Timing and interpretation of tests for diagnosing perinatally acquired hepatitis C virus infection

The diagnosis of hepatitis C virus (HCV) infection in children born to HCV-infected women is based on serologic assays and HCV RNA measurement by PCR. Interpretation of the results of these tests is hampered by uncertainty about the age distribution of loss of maternal antibody and the sensitivity and specificity of PCR at different ages. On the basis of findings from a recent vertical transmission study, we estimated the posttest probability of a child's being infected or uninfected under several test result scenarios. These estimates may assist clinicians in assessing the likelihood of infection in an individual child and in using the currently available assays cost effectively.

National guidelines for the active management of HIV in pregnancy

The number of HIV positive women becoming pregnant in Ireland is increasing, with many pregnancies occurring in women from countries of high HIV prevalence. The management of such patients offers the challenge of reducing the risk of maternal-fetal transmission of HIV infection, avoiding fetal-infant toxicities, and maintaining future maternal antiretroviral options. Guidelines for the optimal management of HIV disease in pregnancy have been produced by a subgroup of the Irish Infection Society consisting of GenitoUrinary Medicine and Infectious Diseases Consultants. They are based on currently available international data and guidelines. The national guidelines offer a broad management outline for HIV positive pregnant patients. Ultimately, each patient is assessed individually by a multidisciplinary team, and a careful plan for antenatal, intrapartum, and postpartum care is determined.

The Heartmate II: design and development of a fully sealed axial flow left ventricular assist system

Our group is developing the control and power transmission components required to implement a permanent and fully sealed left ventricular assist system (LVAS). Starting with the percutaneously powered HeartMate II blood pump, our development efforts are focused in the following areas: a complete redesign of the transcutaneous energy transmission system (TETS) to include a rectification network and autonomous voltage regulation within the secondary coil, a hermetically sealed electronics package containing a miniaturized implementation of the existing redundant drive and control electronics with several power-input options, an implanted rechargeable lithium ion battery pack capable of providing up to 1 h of untethered operation, implantable electrical connectors that allow components to be connected after placement in the body or to be replaced if needed, and a radio telemetry subsystem to transmit diagnostic information and to permit remote adjustment of selected parameters.

Rhinocerebral zygomycosis in childhood acute lymphoblastic leukaemia

The hazards associated with invasive candidiasis and aspergillosis in oncology patients are well recognised. These conditions typically present late in treatment, often after prolonged or recurrent episodes of neutropenia. We report the occurrence of Absidia corymbifera infection causing rhinocerebral zygomycosis in two children with acute lymphoblastic leukaemia, early in the induction phase of treatment and within a 3-month interval, in the same oncology unit. The initial presentation of facial pain was rapidly followed by the development of cranial nerve palsies, cavernous sinus thrombosis, diabetes insipidus, seizures and death within 9 days of symptom onset, despite aggressive management with high-dose liposomal amphotericin (Ambisome), surgical debridement and local instillation of amphotericin solution. These cases highlight the need for awareness of zygomycosis as a potentially lethal fungal infection that can present even with short duration exposure to the usual risk factors. Their occurrence within a limited time period raises questions as to the relative importance of environmental exposure. The failure of medical and surgical intervention to impact on the course illustrates the need to develop appropriate preventative strategies which may have to incorporate measures to reduce the environmental exposure of susceptible patients.

Nonradioactive in situ hybridization to xenopus tissue sections

We describe a protocol for the localization of specific messenger RNAs in Xenopus laevis embryo tissue sections using a nonradioactive detection method. After fixation, embryos are embedded in paraffin wax, sectioned, mounted on slides, and subjected to a series of prehybridization treatments which improve the accessibility of the probe to the target mRNA and reduce nonspecific binding. These treatments are followed by hybridization in situ with single-stranded antisense RNA probe generated by in vitro transcription and labeled with digoxigenin. The hybridization products are detected with preabsorbed alkaline phosphatase-coupled digoxigenin antibody and subsequently localized using a chromogenic substrate that generates a colored precipitate at the hybridization site. The nonradioactive in situ hybridization method we describe is reproducible and has a detection sensitivity akin to those methods that use antisense RNA probes labeled with radioisotopes; however, it is faster, safer, and easier to perform. Sectioning of prestained whole-mount X. laevis embryos does not always show the complete expression pattern of many genes, particularly those in deep endodermal structures, due to inadequate probe penetration. Therefore thorough analysis of gene expression patterns often requires in situ hybridization on presectioned material whereby probe has equal accessibility to all tissue.

Cytological evaluation of the tissue-implant reaction associated with S/C and I/P implantation of ALCAP and HA bioceramics in vivo

It is well documented that several ceramic materials are highly compatible and non-immunogenic with host tissues. Recent studies have demonstrated the need for further investigation of these devices in vivo to further elucidate the possible mechanisms involved in biocompatibility. The purpose of this investigation was to study the morphological characteristics of the fibrous tissue capsule resulting from the implantation of aluminum calcium phosphate (ALCAP) and hydroxyapetite (HA) bioceramics. Implants of ALCAP and HA were implanted into 10 adult male rats subcutaneously (S/C) and intraperitoneally (I/P). At 90 days post-implantation, the animals were euthanized, and the ceramic devices, the fibrous tissue, and vital organs were harvested. Evaluation of routine stained sections (5 microm, hematoxylin & eosin) of the fibrous tissue capsule surrounding the HA and ALCAP ceramics revealed the following: 1) all the ceramic devices had fibrous connective tissue capsules of slightly varying degrees of thickness at the time of sacrifice, depending on the site of implantation and type of material, and 2) there were statistically significant differences (p < 0.05) in the numbers and types of cellular components with respect to implantation site. The number of macrophages, neutrophils, fibroblasts, degree of vascularity, and thickness of the fibrous tissue matrix was found to be statistically different between the S/C implanted ceramic groups. The number of macrophages, neutrophils, fibroblasts, and collagen content comparing the fibrous tissue surrounding the ALCAP and HA ceramics (I/P), was found to be statisically different.

Quantitative analysis of the cellular components of the fibrous tissue matrix surrounding ALCAP, HA, and TCP bioceramics using adult male rats as a model

This investigation was specifically an attempt to correlate the thickness of this fibrous capsule and the various histological components that are seen in the fibrous capsule surrounding ALCAP, HA, and TCP ceramics at the S/C and I/P implantation sites in order to further elucidate the mechanisms of tissue-implant interaction. Eighteen male albino rats were randomly divided into three experimental groups (n = 5/group) and one control (n = 3). Animals in Groups I, II, and III were implanted with the ALCAP, HA, and TCP ceramics, respectively. Animals in Group IV were not implanted and acted as the control group. At 90 days post-implantation, the animals in all groups were euthanized and the fibrous tissue surrounding the ceramic devices and internal organs were harvested. After routine histological processing, sections of tissue was stained with hematoxylin and eosin and evaluated using light microscopy. Analysis of the data revealed the following: 1) The presence of macrophages, neutrophils, fibroblasts, vascularity, and thickness of the fibrous tissue matrix was found to be statistically different among the subcutaneously implanted ceramic groups (ANOVA, p < 0.01). 2) The presence of collagen (S/C) is not statistically different among the three ceramic groups (ANOVA, p = 0.76). 3) The presence of macrophages, neutrophils, fibroblasts, and collagen comprising the fibrous tissue surrounding the ALCAP, HA, and TCP ceramics (I/P), was found to be statistically different (ANOVA, p < 0.01). 4) Vascularity and thickness of the fibrous tissue surrounding the three I/P ceramics were not found to be statistically different among the three ceramic groups (ANOVA, p > 0.05).

Tissue-implant response following soft tissue implantation of poly-L-lysine coated UHMW-polyethylene into adult male rats

It is well demonstrated in the literature that polyethylene materials used in orthopedic applications are highly compatible and non-immunogenic with host tissues. However, recent studies in our laboratory have demonstrated the need for further study of these devices in vivo to further elucidate the mechanisms involved in biocompatibility. The purpose of this investigation was to study the tissue-implant response resulting from the implantation of ultra high molecular weight polyethylene (PE) coated with poly-L-lysine at 90 days post-implantation. In this investigation, implants of PE coated with poly-L-lysine and saline were implanted into 8 adult male rats subcutaneously (S/C) and intraperitoneally (I/P). At 90 days post-implantation, the animals were euthanized; and the PE devices, the fibrous tissue, and vital organs were harvested. Evaluation of routinely stained sections (5 microns, Hematoxylin & Eosin) of the fibrous tissue capsule surrounding the PE implants revealed the following: 1) all the devices had fibrous connective tissue capsules of slightly varying degrees of thickness surrounding them present at the time of sacrifice, 2) the thickness of the fibrous tissue capsule was dependent on the site of implantation and type of coating, 3) the thickness of the fibrous tissue capsules around the subcutaneous devices differed markedly than those retrieved from the peritoneal cavity, and 4) there were statistically significant differences (T-test, p < 0.05) in the numbers and types of cellular components with respect to implantation site and type of coating.

Interrelationships between dietary lysine, sex, and porcine somatotropin administration on growth performance and protein deposition in pigs between 80 and 120 kg live weight

Sixty male and 60 female crossbred pigs were allocated to an experiment to investigate the effects of porcine somatotropin (pST) administration (0 or 6 mg/d) and dietary lysine content on growth performance, tissue deposition, and carcass characteristics over the live weight range of 80 to 120 kg. Pigs receiving pST were given diets containing 6.9, 7.8, 8.8, 9.7, 10.6, or 11.5 g lysine/kg, whereas control pigs received diets containing 4.8, 5.8, 6.9, 7.8, 8.8 or 9.7 g lysine/kg. These dietary levels ranged from 0.40 to 0.70 g available lysine/MJ of DE for pST-treated pigs and from 0.28 to 0.58 g available lysine/MJ of DE for control pigs. Pigs were individually housed in pens, and there were five replicates of each treatment. All diets contained 14.5 MJ of DE/kg and were offered for ad libitum consumption to pigs between 80 and 120 kg live weight. Growth rate increased exponentially and food conversion ratio (FCR) decreased exponentially with increasing levels of lysine. In addition, there was a significant sex x pST interaction such that pST reduced the sex difference in FCR. Growth rate was faster in boars than in gilts and was increased by pST at the higher levels of dietary lysine. Similarly, FCR was lower for boars than for gilts and was decreased by pST at the higher dietary lysine levels. The optimum growth rate and FCR were defined as the lysine level at which growth rate and FCR were 95% and 105%, respectively, of the lysine plateau. The optimum growth rate and FCR were achieved at similar dietary lysine contents and were approximately 0.35 and 0.52 g available lysine/MJ of DE for control and pST-treated pigs, respectively. Protein deposition in the carcass increased exponentially with increasing dietary lysine level, was higher in boars than in gilts, and was increased by pST at the higher dietary lysine contents. Sex had no effect on dietary lysine required to maximize protein deposition. The dietary lysine contents required to ensure 95% of plateau protein deposition of 104 and 153 g/d were 0.39 and 0.55 g available lysine/MJ of DE for control and pST-treated pigs, respectively. The increase in lysine requirement with pST seems to be commensurate with the increase in protein deposition.

Histamine H2 receptor mediated dual signaling: mapping of structural requirements using beta2 adrenergic chimeric receptors

Previously we demonstrated that the histamine H2 receptor can activate both the adenylate cyclase and phosphoinositide/protein kinase (PKC) signaling pathways. Although dual coupling occurs via separate GTP-dependent mechanisms the structural components of the H2 receptor directing differential signaling have not been established. We explored this question by attempting to confer to the beta2-adrenergic receptor (betaAR), which is known to stimulate cAMP formation, the ability to activate PKC through the construction of beta2/H2 chimeric receptors. Intracytoplasmic domains of the human beta2 adrenergic receptor were substituted with the corresponding sequences of the human H2 receptor and stably expressed in HEK-293 cells. Binding of [(3)H]-CGP to chimeric wild type beta2 receptors was comparable. Substitution of the second intracellular loop (2i) of the betaAR led to a significant decrease in coupling to adenylate cyclase while leading to a 139.5 +/- 9.4% control increase in epinephrine mediated PKC activation. Introduction of the H2 receptor 3i also led to a decrease in betaAR mediated cAMP generation but provided the latter with the ability to stimulate PKC (182.2 +/- 8% of control). Concomitant expression of both 2i and 3i led to a substantial increase in epinephrine mediated PKC activation (201.8 +/- 10.5% of control). Addition of the carboxyl terminal tail did not facilitate stimulation of PKC. In summary, the third intracellular loop of the H2 receptor plays an essential role in activating PKC with maximal efficiency conferred by the second intracellular domain.

Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission

BACKGROUND

Little information is available about the timing of mother-to-child transmission of hepatitis C virus (HCV), and no interventions to decrease transmission rates have been identified. We examined the effect of risk factors, including mode of delivery, on the vertical transmission rate.

METHODS

Data from HCV-infected women and their infants from three hospitals in Ireland and from a British Paediatric Surveillance Unit study of infants born to HCV-infected mothers were used to estimate the vertical transmission rate and risk factors for transmission. We used a probabilistic model using methods that simultaneously estimated the time to HCV-antibody loss in uninfected infants and the diagnostic accuracy of PCR tests for HCV RNA.

FINDINGS

441 mother-child pairs from the UK (227) and Ireland (214) were included. 50% of uninfected children became HCV-antibody negative by 8 months and 95% by 13 months. The estimated specificity of PCR for HCV RNA was 97% (95% CI 96-99) and was unrelated to age; sensitivity was only 22% (7-46) in the first month but rose sharply to 97% (85-100) thereafter. The vertical transmission rate was 6.7% (4.1-10.2) overall, and 3.8 times higher in HIV coinfected (n=22) than in HIV-negative women after adjustment for other factors (p=0.06). No effect of breastfeeding on transmission was observed, although only 59 women breastfed. However, delivery by elective caesarean section before membrane rupture was associated with a lower transmission risk than vaginal or emergency caesarean-section delivery (odds ratio 0 [0-0.87], p=0.04, after adjustment for other factors).

INTERPRETATION

The low sensitivity of HCV RNA soon after birth and the finding of a lower transmission rate after delivery by elective caesarean section suggest that HCV transmission occurs predominantly around the time of delivery. If the findings on elective caesarean section are confirmed in other studies, the case for antenatal HCV testing should be reconsidered.

The design and synthesis of thrombin inhibitors: the introduction of in vivo efficacy and oral bioavailability into benzthiazolylalanine inhibitors

The further optimisation of the novel lead compound CGH752 (Fig. 1) is described. By introducing various substituents into the 6-position of the 3,3-dimethyltetrahydroquinoline (DMTHQS) ring we have been able to favourably affect the in vitro and in vivo activity, and the pharmacokinetics of such compounds. One of the inhibitors synthesised (CGH1484) is bioavailable and shows efficacy in animal models of thrombosis.

A supportive-expressive group intervention for women with a family history of breast cancer: results of a phase II study

BACKGROUND

Evidence suggests that there are significant psychological and behavioural sequelae associated with having a family history of breast cancer (BC) which can interfere with comprehension of risk estimates.

PURPOSE

The purpose of this study was to develop, standardize and do preliminary testing of a group intervention designed to address the emotional impact of having a family history of BC.

METHODS

This study is a single-arm pilot design with pre- and post-measures of perceived risk, psychosocial distress, knowledge and screening practices.

RESULTS

The primary study outcome measure of risk comprehension was significantly improved by 70%, according to our predetermined criteria for success. In addition, the most important secondary measures of psychosocial functioning, such as cancer-related distress (p=0.025), depression (p=0.05), anxiety (p=0.005) and unresolved grief (p=0.034) were significantly improved.

CONCLUSION

The results of this initial pilot study are encouraging; however, further research is required, using a randomized controlled study design to evaluate the relative contribution of this intervention to the successful modification of risk comprehension, enhanced psychological functioning, and to promote optimal screening adherence.

VRE in the Republic of Ireland: clinical significance, characteristics and molecular similarity of isolates

There have been increasing reports worldwide of vancomycin resistant enterococci (VRE) since they were first noted over ten years ago. This study sought to investigate the clinical significance of VRE in Ireland and to compare the phenotypic, genotypic and molecular characteristics of isolates recovered from patients in different institutions. The relative contribution of inter-hospital transmission of strains to the dissemination of VRE in Ireland was assessed. Hospital surveillance for VRE is not well established in Ireland. The organism has been detected in seven hospitals. Detection has been predominantly in oncology inpatients in large tertiary referral hospitals in the Dublin metropolitan area in whom strains generally represent asymptomatic gastrointestinal tract colonization. The predominant species is E. faecium with the Van A resistance phenotype. Twenty-seven (87) of 31 isolates from one unit were shown to be of the same or closely related strain as were 10 (63%) of 16 from another unit, indicating significant nosocomial transmission within institutions. There was no evidence for inter-hospital transmission of VRE. VRE is established in Ireland and nosocomial transmission readily occurs. Regular surveillance for VRE is indicated in high-risk populations in large institutions, specific risk factors for the acquisition of VRE need to be defined and optimal control and preventative strategies need to he instituted to detect and preempt the spread of this organism.

Glycopeptide prescribing in a tertiary referral paediatric hospital and applicability of hospital infection control practices advisory committee (HICPAC) guidelines to children

This study was undertaken to investigate the frequency of, indications for and appropriateness of glycopeptide prescription in a paediatric tertiary referral hospital and to assess the usefulness of the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines. A prospective audit of all systemic glycopeptide prescriptions over a 2-month period was undertaken. Clinical and microbiological data were recorded. Of 2810 hospital admissions, systemic IV glycopeptides were prescribed on 57 occasions to 50 patients, 30 (52.6%) for vancomycin and 27 (47.4%) for teicoplanin. Prescriptions were for 34 males and 23 females aged from 2 weeks to 11 years (mean 15 months; median 9 months). Median hospital stay was 50 days. Glycopeptides were given to the following patient groups: cardiology 7 (12%), prophylaxis for cardiac surgery 11 (19%), post-cardiac surgery 1 (1.8%), oncology 14 (24.6%), post-gastrointestinal tract surgical 8 (14%), general surgical 9 (15. 8%) and medical 7 (12.3%). Twenty three children (41.8%) had central lines in situ. Reason for use of glycopeptide was therapeutic in 7 (12.3%), empiric in 38 (66.7%), and as prophylaxis in 12 (21.1%). Eight (14%) prescriptions met strict HICPAC criteria, but a further 22 (39%) prescriptions were considered appropriate in this high-risk population. Glycopeptides were chosen appropriately for cardiac surgery prophylaxis in a further 10 (18%) but timing and duration of use in this group was inappropriate. Of all prescriptions, use was empiric in 38 (76%) and appropriate cultures were obtained at the time of commencement in only 13 (34%) of these. Glycopeptides were not used for routine surgical prophylaxis or for first-line empiric treatment of febrile neutropenia.

CONCLUSIONS

The strict implementation of HICPAC guidelines may not always be appropriate for children at risk of beta-lactam resistant gram-positive infections. Hospital guidelines need to be tailored to the patient population and microbial susceptibility patterns of each institution. Appropriate cultures should be obtained at the time glycopeptide treatment is begun so that duration of exposure can be limited.

Eradication of vancomycin resistant Enterococcus faecium from a paediatric oncology unit and prevalence of colonization in hospitalized and community-based children

We previously reported an outbreak of vancomycin resistant enterococci (VRE) in a paediatric oncology unit in December 1995 which was associated with widespread environmental contamination of the unit with VRE. We undertook this study to evaluate the effectiveness of the infection control policy instituted subsequent to the outbreak and to investigate the underlying prevalence of VRE colonization in hospitalized, outpatient and community-based children. We sought to establish the molecular similarity of VRE isolates from the study. Stool specimens were obtained from outpatients at risk of VRE, hospital inpatients and from healthy community-based children. VRE colonization was eradicated from the inpatient unit within 11 months, but in outpatients, 16 months after the outbreak, 4 of 137 (2.9 %) attending oncology outpatients, 5 of 65 (7.7%) with cystic fibrosis and 1 of 12 (8.3 %) with liver disease were found to be colonized with VRE. The isolates were all Enterococcus faecium, Van A phenotype except one E. casseliflavus of the Van C phenotype. All were unique in SmaI DNA macrorestriction patterns with the exception of two isolates, which were similar to the original outbreak strain and three further isolates of a single strain but which differed from the outbreak strain. Of 315 hospital inpatients, 2.5 % were colonized with VRE of the Van C resistance phenotype but VRE was not detected in 116 healthy, community-based children. We conclude that effective strategies can successfully control spread of VRE but despite a low prevalence of VRE colonization in hospital patients and in community-based children, outbreaks can occur when infection control practices are not optimal. Continued vigilance to detect VRE and limit spread within hospitals is therefore necessary.

Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients

OBJECTIVE

To investigate the hypothesis that occult hypoperfusion (OH) is associated with infectious episodes in major trauma patients.

METHODS

Data were collected prospectively on all adult trauma patients admitted to the Surgical/Trauma Intensive Care Unit from November of 1996 to December of 1998. Treatment was managed by a single physician according to a defined resuscitation protocol directed at correcting OH (lactic acid [LA] > 2.4 mmol/L).

RESULTS

Of a total of 381 consecutive patients, 118 never developed OH and 263 patients exhibited OH. Seventeen patients were excluded because their LA never corrected, and they all subsequently died. One hundred seventy-six infectious episodes occurred in 97 of the 364 patients remaining. The infection rate in patients with no elevation of LA was 13.6% (n = 118) compared with 12.7% (n = 110) in patients whose LA corrected by 12 hours, 40.5% (n = 79; p < 0.01 compared with all other groups) in patients whose LA corrected between 12 and 24 hours, and 65.9% (n = 57; p < 0.01 compared with all other groups) in patients who corrected after 24 hours. Among the patients with infections, there were 276 infection sites with 42% of infections involving the lung and 21% involving bacteremia. There was no difference in proportion of infections occurring at each site between groups. The mortality rate of patients who developed infections was 7.9% versus 1.9% in patients without infections (p < 0.05). Of the patients who developed infections, 69.8% versus 25.8% (p < 0.001) did not have their lactate levels normalized within 12 hours of emergency room admission. Logistic regression demonstrated that both the Injury Severity Score and OH > 12 hours were independently predictive of infection.

CONCLUSION

A clear increase in infections occurred in patients with OH whose lactate levels did not correct by 12 hours, with an associated increase in length of stay, days in surgical/trauma intensive care unit, hospital charges, and mortality.

X-ngnr-1 and Xath3 promote ectopic expression of sensory neuron markers in the neurula ectoderm and have distinct inducing properties in the retina

Xath3 encodes a Xenopus neuronal-specific basic helix-loop-helix transcription factor related to the Drosophila proneural factor atonal. We show here that Xath3 acts downstream of X-ngnr-1 during neuronal differentiation in the neural plate and retina and that its expression and activity are modulated by Notch signaling. X-ngnr-1 activates Xath3 and NeuroD by different mechanisms, and the latter two genes crossactivate each other. In the ectoderm, X-ngnr-1 and Xath3 have similar activities, inducing ectopic sensory neurons. Among the sensory-specific markers tested, only those that label cranial neurons were found to be ectopically activated. By contrast, in the retina, X-ngnr-1 and Xath3 overexpression promote the development of overlapping but distinct subtypes of retinal neurons. Together, these data suggest that X-ngnr-1 and Xath3 regulate successive stages of early neuronal differentiation and that, in addition to their general proneural properties, they may contribute, in a context-dependent manner, to some aspect of neuronal identity.

Single cells can sense their position in a morphogen gradient

Xenopus blastula cells show a morphogen-like response to activin by expressing different genes according to the concentration of activin to which they are exposed. To understand how cells recognize their position in a concentration gradient, it is essential to know whether each cell responds individually to activin concentration. An alternative idea, proposed by previous work, is that cells need to interact with their neighbours to generate a concentration-related response. To distinguish between these ideas, we have cultured blastula cells under conditions which provide different degrees of contact with other cells, allowing nil to maximum communication with their neighbours. The cultures include cells attached to fibronectin and cells resting unattached on an agarose base. The cultures also include cells that have no contact with any cell except their clonal progeny, cells that have lateral contact to neighbouring cells, and cells that are completely enveloped by other cells in a reaggregate. We have used RNase protection and in situ hybridization to assay the expression of the activin-responsive Xenopus genes Xbra, Xgsc, Xeomes, Xapod, Xchordin, Mix1, Xlim1 and Cerberus. We find no difference in gene expression between cells attached to fibronectin and those unattached on agarose. Most importantly, we find that cells respond to activin in a concentration-related way irrespective of their degree of contact with other cells. Therefore interaction among cells is not required for the interpretation of morphogen concentration, at least in the case of the early genes studied here. We conclude that isolated blastula cells can sense and respond individually to activin by expressing genes in a concentration-dependent way.

Design and synthesis of thrombin inhibitors: analogues of MD-805 with reduced stereogenicity and improved potency

Mitsubishi's MD-805, a potent and selective inhibitor of thrombin which contains four stereogenic centers, has been the starting point for an optimization program. A systematic synthetic study resulted in thrombin inhibitors achiral at P2 and P3 but with a 10-fold increase in potency over the original lead. A number of 4-substituted piperidines were synthesized and examined as replacements for 2-carboxy-4-methylpiperidine at P2; 4-fluoroethylpiperidine (FEP) among others provided inhibitors (e.g. 45g) of increased potency. An enantioselective route was developed to 3(R)-methyl-1,2,3,4-tetrahydroquinolinesulfonyl chloride. Inhibitors containing this enantiomerically pure P3 (42d) had similar potency to the racemic material and provided support, with modeling studies, for the preparation of the gem 3,3-disubstituted compounds. A series of inhibitors containing the novel 3, 3-dimethyl-1,2,3,4-tetrahydroquinolinesulfonyl (DMTHQS) P3 (Table 5) were synthesized and showed a similar activity profile as the monomethyl series. The combination of P3-DMTHQS, P2-FEP, and P1-arginine (45g) had a K(i) of 6 nM (MD-805 K(i) = 85 nM). In animal models of both venous and arterial thrombosis, one inhibitor (42e) was shown to produce a dose-dependent inhibition of thrombus formation that in some situations was superior to that of MD-805.

The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma

BACKGROUND

The significance of occult hypoperfusion (OH) in the development of respiratory complications (RC), multiple system organ failure (MSOF), and death, and the effect of rapid identification and correction of OH in the severely injured trauma patient was investigated.

METHODS

A pilot retrospective study and the analysis of a prospective protocol to correct OH were performed. Pilot study: all trauma patients admitted to our Level I trauma center between February and December of 1995, who survived greater than 48 hours, had an Injury Severity Score greater than or equal to 20, and intensive care unit stays greater than 48 hours were evaluated. Prospective study: patients admitted between January 1, 1996, and April 30, 1997, who survived greater than 24 hours, with Injury Severity Score greater than or equal to 20, and who were hemodynamically stable (systolic blood pressure greater than 100, pulse rate less than 120, and urine output greater than 1 mL/kg per hour) were included. Serum lactic acid (LA) levels were measured at arrival and at proscribed intervals. In the pilot study, initial LA levels were examined in relation to outcome and complications. In the prospective study, patients with two consecutive LA levels greater than 2.5 mmol/L underwent invasive monitoring and vigorous resuscitation to correct their lactic acidosis.

RESULTS

Among the 31 patients studied in the pilot study, there were 4 deaths, 6 cases of MSOF, and 13 patients with RC. Lactic acidosis and poor cardiac performance, as evidenced by low cardiac index (CI) with normal filling pressures, were seen in all cases of MSOF and RC, as well as in all deaths. From these results, the prospective study was performed. Eighty-five intensive care unit patients met criteria for inclusion in the study. Six additional patients were excluded because of severe, untreatable intracranial hypertension at admission to the intensive care unit. Fifty-eight of these patients had OH in the first 24 hours. Forty-four patients corrected their OH within 24 hours with vigorous resuscitation. There were no deaths, three cases of MSOF, and 10 cases of RC in those patients who corrected OH within 24 hours. Persistent OH (>24 hours) was seen in 14 patients, despite resuscitative efforts, 43% of whom died. MSOF and RC were present in 36% and 50% of cases, respectively (p<0.05).

CONCLUSION

Initial lactic acidosis is associated with lower cardiac performance and higher morbidity and mortality. Persistent OH is associated with higher rates of RC, MSOF, and death after severe trauma. Early identification and aggressive resuscitation aimed at correcting continued elevation in serum lactate improves survival and reduces complications in severely injured trauma patients.

Anterior endomesoderm specification in Xenopus by Wnt/beta-catenin and TGF-beta signalling pathways

In Xenopus, XHex and cerberus are early marker genes of the anterior endomesoderm (AE), a subset of endoderm cells fated to form the liver and foregut and implicated in head induction. Using XHex and cerberus as markers we have examined the signals underlying AE induction. We show that the AE is specified by the early blastula in the absence of mesodermal signals but that cell-cell contact between presumptive AE cells is required. In overexpression experiments maternal Wnt/beta-catenin and TGF-beta signals (Vg1, Xnr1-2) can induce ectopic XHex and cerberus. Inhibiting these pathways with dominant interfering signalling components blocks endogenous XHex and cerberus expression. We assess the role of signals from the organiser and show that the BMP antagonists noggin and chordin are important for maintaining XHex and cerberus expression. Finally, ventral injection of XHex mRNA can induce ectopic cerberus. Our results indicate that endodermal and mesodermal patterning are closely coordinated and that the AE is likely to be specified by the combined action of dorsal Wnt/beta-catenin signals and endoderm-specific factors mediated by TGF-beta signalling. These results provide a starting point for understanding the molecular events underlying the progressive determination of endodermally derived organs, such as the liver and foregut.

Studies towards the identification of potent, selective and bioavailable thrombin inhibitors

The application of selection criteria, based on potency and physicochemical parameters, to a candidate library of thrombin inhibitors is described. The utility of the approach is exemplified by the discovery of a potent, selective and bioavailable thrombin inhibitor 62.