Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness

We compared the economics of using two-dimensional ultrasound locating devices and more traditional landmark methods for central venous cannulation in the National Health Service (NHS). The evaluation consisted of a systematic review of randomised controlled trials and an economic evaluation using decision analytic cost-effectiveness modelling. Incremental costs per complication avoided associated with landmark and ultrasound central venous cannulation were modelled for patients scheduled for central venous cannulation. The marginal economic cost of using ultrasound for central venous cannulation was less than 10 pounds sterling per procedure, assuming that a machine is used for 15 procedures each week. The base case scenario implied that 2000 pounds sterling worth of resource savings result for every 1000 procedures undertaken and 90 avoided complications. Sensitivity analysis indicated that the results of modelling appear robust to the central assumptions used. Ultrasound guidance used in central venous cannulation procedures saves NHS resources even with conservative modelling assumptions.

Lowering anti-dsDNA antibodies--what's new?

Antibodies to dsDNA are specific to SLE and are pathogenic, both due to their ability to deposit in tissues through a variety of mechanisms, and to their ability, when present in immune complexes, to activate inflammatory cells. The relationship of serum anti-dsDNA antibody levels to disease activity is a complex one and the factors that determine whether or not such antibodies will be pathogenic in an individual SLE patient are incompletely understood. Although anti-dsDNA antibodies can be made by naïve B cells and B cells belonging to the B1 and marginal zone subsets, pathogenic anti-dsDNA antibodies have the hallmarks of germinal center development and exposure to T cell help, including accumulation of somatic mutations and class switching to the IgG isotype. Epitope spreading may result in aquisition of cross-reactivities with multiple target organ antigens and aquisition of a memory phenotype will allow these B cells to acquire antigen presentation functions that amplify the autoreactive response. In the early stages of disease, or after remission induction protocols, autoreactive B cells may be susceptible to treatments that target T cell costimulation or that deplete or tolerize naïve and mature B cells. Therapeutic approaches targeting innate immune responses or regulatory T cells are starting to be tested in pre-clinical models. In later disease stages, memory and plasma cell accumulation may render patients more resistant to this type of therapeutic approach. Deposition of anti-dsDNA antibodies in target tissues can stimulate an inflammatory cascade that leads to tissue damage. A number of murine models have now been developed that show that interruption of this cascade can prevent or reverse such damage. This type of approach may be beneficial for individuals with established disease. As we learn more about the specific defects that cause SLE, it may become possible to individualize therapy based on patient specific biologic markers.

EVE/cyclosporin (etoposide, vincristine, epirubicin with high-dose cyclosporin)-chemotherapy selected for multidrug resistance modulation

Sixteen children and young adults were treated with high-dose cyclosporin combined with a combination of cytotoxics (epirubicin, vincristine and etoposide) (EVE) known to be influenced by P-glycoprotein-mediated multidrug resistance (MDR). Tumour types were neuroblastoma 3, Ewing's sarcoma 2, rhabdomyosarcoma 5, osteosarcoma 3, desmoplastic small round cell tumour 1, nephroblastoma 1, T-acute lymphoblastic leukaemia (ALL) 1. All had progressed or relapsed following at least two of the drug types included in EVE. Acute reactions to cyclosporin and myelosuppression were the major toxicities documented. Renal and hepatic toxicity was rarely severe and always transient. Partial responses (PR) were observed in 2 patients (1 rhabdomyosarcoma, 1 Ewing's sarcoma). We conclude that this combination is tolerable in heavily pretreated patients and may be suitable for further evaluation in untreated poor risk tumours.

Identification of Candida glabrata by a 30-second trehalase test

Rapid (30-s) trehalase tests done with material from colonies of 482 yeasts suspended in a drop of trehalose solution on a commercially supplied glucose test strip were positive for 225 (99.1%) of 227 Candida glabrata isolates grown on either of two differential media, Candida ID medium or CandiSelect medium. The test was positive for only 3 (1.2%) and 12 (4.7%) of 255 isolates of other medically important yeast species grown on the same two media, respectively. A rapid maltase test done with a subset of 255 yeast isolates was negative for all but 1 of 64 trehalase-positive C. glabrata isolates, raising the specificity of the rapid testing for C. glabrata to 98.4 to 100%, depending on the isolation medium used. Rapid trehalase and maltase tests done independently in two laboratories with 217 yeast isolates showed sensitivities of 96.0 to 98.0% and specificities of 98.2 to 99.4% for identification of C. glabrata from colonies grown on Candida ID medium. The specificity was much lower because of frequent false-positive trehalose test results when the source of colonies was Sabouraud agar formulated with 4% glucose. We conclude that direct recognition of C. albicans as blue colonies on Candida ID isolation medium coupled with the performance of the 30-s trehalase and maltase tests for C. glabrata among the white colonies on this medium will allow the rapid presumptive identification of the two yeast species most commonly encountered in clinical samples.

Errorless compliance training: building a cooperative relationship between parents with brain injury and their oppositional children

Errorless compliance training, a noncoercive intervention for improving child compliance, was evaluated in a multiple baseline across-subjects design with 12 oppositional children (ages 2-7 years) and their brain-injured parents, who suffered from cognitive deficits, impulsivity, and/or emotional instability. Generalized and durable increases were observed in child compliance after treatment. Pre/post improvements were also noted on a measure of parent self-esteem. Errorless compliance training may be well suited to intervention with parents with cognitive and behavioral impairments that decrease their potential to benefit from traditional parenting approaches.

A non-immunogenic adenoviral vector, coexpressing CTLA4Ig and bilirubin-uridine-diphosphoglucuronateglucuronosyltransferase permits long-term, repeatable transgene expression in the Gunn rat model of Crigler-Najjar syndrome

Host immune responses limit the duration of expression of transgenes introduced by recombinant adenoviruses, preclude gene transfer upon vector readministration and cause liver injury. CTLA4Ig inhibits immune response by blocking the co-stimulatory interaction between CD28 on T cells and B7 on antigen-presenting cells. We have constructed a recombinant adenovirus, Ad-hUGT1A1-CTLA4Ig that coexpresses human bilirubin-uridinediphosphoglucuronate glucuronosyltransferase (hUGT1A1) and soluble murine CTLA4Ig, both driven by CMV immediate-early promoters. After intravenous injection of this vector (6 x 10(11) p.f.u.) into UGT1A1-deficient jaundiced Gunn rats, serum CTLA4Ig levels peaked at 1.8-2.0 mg/ml on day 7 and declined thereafter to 0.2 mg/ml by day 180. Serum bilirubin declined from mean preinjection levels of 8.0 mg/dl to 0.48-0.6 mg/dl in 3 days, remained normal for 28 weeks, and then gradually increased to 8 mg/dl by day 350. A second injection of Ad-hUGT1A1-CTLA4Ig normalized serum bilirubin. In two rats in this group that were followed longer, serum bilirubin increased to 3.1 and 3.5 mg/dl in 40 weeks, but was normalized again after a third injection. The antibody and cytotoxic lymphocyte (CTL) responses were negligible, and liver biopsy showed no inflammatory cell infiltration. Rats receiving a tertiary challenge with Ad-LacZ (expressing E. coli beta-galactosidase) (5 x 10(11) p.f.u.), 2 months after the second dose of Ad-hUGT1A1-CTLA4Ig, showed beta-galactosidase expression in over 80% of hepatocytes. In contrast, after Ad-hUGT1A1 (which expresses UGT1A1 alone) injection, serum bilirubin remained normal for only 4 weeks, and returned to preinjection levels by day 120. Bilirubin levels did not decline upon reinjection, and beta-galactosidase was not expressed after Ad-LacZ. High levels of adenovirus-specific antibodies and CTL, and hepatic inflammation were found. This is the first demonstration that coexpression of CTLA4Ig permits prolonged expression and repeatable gene transfer by an adenoviral vector.

Allele frequencies of nine STR loci of Jewish and Arab populations in Israel

DNA typing of nine short tandem repeat (STR) loci was carried out on unrelated Israeli Jewish and Arab individuals. All loci were highly polymorphic and the distribution of the obtained genotypes did not deviate from Hardy-Weinberg equilibrium. A comparison between Jewish and Arab population data revealed statistically significant differences in allele frequency distributions for some of the loci. The results presented in this study enable the use of these nine STR loci for forensic, identification and paternity cases in the Jewish and the Arab populations of Israel.

HIV-infected American Indians/Alaska natives in the Western United States

OBJECTIVE

We sought to describe HIV-infected American Indians/Alaska Natives (AI/ AN) in the western United States.

DESIGN

One hundred fifty-one Al/AN and 11,344 non-AI/AN HIV-infected patients in Seattle, Denver, and Los Angeles were followed by medical record review from January 1989 through June 1998 for the Adult/Adolescent Spectrum of HIV-related Diseases study.

METHODS

Bivariate and multivariate statistical analyses comparing HIV-infected Al/AN and non-AI/AN were performed.

RESULTS

There were 103 (68%) male and 48 (32%) female Al/AN patients, while non-Al/AN patients were 86% male and 14% female (P<.001). The median age among AI/ AN was 32 years vs. 34 years among non-AI/AN (P = .05). Male Al/AN were more likely than male non-AI/AN to report the dual risks of having sex with men and injection drug use (32% vs. 14%; P<.001) compared with other HIV risks. Median CD4 cell counts were higher in Al/AN than in non-AI/AN (P< or =.001). AI/AN were more likely to be diagnosed with an acute sexually transmitted disease (STD) than were non-AI/AN (11% vs. 4%, P<.001). Five (6%) of AI/AN with AIDS had active pulmonary tuberculosis (TB) compared with 132 (2%) of non-AI/AN with AIDS (P = .02). While 52% of Al/AN and 44% of non-AI/AN had a psychiatric illness (P = .04), and 13% of AI/AN, and 6% of non-AI/ AN had suicidal ideation (P<.001), these associations became non-significant in analyses stratified by alcohol and drug use (P>.05). In adjusted models, survival and progression to opportunistic infection or CD4 cell count less than 200/mm3 did not significantly differ between Al/AN and non-AI/AN.

CONCLUSIONS

HIV-infected AI/AN were younger than non-AI/AN, and a greater proportion of Al/AN were women relative to non-AI/AN. AI/AN were more likely to be diagnosed with STDs and TB. In adjusted models, their risks of death and developing AIDS did not significantly differ from those of non-AI/AN.

Drosophila-raf acts to elaborate dorsoventral pattern in the ectoderm of developing embryos

In the early Drosophila embryo the activity of the EGF-receptor (Egfr) is required to instruct cells to adopt a ventral neuroectodermal fate. Using a gain-of-function mutation we showed that D-raf acts to transmit this and other late-acting embryonic Egfr signals. A novel role for D-raf was also identified in lateral cell development using partial loss-of-function D-raf mutations. Thus, we provide evidence that zygotic D-raf acts to specify cell fates in two distinct pathways that generate dorsoventral pattern within the ectoderm. These functional requirements for D-raf activity occur subsequent to its maternal role in organizing the anterioposterior axis. The consequences of eliminating key D-raf regulatory domains and specific serine residues in the transmission of Egfr and lateral epidermal signals were also addressed here.

Pigmented villonodular synovitis following arthroscopic laser surgery of the knee

We report a case of a nodular variant of pigmented villonodular synovitis of the knee that developed after an arthroscopic lateral release of the synovium by laser for an unrelated condition. This case, the first reported case of pigmented villonodular synovitis following laser treatment, lends weight to the etiological association with the pathological processes of the response to trauma.

The effect of CD28/B7 blockade on alloreactive T and B cells after liver cell transplantation

BACKGROUND

Hepatocyte cell lines are beginning to be developed as universal donors for isolated liver cell transplantation, which is a less invasive method than orthotopic liver transplantation for treatment of metabolic liver disease. The immune response to isolated liver cell transplantation and its modification by costimulatory blockade are as yet not well delineated.

METHODS

Adenovirus expressing CTLA4Ig was used to study blockade of the costimulatory CD28/B7 pathway in murine models of hepatocyte transplantation, and the effects on alloreactive T and B cells were studied.

RESULTS

CTLA4Ig delayed rejection of subcutaneously administered C57L-derived murine hepatoma cells in CBA/J recipients for >50 days. Activation and cytokine secretion by allospecific CD4+ and CD8+ T cells were initially blocked by CTLA4Ig; delayed rejection was associated with tumor infiltration by CD8+ T cells that did not secrete interferon-gamma. CTLA4Ig failed to block transplant rejection in primed mice, indicating that memory effector T cells were resistant to its action. In contrast, CTLA4Ig suppressed both naive and memory alloreactive B cells. High levels of CTLA4Ig mediated acceptance of hepatoma cells delivered directly into the spleen. However, isolated primary C57BL/6 mouse hepatocytes delivered into the spleen were rejected with only moderately delayed kinetics.

CONCLUSIONS

Transplant antigenicity, transplant site, and CTLA4Ig dose all affected the survival of transplanted liver cells. CD8+ T cells are significant mediators of hepatocyte transplant rejection and are relatively resistant to costimulatory blockade with CTLA4Ig. Strategies to specifically antagonize CD8+ T cells or to modulate MHC class I expression in association with costimulatory blockade by CTLA4Ig may enhance the clinical feasibility of transplanting allogeneic hepatocytes.

A corticotropin releasing hormone receptor antagonist does not delay parturition in rats

OBJECTIVE

To determine the effects of CP-154, 526, a corticotropin releasing hormone (CRH) receptor antagonist, on the length of normal rat gestation.

STUDY DESIGN

Twenty-four timed-pregnant Sprague-Dawley rats were purchased for this study. The drug and placebo were administered to the animals using an osmotic pump surgically inserted in the dorsal subcutaneous space. Six animals received 6 mg/kg/day of the drug, six animals received 12 mg/kg/day of the drug and twelve animals received the placebo. The gestational period, weight of each pup and number of pups in each litter were recorded and compared in the drug group versus placebo group.

RESULTS

No difference was noted in the gestational period of the drug and placebo rats. The mean weight of pups in both the drug and placebo groups was 6.18 g. The number of pups per litter were similar in the drug and placebo groups.

CONCLUSION

Antagonism of CRH receptors in rats has no effect on the length of gestational period, pup weight or number of pups per litter. Further studies are needed to define the role of CRH and its antagonism in primate pregnancy, as has been done in sheep.

Characterization of transmembrane segments 3, 4, and 5 of MalF by mutational analysis

MalF and MalG are the cytoplasmic membrane components of the binding protein-dependent ATP binding cassette maltose transporter in Escherichia coli. They are thought to form the transport channel and are thus of critical importance for the mechanism of transport. To study the contributions of individual transmembrane segments of MalF, we isolated 27 point mutations in membrane-spanning segments 3, 4, and 5. These data complement a previous study, which described the mutagenesis of membrane-spanning segments 6, 7, and 8. While most of the isolated mutations appear to cause assembly defects, L(323)Q in helix 5 could interfere more directly with substrate specificity. The phenotypes and locations of the mutations are consistent with a previously postulated structural model of MalF.

"Room temperature" use of CHROMagar Candida

The color of colonies of 9 Candida species was examined on the chromogenic medium CHROMagar Candida incubated for 24-72 h at 25 degrees C, 30 degrees C or 37 degrees C. Colors and colony forms characteristic of C. albicans, C. dubliniensis, C. krusei and C. tropicalis were formed most rapidly and with the deepest hues at 37 degrees C. After 48 h incubation at 25 degrees C, 9 of 48 C. albicans isolates gave pink colonies instead of the green colonies characteristic for the species, and the blue-purple colony color characteristic of C. tropicalis isolates was not formed until 48 h at 25 degrees C. Incubation of the chromogenic medium at temperatures below 30 degrees C cannot be recommended for reliable presumptive identification of Candida spp., and pink colonies of C. glabrata would not be reliably distinguished from pink colonies formed by other species under any of the incubation conditions used.

Quantitative videofluoroscopic evaluation of pharyngeal function in the dog

Videofluoroscopic evaluation of both liquid barium and barium soaked kibble was performed in 11 adult, clinically normal dogs of varying breeds. Each examination was digitized and evaluated frame by frame to establish the normal timing sequence of the pharyngeal phase of swallowing. Closure of the epiglottis was considered the onset of swallowing. The time to each of the following events was recorded: (1) Maximum pharyngeal contraction, (2) Opening of the epiglottis, (3) Opening of the cranial esophageal sphincter, and (4) Closure of the cranial esophageal sphincter. These values were found to be consistent both intra and interpatient. Retrospective analysis of 3 videofluoroscopic examinations from dogs that met the subjective criteria defining cricopharyngeal achalasia was then performed. A statistically significant delay in the time to opening and closure of the cranial esophageal sphincter was found employing both liquid barium and barium soaked kibble in the dogs with cricopharyngeal achalasia.

Proton magnetic resonance spectroscopy ((1)H-MRS) of the brain following high-dose methotrexate treatment for childhood cancer

BACKGROUND

To avoid the late sequelae associated with cranial radiation therapy in childhood, intermediate- or high-dose intravenous methotrexate (HDMTX) has found increasing application as a means of preventing the development of overt central nervous system disease in childhood acute leukaemia. However, acute and chronic neurotoxicity has been described following HDMTX therapy, and the long-term intellectual outcome in children treated in this way is inadequately documented. Proton magnetic resonance spectroscopy ((1)H-MRS) of the brain is a noninvasive, quantitative way of assessing aspects of cerebral metabolism, which has not previously been applied to the study of children undergoing central nervous system directed therapy.

PROCEDURE

To evaluate the potential role of (1)H-MRS in the investigation of related neurotoxicity, 11 children who had received HDMTX (cumulative dose 6-96 g/m(2)) underwent localised (1)H-MRS, magnetic resonance imaging. Neuropsychological assessments were performed on the children who had more than 1 year of follow-up time since last methotrexate treatment. Control (1)H-MRS studies on 11 adult and 6 young volunteers were undertaken. Eight patients had spectra of adequate quality. Comparisons between (1)H-MRS metabolite ratios and normal controls were made.

RESULTS

Patients had a low choline/water ratio compared to controls (P < 0.01). No differences between patient and control NAA/water, Cr/water, Naa/Cr, and Cho/Cr ratios were seen. Overall, 3 patients had abnormal white matter changes on MRI. The mean IQ of the patients (104.1) was in the normal range.

CONCLUSIONS

It is postulated that choline depletion in the brains of these patients may reflect subclinical disturbances of myelin metabolism as a result of methotrexate therapy and may represent a possible avenue of treatment in patients with clinical chronic methotrexate-related neurotoxicity.

CTLA4Ig inhibits T cell-dependent B-cell maturation in murine systemic lupus erythematosus

Long-term administration of CTLA4Ig prevents the onset of disease in systemic lupus erythematosus-prone (SLE-prone) NZB/NZW F1 mice. To determine the mechanism of this effect, we engineered an adenovirus that expresses murine CTLA4Ig. Administration of a single high dose of this virus results in long-term expression of CTLA4Ig in the serum and absence of an immune response to the adenoviral vector. We administered Ad-CTLA4Ig to 19- to 22-week-old NZB/NZW F1 mice and evaluated the effect on anti-DNA antibody-producing B cells. We show that CTLA4Ig has a beneficial effect on murine SLE for as long as it is present in the serum. This effect is associated with decreased expansion of both the IgM and IgG autoreactive B-cell population, inhibition of immunoglobulin class switching, decreased frequency and altered pattern of somatic mutation, and a marked decrease in the numbers of activated CD4-positive T cells. In contrast, intrinsic B-cell hyperreactivity and the survival of plasma cells in the bone marrow, both of which are less dependent on T-cell help, appear to be unaffected by CTLA4Ig. High-dose CTLA4Ig did not induce permanent tolerance in this autoimmune disease model. Furthermore, although the mice survived in a conventional housing facility, treatment with Ad-CTLA4Ig was immunosuppressive.

Magnetic resonance spectroscopy in the evaluation of neurotoxicity following cranial irradiation for childhood cancer

In order to evaluate the role of proton MR spectroscopy (1H-MRS) in the diagnosis and assessment of long-term radiation-related neurotoxicity, 14 children who had received cranial irradiation for the treatment of childhood leukaemia (n = 6) or brain tumours (n = 8) underwent 1H-MRS, MRI and neuropsychological assessment. Short-term effects at 2 months following treatment were studied in a further three patients. MRI abnormalities were observed in nine patients. No statistically significant differences between patients and controls (n = 17) were seen in any of the calculated 1H-MRS metabolite ratios, in any of the three patient groups. On multivariate logistic regression analysis there was a correlation between the choline/water ratio and a low IQ. It is concluded that any systematic radiation-induced changes in the 1H MRS metabolites must be below the detection threshold of this study.

The role of dysregulated amygdalic emotion in borderline personality disorder

Borderline personality disorder (BPD), is a condition that has a high mortality and is associated with much distress for the sufferers as well as with difficult management problems for health professionals. Taking emotional dysregulation as the core feature of BPD, the authors propose that the disorder arises from impaired modulation of subcortical inputs to consciousness. We hypothesize that the amygdaloid complex, and its connections with thalamus, cingulate cortex and insular cortex are critical in the development and maintenance of the disorder. If this is the case, peptides such as galanin, somatostatin and cholecystokinin will be the most important neurotransmitters, thus explaining the relative lack of efficacy of standard antipsychotic and antidepressant drugs.

A novel signaling molecule for neuropeptide action: activity-dependent neuroprotective protein

The complete coding sequence of a novel protein (828 amino acids, pI 5.99), a potential new mediator of vasoactive intestinal peptide (VIP) activity was recently revealed. The expression of this molecule, activity-dependent neuroprotective protein (ADNP), was augmented in the presence of VIP, in cerebral cortical astrocytes. The mRNA transcripts encoding ADNP were enriched in the mouse hippocampus and cerebellum. The protein deduced sequence contained the following: (1) a unique peptide, NAPVSIPQ, sharing structural and immunological homologies with the previously reported, activity-dependent neurotrophic factor (ADNF) and exhibiting neuroprotection in vitro and in vivo; (2) a glutaredoxin active site; and (3) a classical zinc binding domain. Comparative studies suggested that the peptide, NAPVSIPQ (NAP), was more efficacious than peptides derived from ADNF. ADNP, a potential mediator of VIP-associated neuronal survival, and the new peptide, a potential lead compound for drug design, are discussed below.

Vasoactive intestinal peptide. Link between electrical activity and glia-mediated neurotrophism

Vasoactive intestinal peptide has neurotrophic and neuroprotective properties that influence the survival of activity-dependent neurons in the central nervous system. Investigations of the mechanism of this neurotrophic peptide indicated that these actions are contingent on interactions with astroglia. The complex mixture of neurotrophic mediators released from astroglia include cytokines, a protease inhibitor, and activity-dependent neurotrophic factor, a protein with apparent structural similarities to hsp60. Investigations of ADNF resulted in the discovery of active peptides of extraordinary potency and broad neuroprotective properties. These studies indicate that a nine-amino acid core peptide of ADNF had significantly greater neuroprotective properties in comparison to the parent growth factor and these advantages identify ADNF-9 as an attractive lead compound for drug development.

Evaluation of the susceptibility of Coccidioides immitis to lufenuron, a chitin synthase inhibitor

The activity of the chitin synthase inhibitor lufenuron was evaluated in vitro using the spherule-endospore (SE) phase of Coccidioides immitis. The lufenuron was also used to treat mice infected with C. immitis by the respiratory route. In vitro, lufenuron had no effect upon fungal cell growth. Two formulations of lufenuron were evaluated in vivo. Neither the oral nor the injectable lufenuron extended the survival of mice infected with C. immitis when compared with placebo-treated mice.

Locomotor activity causes a rapid up-regulation of vasoactive intestinal peptide in the rat hippocampus

Vasoactive intestinal peptide (VIP) expression is restricted to interneurons in the hippocampus of normal adult rats. However, 3-6 hours after a 60-minute walk in an activity wheel, VIP was transiently expressed in most pyramidal and granular neurons of the hippocampus. Locomotion was also associated with a dramatic increase in VIP immunoreactivity in the motor cortex, primarily in bipolar cells. Reverse transcriptase-polymerase chain reaction analysis indicated that VIP mRNA increases transiently by more than twofold, before the increases in peptide immunoreactivity in both the hippocampus and motor cortex. By comparison, another marker of inhibitory interneurons, glutamate decarboxylase, did not change its expression pattern after locomotion. The calcium binding protein, calbindin-D28K, normally expressed in interneurons, was now found also in glial cells of the hippocampus and motor cortex. Another marker of enhanced electrical activity, the immediate early gene, c-Fos, was expressed in pyramidal and granular neurons at 3 hours but not at 6 hours after locomotion. These results suggest that mapping of peptide expression in the brain of a docile, inactive rat may not reflect the real distribution and functions of a peptide in an active animal.

A rheumatoid factor specific mimotope identified by a peptide display library

We screened a 10 amino acid peptide display library in filamentous phage with B'20, a monoclonal high affinity IgM rheumatoid factor (RF) expressing the VkIIIa-dependent 4C9 idiotype. Using direct and indirect selection techniques, 12 B'20 reactive peptides were identified, 9 of which belonged to one of two motifs. Binding of B'20 to phage-bearing peptides was inhibited by both IgG and 4C9 antiidiotype. Synthetic peptides corresponding to the two motifs inhibited the Fc binding of a low avidity IgA B'20 construct. Purified IgM from 6/8 RF-positive RA patients and 8/11 monoclonal RFs with VkIII-encoded light chains bound to the phage, whereas none of the four monoclonal RFs with VkI or VkII encoded light chains bound. Phage binding appeared to be RF specific. Three 4C9 positive/RF negative cell lines from RA patients did not bind to phage nor did three B'20 mutants that had lost RF specificity, whereas two mutants that retained RF specificity also retained phage binding. We propose that there is a common epitope(s) recognized by VkIII encoded RFs that is mimicked by the structure of these peptides. Such mimotopes might be exploited to design novel agents that interfere with autoantibody binding.

Duration of apnoea with two different intubating doses of remifentanil

We have studied the apnoea time after induction with two successful drug intubating regimes, both containing remifentanil. Group 1 (n = 20); propofol 2 mg kg-1 and remifentanil 2 micrograms kg-1 and group 2 (n = 20); propofol 2 mg kg-1, remifentanil 1 microgram kg-1 and lignocaine 1 mg kg-1. Intubation was possible in all 40 patients, and regarded as acceptable in 90% and 85% of patients, respectively. The median time to the return of spontaneous respiration was 487 s in group 1 and 270 s in group 2 (P < 0.05). Median end-tidal CO2 concentration at the time of the first spontaneous respiration was 7.37 kPa in group 1 and 6.3 kPa in group 2 (P < 0.05). Both groups had a decrease in heart rate after induction, but this failed to reach either clinical or statistical significance, and no patient required atropine. Similarly, there was a decrease in arterial pressure after induction in both groups (P < 0.05), but this was not deemed to be clinically significant. Only two patients in each group required ephedrine 6 mg before arterial pressure was restored to within 25% of the base-line. Intubating conditions were similar in both groups, but group 2 provided a significantly shorter apnoea time.

An aggressive form of polyarticular arthritis in a man with CD154 mutation (X-linked hyper-IgM syndrome)

Hyper-IgM syndrome (HIM) is a rare immunodeficiency disorder that has been associated with the development of symptoms and clinical features characteristic of rheumatoid arthritis (RA). We describe a patient with HIM and severe erosive arthritis with prominent nodules in the absence of detectable serum rheumatoid factor. Because HIM results from defects in either T cell CD154 (CD40 ligand) expression or abnormal CD40 signaling, the molecular basis of the patient's disease was analyzed. Activated CD4+ T cells failed to express surface CD154 protein, and molecular analysis of CD154 complementary DNA revealed a nucleotide transversion resulting in the nonconservative amino acid substitution G-D at amino acid 257. This case indicates that defective CD154-dependent CD40 signaling can be associated with susceptibility to a severe inflammatory arthritis that has both similarities to and differences from idiopathic RA.

Mapping the active site in vasoactive intestinal peptide to a core of four amino acids: neuroprotective drug design

The understanding of the molecular mechanisms leading to peptide action entails the identification of a core active site. The major 28-aa neuropeptide, vasoactive intestinal peptide (VIP), provides neuroprotection. A lipophilic derivative with a stearyl moiety at the N-terminal and norleucine residue replacing the Met-17 was 100-fold more potent than VIP in promoting neuronal survival, acting at femtomolar-picomolar concentration. To identify the active site in VIP, over 50 related fragments containing an N-terminal stearic acid attachment and an amidated C terminus were designed, synthesized, and tested for neuroprotective properties. Stearyl-Lys-Lys-Tyr-Leu-NH2 (derived from the C terminus of VIP and the related peptide, pituitary adenylate cyclase activating peptide) captured the neurotrophic effects offered by the entire 28-aa parent lipophilic derivative and protected against beta-amyloid toxicity in vitro. Furthermore, the 4-aa lipophilic peptide recognized VIP-binding sites and enhanced choline acetyltransferase activity as well as cognitive functions in Alzheimer's disease-related in vivo models. Biodistribution studies following intranasal administration of radiolabeled peptide demonstrated intact peptide in the brain 30 min after administration. Thus, lipophilic peptide fragments offer bioavailability and stability, providing lead compounds for drug design against neurodegenerative diseases.

Synovial non-Hodgkin's lymphoma in a human immunodeficiency virus infected patient

We describe a case of articular non-Hodgkin's lymphoma (NHL) with malignant lymphoma cells observed in synovial fluid. Bone involvement in NHL is common, but an English language Medline search revealed only 14 reported cases of synovial NHL. Although NHL is a well recognized complication of human immunodeficiency virus (HIV) infection, this is the first report of synovial NHL in an HIV infected patient.

Complete sequence of a novel protein containing a femtomolar-activity-dependent neuroprotective peptide

The vulnerability of neurons and the irreversibility of loss make discoveries of neuroprotective compounds fundamentally important. Here, the complete coding sequence of a novel protein (828 amino acids, pI 5.99), derived from mouse neuroglial cells, is revealed. The sequence contained (1) a neuroprotective peptide, NAPVSIPQ, sharing structural and immunological homologies with the previously reported, activity-dependent neurotrophic factor; (2) a glutaredoxin active site; and (3) a zinc binding domain. Gene expression was enriched in the mouse hippocampus and cerebellum and augmented in the presence of the neuropeptide vasoactive intestinal peptide, in cerebral cortical astrocytes. In mixed neuron-astrocyte cultures, NAPVSIPQ provided neuroprotection at subfemtomolar concentrations against toxicity associated with tetrodotoxin (electrical blockade), the beta-amyloid peptide (the Alzheimer's disease neurotoxin), N-methyl-D-aspartate (excitotoxicity), and the human immunodeficiency virus envelope protein. Daily NAPVSIPQ injections to newborn apolipoprotein E-deficient mice accelerated the acquisition of developmental reflexes and prevented short-term memory deficits. Comparative studies suggested that NAPVSIPQ was more efficacious than other neuroprotective peptides in the apolipoprotein E-deficiency model. A potential basis for rational drug design against neurodegeneration is suggested with NAPVSIPQ as a lead compound. The relative enrichment of the novel mRNA transcripts in the brain and the increases found in the presence of vasoactive intestinal peptide, an established neuroprotective substance, imply a role for the cloned protein in neuronal function.

Mutational analysis of amino acid residues involved in argininosuccinate lyase activity in duck delta II crystallin

Delta-crystallins are the major structural eye lens proteins of most birds and reptiles and are direct homologues of the urea cycle enzyme argininosuccinate lyase. There are two isoforms of delta-crystallin, delta Iota and delta IotaIota, but only delta IotaIota crystallin exhibits argininosuccinate lyase (ASL) activity. At the onset of this study, the structure of argininosuccinate lyase/delta IotaIota crystallin with bound inhibitor or substrate analogue was not available. Biochemical and X-ray crystallographic studies had suggested that H162 may function as the catalytic base in the argininosuccinate lyase/delta IotaIota crystallin reaction mechanism, either directly or indirectly through the activation of a water molecule. The identity of the catalytic acid was unknown. In this study, the argininosuccinate substrate was modeled into the active site of duck delta IotaIota crystallin, using the coordinates of an inhibitor-bound Escherichia coli fumarase C structure to orient the fumarate moiety of the substrate. The model served as a means of identifying active site residues which are positioned to potentially participate in substrate binding and/or catalysis. On the basis of the results of the modeling, site-directed mutagenesis was performed on several amino acids, and the kinetic and thermodynamic properties of each mutant were determined. Kinetic studies reveal that five residues, R115, N116, T161, S283, and E296, are essential for catalytic activity. Determination of the free energy of unfolding/refolding of wild-type and mutant delta II crystallins revealed that all constructs exhibit similar thermodynamic stabilities. During the course of this work, the structure of an inactive delta IotaIota crystallin mutant with bound substrate was solved [Vallee et al. (1999) Biochemistry 38, 2425-2434], which has allowed the kinetic data to be interpreted on a structural basis.