Mapping Solute Clearance From the Mouse Hippocampus Using a 3D Imaging Cryomicrotome

The hippocampus is susceptible to protein aggregation in neurodegenerative diseases such as Alzheimer’s disease. This protein accumulation is partially attributed to an impaired clearance; however, the removal pathways for fluids and waste products are not fully understood. The aim of this study was therefore to map the clearance pathways from the mouse brain. A mixture of two fluorescently labeled tracers with different molecular weights was infused into the hippocampus. A small subset of mice (n = 3) was sacrificed directly after an infusion period of 10 min to determine dispersion of the tracer due to the infusion, while another group was sacrificed after spreading of the tracers for an additional 80 min (n = 7). Upon sacrifice, mice were frozen and sectioned as a whole by the use of a custom-built automated imaging cryomicrotome. Detailed 3D reconstructions were created to map the tracer spreading. We observed that tracers distributed over the hippocampus and entered adjacent brain structures, such as the cortex and cerebroventricular system. An important clearance pathway was found along the ventral part of the hippocampus and its bordering interpeduncular cistern. From there, tracers left the brain via the subarachnoid spaces in the directions of both the nose and the spinal cord. Although both tracers followed the same route, the small tracer distributed further, implying a major role for diffusion in addition to convection. Taken together, these results reveal an important clearance pathway of solutes from the hippocampus.

Modern approaches to infusion therapy in pediatrics and chemotherapy

Background. Systems for intravenous administration of blood products and drugs are divided into the systems for transfusion (pore diameter – 114-200 μm) and systems for infusion (pore diameter – 15-75 μm). Gravity delivery systems consist of a drip chamber, an infusion rate regulator, a needle connector, a system tube, an injection needle, and a system fixation patch. Objective. To describe modern approaches and devices for infusion therapy. Materials and methods. Analysis of the literature on this issue. Results and discussion. If the needle is integrated into a drip chamber, it should contain two channels at different levels: a channel for the drug and an air channel with a built-in antibacterial filter. This is important because air is always considered a non-sterile environment. The use of antibacterial filter systems for injection of drugs into the vial is prohibited. Filter materials are able to absorb on its surface from 10 to 90 % of the drug. In addition, drying of some solutions make the filter impermeable to air. Another important filter in infusion systems is the drip chamber filter, which prevents insoluble particles of the drug, particles of ampoule glass, plastic or rubber stopper from entering the bloodstream. Typical characteristic of infusion from plastic vials is the absence of need for an air needle or opening of the ventilating chamber. During the infusion, air does not enter the vial, so it deforms. On an additional inverted scale you can see the amount of drug infused. The main materials for the systems are polyvinyl chloride, diethylhexyl phthalate, and thermoplastic elastomers. The most modern and safe systems are made of thermoplastic elastomers or neutral polyurethane, however, imperfect cheap systems made of polyvinyl chloride and diethylhexyl phthalate are still widespread in Ukraine. Parenteral uptake of phthalates has antiandrogenic, antiestrogenic, antithyroid, carcinogenic, and mutagenic effects. This increases the risk of reproductive problems, diabetes, obesity. Special care should also be taken when using latex-containing systems, as 3-17 % of inpatients are allergic to latex. Anaphylactic shock can develop even 4 hours after surgery. Ukrainian company “Yuria-Pharm” produces modern phthalate-free systems, including a system for the introduction of light-sensitive solutions. There are also closed non-drop level systems designed for both gravity infusion and use with volumetric infusion pumps of open type. Automatic filling of the system due to the use of a purge filter with a hydrophobic membrane allows to reduce drug losses when filling the system, to reduce the risk of chemical contamination, and significantly save time to fill the system. The nurse also does not have to look for a drain tray when filling the system. The drip system filter with non-drop level function allows not to lose the required fluid level during massive infusion therapy, significantly save the nurse’s time spent on monitoring the fluid level in the vial and refilling the system, reduce the number of “alarm” staff calls, reduce risk and chemical contamination of the vial. In turn, closed systems with a graduated regulator are designed for the infusion of drugs that require accurate dosing and careful rate control throughout the infusion period (Flow Set). Conclusions. 1. Systems for intravenous administration are divided into systems for transfusion and systems for infusion. 2. The most modern and safe systems are made of thermoplastic elastomers or neutral polyurethane. 3. There are closed systems with non-drop level, designed for both gravity infusion and the use with volumetric infusion pumps. 4. Closed systems with a graduated regulator are designed for the infusion of drugs that require accurate dosing and careful rate control throughout the infusion period.

Implementing the 4Ms in a Rural Federally Qualified Health Center: Lessons Learned

The University of Louisville GWEP has partnered with Mountain Comprehensive Care, a FQHC with 9 practices in 5 rural counties in KY, to infuse the 4 M’s of age-friendly health care systems into their daily practices, namely what matters most, medication management, mentation and mobility. Many lessons were learned during this infusion period, specifically related to cultural and rural barriers that make some of these principles very difficult to implement. Specifically, what matters most to older adults in these very poor rural areas may not be the safest way to proceed; medication management may be difficult to do due to the extent of opioid addictions in these areas, mentation has many challenges related to isolation and lack of understanding of dementia and mobility issues are complicated due to the many home barriers to fall safety environments. These lessons will be discussed in this part of the symposium presentation.

Phase I trial of autologous cMET-directed CAR-t cells administered intravenously in patients with melanoma & breast carcinoma.

10035 Background: Advanced relapsed/refractory melanoma and metastatic triple-negative breast cancer are lethal diseases for which effective therapies are limited. We conducted a pilot phase I clinical trial (NCT03060356) to establish the safety and feasibility of intravenous autologous chimeric antigen receptor (CAR) T cell immunotherapy targeting cMET, a cell-surface antigen that is highly expressed in these cancers. Methods: Subjects had metastatic or unresectable melanoma (Mel) or triple-negative breast cancer (BC) with ≥30% expression of cMET on archival tissue or screening biopsy. Eligible subjects had measurable disease and progression on at least 1 prior therapy. Patients (pts) received up to 6 doses (1x108 total T-cells per dose) of RNA electroporated anti-cMET CAR T cells over a 2-week period without antecedent lymphodepleting chemotherapy. Subjects underwent pre- and post-infusion biopsies. The primary objective was to determine feasibility and safety of treatment. Results: 77 subjects (39 mel, 38 BC) were prescreened for tumor cMET expression and 37 (17 mel, 20 BC) met the eligibility threshold. Seven pts (4 BC, 3 Mel) received cMET-directed CAR T infusions on study. Mean age was 50 years (35-64); median (M) ECOG 0 (0-1); M prior lines of chemotherapy/immunotherapy were 4/0 for BC pts and 1/3 for Mel pts. 6 of 7 pts received all planned CAR T cell infusions, and 1 received 5 infusions. 5 pts experienced grade (G) 1 or G 2 toxicity that was possibly or definitely related to study. Toxicities occurring in ≥1 pt included: anemia (n = 3), fatigue (n = 2), and malaise (n = 2). No G ≥3 toxicities or cytokine release syndrome were observed. No pts discontinued therapy due to toxicity. Best response was stable disease in 4 pts (2 BC, 2 Mel) and PD in 3 pts (2 BC, 1 Mel). Messenger RNA signals corresponding to CAR T cells were detected by RT-PCR in the peripheral blood of all pts during the infusion period and in 2 pts after the infusion period. 6 pts underwent baseline biopsy and 4 pts underwent post-infusion biopsy. Immunohistochemical stains of CD3, CD4, CD8, CD163, L26, PD1, PDL1, Foxp3, Ki67, Granzyme B and Phospho-S6 were performed on pre- and post-treatment tissue biopsies and are being evaluated. Conclusions: Intravenous administration of RNA-electroporated cMET-directed CAR T cells was safe and feasible. Future directions include examination of this target using a lentiviral construct in combination with lymphodepleting chemotherapy. Clinical trial information: NCT03060356.

Loop Diuretic Administration in Patients with Acute Heart Failure and Reduced Systolic Function: Effects of Different Intravenous Diuretic Doses and Diuretic Response Measurements

Background: Despite the fact that loop diuretics are a landmark in acute heart failure (AHF) treatment, few trials exist that evaluate whether the duration and timing of their administration and drug amount affect outcome. In this study, we sought to evaluate different loop diuretic infusion doses in relation to outcome and to diuretic response (DR), which was serially measured during hospitalization. Methods: This is a post-hoc analysis of a DIUR-HF trial. We divided our sample on the basis of intravenous diuretic dose during hospitalization. Patients taking less than 125 mg of intravenous furosemide (median value) were included in the low dose group (LD), patients with a diuretic amount above this threshold were inserted in the high dose group (HD). The DR formula was defined as weight loss/40 mg daily of furosemide and it was measured during the first 24 h, 72 h, and over the whole infusion period. Outcome was considered as death due to cardiovascular causes or heart failure hospitalization. Results: One hundred and twenty-one AHF patients with reduced ejection fractions (EF) were evaluated. The cardiovascular (CV) death/heart failure (HF) re-hospitalization rate was significantly higher in the HD group compared to the LD group (75% vs. 22%; p < 0.001). Both low DR, measured during the entire infusion period (HR 3.25 (CI: 1.92–5.50); p < 0.001) and the intravenous diuretic HD (HR 5.43 [CI: 2.82–10.45]; p < 0.001) were related to outcome occurrence. Multivariable analysis showed that DR (HR 3.01 (1.36–6.65); p = 0.006), intravenous diuretic HD (HR 2.83 (1.24–6.42); p=0.01) and worsening renal function (WRF) (HR 2.21 (1.14–4.28); p = 0.01) were related to poor prognosis. Conclusions: HD intravenous loop diuretic administration is associated with poor prognosis and less DR. Low DR measured during the whole intravenous administration better predicts outcome compared to DR measured in the early phases. ClinicalTrials.gov Acronym and Identifier Number: DIUR-HF; NCT01441245; registered on 23 September 2011.

Comparing Survival for Different CAR Ts: Need for Addressing Bias Due to Differences in the Pre-Infusion Period

Introduction Patients with relapsed/refractory large B-cell lymphoma (RR-LBCL) treated with salvage chemotherapy have a poor prognosis, with a median survival of 6.3 months (Crump 2017). Given the recent approval of chimeric antigen receptor T-cell therapies (CAR T) for patients with RR-LBCL, efforts to demonstrate the comparative effectiveness of different CAR Ts are imminent. In the absence of head-to-head trials, such an assessment will likely be based on indirect or between-trial comparisons of reported survival estimates. Due to differences in the multi-step manufacturing process preceding the infusion of CAR T cells, the duration of the pre-infusion period, which accounts for time from leukapheresis to infusion, may vary across CAR Ts. This variability may be associated with differences in the prognostic characteristics of patients who endure the pre-infusion period. As such, comparisons of reported survival among these selected patients with the different CAR Ts evaluated in different trials may be biased. Estimating the comparative effects of CAR T therapies on survival requires careful attention to these potential differences and the use of thoughtful analytic approaches to address bias. We aimed to review current methodological approaches used to address bias related to time-to-treatment initiation and assess their potential utility in comparative analyses of CAR T based on between-trial comparisons. Methods A targeted literature review was performed to identify studies that used methods to adjust for bias related to time-to-treatment initiation when estimating relative treatment effects regarding survival outcomes between interventions in oncology. Relevant studies published in English from 2008 onwards were identified by searching the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica dataBASE (EMBASE). In addition, manual searches of the reference lists of the identified studies were performed. Studies that provided the most recent application of a proposed method were selected for inclusion. Results We identified several manuscripts that utilized methods to address survival or survival treatment selection bias (STSB) in observational studies where the classification of "treated" individuals required them to have survived until treatment initiation, and individuals who died early without the opportunity to get treatment were classified as "untreated". The identified methods to adjust for the over-estimation of the treatment effect include landmark survival and time-dependent exposure assignment. The landmark method restricts the analysis sample to patients who are event-free and alive at a given point (i.e, landmark) during follow-up; patients are assigned to risk groups based on their status at the landmark and survival outcomes are estimated from that point. Time-dependent exposure assignment addresses STSB by accounting for changes in patient exposure or treatment status during the course of follow-up. All patients begin in the same risk group; when exposure changes, patients and person-time are switched to the applicable risk group at that point. However, these methods do not address bias resulting from a comparison of reported survival estimates between different CAR Ts for a follow-up starting at the successful infusion of the CAR T cells. When comparing CAR Ts, the differences in prognostic patient characteristics due to differences in the pre-infusion phase are similar to channeling bias or confounding-by-indication. These concepts are well known, and established methods are available. However, those methods have limited applicability without access to individual patient data for the CAR Ts of interest. Conclusion Comparing survival upon successful infusion with different CAR Ts reported in separate studies is likely to be biased due to differences in the duration of the pre-infusion period. Methods previously used to address bias related to differences in time-to-treatment initiation may not be relevant or applicable, particularly in the absence of patient-level data. A between-trial comparison of reported survival estimates with the different CAR Ts might benefit from incorporating external evidence to inform the mortality during the pre-infusion periods. Disclosures Katz: Amgen: Other: Former employee and stockholder; Kite, a GILEAD Company: Consultancy. Lin:Kite/Gilead: Employment. Blaylock:Kite, A Gilead Company: Consultancy. Jansen:Kite, A Gilead Company: Consultancy.

Effect of IV glyburide on adjudicated edema endpoints in the GAMES-RP Trial

ObjectiveIn this secondary analysis of the Glyburide Advantage in Malignant Edema and Stroke (GAMES-RP) Trial, we report the effect of IV glyburide on adjudicated, edema-related endpoints.MethodsBlinded adjudicators assigned designations for hemorrhagic transformation, neurologic deterioration, malignant edema, and edema-related death to patients from the GAMES-RP phase II randomized controlled trial of IV glyburide for large hemispheric infarct. Rates of these endpoints were compared between treatment arms in the per-protocol sample. In those participants with malignant edema, the effects of treatment on additional markers of edema and clinical deterioration were examined.ResultsIn the per-protocol sample, 41 patients received glyburide and 36 received placebo. There was no difference in the frequency of hemorrhagic transformation (n = 24 [58.5%] in IV glyburide vs n = 23 [63.9%] in placebo, p = 0.91) or the incidence of malignant edema (n = 19 [46%] in IV glyburide vs n = 17 [47%] in placebo, p = 0.94). However, treatment with IV glyburide was associated with a reduced proportion of deaths attributed to cerebral edema (n = 1 [2.4%] with IV glyburide vs n = 8 [22.2%] with placebo, p = 0.01). In the subset of patients with malignant edema, those treated with IV glyburide had less midline shift (p < 0.01) and reduced MMP-9 (matrix metalloproteinase 9) levels (p < 0.01). The glyburide treatment group had lower rate of NIH Stroke Scale (NIHSS) increase of ≥4 during the infusion period (n = 7 [37%] in IV glyburide vs n = 12 [71%] in placebo, p = 0.043), and of change in level of alertness (NIHSS subscore 1a; n = 11 [58%] vs n = 15 [94%], p = 0.016).ConclusionIV glyburide was associated with improvements in midline shift, level of alertness, and NIHSS, and there were fewer deaths attributed to edema. Additional studies of IV glyburide in large hemispheric infarction are warranted to corroborate these findings.ClinicalTrials.gov identifierNCT01794182.Level of evidenceThis study provides Class II evidence that for patients with large hemispheric infarction, IV glyburide improves some edema-related endpoints.