Brief review: Angiotensin converting enzyme inhibitors and angioedema: anesthetic implications

PURPOSE: Angiotensin converting enzyme inhibitors (ACEIs) are a group of drugs used to treat hypertension and heart failure, with additional benefits, such as cardiovascular and renal protection, in patients with diabetes. However, angioedema as a complication of ACEI therapy is under-recognized. As there are important implications for anesthesiologists and emergency medicine physicians, a review was undertaken to document the scope of the problem of ACEI-induced angioedema.. METHODS: A review of the published literature (identified by searching Medline, EMBASE and CINAHL) was undertaken, addressing the clinical uses of ACEIs and the incidence, risk factors, pathophysiology, clinical presentation and management of angioedema associated with the use of these drugs. PRINCIPAL FINDINGS: The incidence of ACEI related angioedema has increased from 0.1-0.2% to 1% over the last decade. Patients who are receiving ACEIs are predisposed to developing angioedema which may be triggered by trauma, airway instrumentation, infection, and irritant fumes, particularly in those who are at increased risk. Cases of acute facial and airway oedema, due to ACEI drug administration, may be misdiagnosed as an anaphylactic reaction, and the association with ACEIs may be ignored. Some cases of intraoperative and postoperative airway edema may be precipitated by airway instrumentation in patients receiving ACEI drugs. The severity of airway compromise ranges from mild facial edema to severe laryngeal or subglottic edema which may prove life-threatening. CONCLUSION: In view of the widespread clinical indications and ever-increasing use of ACEI drugs, the potentially life-threatening adverse reaction of ACEI-associated angioedema, and its treatment, must be recognized by anesthesiologists and all clinicians involved in airway management.     

Vascular endothelial growth factor immunoneutralization in combination with cisplatin reduces EAC tumor growth

In the present study, we evaluated the effects of a neutralizing anti-Vascular Endothelial Growth Factor (VEGF) polyclonal antibody on murine EAC tumor growth both in vitro and in vivo. Furthermore, we investigated if in the presence of effective VEGF blockade, a conventional chemotherapeutic drug Cisplatin could be effective, and if so would there be an additive effect of the combination regimen. An in vitro cell proliferation assay using MTT kit showed that VEGF antibody alone inhibited proliferation of EAC cells significantly in all the three time intervals (p<0.05). But cisplatin treatment in combination with VEGF antibody resulted in highly significant inhibition (p<0.001) of cell proliferation. Apoptosis assay by FACS analysis showed that VEGF antibody-cisplatin combination treatment induced apoptosis in cultured EAC cells. Intraperitoneal administration of VEGF antibody (100 mug/dose) and cisplatin (0.5 mg/kg/dose) combination was observed to be more effective in reducing tumor burden and increasing life span when compared to VEGF antibody or cisplatin treatment alone in EAC solid tumor bearing mice. In EAC ascites tumor model, all the three types of treatment inhibited tumor burden and increased life span, but the inhibition was less compared to EAC solid tumor bearing mice. VEGF antibody singly and in combination with cisplatin reduced neoangiogenesis and vascular hyperpermeability. However, it is clear from the results that the combination treatment had no additive effect in reducing vascular hyperpermeability. Serum VEGF was not reduced significantly after treatment in EAC ascites tumor bearing mice, whereas in EAC solid tumor bearing mice it was reduced significantly after treatment. The results clearly show that though alone cisplatin showed antitumor efficacy but it had no significant inhibitory effect on neoangiogenesis and vascular hyperpermeability. Thus the present study suggests that anti-VEGF agent can be combined with traditional treatment modalities to ensure more effectiveness.     

Clinical review: Respiratory failure in HIV-infected patients - a changing picture

Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.     

Isolation and purification of vascular endothelial growth factor (VEGF) from ascitic fluid of ovarian cancer patients

Vascular Endothelial Growth Factor (VEGF) or Vascular Permeability Factor (VPF) is an angiogenic cytokine expressed by many human and animal tumors. Because of the importance of VEGF in animal tumors, we purified VEGF/VPF from ascitic fluid of ovarian cancer patients with heparin sepharose column. The purified protein gave protein bands of 37 and 26 kD, respectively in 12% SDS PAGE. The specificity of the purified protein was determined with dot blot, trans-immunoblot and ELISA using polyclonal goat anti-VEGF antibody (Santa Cruz Biotechnology). The vasodilatatory effect of the purified protein was confirmed by a vascular permeability assay on mouse. A polyclonal mouse antibody was raised against the purified protein, which recognized the same protein by ELISA, transimmunoblot and dot-blot analysis. It has been also found that the raised polyclonal antibody in mouse- and the commercial VEGF polyclonal antibody (Santa Cruz Biotechnology) both inhibited in vitrocell proliferation of human MCF-7 cell line. This study shows for the first time an effort to purify VEGF from human source.(Pathology Oncology Research Vol 10, No 2, 104–108)     

Tree Diversity and Ecosystem Carbon Stock Assessment in Nambor Wildlife Sanctuary,Assam

Proceedings of the National Academy of Sciences, India Section B: Biological Sciences - A study was carried out to assess tree diversity, forest carbon stock and carbon dioxide (CO2) sequestration...     

Localization of phosphate dependent glutaminase in ascites fluid of ovarian cancer patient

Phosphate dependent glutaminase was purified from ascites fluid of ovarian cancer patients. The purified enzyme showed a final specific activity of 110 unit / mg protein with 72 fold purification and 21% yield. Purified enzyme gives one dark band of Mr approximately 65.5 KD and two light bands of Mr approximately 47.5 KD and approximately 45 KD respectively on 10% SDS-PAGE. One major immunoreactive band was found in trans-immunoblot analysis using antibodies against rat kidney and ascites fluid glutaminase raised in rabbit and mice respectively. Phosphate dependent glutaminase enzyme purified from mitochondria of malignant and non malignant ovarian tissue also showed bands of same molecular weight on 10% SDS-PAGE and gave same immunoreactive bands in trans-immunoblot like the purified glutaminase from ascites fluid. This result was confirmed by using the specific activity stain for glutaminase, which indicates that same enzyme activity is probably due to leakage of the same enzyme from malignant tissue into the ascites fluid. The purified enzyme from human peritoneal fluid showed a high specificity toward glutamine, therefore is a true glutaminase. Moreover, ascites fluid taken from patients of different age group with different stages of ovarian carcinoma revealed the presence of same glutaminase on 10% SDS-PAGE, and exhibited immunoreaction on ELISA, trans-immunoblot and dot immunoblot analysis.     

Angiogenesis - A putative new approach in glutamine related therapy

Angiogenesis or the generation of new blood vessels, is an important factor regarding the growth of a tumor. Hence, it becomes a necessary parameter of any kind in therapeutic studies. Glutamine is an essential nutrient of tumor tissue and glutamine related therapy involves clearance of circulatory glutamine by glutaminase. So, whether this enzyme has any effect on angiogenesis of a tumor or not becomes an obvious question. To address this question, this study has been carried out with different murine tumor models.The results indicate that purified glutaminase reduces tumor volume as well as restricts the generation of new blood vessels. Glutaminase is effective in the case of solid as well as ascites tumor models. In the case of induced cancer, the host exhibits delayed onset of neoplasia following enzyme treatment and tumor host interactions determine the intensity of the neovascularisation process. Therefore, it can be concluded that this enzyme might be an effective agent against cancer metastasis.     

Modulation of metastatic potential of B16F10 melanoma cells by acivicin: synergistic action of glutaminase and potentiation of cisplatin cytotoxicity.

Treatment for metastatic melanoma has mostly been unsatisfactory despite advances in ongoing medical research. Here we investigated the role of acivicin, a glutamine analogue, singly and in combination with either E. coli glutaminase or cisplatin, on the growth, angiogenic activity and invasiveness of B16F10 cells in vitro and after allografting in C57BL/6 mice. B16F10 melanoma colonization in the lungs of mice was measured by monitoring colony counts. Host toxicity was assessed with reference to tumor bearing host's weight and survivability. Acivicin promoted melanoma dormancy and reduced melanoma associated angiogenic factors like VEGF level and vessel diameter. Acivicin in combination with glutaminase significantly suppressed tumor growth by 66.7% and increased life-span by 43.5% without host toxicity. Tumor VEGF content was significantly lowered by combination therapy as assessed by ELISA. Accelerated cytotoxicity, reduced invasion and enhanced apoptosis of melanoma cells were exhibited in vitro by combined than by single agent treatment. Moreover, invasion of melanoma cells through matrigel chambers was reduced in presence of acivicin and glutaminase combination. These findings support future studies of acivicin in combination with other anticancer agents for prevention of melanoma metastasis.     

Augmented antitumor effects of combination therapy with VEGF antibody and cisplatin on murine B16F10 melanoma cells

Our previous studies with EAC tumor model demonstrated that a VEGF polyclonal antibody combined with cisplatin inhibited tumor growth. Here we report the antitumor effect of VEGF antibody plus cisplatin on a murine metastatic tumor model specially emphasizing its effect on different angiogenic parameters both in vitro and in vivo. Mouse B16F10 melanoma cells were cultured in vitro in DMEM media containing 10% FBS, nonessential amino acids and antibiotics in a 5% CO(2) incubator at 37 degrees C and the effect of VEGF antibody singly and in combination with cisplatin on this cell was assessed by MTT assay, matrigel invasion study and MMP-9 expression study in vitro. In vivo studies were performed by two tumor models viz B16F10 solid tumor model and B16LuF10 lung tumor model. The mice treated with VEGF antibody (PAb) alone, cisplatin alone and combination of VEGF antibody and cisplatin on alternative days from the next day of tumor transplantation. Antitumor as well as antiangiogenic efficacy was monitored by measuring tumor burden, survivability, MVD measurement, serum NO value measurement and bcl-2 expression study. It was observed that administration of combined therapy with VEGF antibody and cisplatin augmented antitumor activity in B16F10 melanoma models than the either agents alone. Thus our experiments show a successful VEGF antibody based combination therapy with cisplatin and suggests that the enhancement of antitumor activity could be explained by a concomitant effect on both endothelial and tumor cell compartment.