Transcutaneous immunization with heat-labile enterotoxin: development of a needle-free vaccine patch

The skin is an attractive target for vaccine delivery. Adjuvants and antigens delivered into the skin can result in potent immune responses and an unmatched safety profile. The heat-labile enterotoxin (LT) from Escherichia coli, which acts both as antigen and adjuvant, has been shown to be delivered to human skin efficiently when used in a patch, resulting in strong immune responses. Iomai scientists have capitalized on these observations to develop late-stage products based on LT. This has encouraged commercial-level product development of a delivery system that is efficient, user-friendly and designed to address important medical needs. Over the past 2 years, extensive clinical testing and optimization has allowed the patch to evolve to a late-stage product. As a strategy for approval of a revolutionary vaccine-delivery system, the singular focus on optimization of LT delivery has enabled technical progress to extend patch-vaccine product development beyond LT. The field efficacy of the LT-based travelers' diarrhea vaccine has validated this approach. The discussion of transcutaneous immunization is unique, in that any consideration of the adjuvant must also include delivery, and the significant advances in a commercial patch application system are described. In this review, we integrate these concepts, update the clinical data and look to the future.     

Transcutaneous immunization with Intercell's vaccine delivery system

Transcutaneous immunization (TCI) has become an attractive alternate route of immunization due to increase understanding of the skin immune system and to recent technical innovations in skin patch delivery systems. Basic principles of TCI have been demonstrated in animal and human studies, covering a variety of bacterial, viral, and cancer diseases. At Intercell, we have advanced two major platforms of TCI: 1) a needle-free vaccine delivery patch (VDP) and 2) a vaccine enhancement patch (VEP). Simplified, the VDP contains an antigen with or without an adjuvant that is administered on the skin; while the VEP contains only the adjuvant and is used in combination with an injected vaccine. In many of our TCI studies, the VDP or VEP is routinely applied on pretreated skin, in which the stratum corneum has been partially removed by mild abrasion. Recently, we have achieved technical breakthroughs in formulating and stabilizing vaccines in a dry patch format. For instance, a microplate-based screening process has been implemented to rapidly identify excipients, singularly or in combination, to stabilize biological macromolecules in patch blend formulations. A second technical innovation is our nonwoven (patch) disc matrix-supported drying technology, which allows efficient drying of our patch formulation blend to produce dry stable dosage forms of VDP or VEP. The low cost and the facileness in the manufacturing of VDP (or VEP) combined with the development of thermostable dry patches should improve the supply chain efficiency and reduce the dependence on cold chain.     

Occurrence of extended spectrum beta-lactamase enzymes in clinical isolates of Klebsiella species from Harar region, eastern Ethiopia

Extended Spectrum beta-Lactamases (ESBLs) producer and multidrug resistant Klebsiella spp. are becoming a major nosocomial pathogen globally. There are no documented reports yet on the occurrence of ESBL enzymes in Klebsiella spp. species from Ethiopia. This study was undertaken to isolate and determine the occurrence of ESBLs and multi-drug resistant Klebsiella spp. in different clinical samples obtained from patients. A cross-sectional survey was conducted in four different hospitals of Harar region (Hiwot Fana, Misrak-Arbegnoch, Police and Army) from December 2003 to February 2004. Three hundred and eighty four clinical specimens (202 sputum, 164 urine and 18 pus) were collected from patients admitted in different wards. Antimicrobial susceptibilities were performed on 57 clinical isolates by standard disk diffusion procedures against eight antimicrobial agents. The ESBLs detection was made by using cefotaxime and ceftazidime alone and in combination with clavulanate. A total of 57 (15%) Klebsiella spp. were isolated from 384 patients. Of the 57 isolates, 33 (58%) were from sputum, 18 (31.5%) from urine and 6 (10.5%) from pus. Of the 57 Klebsiella spp., 54 (94.7%) were identified as K. pneumoniae and 3 (5.3%) as K. oxytoca. Resistance was found against cephalosporins [cefotaxime (39.0%), cefoxitin (39.0%), ceftazidime (40.0%), ceftriaxone (40.0%), cephalothin (42.0%)], chloramphenicol (70.0%), gentamicin (61.0%) and trimethoprim-sulphamethoxazole (65.0%). Analyzed Klebsiella isolates were characterized also by a high degree of multi-resistance (67.0%). In 19/57 (33.3%) of the Klebsiella isolates, ESBL production was detected. Rates of detection of ESBL producers were 42.1, 26.3, 26.3 and 5.3% in Hiwot-Fana, Misrak-Arbegnoch, Police and Army hospitals, respectively. Multi-drug resistant isolates were more prevalent among the ESBLs producers (95.0%) than non-producers (53.0%) (p=0.24). In conclusion, our results show that awareness of ESBL production by Klebsiella spp. is clinically important. In the absence of infection control measures, ESBL producing organisms readily pass horizontally from patient to patient. These strains also transiently colonize the hands of hospital staff members, thereby facilitating patient-to-patient transmission of the organism.     

Reversal of multidrug resistance in murine fibrosarcoma cells by thioxanthene flupentixol

Summary The purpose of this study was to identify calcium channel and calmodulin antagonists effective in increasing the cytotoxic effects of several chemotherapeutic drugs against UV-2237 murine fibrosarcoma MDR cells. Among 8 compounds tested at nontoxic concentrations, flupentixol, a piperazine-substituted thioxanthene, was the most potent in enhancing the cytotoxicity of anticancer drugs commonly associated with the multidrug resistant (MDR) phenotype, such as Adriamycin, actinomycin D, vinblastine, and vincristine, but not 5-fluorouracil, a drug usually unaffected by MDR. The chemosensitizing effects of flupentixol were produced by increasing intracellular drug accumulation via a mechanism unrelated to the binding of the plasma membrane P-glycoprotein.     

Introduction of Shigella flexneri 2a type and group antigen genes into oral typhoid vaccine strain Salmonella typhi Ty21a.

For protection against dysentery caused by Shigella flexneri 2a, an in vivo-constructed recombinant plasmid with genes specifying the S. flexneri type and group antigens located near the pro (min 6) and his (min 44) chromosomal markers, respectively, was made and transferred to the galE Salmonella typhi strain Ty21a. Strain Ty21a carrying this recombinant plasmid was shown by immunological and biochemical analyses to express the S. flexneri 2a type and group antigens. Mice immunized with this vaccine strain were found to be protected against challenge with virulent S. flexneri 2a, but not significantly against S. typhi challenge, presumably because synthesis of the Shigella antigens interfered with expression of the typhoid antigens. Elimination of the recombinant plasmid from Ty21a allowed this strain to again express typical S. typhi O antigens. Mouse protection against both S. typhi and S. flexneri 2a challenges was achieved with a whole-cell vaccine mixture composed of equal parts of Ty21a and the Ty21a-S. flexneri 2a hybrid strain.     

Actinomycosis of the middle ear

Actinomycosis is an uncommon infection of the middle ear. Only 21 cases of actinomycosis of the middle ear have been reported in the English literature prior to this paper. The offending organism is Actinomyces israelii, which is an anaerobic, filamentous organism that is difficult to grow in culture. The infection is chronic and is seldom diagnosed prior to tympanomastoidectomy. The identification of small, yellow, glue-like masses, which are called sulfur granules, is often the key to making the diagnosis of actinomycosis of the middle ear. Following tympanomastoidectomy, penicillin is given orally for 3-6 months.     

Incidence of complications following laparoscopic hernioplasty

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Multifactorial Preoperative Predictors for Postcesarean Section Pain and Analgesic Requirement

Background: The study aimed to determine predictive factors for postcesarean pain and analgesia using an assessment of pain threshold and suprathreshold thermal stimuli as well as degree of somatization and anxiety.

Methods: Thirty-four healthy parturients scheduled for cesarean delivery under subarachnoid anesthesia were enrolled. Preoperative thermal pain threshold, intensity, and unpleasantness to heat stimuli applied to arm and lower back, State Trait Anxiety Inventory, and patient expectation for postoperative pain and need for analgesia were assessed. After surgery, overall, resting, and movement pain and analgesic consumption were recorded. Prediction of pain and analgesic use outcomes was made by principal component factor analysis, followed by stepwise linear regression.

Results: Resting pain was predicted by two factors, thermal pain and unpleasantness and patient expectation (r2 = 0.26, P < 0.01), evoked pain by thermal pain threshold in the back (r2 = 0.20, P < 0.009), composite pain by thermal pain and unpleasantness and preoperative blood pressure (r2 = 0.28, P < 0.008), intraoperative analgesic need by preexisting pain (r2 = 0.22, P < 0.006), recovery room analgesia by thermal pain threshold and State Trait Anxiety Inventory (r2 = 0.27, P < 0.01), and total analgesic need by State Trait Anxiety Inventory (r2 = 0.22, P < 0.01). These models predicted the upper twentieth percentile of composite pain scores and analgesic requirement with sensitivity of 0.71 to 0.80 and specificity of 0.76 to 0.80.