Standards and practice guidelines as the foundation for clinical practice

The structure and organization of health care delivery are in the midst of rapid change. Health care providers from a variety of disciplines are being challenged to define their practice and the expected patient outcomes resulting from their processes of care delivery. Standards and clinical practice guidelines are important tools for enhancing the quality of health care delivery and for documenting care. The article describes a process for developing standards and clinical practice guidelines and presents an organizational scheme for them. Based on recommendations from diverse national groups, a format for practice guidelines is presented, and a system for implementation and ongoing evaluation is recommended.

Superantigen-based immunotherapy: a phase I trial of PNU-214565, a monoclonal antibody-staphylococcal enterotoxin A recombinant fusion protein, in advanced pancreatic and colorectal cancer

PURPOSE

To establish the maximum-tolerated dose (MTD) and define the toxicities of a single-dose infusion of PNU-214565, a recombinant Escherichia coli-derived fusion protein of Staphylococcal enterotoxin A (SEA) and the Fab-fragment of the C242 monoclonal antibody in patients with advanced colorectal and pancreatic carcinomas. To investigate the capability of PNU-214565 to induce a superantigen (SAg) response resulting in cytokine production and tumor regression.

PATIENTS AND METHODS

Twenty-one patients (age range, 39 to 76 years; median, 64; 12 men, nine women; 18 colorectal, three pancreatic cancers) were treated with a single 3-hour infusion of PNU-214565, with doses ranging from 0.01 to 1.5 ng/kg. All patients had prior chemotherapy and a good performance status Eastern Cooperative Oncology Group [ECOG] performance status [PS] = 0 [n = 10]; PS = 1 [n = 11]), 10 had prior radiation, and 18 had prior surgery.

RESULTS

Fever and hypotension were the most common toxicities. Fever of any grade occurred in 16 of 21 patients (76%): four of 21 (19%) with grade 2 and two of 21 (9.5%) with grade 3. Hypotension of any grade occurred in 13 of 21 (62%): four of 21 with grade 2 and one of 21 (5%) with grade 3. Interleukin-2 (IL-2) and tumor necrosis factor alpha (TNF alpha) induction correlated with toxicity. In the two patients with grade 3 fever, peak IL-2 and TNF alpha levels were 2.9 IU/mL and 165 pg/mL, and 8.3 IU/mL and 245 pg/mL, respectively. Transient, > or = 50% decreases in circulating monocytes were observed in 17 of 21 patients as early as 0.5 hours (median time, 2 hours) from the start of infusion. Decreases (mean 33%) in circulating lymphocytes were observed in seven of 21 patients. All three patients with grade 3 toxicity were treated at the 0.5-ng/kg dose. The significance of baseline anti-SEA, human antimouse antibody (HAMA), CA242-soluble antigen levels, and T-cell receptor variable beta region (TCR V beta) subsets and histocompatibility leukocyte antigen-DR (HLA-DR) genotypes was assessed as possible predictors of toxicity. All toxicities were transient and easily managed. No grade 3 toxicity occurred at the higher dose levels.

CONCLUSION

PNU-214565, a SAg-based tumor targeted therapy, is safe when given as a single 3-hour infusion at doses up to 1.5 ng/kg. The MTD for a single dose was not determined. The safety of a repeated dose schedule is currently under investigation, beginning with doses determined to be safe in this trial.

Capillary Rise for Thermodynamic Characterization of Solid Particle Surface

Surface properties in terms of surface free energy of solid particles were investigated using capillary rise experimental methods based on Washburn's equation. Two different approaches related to height and weight gain measurements were validated by silica flour and calcium carbonate surface studies. Dispersive components of the surface free energy and nondispersive components of solid-liquid energy of interaction were computed. Some differences observed are related to experimental data acquisitions. Many experimental difficulties, which led in the past to inaccurate wettability characteristics, have been controlled. A new link to the so-called geometrical factor of Washburn's equation has also been established after comparison of theoretical and experimental static and hydrodynamic radii. The high precision of the weight gain approach was achieved by strict control of experimental parameters such as temperature, powder packing, and sintered glass porosity.

SAM as a protein interaction domain involved in developmental regulation

More than 60 previously undetected SAM domain-containing proteins have been identified using profile searching methods. Among these are over 40 EPH-related receptor tyrosine kinases (RPTK), Drosophila bicaudal-C, a p53 from Loligo forbesi, and diacyglycerol-kinase isoform delta. This extended dataset suggests that SAM is an evolutionary conserved protein binding domain that is involved in the regulation of numerous developmental processes among diverse eukaryotes. A conserved tyrosine in the SAM sequences of the EPH related RPTKs is likely to mediate cell-cell initiated signal transduction via the binding of SH2 containing proteins to phosphotyrosine.

Mechanism and specificity of human alpha-1,3-fucosyltransferase V

Human alpha-1,3-fucosyltransferase catalyzes the transfer of the L-fucose moiety from guanosine diphosphate-beta-L-fucose (GDP-Fuc) to acceptor sugars to form biologically important fucoglycoconjugates, including sialyl Lewis x (SLex). Evidence for a general base mechanism is supported by a pH-rate profile that revealed a catalytic residue with a pKa of 4.1. The characterized solvent kinetic isotope effect (Dv = 2.9, Dv/k = 2.1) in a proton inventory study indicates that only one-proton transfer is involved in the catalytic step leading to the formation of the transition state. Evidence for Mn2+ as an electrophilic catalyst was supported by the observation that the nonenzymatic transfer of L-fucose from GDP-Fuc to the hydroxyl group of water in the presence of 10 mM MnCl2 at 20 degrees C was accelerated from K(obs)= 3.5 x 10(-6) to 3.8 x 10(-5) min-1. Using the GDP-Fuc hydrolysis as the nonenzymatic rate, the enzymatic proficiency of FucT V, (Kcat/Ki,GDP-fuc. K(m),1.acNAc)/K(non), was estimated to be 1.2 x 10(10) M-1 with a transition-state affinity of 8.6 x 10(-11) M. The Km for Mn2+ was determined to be 6.1 mM, and alternative divalent metal cofactors were identified as Ca2+, Co2+, and Mg2+. Detailed kinetic characterization of the acceptor sugar specificity indicated that incorporation of hydrophobic functionality [e.g. -O-(CH2)5CO2CH3] to the reducing end of the acceptor sugar substantially decreased the K(m),acceptor by over 100-fold. The role of the nucleotide was investigated by studying the inhibition of nucleotides, including the guanosine series. The inhibitory potency trend (GTP approximately GDP > GMP > > guanosine) is consistent with bidentate chelation of Mn2+ by GDP-Fuc. The role of charge and distance in the synergistic inhibitory effect by the combination of GDP, an aza sugar, and the acceptor sugar was probed. A mechanism for fucosyl transfer incorporating these findings is proposed and discussed.

Structure of the WW domain of a kinase-associated protein complexed with a proline-rich peptide

The WW domain is a new protein module with two highly conserved tryptophans that binds proline-rich peptide motifs in vitro. It is present in a number of signalling and regulatory proteins, often in several copies. Here we investigate the solution structure of the WW domain of human YAP65 (for Yes kinase-associated protein) in complex with proline-rich peptides containing the core motif PPxY. The structure of the domain with the bound peptide GTPPPPYTVG is a slightly curved, three-stranded, antiparallel beta-sheet. Two prolines pack against the first tryptophan, forming a hydrophobic buckle on the convex side of the sheet. The concave side has three exposed hydrophobic residues (tyrosine, tryptophan and leucine) which form the binding site for the ligand. A non-conserved isoleucine in the amino-terminal flanking region covers a hydrophobic patch and stabilizes the WW domain of human YAP65 in vitro. The structure of the WW domain differs from that of the SH3 domain and reveals a new design for a protein module that uses stacked aromatic surface residues to arrange a binding site for proline-rich peptides.

The protein phosphatase 2C (PP2C) superfamily: detection of bacterial homologues

A thorough sequence analysis of the various members of the eukaryotic protein serine/threonine phosphatase 2C (PP2C) family revealed the conservation of 11 motifs. These motifs could be identified in numerous other sequences, including fungal adenylate cyclases that are predicted to contain a functionally active PP2C domain, and a family of prokaryotic serine/threonine phosphatases including SpoIIE. Phylogenetic analysis of all the proteins indicates a widespread sequence family for which a considerable number of isoenzymes can be inferred.

Spatial heterogeneity of blood flow in the dog heart. I. Glucose uptake, free adenosine and oxidative/glycolytic enzyme activity

The spatial heterogeneity of myocardial perfusion and metabolism was studied in 11 anaesthetized dogs under resting conditions. In each heart local myocardial blood flow was assessed using the tracer microsphere technique in 256 samples (mean mass: 83.1 mg) taken from the left anterior ventricular wall. In the same samples, the following biochemical parameters were determined: accumulation of [3H]-deoxyglucose (a measure of glucose uptake), free cytosolic adenosine (S-adenosylhomocysteine accumulation technique, a measure of tissue oxygenation and a possible mediator of blood flow regulation), and the specific activities of oxidative (citrate synthase, cytochrome-c-oxidase) and glycolytic (hexokinase, phosphoglycerate kinase) enzymes. Capillary density and mitochondrial and myofibril volume densities were determined by morphometry. Myocardial perfusion in each sample (average 0.77 ml min-1 g-1) varied between 0.1 and 2.5 times the mean (coefficient of variation 0.30+/-0.02). [3H]-deoxyglucose was deposited locally in proportion to perfusion. Samples showing low flow (<0.2 ml min-1 g-1) did not exhibit increased levels of cytosolic adenosine. The specific activities of the oxidative and glycolytic enzymes, however, were uniformly distributed between low and high flow areas. Furthermore, capillary density and mitochondrial and myofibril densities were similar in high and low flow regions. The results show firstly that local glucose metabolism in the heart occurs in proportion to local blood flow, suggesting that high flow regions have a higher than average metabolic rate. Secondly, regions of low flow are not compromized by critical oxygenation and most likely have a lower than average oxygen demand and finally, the homogeneous distribution of oxidative and glycolytic enzymes, as well as the homogeneous myocardial ultrastructure, suggest that areas with high and low blood flow under resting conditions may increase their metabolic rate to similar levels when required.

Interactions of spermidine and methylspermidine with DNA studied by nuclear magnetic resonance self-diffusion measurements

The NMR pulsed field gradient self-diffusion method has been used to study the self-diffusion of the polyamine spermidine and the polyamine analog methylspermidine (completely N-methylated spermidine). The self-diffusion coefficient, D, was measured in solutions of calf thymus DNA prepared from nucleosome core particles (with an average length of 120 base pairs) as a function of the concentration ratio of polyamine to DNA phosphate. A study of the self-diffusion quotient, D/Do (where Do is the diffusion coefficient for free polyamine, not associated with DNA), in additions of spermidine and methyl-spermidine to solutions of NaDNA/NaCl, gave almost identical results with complete association of polyamine to DNA in the initial part of the titrations, indicating similar affinities for DNA. A large influence on the measured self-diffusion coefficients was detected for methylspermidine in NaDNA solutions with different concentrations of NaCl, which shows a considerable salt effect on the polyamine-DNA association. No notable differences in D/Do for methylspermidine were observed in competitive titrations of solutions of Li- and NaDNA, indicating that sodium and lithium ions behave similarly in their interactions with DNA. In titration experiments of methylspermidine into MgDNA solution, the results showed that the polyamine association is less effective than in the case of NaDNA, because of competition from magnesium binding to DNA. Comparisons with calculations based on the electrostatic Poisson-Boltzmann cell model were performed. It is suggested that the interaction is primarily of electrostatic nature, with no binding to specific sites on the DNA molecule.

Reduction of rat myocardial ischemia and reperfusion injury by sialyl Lewis x oligosaccharide and anti-rat P-selectin antibodies

Polymorphonuclear leukocytes (PMN) are directly involved in development of ischemic myocardial injury. Adhesion of PMN to endothelial cells is an initial step that triggers a sequential process leading to acute inflammatory responses. Interaction between P-selectin and its oligosaccharide ligand, sialyl Lewis x (sLex), plays an important role in the early stage of the adhesion. To examine the role of P-selectin in various animal disease models especially in rats, we have cloned rat E- and P-selectin cDNAs and established monoclonal antibodies against these rat selectins. In this report, we describe the generation and characterization of anti-rat P-selectin antibodies (ARPs). These antibodies detect cell surface P-selectin on thrombin-stimulated rat platelets. More importantly, intravenous administration of ARP2-4 reduced infarction developed after 30 min of ischemia followed by 24 h of reperfusion in a rat myocardial injury model. In addition, similar protective effect was also observed by administration of a sLex-oligosaccharide. These results indicate that cell adhesion mediated via P-selectin is involved in the development of ischemia and reperfusion injury in rat heart.

Expression of the protooncogene bcl-2 in Alzheimer's disease brain

To investigate the role of the apopotosis-related protooncogene bcl-2 in Alzheimer's disease (AD), we compared levels of its protein product, designated Bcl-2, in AD and nondemented (ND) age-matched control neocortical samples. The 26 kD Bcl-2 protein is increased in expression by more than three-fold in AD compared to ND samples as detected by immunoblots. Immunohistochemical analyses give similar results. In AD patients Bcl-2 immunoreactivity is dense and profuse and appears to occur on reactive astrocytes, whereas Bcl-2 immunoreactivity of astrocytes in ND patients is light and sparse. Staining of both gray and white matter is observed but is most prominent in the latter. Increased expression of Bcl-2 by astrocytes may partially underlie their resistance to loss in AD. By contrast, neuronal Bcl-2 immunoreactivity is more sparse and equivocal, perhaps reflecting the vulnerability of this cell type to apoptotic mechanisms in AD. High levels of Bcl-2 in glial cells may aid in cell survival of reactive astrocytes resulting in either beneficial or deleterious effects on neuronal viability.

A New Theoretical Approach to Cavitation in Rubber

In order to analyse the stability and bifurcation phenomena occurring during expansion of a small void in a rubbery material, the behavior of spherical shells submitted to a combined far-field pressure and uniaxial tension has been investigated, considering a general nonlinear isotropic elastic compressible behavior of the material and without any restrictions on the shell thickness. A radial solution for the deformation gradient with a spherical symmetry has been exhibited, which is valid for any behavior law and consists of a homogeneous deformation. The three-dimensional problem is then linearized around this trivial solution, and we show the existence of a pressure interval containing the zero value, in which the solution is reduced to the trivial solution, which is therefore infenitesimally stable. When the applied pressure lies outside the stability interval, we determine the bifurcation points of the shell around the trivial solution, first when only a pressure is applied and secondly when there is an additional far-field tension, much smaller than the applied pressure. The form of the stress distribution on the boundary of the cavity suggests a possible bifurcation of the spherical solution towards a family of axisymmetric solutions. Within this hypothesis, we get a relation between the geometrical parameter of the shell (its radius and thickness), the mechanical properties of the material and the critical load.

Signal transduction and growth control in yeast

An understanding of how an extracellular stimulus causes changes in cell growth is emerging from the study of four signal transduction pathways in Saccharomyces cerevisiae: the pheromone-response, pseudohyphal differentiation, osmolarity-response, and protein kinase C activated pathways. Each of these pathways contains at its core a distinct mitogen-activated protein kinase cascade. Biochemical and molecular studies have determined the functional order of the kinases in the pheromone-response pathway and have suggested that they are organized into a complex by a protein scaffold. The cell surface sensor system for the osmolarity-response pathway has been identified. It shows striking similarity to bacterial two-component sensor-responder systems. Finally, components that integrate information from these pathways and communicate it to cell growth regulators have been revealed.

Enhanced cytotoxicity of amyloid beta-peptide by a complement dependent mechanism

Amyloid beta-peptide (A beta) has been shown to activate the classical complement pathway in vitro. Here, we demonstrate that this interaction is fully capable of killing cells and damaging cellular processes in mixed hippocampal cultures from embryonic day 18 rat fetuses. Lactic acid dehydrogenase (LDH) release and morphologic changes were used to evaluate toxicity.