M.J. Welsh and A.E. Smith, RAC Application 
Ad2-ORF6/PGK-CFTR 
Item 5 - Clinical Protocol 
Timing of Evaluations and of Repeat Administrations 
Timing of pretreatment evaluations and repeat administrations are the same as in Part A of this protocol. 
The flow sheet shows the timing of specific interventions and evaluations. 
Timing of Initiation of Study. 
We will not begin Part B of this study until we have administered a dose of 2xl0 9 IU to at least two 
patients in Part A. We will also use the data from Part A to guide us in Part B. For example, if we find 
evidence of a response to Ad2-ORF6/PGK-CFTR that would suggest problems with safety, we will 
delay Part B until the source of the problems can be identified and solved. 
Vector Application to the Maxillary Sinus. 
Patients will be admitted to the Clinical Research Center at the University of Iowa. After vector 
administration, they will be placed in isolation in a hospital room for one day. They will be discharged 
from the hospital the day after Ad2-ORF6/PGK-CFTR administration. 
The patient's nose will initially be suctioned free of any excess 
mucus. It will then be sprayed with a solution of 2% Pontocaine 
and 1/4% Neo-Synephrine. In addition, as mild sedation and to 
minimize movement during the application, they will also receive 
Midazolam 1-2 mg. IV. shortly before application. Five min 
after spraying, the nose will be endoscopically examined. At 
this stage, under endoscopic control, cottonoid neurosurgical 
pledgets soaked in a solution of 5% cocaine (to a maximal dose 
of 100 mg) will be placed high in the inferior meatus. After 15 
min the pledgets will be removed. The inferior meatus will be 
visualized using a headlight and a Lichtwitz cannula introduced 
into the maxillary sinus via the inferior meatus (Fig. 2). This 
cannula is introduced high in the inferior meatus near the apex of 
the attachment of the inferior turbinate in the thin bone and 
membranous portion of the lateral nasal wall (42,43). This 
procedure is a very common, simple outpatient procedure in the 
Otolaryngology Clinic. 
Fluid will be removed from the maxillary sinuses and evaluated for: a) quantitative bacteriologic cultures 
(both aerobic and anaerobic); b) cytologic analysis for total and differential white blood count; c) 
evaluation of inflammatory cytokines and mediators including IL-1B, IL-8, and TNF (44-46); these 
agents are associated with inflammatory airway disease in CF; d) type-specific and neutralizing antibod}' 
to adenovirus. The maxillary sinuses will then be lavaged with saline several times and we will measure 
transepithelial voltage (V t). Although we have not previously measured V t in the maxillary sinuses, we 
will use methodology similar to that which we use in the nasal epithelium. 
After completion of these procedures, both maxillary sinuses will be cannulated with indwelling Silastic 
flanged tubes. The soft flanges will maintain the tubes in the sinuses. The other end of the tube will be 
taped to the cheek. Maxillary sinus lavage with antibiotics will be continued three times a day for seven 
days. The choice of antibiotics will initially be guided by previous cultures from the patient and then by 
results of our cultures from the maxillary sinuses. For example, lavage with 40 mg tobramycin three 
times a day is frequently used (30). After such treatment, previous studies have shown that the maxillary 
sinuses are relatively free of mucus and thus should be accessible to the applied vector. Of importance, 
even with such treatment, the mucosa will remain thickened and the secretions invariably reaccumulate. 
On the 8th day, we will repeat the lavage and make the measurements described above, including a 
limited-cut CT of the maxillary sinus. Then the vector will be applied and the catheters will be removed. 
At the time of repeat vector administration, we will repeat all of the evaluations (including the limited-cut 
maxillary sinus CT, measurement of sinus V t , cultures, measurement of inflammatory cells, cytokines, 
etc., see below). We will administer the vector using the same procedures as described for the first 
administration. We will not, however, place the indwelling Silastic flanged tubes nor will we lavage the 
Recombinant DNA Research, Volume 18 
[875] 
