. Thus, we believe that the use of pGM-CSF may be helpful for vaccine strategies focused on the activation of anti-HIV CD4+ T-cell immunity.

Stone-ground wood pulp-reinforced polypropylene composites: water uptake and thermal properties

Two of the drawbacks of using natural-based composites in industrial applications are thermal instability and water uptake capacity. In this work, mechanical wood pulp was used to reinforce polypropylene at a level of 20 to 50 wt. %. Composites were mixed by means of a Brabender internal mixer for both non-coupled and coupled formulations. Differential scanning calorimetry (DSC) and thermogravimetric analysis (TGA) were used to determine the thermal properties of the composites. The water uptake behavior was evaluated by immersion of the composites in water until an equilibrium state was reached. Results of water absorption tests revealed that the amount of water absorption was clearly dependent upon the fiber content. The coupled composites showed lower water absorption compared to the uncoupled composites. The incorporation of mechanical wood pulp into the polypropylene matrix produced a clear nucleating effect by increasing the crystallinity degree of the polymer and also increasing the temperature of polymer degradation. The maximum degradation temperature for stone ground wood pulp–reinforced composites was in the range of 330 to 345 ºC

Tensile strength characteristics of polypropylene composites reinforced with stone groundwood fibers from softwood

The behavior of stone groundwood / polypropylene injection-molded composites was evaluated with and without coupling agent. Stone groundwood (SGW) is a fibrous material commonly prepared in a high yield process and mainly used for papermaking applications. In this work, the use of SGW fibers was explored as a reinforcing element of polypropylene (PP) composites. The surface charge density of the composite components was evaluated, as well as the fiber’s length and diameter inside the composite material. Two mixing extrusion processes were evaluated, and the use of a kinetic mixer, instead of an internal mixer, resulted in longer mean fiber lengths of the reinforcing fibers. On the other hand, the accessibility of surface hydroxyl groups of stone groundwood fibers was improved by treating the fibers with 5% of sodium hydroxide, resulting in a noticeable increase of the tensile strength of the composites, for a similar percentage of coupling agent. A new parameter called Fiber Tensile Strength Factor is defined and used as a baseline for the comparison of the properties of the different composite materials. Finally the competitiveness of stone groundwood / polypropylene / polypropylene-co-maleic anhydride system, which compared favorably to sized glass-fiber / polypropylene GF/PP and glass-fiber / polypropylene / polypropylene-co-maleic anhydride composite formulations, was quantified by means of the fiber tensile strength factor

Evaluation of melanoma vaccines with molecularly defined antigens by ex vivo monitoring of tumor-specific T cells.

Immunotherapy of melanoma is aimed to mobilize cytolytic CD8+ T cells playing a central role in protective immunity. Despite numerous clinical vaccine trials, only few patients exhibited strong antigen-specific T-cell activation, stressing the need to improve vaccine strategies. For a rational development, we propose to focus on molecularly defined vaccine components, and evaluate their immunogenicity with highly reproducible and standardized methods for ex vivo immune monitoring. Careful immunogenicity comparison of vaccine formulations in phase I/II studies allow to select optimized vaccines for subsequent clinical efficacy testing in large scale phase III trials.

Allergo-immunologie [Allergie rhinoconjunctivitis and immunotherapy: an uptodate]

Rhinitis and allergic conjunctivitis are frequent and may have severe impact on quality of life. Moreover risks of evolution of rhinitis to asthma are high, whereas conjunctivitis may either lead to eye-related complications when some topical drugs (such as steroids) are used, or when severe ailments are belatedly diagnosed. This article enables to review the treatment of allergic rhino-conjunctivitis. It also presents recent progress realized in the domain of allergen specific immunotherapy. In particular, this review underlines the search for hypoallergenic formulations that may minimize the risk of systemic allergic side effects as well as the use of new adjuvants to improve the efficiency of treatment and reduce its duration.

Drug uptake in a rodent sarcoma model after intravenous injection or isolated lung perfusion of free liposomal doxorubicin /

Rapport de synthèseDrug uptake in a rodent sarcoma model after intravenous injection or isolated lungperfusion of free/liposomal doxorubicinIntroductionLa distribution de doxorubicine libre et doxorubicin liposomale pegylée (Liporubicin?) a été comparée après administration intraveineuse ou application via perfusion isolée du poumon (ILP) dans le parenchyme pulmonaire et dans la tumeur des poumons de rongeurs, porteurs d'une tumeur sarcomateuse.Matériel et méthodeUne tumeur sarcomateuse unique a été générée dans le poumon gauche de 36 rongeurs (Fisher rats) suivie, 10 jours plus tard, par application de doxorubicine ou Liporubicin? soit par perfusion isolée du poumon (n = 20) ou administration intraveineuse (n = 12). Deux différentes concentrations ont été utilisées (100 μg et 400 pg) à doses équimolaires pour les deux formulations de doxorubicine. La concentration des agents cytostatiques ont été mesurées dans la tumeur et le parenchyme pulmonaire à l'aide de chromatographic (HPLC).RésultatsLes résultats indiquent que pour doxorubicine libre, le taux de concentration dans la tumeur et le parenchyme pulmonaire est 3 fois (dosage de 100 μ§) et 10 fois (dosage de 400 plus élevé après ILP par rapport à l'administration intraveineuse. En revanche, pour Liporubicin , le taux de concentration est similaire dans la tumeur et le parenchyme pulmonaire entre ILP et administration intraveineuse, pour les deux doses appliquées.ConclusionPour ILP et administration intraveineuse, le ratio entre accumulation de l'agent cytostatique dans la tumeur versus dans le parenchyme pulmonaire a été comparé pour les deux formulations de doxorubicine ainsi que pour les deux dosages. Pour les deux formulations et dosages de doxorubicine, ILP aboutit à un ratio plus élevé par rapport à l'administration intraveineuse. Cependant, pour les deux formulations et dosages de doxorubicine, ILP résulte également en une distribution de l'agent cytostatique plus hétérogène dans le parenchyme pulmonaire comparé à l'administration intraveineuse.En résumé, l'application de doxorubicine par ILP aboutit donc à une accumulation tumorale élevée et à une augmentation du ratio tumeur-parenchyme pulmonaire, mais en même temps également à une distribution plus hétérogène dans le parenchyme pulmonaire par rapport à l'application intraveineuse. Ceci a été observé pour les deux formulations de doxorubicine et pour les deux dosages appliqué.

In vivo characterisation of a novel water-soluble Cyclosporine A prodrug for the treatment of dry eye disease.

Cyclosporine A (CsA) has been demonstrated to be effective for the treatment of a variety of ophthalmological conditions, including ocular surface disorders such as the dry eye disease (DED). Since CsA is characterised by its low water solubility, the development of a topical ophthalmic formulation represents an interesting pharmaceutical question. In the present study, two different strategies to address this challenge were studied and compared: (i) a water-soluble CsA prodrug formulated within an aqueous solution and (ii) a CsA oil-in-water emulsion (Restasis, Allergan Inc., Irvine, CA). First, the prodrug formulation was shown to have an excellent ocular tolerance as well as no influence on the basal tear production; maintaining the ocular surface properties remained unchanged. Then, in order to allow in vivo investigations, a specific analytical method based on ultra high pressure liquid chromatography coupled with triple quadrupole mass spectrometer (UHPLC-MS/MS) was developed and optimised to quantify CsA in ocular tissues and fluids. The CsA ocular kinetics in lachrymal fluid for both formulations were found to be similar between 15 min and 48 h. The CsA ocular distribution study evidenced the ability of the prodrug formulation to penetrate into the eye, achieving therapeutically active CsA levels in tissues of both the anterior and posterior segments. In addition, the detailed analysis of the in vivo data using a bicompartmental model pointed out a higher bioavailability and lower elimination rate for CsA when it is generated from the prodrug than after direct application as an emulsion. The interesting in vivo properties displayed by the prodrug solution make it a safe and suitable option for the treatment of DED.

The achievable region approach to the optimal control of stochastic systems

The achievable region approach seeks solutions to stochastic optimisation problems by: (i) characterising the space of all possible performances(the achievable region) of the system of interest, and (ii) optimisingthe overall system-wide performance objective over this space. This isradically different from conventional formulations based on dynamicprogramming. The approach is explained with reference to a simpletwo-class queueing system. Powerful new methodologies due to the authorsand co-workers are deployed to analyse a general multiclass queueingsystem with parallel servers and then to develop an approach to optimalload distribution across a network of interconnected stations. Finally,the approach is used for the first time to analyse a class of intensitycontrol problems.

Network revenue management with product-specific no-shows

Revenue management practices often include overbooking capacity to account for customerswho make reservations but do not show up. In this paper, we consider the network revenuemanagement problem with no-shows and overbooking, where the show-up probabilities are specificto each product. No-show rates differ significantly by product (for instance, each itinerary andfare combination for an airline) as sale restrictions and the demand characteristics vary byproduct. However, models that consider no-show rates by each individual product are difficultto handle as the state-space in dynamic programming formulations (or the variable space inapproximations) increases significantly. In this paper, we propose a randomized linear program tojointly make the capacity control and overbooking decisions with product-specific no-shows. Weestablish that our formulation gives an upper bound on the optimal expected total profit andour upper bound is tighter than a deterministic linear programming upper bound that appearsin the existing literature. Furthermore, we show that our upper bound is asymptotically tightin a regime where the leg capacities and the expected demand is scaled linearly with the samerate. We also describe how the randomized linear program can be used to obtain a bid price controlpolicy. Computational experiments indicate that our approach is quite fast, able to scale to industrialproblems and can provide significant improvements over standard benchmarks.

A tractable consideration set structure for network revenue management

Models incorporating more realistic models of customer behavior, as customers choosing from an offerset, have recently become popular in assortment optimization and revenue management. The dynamicprogram for these models is intractable and approximated by a deterministic linear program called theCDLP which has an exponential number of columns. When there are products that are being consideredfor purchase by more than one customer segment, CDLP is difficult to solve since column generationis known to be NP-hard. However, recent research indicates that a formulation based on segments withcuts imposing consistency (SDCP+) is tractable and approximates the CDLP value very closely. In thispaper we investigate the structure of the consideration sets that make the two formulations exactly equal.We show that if the segment consideration sets follow a tree structure, CDLP = SDCP+. We give acounterexample to show that cycles can induce a gap between the CDLP and the SDCP+ relaxation.We derive two classes of valid inequalities called flow and synchronization inequalities to further improve(SDCP+), based on cycles in the consideration set structure. We give a numeric study showing theperformance of these cycle-based cuts.

Invasive candidiasis as a cause of sepsis in the critically ill patient.

Invasive fungal infections are an increasingly frequent etiology of sepsis in critically ill patients causing substantial morbidity and mortality. Candida species are by far the predominant agent of fungal sepsis accounting for 10% to 15% of health-care associated infections, about 5% of all cases of severe sepsis and septic shock and are the fourth most common bloodstream isolates in the United States. One-third of all episodes of candidemia occur in the intensive care setting. Early diagnosis of invasive candidiasis is critical in order to initiate antifungal agents promptly. Delay in the administration of appropriate therapy increases mortality. Unfortunately, risk factors, clinical and radiological manifestations are quite unspecific and conventional culture methods are suboptimal. Non-culture based methods (such as mannan, anti-mannan, β-d-glucan, and polymerase chain reaction) have emerged but remain investigational or require additional testing in the ICU setting. Few prophylactic or pre-emptive studies have been performed in critically ill patients. They tended to be underpowered and their clinical usefulness remains to be established under most circumstances. The antifungal armamentarium has expanded considerably with the advent of lipid formulations of amphotericin B, the newest triazoles and the echinocandins. Clinical trials have shown that the triazoles and echinocandins are efficacious and well tolerated antifungal therapies. Clinical practice guidelines for the management of invasive candidiasis have been published by the European Society for Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of North America.

Thérapies inhalées dans la mucoviscidose [Inhaled therapies for cystic fibrosis].

Inhaled therapies play a significant role in the management of cystic fibrosis patients. Mucolytic and airway-rehydrating agents improve mucociliary clearance and respiratory functional status. Nebulized antibiotherapy achieve high local concentration, while reducing systemic toxicity. Tolerance to inhaled treatments is good excepting frequent bronchoconstriction which can usually be prevented by prior administration of beta2-mimetics. The majority of treatments are only available in liquid formulations. Thus, nebulization is the most frequently used inhalation mode. Vibrating-mesh nebulizers have significantly reduced inhalation time.