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Abstract The purpose of this double-blind, placebo-controlled study was to measure the effects of FTY720, a novel immunomodulator, on heart rate and rhythm in healthy volunteers. Subjects (n = 66) were randomized to FTY720 1.25 mg or 5 mg or placebo administered once daily for 7 days. Continuous telemetry revealed an acute, dose-dependent decrease in mean heart rate (10-bpm decrease vs placebo) following the first dose of FTY720, with a nadir generally 4 hours postdose. Although a persistent FTY720-related decrease in heart rate was measured from day 2 to day 7, additional doses of FTY720 after day 2 resulted in no further incremental decreases. Mean PR interval increased by approximately 8 to 10 msec in FTY720-treated subjects on day 1. FTY720 did not increase the QRS or QT interval. These results confirm that the first dose of FTY720 has a mild to moderate negative chronotropic effect.
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FTY720 is a novel immunomodulator that acts as a sphingosine-1-phosphate (S1P) receptor agonist, thereby reducing the recirculation of lymphocytes to blood and peripheral tissues, including inflammatory lesions and graft sites. – In contrast to classic immuno-suppressants, FTY720 does not impair cellular or humoral immunity to systemic viral infection and does not affect the activation, expansion, or proliferation of T lymphocytes or immunological memory in preclinical models. FTY720 was effective in prolonging allograft survival in preclinical models of cardiac, renal, and hepatic transplantation. Furthermore, a synergistic effect was noted when FTY720 was used in combination with subtherapeutic or therapeutic doses of cyclosporine in a number of different allograft models. The results of phase II clinical studies demonstrated that FTY720 can be used effectively and safely in combination with classic immunosuppressive agents, including cyclosporine and everolimus.
FTY720 has been well tolerated in comparative studies conducted in renal transplant recipients to date. However, a recurring finding in these trials has been a reduction in heart rate with initiation of FTY720 treatment. – This negative chronotropic effect appears to be temporally associated with the first dose of FTY720. A nadir in heart rate is observed within 4 to 12 hours of drug administration, with heart rate recovering close to baseline within 48 hours after a single dose of FTY720. – The mechanism underlying the effect of FTY720 on heart rate appears to be mediated by its capacity to agonize S1P receptors in the heart. Animal studies have shown that S1P receptors are present in the heart, especially in atrial myocytes, and that S1P can signal to these receptors, resulting in decreased heart rate.
– Koyrakh et al confirm that FTY720 shares these features with S1P, with both agents able to activate the cardiac G-protein-gated potassium channel I. Decreased heart rate is a commonly reported adverse event experienced early in the posttransplant course and may be due to multiple factors, including increased vagal tone from general anesthesia, reduced gut function, and perioperative pain. In one clinical study with FTY720 following de novo renal transplantation, the rate of bradycardia adverse events in patients randomized to mycophenolate mofetil was 5%.
In contrast, the rate of bradycardia in FTY720-treated subjects was 26% to 30%. The majority of these bradycardia events did not require medical intervention; however, 11% to 14% were treated with short courses of atropine and/or beta agonists. There was no measurable increase in mortality and/or cardiac morbidity in either the mycophenolate mofetiltreated or FTY720-treated groups. –, The current study was designed to measure the effect of FTY720 on cardiac rate and rhythm in healthy subjects.
Although the effect of FTY720 on heart rate has been described briefly in renal transplant recipients, there are many confounding variables contributing to heart rate changes in transplant patients, such as autonomic and cardiovascular comorbidities and concomitant medications, which complicate the assessment of this dynamic effect of FTY720 in this patient group. Given these constraints, the current study used a placebo-controlled, randomized design to rigorously collect heart rate and rhythm data in healthy subjects. The purpose of this study was to definitively measure the effect of FTY720 on heart rate and rhythm and, in addition, to characterize the effect of interventions on these effects. METHODS Study Design This was a single-center, double-blind, parallel-group, placebo-controlled, multiple-dose study conducted in healthy subjects. The protocol was approved by the Research Consultant's Review Committee (Austin, Tex). All subjects gave written informed consent to participate in the trial. A total of 66 eligible subjects were enrolled, and 60 subjects completed the study.
All discontinuations occurred during the run-in period before subjects received FTY720. The 60 subjects who completed the study were 32 men and 34 women, aged 18 to 44 years and weighing 50 to 111 kg. All subjects were required to have a resting heart rate greater than 50 beats per minute (bpm) and systolic blood pressure (BP) and diastolic BP within the ranges of 90 to 140 mm Hg and 50 to 90 mm Hg, respectively. The in-center portion of the study included a 2-day placebo run-in phase; an 8-day treatment/evaluation phase during which subjects were randomized to receive once-daily dosing with FTY720 1.25 mg, FTY720 5 mg, or matching placebo for 7 days; and an end-of-study evaluation on day 8, after which participants were discharged from the study center. Subjects fasted overnight before administration of study medication at approximately 8:00 am and consumed at least 200 mL of fluid every 4 hours during the waking hours of the study.
Unless performing a study assessment, subjects were required to rest quietly in an upright position for 4 hours after administration of medication. In addition to cardiac monitoring described below, the study also measured the general tolerability of FTY720, its pharmacokinetics, and its effect on lymphocyte counts as reported previously. Assessments of Cardiac Function Assessments of cardiac responses to FTY720 and placebo administration included 12-lead electrocar-diography (ECG), Holter monitoring, telemetry, and pressor and exercise stress tests. 12-Lead ECG: Conduction Intervals The primary pharmacodynamic measurement of the effect of FTY720 on conduction intervals used serial 12-lead ECG.
Tracings were recorded every 2 hours over 24-hour intervals on the placebo baseline Day -1 and the FTY720 or placebo treatment days 1 and 7. Conduction intervals (QRS, PQ, PR, RR, QT) were measured by manual digitization. The QT interval was corrected for heart rate (QTc) using Bazett's (QTcB), Frederica's (QTcF), and individual (QTcI) correction methods assuming a power model.
Time-averaged QT or QTc intervals were derived by averaging the within-subject observations from 12-lead ECGs obtained over the course of the day. Holter Monitoring: Total Daily Heartbeats, Arrhythmia Detection, Sinus Pauses, and Conduction Blocks Five-lead Holter monitoring at baseline, day 1, and day 7 was used to measure the total number of heartbeats over a 24-hour period (8:00 am to 8:00 am) and to record the frequency and duration of sinus pauses, conduction blocks, and ectopy.
Telemetry: Safety, Hourly Mean Heart Rate, Events Outside of Holter Monitoring Intervals, and Heart Rate During Interventions Telemetry was used to continuously monitor the heart rate of all subjects while they were in the study center from baseline through day 7. These data were continuously stored in a database, which allowed the calculation of a mean hourly heart rate by hour and day for each subject. The effect of FTY720 on the hearts' autonomic response to extrinsic factors was evaluated by the cold pressor test (CPT) and exercise stress test (EST) on days -2, 2, 4, and 6.
The CPT was used to evaluate parasympathetic vagal function; typically, this test results in reduced heart rate. Resting heart rate was collected for a 10-minute interval, after which subjects immersed a hand in an ice bath for 2 minutes.
Following immersion, subjects remained in a resting state while heart rate was collected over the next 10 minutes. The EST employed a modified Bruce protocol and was used to evaluate cardiac response to sympathetic stimuli; typically, this protocol results in a staged increase in heart rate. Resting heart rate was collected for 10 minutes before exercise induction. Exercise intensity was then increased every 3 minutes over the following 12 minutes. Subjects were allowed to rest over the next 2 minutes, and heart rate continued to be monitored for a further 8 minutes.
Blood Pressure Predose BP measured by automated cuff was collected daily throughout the study. In addition, standing and supine BP was collected predose and at 1, 2, 3, 4, 5, 6, 7, 8, and 10 hours after FTY720 or placebo administration on day 1.
These data were used to construct 2 measures of effect: the mean area under the BP effect curve during the 12-hour period (AUE 0–12) and the mean minimum blood pressure over the same period. Mean BP over the 12-hour period was derived by dividing the AUE 0–12 by 12. Statistical and Exposure—Response Analyses Separate analysis of covariance (ANCOVA) was performed for each of the derived pharmacodynamic parameter data sets: hourly mean heart rate, cardiac conduction intervals, and BP, with treatment as a factor and baseline value as a covariate. P values and 95% confidence intervals (CIs) were derived from pairwise comparisons between treatments within the ANCOVA to evaluate treatment effect.
As reported previously, a 24-hour area under the FTY720 concentration-time curve (AUC 0-24) was measured on days 1 and 7, and morning trough FTY720 blood levels were collected on days 2 through 6. A scatterplot of the day 1 AUC 0-24 versus nadir heart rate was generated, and an inhibitory E max model was fit to the data. The model was parameterized as follows: E = E0 - (E max C)/EC 50 + C), where E0 is the nadir heart rate in the placebo group, E max is the maximal effect of FTY720 on the nadir heart rate (ie, the lowest heart rate nadir), C is the FTY720 AUC 0-24, and EC 50 is the AUC 0-24 at which half-maximal response occurs.
RESULTS Heart Rate The mean total heartbeat data collected over a 24-hour period at baseline and on days 1 and 7 measured by Holter monitoring are summarized in. All 3 groups had similar baseline mean total heartbeat data reflecting the homogeneity of these healthy subjects. In contrast to the placebo group, both the FTY720 1.25-mg and FTY720 5-mg groups manifested a significant decrease in the mean total number of heartbeats on day 1 compared with baseline, exhibiting a modest FTY720 dose effect (−12.6% P. Table I. Holter Monitor Event Data Placebo FTY720 1.25 mg FTY720 5 mg Parameter Baseline Day 1 Day 7 Baseline Day 1 Day 7 Baseline Day 1 Day 7. P. Mean hourly heart rate (HR) recorded by continuous telemetry on (a) day 1 and (b) day 7 after administration of FTY720 1.25 mg, FTY720 5 mg, or placebo. The arrow indicates time of dosing.
During days 2 to 6, both FTY720 treatment groups had a similar mean heart rate, which was consistently lower than that in the placebo group by approximately 4 to 10 bpm; however, the diurnal pattern of heart rate variation was similar in all groups (data not shown). Even though FTY720- treated subjects received an additional 6 days of once-daily FTY720 dosing after day 1 with increasing drug blood levels, no additive, acute effect of FTY720 treatment on heart rate was apparent on day 7. Instead, the mean heart rate in the FTY720 treatment groups showed a trend toward the value of the placebo group (eg, hour 23 in ). To provide information on variability and individual outliers, we replotted the data shown in as boxplots showing the central value and spread in. FTY720 treatment did not appear to increase the variability of hourly mean heart rate when compared with the placebo group.
No subjects manifested heart rates lower than 40 bpm in any group. Boxplots of hourly heart rate recorded by telemetry on day 1 after administration of FTY720 1.25 mg, FTY720 5 mg, or placebo. The box extends from the first to the third quartile and is divided at the median; the bars are at 1.5 interquartile range from the edges.
Open circles outside the bars denote outliers. Cardiac Conduction Intervals Mean QRS change from baseline was comparable for all groups on days 1 and 7. There was a significant increase in the mean PR interval on day 1 following both FTY720 1.25 mg ( P =.006) and 5 mg ( P =.002) versus placebo (7.5 and 9.5 msec vs 0.0 msec, respectively). However, by day 7, the effect of FTY720 on the PR interval had diminished, and no significant increase in the change of the mean PR interval from baseline was noted when comparing FTY720 treatment groups with those receiving placebo. Consistent with FTY720's effect of slowing sinus rhythm, there was a significant increase in the mean RR interval from baseline on both days 1 and 7 following FTY720 1.25 mg and 5 mg versus placebo (day 1: 96.7 msec P.
Plot of individual changes in QT/QTc at the time of peak FTY720 blood levels from mean baseline QT/QTc versus FTY720 peak blood level. The dotted line indicates theoretical line of no change, and the continuous line indicates simple linear regression. Arrhythmia Detection No atrial fibrillations were noted on Holter monitoring in FTY720-treated subjects, and there was no increase in the rate of ventricular ectopy when compared with the placebo group. There appeared to be an increase in the rate of supraventricular ectopy following FTY720 5 mg on day 1 compared with baseline; however, this effect attenuated by day 7. The supraventricular ectopy consisted almost entirely of premature atrial beats.
Sinus Pauses and Conduction Blocks On day 1 of treatment, there was an increased incidence of low-grade sinus pauses lasting 2 to 3 seconds in all groups; however, the frequency of this event was higher in FTY720 treatment groups and was dose dependent (25 and 116 events in the FTY720 1.25- and 5-mg groups, respectively, vs 13 in the placebo group). Inspection of the Holter records of these low-grade sinus pauses revealed that these events were almost entirely the result of sinus arrhythmia superimposed on transient periods of low nadir heart rate (32–35 bpm) in a small number of subjects. No high-grade sinus pauses greater than 3 seconds were detected in either FTY720 treatment group on day 1, and no sinus pauses were detected in any group by day 7.
No third-degree or second-degree type 2 atrioven-tricular (AV) blocks were observed during the study. Six subjects exhibited transient, second-degree, type 1 AV block (Wenckebach) events. Of these events, 3 occurred during the placebo run-in period, whereas the other 3 occurred in FTY720-treated subjects 1, 5, and 15 hours after administration on day 1. All subjects experiencing AV block were asymptomatic and required no medical intervention. No AV blocks were identified by Holter monitoring on day 7, and there were no new-onset AV blocks identified by telemetry on days 2 to 6. Heart Rate Interventions Cold Pressor Test Using telemetry, the CPT evaluated the cardiac response to increased vagal stimuli in the setting of placebo or FTY720 treatment. On Day -2, a slight slowing of heart rate of approximately 6 bpm in response to CPT was seen in all groups (data not shown); CPT data obtained from day 2 are shown in.
Although resting heart rate was reduced in both FTY720 groups, all 3 groups manifested a similar, approximately 5-bpm decrease in heart rate in response to the CPT. Similar CPT findings were seen on days 4 and 6 (data not shown). Mean heart rate (HR) during cold pressor testing on day 2 after administration of FTY720 1.25 mg, FTY720 5 mg, or placebo. The horizontal line indicates the period during which the subject's hand was immersed in an ice bath (minutes 10–12). Exercise Stress Test The EST measured the capacity of the heart to increase heart rate in response to exercise in the setting of placebo or FTY720 treatment. On Day -2, all 3 groups had a similar staged increase in mean heart rate in response to exercise (data not shown).
The mean heart rate during EST by group on day 2 is shown in; both FTY720 treatment groups had lower mean heart rates than those observed in the placebo group (∼60 bpm vs ∼85 bpm). However, all 3 groups had very similar trajectories of heart rate increase in response to exercise. Both FTY720 1.25- mg and 5-mg treatment groups displayed a significantly greater percentage change (78%, P =.028 and 94%, P. Mean heart rate (HR) during exercise stress testing on day 2. The recovery period is indicated by the horizontal line. Blood Pressure On day 1, FTY720 5-mg treatment was associated with a significant decrease in systemic BP when compared with placebo ; both the supine systolic and diastolic AUE 0–12 decreased by approximately 5% to 6% ( P.
Table II. Supine and Standing Blood Pressure Over 12 Hours Postdose on Day 1 Supine Standing Parameter SBP DBP SBP DBP. Values are mean ± standard deviation. SBP, systolic blood pressure; DBP, diastolic blood pressure; AUE 0-12, area under the effect curve over 12 hours postdose. Scatterplot of FTY720 area under the concentration-time profile AUC 0-24 on day 1 versus the nadir heart rate.
The line shown is the best fit of an inhibitory E max model to the data. DISCUSSION This study is the first clinical trial to rigorously measure the effect of daily dosing with FTY720 on heart rate and rhythm under blinded, placebo-controlled, randomized conditions. The study also included cold pressor and exercise stress testing to allow assessments of the effect of vagal and adrenergic stimulation in the setting of FTY720 treatment. A single administration of either 1.25 or 5 mg FTY720 was shown to produce a significant acute reduction in heart rate after the first FTY720 dose. The onset of heart rate reduction appeared to be dose dependent and occurred during the initial 4-hour period after FTY720 administration, with the effect then diminishing over the following 12 hours. Unlike previous clinical trials with FTY720, this study included continuous cardiac monitoring, which enabled the effect of FTY720 on cardiac morphology, conduction intervals, and autonomic responsiveness to be evaluated. Continuous telemetry demonstrated that the onset of the effect of FTY720 on heart rate was rapid and sustained in both dose groups.
Furthermore, it appeared that the resting heart rate attained a lower set point of approximately 10 bpm following daily administration of FTY720, which was sustained for the remainder of the 7-day dosing interval. No incremental decrease in heart rate occurred after day 1 with additional daily doses of FTY720. An inhibitory E max model estimated that the effect of FTY720 on heart rate nadir is near maximal with a single 1.25-mg dose of the drug.
Thus, FTY720 doses higher than 5 mg are not expected to result in any further decrease in heart rate. Over the 7-day treatment course of this study, the mean heart rate in both FTY720 treatment groups was lower than in the placebo group.
However, there are several lines of evidence that even at 7 days, the effect of FTY720 on the heart was beginning to wane. First, the total number of heartbeats per day had returned to within 3% of baseline values by day 7. Second, the higher rate of sinus pauses measured in the FTY720 treatment groups decreased to 0 by the last day of the study. In addition, the significantly prolonged mean PR interval seen at day 1 in those receiving FTY720 treatment had almost completely resolved by day 7. Finally, the difference in mean systolic and diastolic BP between the FTY720 5-mg and placebo groups had diminished to only 2 to 3 mm Hg by day 7.
This attenuation of the effect of FTY720 on the heart with continued dosing is supported both by clinical and Holter data obtained from a phase II trial of FTY720 in de novo renal transplantation in which, beyond 2 weeks of treatment, mean heart rate was identical in the FTY720 and comparator groups. Although the mechanism of this adaptive, homoeostatic response of the heart is not fully elucidated, Matloubian et al showed that S1P receptors located on lymphocytes are internalized during FTY720 treatment and no longer available for signaling. S1P receptors on atrial myocytes responding in a similar way to chronic FTY720 dosing could explain this adaptive phenomenon. Despite the fact that FTY720 treatment resulted in a new heart rate set point during the 7-day treatment period, FTY720-treated subjects displayed normal responses to both CPT and EST, indicating that vagal and adrenergic stimulatory responses were intact. Furthermore, normal circadian patterns in heart rate were observed over the 8-day monitoring period in subjects receiving FTY720. These data suggest that the response of the heart to both intrinsic and extrinsic autonomic stimuli is intact during multiple-dose FTY720 1.25 or 5 mg. Holter monitoring demonstrated that FTY720 treatment was not associated with any atrial fibrillation or with an increase in the rate of ventricular ectopy.
When administered at a 5-mg dose, FTY720 appeared to increase the frequency of premature atrial beats in some subjects on day 1; however, this treatment effect appeared to attenuate by day 7. In addition, a dose-dependent increase in the incidence of low-grade sinus pauses (2–3 seconds) was also apparent following the administration of the first dose of FTY720. This effect also diminished by day 7 of treatment, with no sinus pauses detectable in FTY720 treatment groups by day 7. Asymptomatic and transient second-degree, type 1 AV block (Wenckebach) was detected in 6 subjects during the study. Half of these events occurred in the placebo group, whereas the other half occurred in FTY720-treated subjects on day 1 of treatment.
No new-onset AV blocks were identified by telemetry on days 2 to 6. It is possible that these benign AV block events may be due to the effect of higher vagal tone associated with the stress of participating in a clinical trial involving intensive monitoring or may represent the background rate of this event in a relatively young and healthy population.
However, given these events and the activity of FTY720 on the sinoatrial node, it is likely that FTY720 also has some AV nodal effects. The principal pharmacological effect of FTY720 appears to result in more refractory AV nodal conduction, similar to that seen with increased vagal tone. Human electrophysiology studies would help to better elucidate the AV nodal effects of FTY720. The mean ECG QRS interval remained similar in the FTY720 and placebo groups. The ECG PR interval was increased on day 1 of FTY720 treatment. Consistent with the negative chronotropic effect of FTY720, a significant increase in the ECG RR interval was also observed with treatment. There was no consistent dose- or concentration-dependent effect of FTY720 on the QT interval.
This finding is consistent with all in vitro studies with FTY720 to date, which show that the agent should have no effect on cardiac repolarization (data on file, Novartis Pharma AG, Basel, Switzerland). FTY720 5-mg/d treatment was associated with a mild, significant, dose-dependent decrease in systemic BP of approximately 5% to 10% on the first day of treatment. Whereas this effect was clearly seen in the FTY720 5-mg cohort, the FTY720 1.25-mg cohort manifested this effect to a lesser, statistically nonsignificant degree. Over the remaining 6 days of daily dosing, it was difficult to detect a clear effect of FTY720 on BP, with a decrease of 2 to 3 mm Hg being observed at most.
The mechanism of this acute, mild effect of FTY720 on BP is currently not known. One possibility is that the acute heart rate—reducing effect of FTY720 may have transiently lowered BP.
Research on noncardiac effects of FTY720 (eg, vascular effects of the drug) is currently ongoing. The findings of this study are consistent with those of clinical trials with FTY720 in maintenance renal transplant patients, which suggest that the agent mildly reduces heart rate., Similar to the current study, the effect of FTY720 on heart rate in renal transplant patients was temporally associated with administration of the first dose of the drug and a nadir heart rate at 4 to 12 hours postdose.
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Signs or symptoms of this lower heart rate returned close to baseline within the first 48 hours of treatment, and subsequent doses caused no further reduction. Most subjects experiencing bradycardia in these studies were asymptomatic and required no medical intervention; no further ECG abnormalities were observed, and there were no specific changes in BP values., In the current study, the effect of FTY720 on heart rate was dose dependent over the initial 4-hour period after dosing, with the effect diminishing over the following 12 hours. This effect was also observed following a single administration of FTY720 0.25 to 3.5 mg in stable renal transplant recipients; however, no dose-dependent effect of FTY720 on heart rate was observed in renal transplant recipients following multiple dosing. These findings are consistent with the agonism of S1P receptors on the heart being an evident but relatively weak regulatory input to heart rate, which can be compensated for by competing regulatory pathways. The mechanism of FTY720's effect on heart rate is becoming increasingly clear. In 1996, Bunemann et al reported the discovery of a G-protein-coupled receptor present in guinea pig atrial myocytes that was signaled by S1P. Three years later, Guo et al showed that S1P resulted in slowing of the rabbit sinoatrial node, and it was later proposed that S1P was a naturally occurring regulator of the heart.
FTY720, in its phosphorylated in vivo form, shares both structural and functional homology to S1P. FTY720-phosphate targets multiple S1P receptors, including S1P 1 and S1P 3, with an EC 50 almost identical to that of S1P. 1 Chiba K, Yanagawa Y, Masubuchi Y, et al. FTY720, a novel immunosuppressant, induces sequestration of circulating lymphocytes by acceleration of lymphocyte homing in rats: I. FTY720 selectively decreases the number of circulating mature lymphocytes by acceleration of lymphocyte homing.
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6 Walker R, Ferguson RM, Mulgaonker S, et al. FTY720 with reduced cyclosporine exposure is efficacious in preventing rejection in renal transplantation: 12-month preliminary results. Presented at: World Congress of Nephrology; June 8–12, 2003; Berlin. Abstract T680.
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Presented at: the World Congress of Nephrology; June 8–12, 2003; Berlin. Abstract T679. 8 Budde K, Schmouder RL, Brunkhorst R, et al. First human trial of FTY720, a novel immunomodulator, in stable renal transplant patients. J Am Soc Nephrol 2002; 13: 1073– 1083. 9 Kahan BD, Karlix JL, Ferguson RM, et al.
Pharmacodynamics, pharmacokinetics, and safety of multiple doses of FTY720 in stable renal transplant patients: a multicenter, randomized, placebo-controlled, phase I study. Transplantation 2003; 76: 1079– 1084. 10 Liliom K, Sun G, Bunemann M, et al. Sphingosylphosphocholine is a naturally occurring lipid mediator in blood plasma: a possible role in regulating cardiac function via sphingolipid receptors. Biochem J 2001; 355: 189– 197. 11 Guo J, MacDonell KL, Giles WR. Effects of sphingosine 1-phosphate on pacemaker activity in rabbit sino-atrial node cells.
Pflugers Arch 1999; 438: 642– 648. 12 Mazurais D, Robert P, Gout B, Berrebi-Bertrand I, Laville MP, Calm T. Cell type-specific localization of human cardiac S1P receptors. J Histochem Cytochem 2002; 50: 661– 670. 13 Koyrakh L, Roman MI, Brinkmann V, Wickman K. The heart rate decrease caused by acute FTY720 administration is mediated by the G protein-gated potassium channel I. Am J Transplant 2005; 5: 529– 536.
14 Ferguson R. FTY720 immunomodulation: optimism for improved transplant regimens. Transplant Proc 2004; 36 ( suppl 2): 549S– 553S.
15 Kovarik JM, Schmouder R, Barilla D, Riviere GJ, Wang Y, Hunt T. Multiple-dose FTY720: tolerability, pharmacokinetics, and lymphocyte responses in healthy subjects.
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Methods of exercise testing: step test, bicycle, treadmill, isometrics. Am J Cardiol 1974; 33: 715– 720. 17 Jardine A, Grinyo JM, Mulgaonkar S, Ferguson RM, Cremer M, Preiss R. FTY720, a sphingosine-1-phosphate receptor agonist, does not elicit adverse effects on cardiac rhythm in renal transplant patients on maintenance therapy. Presented at: American Transplant Congress; May 15–19, 2004; Boston. Abstract 1040. 18 Matloubian M, Lo CG, Cinamon G, et al.
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A novel membrane receptor with high affinity for lysosphingomyelin and sphingosine-1-phosphate in atrial myocytes. EMBO J 1996; 15: 5527– 5534. 20 Brinkmann V, Davis MD, Heise CE, et al. The immune modulator FTY720 targets sphingosine 1-phosphate receptors. J Biol Chem 2002; 277: 21453– 21457.
21 Forrest M, Sun SY, Hajdu R, et al. Immune cell regulation and cardiovascular effects of sphingosine 1-phosphate receptor agonists in rodents are mediated via distinct receptor subtypes. J Pharmacol Exp Ther 2004; 309: 758– 768.
22 Sanna MG, Liao J, Jo E, et al. Sphingosine 1-phosphate (S1P) receptor subtypes S1P1 and S1P3, respectively, regulate lymphocyte recirculation and heart rate. J Biol Chem 2004; 279: 13839– 13848. Related content.
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