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Evidence for this in vivo remains to be determined. A converse theory is that CMV promoter activity is essentially dependent on one or more transcriptional activators that are transiently induced early after vector delivery. Promoter activity then declines in concert with the decline in the levels of these activators. Loser et al. [48] have provided evidence that the activity of the CMV promoter in mouse liver is dependent on the transcription factor NFκB. Mice were given a partial hepatectomy or lipopolysaccharide (LPS) 28 days postinfection with an adenoviral vector.

The increased enrollment will yield necessary information to allow the overall effectiveness and safety of the therapy to be statistically determined. The FDA’s primary objectives in reviewing the IND documentation are to assure the safety and rights of the subjects. The central theme of the initial IND submission should be on the general investigational plan and the protocols for specific human studies. Subsequent amendments to the IND document, either in response to inquiries by the FDA or modifications to the clinical trial protocols as the result of additional information, should build logically on previous submissions and should be supported by additional information, including the results of animal toxicology studies or other human studies as appropriate.

In theory, a self-perpetuating positive feedback loop could be established by having the transactivator activate its own expression in addition to the transgene by placing binding sites into the promoter expressing the transactivator (Fig. 4) [83]. Alternatively, both the transgene and transactivator could be expressed from one transcript using an internal ribosomal entry site [83]. IV. REDUCING THE IMMUNE RESPONSE TO INCREASE DURATION OF EXPRESSION Of the three requirements for sustained gene expression, reducing the immune response to the vector and the transgene is perhaps the most consequential.

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